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L^n iHiiuiitkniid tvlp 
Venn *Jrt^* '"^ 

L«ft pulmoDifr ifBT 

V^Uinp of tup- 0*> 

Aorta ^ 

rcu<>i *fiiirUde 

L«lt ftPirlaillf 

Kin, l.'^Thc heut uxl Kreat vvAeU. viewnl fruja ttaa fronts (Aft«r Pl^rwl.) 

J.«ft pulmonary ftrtitry 
^nppnnr Uft putnuHiary vein- 

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'Supeiior vriiu vnvn. 

Supvrictr rijflit pulcnnnkry vf^n 
Uisht pulmonary arteiy 

ff*Hor rJcht pulmoiuLry wio 

CuTUTiury "inu* 

RighJ **(*rcmiir>' vrm 
'rfmn"v»»riir Kmiki'U of riKbt 

(Igl^t mronHty ■fl*fy 
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of the 












Printed by J. B. LippinooU Company 
The Waahinglon Square fresi, PhiladeljAia, V. S. A. 



rmtnaot «! CMalal Mtdldu, Lclud Snnrord Juki L'slrnnr 

rroCrvor of MtdtdH. Johu Hopkiat UDlv«*l(y 









The researches in the great field of inner medicine have so multiplied 
in recent years that it has become highly desirable that we should have 
from time to time, in addition to the aummaries of pi'ogress contained 
in the general text-books on practice, monographs which picture more 
completely the status of our knowledge in the several special divisions 
of the subject. In diseases of the circulatory system new methods of 
study have led to the discovery of many new facts, and a great many 
workers have been attracted during the last twenty years to this domain 
of cardiovascular inquiry. 

In the medical clinic at the Johns Hopkins Hospital, Dr. Hirsch- 
felder has during the past few years occupied himself especially with 
such studies. The present volume is an attempt to epitomize the actual 
condition of the subject at the present time, as viewed from the stand- 
point of an active investigator of extensive first-hand experience who 
has also a wide acquaintance with the literature of the physiology and 
pathology of the circulatory apparatus. 

The clearness and brevity of the presentation and the excellent 
arrangement of the material will, I am sure, appeal to students and 
practitioners of medicine. It is no easy matter adequately to combine 
the most recent results of anatomical, physiological, pathological, and 
clinical studies in a form which will satisfy the critical demands of the 
scientific investigator and at the same time be useful as a guide to 
the everj'-day practitioner. Especial attention has been paid in the 
volume to the practical facts of diagnosis and treatment; in the more 
theoretical portions there will be found evidence of careful, critical 
sifting, and an appreciation of the distinction between what is essential 
and what non-essential for the more general reader. 

The bibliographic references make no attempt at completeness, but 
have been chosen with the idea in mind of permitting those who desire 
to do so to consult the most important, and especially the more recent, 
treatises, monographs, and original articles which deal with the various 
matters discussed. 

A notable feature of Dr. Hirschfelder's book is the liberality of illus- 
trations; the majority of the figures are made from original drawings 
and tracings and are in pleasing contrast with the time-worn figures 
which pass from compilation to compilation. 

Lewellts F. Barker. 
Baltimore, May 12. 1910. 



In the preparation of this book it has been the writer's aim to present 
fflde by side the phenomena observed at the bedside and the facts learned 
in the laboratory in order to show how each supplements the other in 
teaching us how to observe the patient and to direct the treatment. Many 
of the results obtained in the laboratory have not yet attained practical 
importance because they have been scattered through the literature and 
have not reached the eye of the clinician; but wherever the clinicians have 
looked to the laboratory or laboratory workers have looked to the clinic 
for verification or application of their theories the great pillars of progress 
have been raised. In accordance with this idea the clinical presentation 
in each chapter is preceded by an introductory section dealing with the 
experimental pathology and more fundamental principles of the subject, 
which has been used as a basis for frequent reference in the clinical dis- 

The trend of clinical observation during the past two decades has been 
toward more accurate study of disturbances of function and toward the 
introduction of mechanical methods for their observation, methods of 
precision which tend to supplement or supplant the older and simpler 
methods of physical diagnosis. Chief among these may be mentioned the 
study of blood -pressure, the graphic studies upon alterations in cardiac 
rhythm by means of the venous pulse, the ou+'ning of the heart and vessels 
by means of the X-ray, and the phonograpL recording of the heart sounds. 
Each of these subjects has been reviewed with special reference to the 
general principles upon which the method is based, in order to point out 
its applicability, its limitations, the character of information which it has 
yielded in clinical conditions, the conditions under which the same informa- 
tion may be gained by simpler methods, the conditions under which its 
employment is essential and those under which it is superfluous. 

The failure of the heart has been traced through its varying stages 
from the simple fatigue of the normal heart in exercise, through the stage 
of primary overstrain, to that of broken compensation, especial attention 
being devoted to the states of broken pulmonary compensation arising 
from failure of the left ventricle and of broken systemic compensation 
from failure of the right. 


viu ^^H FBEFACE. 

The pathogenesis of cardiac symptoms is fully (UwuMw], with their 
pfttliotogicul phyMology, occurrence*, and the sj-mptomatic treatment for 
their relief. 

The general niethods of trcatmcut in cardiac diseasea, dietetic, phar« 
tnacological, gymnaalio, hydrotherapeutic, and electrirat, have bevn treated 
both an cnipiricitl procedures and us oxpc-rimcntal methods to correct 
definite dUturbanceH in the phyeiiolo/^ of the circulation, ei^pedally changes 
ID cardiac force, cardiac tonicity, and peripheral ri'«i£ta&cc. 

The chapters upon the individual organic lesions include discututions 
of pathological nnatonty, palhogvncsis, pathological phydolog}', as well 
aa of symptomatolog)', course, notes of typical cases, diagnosis, treatment, 
and progiiOKLS. CoDifldcrable attention is also paid to functional disturb- 
ances (valvular insufficiencies, etc.) which may bring about conditions 
Bimilar to those resulting from organic changes or may accompany the 
latter. The Adams-Stokes syndrome seems so definitely associated with 
lesions of the auriculovcntricular muscle bundles as to justify its clsssiG- 
cation among conditions due to organic Icaons. 

The congenital heart lesionit tire viewed as disturbances in cmbTyolo^c 
development in which primary malformations or states in fetal Ufe have 
diverted the blooil current, modifying the further course of development 
and producing concomitant secondary malformations. The effect of these 
le»ons upon the adult cireulation and their relation to cardiac overstrain 
in producing the syndrome of the morbus corulcus arc discussed, as well 
as the signs, diagnosis, prognoius, and treatment. 

Short chapters arc devoted to the mibjccta of pregnancy in heart 
diaeaac and the effects of trauma and wounds of the heart. 

Considerable space Is given to the purely functional disturbances of 
cardiac action, especially to the physiological mechanisms by which many 
of them result from disturbances in distant organs as well as to the improve- 
menta resulting when these disturbances are corrected. 

A great deal of care has becEi bestowed by the writer in the prepara- 
tion of the illustrations, especially upon the cardiosphyginographic trac- 
ings, the diagrammatic representations of clinical conditions and of effects 
upon the blood flow in different parts of the circulation as well as in difler- 
ent stages of the diseaao. When ucccaaaiy. figures have been borrowed 
from other sources, to whom due credit has been given, 

Since the aim of the book i» not only to present the principal facts 
but to ud the reader in following out lines in which he i.s e.-<pecinl!y inter- 
ested, an adequate bibUography has been added to each chapter, embrac- 
ing the articles referred to in the text. 

It is a pleasant duty for the writ«r, in conclusion, to express his thanks 
to Professors Barker and Thayer for the privilege of using the clinical 



material and records of the Johns Hopkins HoBpitaJ, to Professor T. B. 
Futcher for that of the Johns Hopkins Dispensary, and to his father, Pro- 
fessor J. 0. HlrscMelder, for the cases at the City and County Hospital 
of San Francisco; to Professor F. P. Mall and Drs. Knowcr, Retzer, and 
Evans in matters of anatomy and embryology ; to Professors W. H. Howell, 
J. Loeb, and Dr. D. R. Hooker in physiology; to Professors W. S, Hal- 
sted, T. S, Cullen, and J. M. Slemons in matters of surgery, gynaecology, 
and obstetrics; to Professors W, G. MacCallum and W. Ophiils, as well 
as to Major F. F. Russell, Dr. Lamb, and Dr. Gray, of the Army Medical 
Museum, for the use of pathological material; to Professor C. M. Cooper 
for the collection of radiographs; to Dr. Chas. S. Bond for hia untiring 
labors in the preparation of photomicrographs; to Professor W. Einthoven 
of Leyden for the use of electrocardiograms; to Professor Max Broedel 
for his kind instruction and suggestions in matters of illustration; to Dr. 
Caroline B, Towles for her assistance in reading of proof as well as for 
many helpful suggestions; and to Miss Alberta E. Bush for her care in the 
t^bnical matters pertaining to the manuscript ajid index. 






III. The Arterial Pl-ue 41 

IV. The Vexuuh Pulhe a.\d Electro cardioo bah in Health akd Disease . . 49 
V. X-Ray Examination 82 

VI. PnvaiCAL Examination- 88 



II, Pathological Pbyhiolooy of Exercise, Cardiac Overstrain, Heabt 

Failcrb, aso Broken CoHFENaATioN 129 


IV. Genebal Principles or Treatment of Failure of the Heart 163 

V. The Effects of Dhuuh in Cardiac Disease 172 


VII. Hypertrophy and Atrophy 203 

VIII. Fatty Deposits in asd about the Heart 214 

IX. Affectioss of the Myocardium 224 

X. Abtebiosclerosis. 249 

XI. Vasomotor Crises, etc., an-o thm Angioneurotic Lesions. 270 

XII. Sclerosis of the Coronary Arteries, and Angina Pectoris 280 



I. Endocarditis 299 

II. Mitral Insufficiency 321 

III. Mitral Stenosis ;i41 

IV, Aortic Insufficiency 360 

V. Aortic Stenosis 3S1 

VI. PcLMONABY Insufficiency 390 




VII. TmccspiD Insufticieiict .^ 398 

VIII. THicnsPiD STBNoaxB 40& 

IX. pREONANcr AND Labob in Cases of Hbabt Dubask 413 

X. CoKOBNiTAL Hbabt Disease 421 

XI. Hbabt-Block and Adaiib^toebb Stndboub 460 



XIV. Ameubisu 421 



I. Fasoxtbual Tachycabdia 560 

II. Thtboid Heart 574 

III. H1BCXU.ANEOU8 D1STCRBANCE8 OF Cabdiac Function — The So-called 

" Cabdiac Neuroses " and " Cardiac Neoeabtbenia " S93 


ria. nam 

1. The heart and great vessels, viewed from the front frontispiece 

2. The heart and great veaseU, from behind frontispiece 

3. Relations of the heart and great vessels, viewed from the front xxiv 

4. The heart and thoracic viscera, viewed from behind xxiv 

5. Sagittal aection of the thorax, viewed from the right xxiv 

6. Heart muscle^bres 1 

7. Section through the endocardium, showing section of the muscle-fibres 2 

8. Apparatus for perfusing the mammalian heart 3 

9. The auricular end of the human heart, viewed from the right 5 

10. The sinus region of the heart, the veno-auricular or venosinai bands of striated 

muscle, and the auric ulo(atrio) ventricular or aino ventricular muscle bundle ... 6 

11. Arrangement of ventricular muscle-fibres 8 

12. Apparatus for registering the volume of the ventricles 9 

13. Volume curves of the ventricles at different heart rates 9 

14. Methods for demonstrating the movements of the heart valves 10 

15. Volume curves showing the effect of variations in venous pressure and in tonicity 

upon the rate at which the ventricles are filled during diastole 12 

16. Volume curve showing the effect of low venous pressure or of high tonicity upon 

the amount of blood entering the ventricles 12 

17. Diagram illustrating the changes in volume of the ventricles in systole and diastole 

associated with variations in tonicity and systolic output 12 

18. Origin and course of the cardiac nerves, and cutaneous dietribution of the corre- 

sponding schematic branches 14 

19. Curve of intraventricular and aortic pressures 18 

20. Riva-Rocci blood-pressure apparatus as modified fay Stanton 20 

21. Correct method of feeling the pulse in Straaburger's determination of minimal 

pressure 21 

22. Erianger blood -pressure apparatus with Hirschfelder polygraph attachment. ... 21 

23. Diagram showing arrangement of Erianger apparatus 23 

24. Curve taken with the Erianger apparatus, showing points of maximal and minimal 

pressures 22 

25. V, Recklinghausen apparatus for determining the maximal and minimal blood- 

pressure in man 22 

26. Diagram showing the maximal and minimal pressures in various parts of the 

circulatory system 24 

27. Diagram showing effects of vasoconstriction, vasodilation, increased and decreased 

force of ventricular contraction upon the maitimal and minimal blood-pressures 

and upbD the form of the pulse 25 

28. MoBso plethyamograph 26 

29. Diagram abowing the curve of blood-pressure during asphyxia 27 

30. Diagram showing typical blood -pressures in various diseases 29 

31. Hooker and Eyster's modification of V. Recklinghausen's method of determining 

the venous pressure in man 33 

32. Detennann's apparatus for determining the viscosity of the blood . 38 

33. Brachial pulse-curves taken with the Erianger blood-pressure apparatus from the 

arms of two patients 42 




'M. Abwolutc npbygmapum, all of n-liicli cun«s]K)ii(l lo tb« milinl Imcinic nbove — 43 

3fi. .SiKniHcance of tlw pnlao-ciirvo 44 

36. Dingnun Bbuwiiig the Uine rHlaiioiu uf t-CDiricular ^■oIun]U uhI pitwurc eun-m U> 

pulse trM^niiK frpm the ftortit, carotid and radial nrtcrin - 44 

$7. Tliive ty|im of arlen&l pulM-curvr correeponding (a ihc saiae pul>«-i)rnBUR! and 

wuni- pubp-ntp . . . . 45 

liH, ICffrrl. of inhalntion of aniyl nilritt^ upon piilfm form .... 4,S 

39. Afcrcuiy iiiiLiioniC'It^r truuiug from lliv Furoli<l uriery uf a dog. Khoiring rhythmic 

vnrintioiut in HcxKi-prpwHin- nnd rhj-lhmic iiicrpii»c in <lirroliiiin 46 

40, DiajKrain ahoa-ing vuriuiu forma of pulse-curve encountered eliDioally. 40 

4). Sit«ii for recording Ihc jUftuUr luul cnrolid pulaatiotu fit 

42. AppomtlU (or rticording thp rMpimtion 52 

43. V. Jaiiuet'scardiuephyKiiiognpii... ....i. K2 

44. NormnJ vrnous tradngii , S3 

45. Diajenim ntpn-Heiiliiig; Ihe varioiu events 111 Jt eaitU&e cycle. 58 

40. Venom ImcinK showioft at^rnrr of thn e wnvu in a eoac of heart failure H 

47. Vpnous Iraciii^ showing aurioular paralyiiis (abwnco of a wave) wltli large (n) 

ileprMHioii — - . S4 

4R. Vrnoufi tmcinjc frmn n t-trry >ilow heart, with loud tbinl licurt nouni), showing the 

pr«ncnce of (he h wave . , 5ft 

49. Tracing from the nunc pcrvon one hour lateT, after giving atrDjiiitc and qiiickcninK 

the piilw 3ft 

fiO. Showing a mve w occurring nhortly before tlie n wave ,. K 

31. I'onitivc or iTntricuIn/ type t>f vcnoui pulw in triounpid iiwufflciency, aboidnf; 

abaeiice uf the u wai-e J7 

52. Potiitivc or veiitriculiir type of veiioua puW ij) Irioiwpid bwufficicncy, ohnwing 

absrncc of Iho a wave 57 

£3. Mcihod uf taking tracing from ttu; tmoplutgu* (oahow the contraction* of the lefi 

uiiriclc . - . . 5S 

54. (Eoophapnl mid ciiroli<l tracings from u iionnnl mun ..... AS 

0^. Biinplmt form of npparatiM for recording the clcctrocnrdiogram and cudiognui 

itimuIlaJKOutily S8 

5ft. Putient with both hand* in Httl-eolulion jnra rvady for laldng electnicanliaipwn . - M 

S7. Coiirao of th» olwtriciil variationH due to the hearl-l>eat in man . - SO 

56. Norrtuil dcctrocanliogram Khowing the time relation* to the venoun and carotid 

puW-wavm S9 

jO. Normal clwlrocurdiognun .W 

60. Diogrtun ippmwnttnit variouo typea of imegiilnr pulw BTt 

61. Rc«|>in«tor>' iiiThylluuia. . W 

S2. ^''^nulK tncinj^ in licurt-block. I*itrtial heort-bluck (It : t rhythm) <luring prm- 

HUrc on the vivKuv. In a caw of Adama-Stokea diwase 6ft 

63. Venoui traciiigB in heart-block. C^omplele heort-blook iu a cave uf Adonw^tokc* 

diaow , M 

64. Occasional abwDoe of apex inpidM<hiriiig{B«frfra(IonibniUMiRginurreiririe^ 

heart-block 67 

flft. Altcrnaiinx piilM tnacsMof paroxyunal inchycantia 68 

66. Hm|Hiiuie uf frog's ventricle tu abnormal nliinah B8 

67. Tracing fmm jugular v«in and brachial art«ry in man, ihowiRg ventricular 

exi raFVelotm 60 

eS. Tmcingi from the jugular vnn and brncliio) artery of a patient with trigeminal 

pulse - . 69 

69. Diagrauimatio reproduction of (he el<<eirocurdio^ram obtained in the dog a» the 

rtMtIt of cxtrojiyiitolm .. - ... 70 

70. Elect rocardiogroBi of a patient with mitral H(enoei«, ahowinR rxtrsnyBtolM. .... 70 


71. Valumecurveof the veDtriclea,Biiowing the dilatation which followed the entrance 

of an air-bubble into the right auricle 71 

72. EztrasyHtolea with shortened conduction time, supposed to srise in Che auriculo- 

ventricuUr bundle 73 

73. Variations in conduction time in a case of mitral stenosis 73 

74. Tracing showing absolute arrhythmia with weak ineffectual systoles 74 

75. Diagram showing the alterations of rhythm which may cause a pulsus bigeminus . . 74 

76. Absolute permanent irregularity with a wave preserved in a case of mitral 

Btenoeds 75 

77. Perpetually irr^ular pulse with absence of a wave 76 

78. Ekctrocardiogram from a case of perpetual absolute arriiythmia showing extra- 

systole 77 

79. Effect of arrhythmia on the circulation, blood-pressure, and volume of the 

ventricles 77 

80. Radiograph of normal chest 83 

81. X-ray shadows in different axes of the body 84 

82. A simple form of orthodiagraph 85 

83. Diagtam showii^g the use of the orthodiagraph 85 

84. Orthodiagraphic outline of normal heart, showing Monti's conjugates — 85 

85. Movements of the heart leading to the pratrudons and retraction during systole . . 89 

86. Rubber funnel for cardiographic tracings 90 

87. Cardiograms obtained over right and left ventricles 90 

88. Various forms of apex tracings 91 

89. Areas of pulsation and retraction 92 

90. Eddies producing thrills as illustrated by a stream of water 92 

91. Goldscheider's orthopercussion 93 

92. Percussion with the orthoplessimeter 94 

93. Diagram to show the cause of unavoidable error in percussion of the cardiac 

outlines 95 

94. Areas of cardiac dulnesa and flatness in a normal man 95 

95. Cardiac outlines in a child of nine years . 96 

96. Diagrams illustrating the movements of the normal heart on change of pasture 

from side to aide, and in the various phases of respiration 97 

97. Graphic records of the heart sounds 98 

98. Diagram for representing the heart sounds in clinical notes , . 99 

99. Choice of stethoecoiie l>elU 101 

100. The" valvular a(«as" 102 

101. The propagation of the heart sounds from valves to chest u-all 103 

102. Graphic records of the fetal heart sounds 104 

103. Diagram illustrating the split sounds anil gallop rhythms and their phonetic 

equivalents 105 

104. Graphic record of a split pulmonic second sound 106 

105. Graphic record of the third heart sound , , 107 

106. Jugular and carotid tracings from a normal in<)ividual with a u'ell-marked third 

heart sound 108 

107. Forces supposed to be at work in the production of the thir^l heart sound 108 

108. Similarity between the production of voice sounds and the production of murmurs 110 

109. Distribution of the accidental murmur 114 

110. Graphic record of an accidental murmur 115 

111. Diagram showing the relation of the more common simple munnum to events of 

the cardiac cycle 110 

112. Cardiac dulness in v. Leyden's case upon his three successive ailmissions 125 

113. Alterations of blood-pressure due to rapid lifting of light weights with the feet.. 130 

114. Eiffect on patient with badly broken compensation of walking on a level. . , 131 



IIS. Effect of prolonKcl exorcise upon (he blood-presgure of men in various degnta of 

muaculamtreii^li 131 

lis. lUflc of blood-prcuHUrt! duriDR ViUmlva'n expcrinirnt anil dtmng eJCpreiae. . 133 

117. Variatlona [n size of ihe heart of a lon^-dieianoe bicycle ridm', as the rhuIe of a 

rery long r»ee 133 

1 IK. Effect of fttmin upon the (laf;'x hrnrt wbnw tomrlty is good ISS 

119. Volume eurt-e of a ilo^ whoae cardiac toiiiciiy In low 186 

120. Effect upon the volume of the dog'a heart produced by cliunpinft tlie doccndiiig 

thoracic 9u>rla 137 

131. Diagnua idiowiDg obaugies io the cinrulation: 1, normal; II, broken pulmonary 
compeiuuition; 111, bmkro nyKtcmio oampcnntioni IV, both coaipenmtioiw 
fail; slasee in hinm and veinit 139 

122. Tbt two lypei of dieyne-StokM respiratioii in their rvlutioiw la liie blood-prtwiuv 

ciir%T»- - - ..,..,.. tS2 

123. Lt^of a pailent with exf rvme oMlema and in>meniioiiB ulcere IM 

121. (^irKchRiacin'a niudifi cation uf tlie SouOicy lubea for dmiuiiiK a-dema of tlie IcgH . . tSS 

IS.'i. IC!cctrir-nt rrconl of .tiTpreiil iinpuliim trnvcUinft up the vafp \S7 

12ti. liuiertioii uf llie kuife in vvneaeclion , ISA 

127. EffM:t of vcnnMction on the canlinc outline, ■howiug diminution in nitc of right 

heart 187 

I2N. 'lypical elTuct of veneBOt'lion upon the circulation .-..••.. ..,.,. ....... ,.■.... 167 

1*20. Tmcins Rhowinx the .ictton of di)[ilsliii ujiou tin- dog** blood ■pimiure ITS 

130. Vitrialiuufl in blood>pr(wnin' in a palienl under the influence of di(!ilsliti and 

nitroglycerin 176 

131. Efferr of ditptnlin on enrdiae tonicity In the dog. 177 

133. Cum iihou'itii: llie effecl of Htryrbnino upon cardiac tonicity . 1S2 

133, Gdfecl* of driiip of the iiitriMneriM upon the bluod-pruourc in iniui . IS7 

131. Schott tewihieil niovenicnl*.. I9U 

13.$. OrtticKtiiiKrti|>lu(-> mitline of a patient with dilated heart, iihowing tlie efTcet of 

8chott movement* ., 197 

1311. Ilyiiertruphic, normal, and alropliie lieaila , 303 

137. Pholomlcrugruptu of atrophic and hypertrophic lieurt miutelo 204 

ISS, HtArt of niirmiit <lo|i and nf iln)i which hnii run for Ihiec inonlhn on n tirndmill . . 20C 
I.IV. AreoHOf piiUution and retritction hy|iertrophy of the riicht and left ventrietus . . 209 

140. Diajrranmhowinxi'DH'erof iionnul and hypertmplucil (utldele'ii) heart, at rent and 

durinii eierciw, ei>mpare<i wilb that of a dlseawcd heart 311 

141. UiHlribuItun of Ul iu u;id about the heart 214 

142. l'bnlon>ieniKT»|i)ui of fat depusita in Ilie heart SU 

143. All excewivc dejionil of epicftrdinl fnt 310 

144. Infiltmtiun nlung the coiiive of the hloiHl-r«««ls in lUljuculV inyuctirdilin; blooil- 

VMmeln injected 235 

145. Septic myocanlltia with multiple abacemee in the heart wall 338 

His. ['hoIoinicragrapJi Nbuning an abactw* iu the heart niUHcle 3S7 

147. Onhodiaxraphie ouiUnee of the heart of m child during tb* coniw of o Mvere 

diphllieria 230 

14S. SiHvimcn sliowiiig u cardiac uneuriun covered witli pericnrUiol adheiiona 284 

14!*. Chronic myncanliii* (caolioM'leroeijt) 284 

150. I>pecinieiiB nhowiTig chruiiic tnyiieuRlitis 235 

151. Hypertrophy of wome miiKle biindleii in the auricle with atn^y.,(tmniipnrency} 

of other »reiis . - 230 

152. Curvi'ofblaud-prr«urcinacn«enf chronic myocttrditi*; high blood-pr«Biure pcr- 

eiminic until khortlj' Itefore death 237 

153. VariouB typcaof urtcriuBcIerotiolceioiui. (Seliemalic.) 351 

154. Cronmeclinn of a tnilinl nrterj- Nhoving arierioMlcfotie changes in tlie ibe<lia 2(3 


155. ArtericMclerone of the descending aorta, showing atheromatous plaques 253 

156. Atheromatous plaque, showing the changes in the intima 254 

167. Tortuous radial artery 260 

158. Retinal changes in arterioecleroeis '. 260 

150. Effect of arteriosclerosis upon the circulation 261 

160. Blood-pressure chart of case of typical vasomotor crises 271 

161. Blood-pressure chart showing a vascular crisis of the cerebral type 272 

162. Diagram to illustrate the elimination of CO, by the blood in normal and aclerottc 

arteries , 273 

163. Thromboangitis obliterans and endarteritis obliterans 276 

164. Hands and feet of a patient with Raynaud's disease, showing gangrenous ulcers 

and the stumps of amputated toes 277 

165. Effect of hgation of a large coronary artery upon the blood -pressure 2S0 

166. Sclerosis of a coronary' arterj', producing an area of infarction near the apex 282 

167. Distribution of pain in attacks of angina pectoris 286 

168. Distribution of attacks of pain and sensory disturbances in a case of angina 

pectoris 287 

169. Blood-pressure curve showing crises ot hypertension during attacks of angina 

pccloris 388 

170. Fibrinous deposit upon an aortic cusp one hour 'after mechanically injuring the 

val^-e 299 

171. Mitral endocarditis showing large vegetations 300 

172. Injection of chronically inflamed valves 300 

173. Structure of the normal auriculo ventricular valve 301 

174. Photomicrograph of a specimen showing apute and subacute endocarditic lesions 

upon the mitral valve 302 

175. Portals of infection in endocarditis 303 

176. Temperature curve from a case of malignant endocardiiis 305 

177. Temperature curve from a case of simple acute endocaniitis 305 

178. Diagram shotting relative frequency ot the nioat important valvular lesions at 

various ages 312 

170. Diagram shonin^ (lie relative frequency of the various valviilar le.iions in coHes of 

valvular heart disea.'^e 312 

180. Regurgitant streams in organic and functional mitral insufficiencies 322 

181. Diagram showing the volume and prewure curves under these conditions 324 

182. Curve of intraventricular pressure in mitral insufliciency pro<luced on a meclianical 

model 325 

183. Diagram showing the effects of mitral insufficiency upon the circulation 326 

184. Distribution of the murmur in mitral insufficiency 329 

185. Cross section of the bo<ly shotting hott' the murmur reaches the chest wall 330 

186. Radiograph of a patient with miti^l insufficiency, showing horizontal enlarge- 

ment ot the heart to the left 330 

187. Diagram of Fig. 186, showing the directions in tt'luch cardiac enlaigement has 

taken place 331 

188. Graphic records of the heart sounds, showing the systolic murmur 331 

189. Human heart, showing mitral and tricuspid stenosis; vieweil from above; the 

auricles have been cut through 341 

190. Diagram showing the changes in the circulation due to mitral stenosis 343 

191. Volume of the ventricles in eitpcrimental mitral atenosis 344 

192. The variationsin the volume curve of the ventricles in increasing degrees of mitral 

stenosis 344 

193. Direction of the stream entering the left ventricle through the stenotic mitral 

orifice .146 

194. Cardiac outline and distribution of the presystolic nunble in mitral stenosis 347 




196. Il«(ltOf;rapli from u eaan ot iiiitrul sMnoidit, Hhou-ing iiicrraurof Ihp Hhadow due U> 

tlw dilnlcii left iiuriplc 

ItHi. Dij^rani ropmienling the shadowH Hhourn in Pig. I9>S 

197. Uniphio ivconi <■( carotid piitw unil lii^jirl souniU in miCrnl hU'ikuiiii 

I9& Oli^iraBI sbowing thp rrlaliniui of ilic \Dhi)iih nouiiiIh limn] iu imcompiicslrd 
mitral nlvnoniB (oevCTiU in itii- lillin^ uiid pniiit}-iu)t nt itip vrnlriclp. ... 

190. Vnow puluc of II juitimt with mitml i.tcnntai- iluring hii iitlack of acutv hi^iirl 

200. Pormnncnt atrhjrihnun in n ciue of initral glMiosis, slinwinE penixtence of llie 

auricular cnnlractionti (n wnvr) iijHin the vcntiiid piiW 

201. Sjieciintn showiii^c vtv^tations tijioii thi! iiortic vulvn. . 
1IT2. The vnrioiiH fonnn of Iniion producing imrlic inimtficirnry 
20^). EITwt of iLurtio iiiBUltlcipnc.v in Ihe mrchniiical iiiodd. 
2(M. Diiinmm of ihc circuliition in riorlic insiilBpicncy, ..... 

205. DiiHiram nliowiriK liow the hijrh rardinc tonicity hiwlrns (lie c«|iiilibriiiiii iwtwwn 

uorlip pn-mure, inlmventriculur presBun.-, ddiI tonicity, iind ihui. diniiniNhen 
the umoiint of bloiKl rr^rnrgiliiting. 

206. KScct i)t rupturing un iiurtic valvr in a dof, iilioiriug n (mwitory dilaintion 

foMownd hy n pcnuiuiMil diniiiiulion in rite 

307, Ann ot carc!iu« >1uItic«h and diitlribiilinn of the mnliac Boundn mihI uiumiiin in 

norlic irwulTicifiicy , , , . 

'iOH. Rudiocraph o4 a case of sortie inaufficiency, ahowiojt donfatJon of tbe long axi» of 

the hporl ,. 

209. Diaicram of F^. 208, showing the hypertrophy of the left, vmtrirlc 

210. DirMliun of the pt4raary reffntKltanl streams In aortic ineulficii-ncy . . . . 

21 1. Itrlntion of miinnuni in aortic in»ulfici«7ncy lo iJie cimliuc cycle . . 

213. Kuncliooul iniiral sleniwis in aortic iiumifliciency ut> demonot rated un the exciwd 

heart by Bauniiiartcn'ii method . 

2)3. Variations in the funti of tlie pulnc-wsve encountere^l clinically in aortic in«uHi- 
clency - 

214. Tncintpi from a dc« with cxprrimenlal aortic insulGciency. showing tiic con- 

vcnioniif ucuDaiMinginloun luiacnilic pulw bydninpiof: the dnTcndinK aorta 
21i. Radial pulw tracinjwsliowiiytcitranyinolw", probably of ventricular orijrin. 
21B. Specimen Bliuwuie aortic iti^tioiiiii. Viewed from above 

217. Forms of ulrnolic aortic oriliciiii . . . . 

218. Carotid indse and in t raven tricii tar prcesiire In experimental aortic HtenoHis . . 

219. niaKTnm of tlie circuluiioo vbowing the cRcct of aortic Klcnomii 

230. Diagmm iihoH-inK the cnrdiM outline nnd liiiilrihtition of tlip nuiirmtir in aorlie 


221. Murmtir of nortic iitenoM* ....... 

222. Uiagram ahowinit the piiUiu lardti* and the anacrotic iy|M- 
233. PuIm! trncEn^ from ounw of aortic slvnoniii 

224. PinKrani of (he circuliiiion in i>iiliiicmnry iiumfficicnry 

225. Diitribution of the iimnnur in pulnioniiry insiilficiency ... 

236. The outline of n normal tieurt supcriMKcd ii|)on thnt of u diluted hrart, xhovinitlhe 

enlargement of Ihe tricuspid orifiw 

237. Dingmtn iihuwiDg the cbunmw in the circulation In IrlciiBpiil tiiBUfiiciency . . 

238. VcDoiia jniliw oi pHticJil> n-ith tricuipid inaufhcicncy (punitit-e venou* puUr) 

220. VenoUH piilw of anollier (latient 

230. DiMributioii of the niunnur luid cunliae outUue in trietispid influlfitienc}' 

231. CrOBS aection of the boijy, sliowinn the pntlw »f propn^ition of tlie miimiiir of 

tricu*pKl inaiifficieiicy 

332. TrMnnga of liver pukation — • 

333. Syatolio pulsation of ihe Hvw of patient W. H 

















234. Diagram showing the eh&Dges in the circulation in tricuspid stenosis 40S 

235. Cardiac outline and diatribution of the presyetolic rumble and snappini; first 

sound in tricuspid stenods 409 

236. Very early stage in the development of the human circulatory syBtem 421 

237. Human embryo 4 mm. long 422 

238. Heart of an embryo 4 mm. long slightly older thau that shown in Fig. 237, show- 

ing the earliest stages in the formation of two auricular and two ventricular 
pouches 423 

239. A diagram showing the interior of this heart 423 

240. Development of the arterial system from out of the primitive aortic arches 423 

241. Heart of slightly older embryo, showing separation of aortic and pulmonary- 

channels in truncus arterioeus 424 

242. Still later stage, showing the complete division of the truncus arteriosus into 

pulmonary artery and aorta 425 

243. Auricular end of the same heart 425 

244. Development of the pericardial cavity 426 

245. The circulation in the fcetus just before birth 428 

246. Pulmonary stenoeia due to fusion of the cuape 431 

247. Pulmonary stenosis due to a lesion of the infundibulum 431 

248- Complete pulmonary atresia 431 

240. Scliema illustrating the genesis of pulmonary stenosis 432 

250. Currents and lines of force in the embryonic heart which result from pulmonary 

stenosis and tend to produce patency of the septa and of the ductus 

arterioeus 434 

2£1. Three-chambered heart (cor biatriatum triloculare) produced by complete 

atresia of the pulmonary and tricuspid orifices 435 

252. Diagram of the circulation in pulmonary stenoais and atresia 436 

253. Dilatation and irregularity of the retinal vessels 439 

254. Clubbed fingera 439 

255. Distribution of the pulmonary systolic murmur of pulmonary stenosis 440 

256. Direction of blood-streams and propagation of murmurs accompanying defect in 

the interventricular septum, pulmonary stenosis, and open ductus arterioAUH. . 440 

257. Distribution and character of the murmur due to a patent interventricular 

septum (Roger's murmur) 444 

258. Open foramen ovale 446 

259. Diagram showing a cross section of the same 446 

260. Openings between strands of muscle in the intcrauricular septum 447 

261 . Radiograph of a thirteen year old boy with patent ductus arteriosus and aneuris- 

mal dilatation of the ductus and pulmonary artery 451 

262. Stenosis of the isthmus of tlie aorta above the ductus arteriosus, type of the 

new-bom 453 

283. Stenosie below the ductus arteriosus, adult type 454 

264. Transposition of the viscera in embryo and adult 456 

265. Transposition of the valves 457 

266. Pulmonary artery with four cusps 457 

267. Tracing of the apex beat in a case of Adams-titokes disease 461 

268. Partial heart-block (3 : 1 rhythm) produced by pressure upon the vagus in a 

patient with disturbed conductivity who was also subject to attacks of the 
Adams-Stokes syndrome 462 

269. The right branch of tlie auriculo ventricular bundle in the dog's heart 463 

270. Tracings from the carotid artery and the jugular vein of a patient with Adoms- 

Stokes disease 464 

271. The Erianger heart-block clamp compressing the auriculo ventricular bundle 465 

272. Effect of gradually tightening the clamp 4S5 


273. Tracing from jugular vein and carotid artery in a caM of complete heart-block 

after the syncopal attacks had subsided 487 

274. Diagram representing the conditions found in the tracing Fig. 273 468 

275. Heart of a patient showing calcifications which produced Adams-Stokes disease . . 469 

276. Diagram showing the two types of ventricular stoppage producing the Adams- 

Stokes syndrome 470 

277. Section of a luetic infiltration of the auriculoventricular bundle 470 

278. Acute fibrinous pericarditis 482 

279. Tuberculous pericarditis (cor villceum) 482 

280. Diagram showing the relations of the pericardial and pleural frictions to tbe 

cardiac and respiratory movements 484 

281. The circulation in cases with pericardial effusion 488 

282. Area of cardiac duiness from pericardial effusion 480 

283. Positions of the heart in pericarditis with effusion 491 

284. Radiograph of a patient with pericardial effusion 492 

285. Sites for paracentesis pericardii and pericardiotomy 496 

286. Specimen showing the two layers of pericardium united in some parts by long 

strands and in others by short bands of dense adhesions 500 

387. Sections showing adherent pericardium 501 

288. Anterior and posterior pericardial adhesions (Semi-schematic) 502 

289. Cardiac outline in adherent pericardium 505 

290. Adhesions causing inspiratory and expiratory dropping of beats (Ridel's pulse 

and the pulsus paradoxus) 506 

291. Radiograph of a case of adherent pericardium 507 

292. Case of pericarditic pseudocirrbosis 509 

293. Wounda of the left ventricle 514 

294. Exposure of the heart for suturing a wound 5lfl 

295. Specimen of a large aneurism 521 

296. Aneurism arising just above a sinus of Valsalva 524 

297. Aneurism of the ascending arch and innominate artery 524 

298. Aneurism of '.he transverse portioA of the aortic arch penetrating through the 

sternum ...» 524 

290. Aneurism of the descending aorta eroding the vertebrte 524 

300. Sections through the wall of an aneurism 525 

301. Composite figure showing the relations of various aneurisms to surrounding 

structures 528 

302. Tracings of the outlines o^ an aneurism of the innominate artery, showing its 

growth and the fonnation of secondary prominences upon its surface 529 

303. Method of inspecting for pulsations 532 

304. Effect upon the circulation of interposing an inelastic and an elastic bulb along 

the course of an artery in a model of the circulation 534 

305. Effect of aneurisms at various sites upon the blood-prcssurc, rate of transmiseton, 

and the form of the puise-wavc 536 

306. Radial pulse tracings from the right and left radial arteries of a patient with 

aneurism of the first part o( the arch of the aorta 535 

307. Radiograph of a patient with a large aneurism of the ascending aorta and the 

arch, viewed from behind 536 

308. Radiograph of a patient with diffuse dilatation of the arch of the aorta 537 

309. Diagram of the radiograph shown in Fig. 308 537 

310. Cardiac duiness in cases of aneurism 540 

311. Area of cardiac duiness in a patient with dilated arch of the aorta 543 

312. Tumor and pulsation in a case of aneurism of the abdominal aorta 545 

313. Tortuous subclavian artery, simulating a small aneurism 546 

314. Dissecting aneurisms 547 


315. Diagram ghowing the various methoda for the operative treatment of aneurism. . 553 

316. Specimen of wired abdominal aneurism, showing an island of clot within the coils 

of wire surrounded by a free blood channel 554 

317. Venous pulse in a case of paroTysm&l tachycardia 5fil 

31S. Diagram showing the various typee of tachycardia 562 

319. Experimental paroxysm of tachycardia produced by faradisation of the dog's 

auricle 563 

320. Diagram showing the effect of a paroxysm of tachycardia upon the circulation. . . . 665 

321. Phott^raph of a patient with Basedow's disease 57^ 

322. Fhott^raph of a portion of the thyroid gland removed from the patient shown 

in Fig. 321 577 

323. Drawing of a histolc^cal specimen from the same thyroid 57R 

324. Diagram showing the relation of tile various anatomical structures concerned in 

the production of the ocular and cardiac manifestations of Basedow's disease. . 584 

325. Respiratory arrhythmia in a young cigarette smoker 594 

326. Cross section of the thorax of a Rat-chested individual, showing the systolic 

heaving of the chest wall and the forces bringing it about 596 

327. Low, normal, and high hearts, (Semi-schematic.) 598 

328. Radiograph of a patient with dropping heart (bathycardia) , , 59B 

329. Photograph of a patient with enteroptoeis 602 


Old TcnnmoLogy. 


Auriculoventricular groove. . , 

Interventricular aeptum 

HuBCular septiun . . . '. 

HembnuiouB septum 


Auricular appeodii 

InterauricuUr septum 

Columiue cameK 

AnnuluB ovalis 

Coronary sulcus 

Septum of ventricles. 




Septum of atria . . . 

Fleshy cords 

Ed^ of oval fossa . 

Intervenous tubercle of Lower 
Eustachian valve 

Valve of Thebesius; coronary 

Faramina Thebeaii 

Tricuspid valve {right auri- 
culoventricular valve) 

Infundibular cusp 

Mai;ginBl cusp 

Septal cusp 

Left auriculoventricular valve 

Corpora Arantii 

DurtuB arteriosus (Botalli) . . . 

Auriculoventricular bundle 
(Kent, His) 

Valve of inferior vena cava. 
Value of coronary sinus. . . . 

Foramina of the smallest 

Tricuspid valve. 

Anterior cusp 

Posterior cusp 

Medial cusp 

Bicuspid or mitral valve . . . . 

Nodules of the semilunar 

Arterial duct 

Atrioventricular bundle (His) 

Sulcus coronariua. 
Septum ventriculorum. 
Septum musculare. 
Septum membranaceum. 
Septum atriorum. 
Trabeculae cameae. 

limbus fossae ovalis (Vieus- 


Tuberculum intervenosum 

Valvula venae cavae (infe- 

rioris, Eustachii). 

Valvula sinus coronarii (The- 


Foramina venarum minim- 
arum (Thebesii). 

Valvula tricuspidalis. 

Cuspis anterior. 
Cuspis posterior. 
Cuspis medialis. 

Valvula bicuspidalis (mi- 


Noduli valvularum eemilu- 

Ductus arteriosus (Botalli). 

Fasciculus atrioventricu- 


'Quoted from Barker, L. F., Anatomical Terminology, with special reference to the 

The Basle Anatomical Nomenclature (BNA) is the terminology adopted by an inter- 
national convention of anatomists at Bssle in 1895. for the purpose of securing uniformity 
of terminology. As it has not yet supplanted the old terminology in clinical usafte, 
the latter is adhered to in this book, though the BNA terms are frequently given in 

Fin. S. — ReUlioni ol Iht lin»rl in.i k"-: ■ ■'■■, ■ !•■■.' '4 (r,,::j it:.- (nmt. S F C, niiienor vm* 
ova: R A, ngbl auricle untlumj; L V, Ml vHiUicla; It I , righi rpntnclr: f .1. imlmonur iiruvy; 

Via. A. — Tti* heart >■»! lliamde vUcif* vinnd 
frotabaUn'!. Th> liinci have Ixca cut ■■ay. I. A, 
ltd auiioU i L V, l>(t vcolridr. 

VlO.5. — t^aaillal HTljan ol <li« iborax tiirrtd 
trcm llx (Iflit. AZ.. imi auwM vain : POST. 
UKDIAST., pnMnriar intOiailiuuu : .4.Vr£A. 
llSDtAi*r.. aBt^iieii tnr'lin>liiiiiui^ It A, ciitht 
■un*l«; /'//AKA'. nsbt plitniieiisrvr. 







i-itoi-EitTiEK OF hi:akt MfBCU:. 

The heart is coniposerl of striiitcd imiscltf-fibrcs which differ anstomi- 
cally from thu skclotnl mu»:lr« in lieitig alDiost devoid of connective- tissue 
sheuthd uid from nio^t of thv skHctoI mtiitdcs' in the fnct that they una»- 
tomoee frocly with one another, forming a contiiiuous meshwork of muscle 


Fm.A.— HwrlDuMl^AirH. xZJi. (AtMt Pianul.) 

tissue (KiRH. G and 7). FhysioloRicotly b<>art, musele difFera from skeletal 
Imuflcle. for (]) it is continually undergoinjB; rhythmic contxnctionH, and 

(2), as Bowditch has shown, every contraction is maximal. 

A great deal of jierspicHity has been added, esiicciaily t« the clinical 
Ivtudyof the vardinc function, by discriminating between inftuencea which 

affect iho cardinal properties of the cardiac muscle (Kngrlmann). One 

rveogoiioa thowc which affect (1} rhythniicity (chronotropic tn- 

' Tlitr tOQKuc of (ho fro){ and Mnut oUmc (otiiu of niuacle aoiucnliat rvauublo h«Mt 
mtiaole la «tru«iiuv. 



fluencBB); (2) irritatility (bathmotropic); (3) conductivity 
(dromotropic) ; (4) contractility (inotropic), aa well as (5) 
tonicity (.MnckciiKie). 

InRuenccs improving the*»c propftrties are designated aa positive, 
tkoae which depress them as negative. 

Elulnthrtlllin , 

Subcii'lnth^ii] - 

tajBi tfrli ill 
DMpwi Uyw - 

Fm. T^^eotlon thraush iha cnijonnliuiD ■bowiuc cron-ttKliva at llie maid^abiM. IKtXmi FimmIJ 


R6le of the Salts. — Merunowici, under Ludwig'a direction, demon- 
strated that the rhythmicity of the heart depended not only upon iia 
intrinsic characteristics but particularly upon the action of the inorganic 
Baits present in the blood serum. Ringer (1882), and later Howell, showed 
that the untagutiistic actions of potiuwiuni and calcium salts were the 
factors chiefly concerned in determininf; the rhythm of the heart, while 
Loci) and bis pupil, Lioglc, showed that without the Rodiuin salts it 
would not beat at all. Accordingly, as Loeb and Howell agree, the heart- 
beat can be maintained only when these three salts or their ions are 
present in certain delinite proportions, or in what T.ocb hits termed "a 
balanced solution." However, while RinRer and Howell 
believe that the calcium liberates the motive power ol 
the cardiac contraction, Loeb and bis pupils believe^ 
that this is done by the aodium and that the calcium and 
potassium merely keep the sodium from liberating too much. 

Their mode of action has been explained by Loeb in 1S99 in t)ie 
following words; 

" The ralM or dectrolj^Us in gt^nvral do nut enbit In living liiwuBi aa such ticliuivclyi 
but arr in cnmhjnation with j>mUdd> (or falty acicU). The uilU or rlcclrolytM i ~ 
out «iit«r Into this combiiiutlon a» a. whola, but tbraiiKb ihoir ioiu. The icrvat Linpoiw ' 
laxux of UiMC ioii-prutcid ruiDbinuliiiTUs (or ao«p«) liea in tlw fftct thnt by substitution of 
one ion for nnothnr, thn phynicAl propcKic* of the protcid cbangc {,t^., Ihtdr Riirfnca tei>-J 
■ion, thoir powur to absorb w»i«r or tlirir viflcosily nr «t4it« of nmtler). We thua puim« 
in th«c ion-prolcid or soap conipotiixtii uwi-Dtiul ruikslit tiiMita ot living mntlcr. which can 
be nioditir<l al doircnnd jic^rirnon.iltli? ui to vnry and control tbn life phrnoTncnn Ibfisiodmn. 
''Lil» plieiioin«na, and especially irritability, depend upon 
the |ir«»encc in tlic titnuea of a number of tbe rariou* metal pro- 
teids, or eo*pa (Xn, Cs, K. and Mtt) in definite proporiionv. . . . 
SolutioDt oi iittwlu produce rhyihnucal oootractUiiis only If Uie musclu cclh contain 



Oit-iana in mfGcient numbcrn. An mmr an them in n lack of Ca-ion* in the tLwiics Iho Na- 
ions an no lonpr aUe to cauw rhythmical ooniractioiui. On ilie otiior liiinj, if we add 
Cnpaklta in mBidcnl <iiuuatity to (liv .\nCI soluiiiMi, ii will no tuoger caum rhylltmical Mm* 
tractions in tbn (rvah munctr or Ibc froR. , . . It t« hnrdly nccewnry t« mrniinn that 
Ihiit augi^tcd the )>08dl)ility IImI mu^iikr contraelion In (wncral u due to a sulBti:utioa 
of Na for Co, or sict iw«a, in certain nttnpoundi (prolcinii or auupij in Ibu muaelu." 

The hypotl)P8ii< thnt tho main ptiysiolo^'cal antagonism lies between 
K and Ca is slated by Ilowell in the following words: 

" Tbe well-nourishod IiMrt contains a large supply of coet^y-yielditig material wliiofa 
ii in a atable form, no tlutt it neither diiBOciat«« •pDntancoiuily nor con be made to do ao 
by the action of rxlcmal itimuli. It in pouihb that this atable, oon<dJiMOCiabl* form OOD* 
nsU uf a oofiibination betvcfi) it and th« potamiuio or the polawdum aalte, aoil tba'« 
therein lie* Ibc fuactiuii;il iuiijortanci! of tbe pottwaium cootMned in the lia«ue. TbiN 
compound reacts n-ich the ralcium or with the ciiicium and lodium nalts and a portion of 
the potttMlum ia replaced: an>l n compound [a formei,l which U uustable. At the end of 
line diaMotio pcrinil thii oumpound rcucbes u oomlitiun of inilability mch that it diaco- 
ciates spontsnco«iiily. tci^'intt ''i"c to tbe chain of event* that culminates in the normal 
syitolc. Uefore apuntaneuUB diHM>ciation occuni it iimy tw husteiiiiil by an external stimu- 
hia, aa wa know in tho cune wbeu a niechanical or elcotricol <hock ii applied to the heart at 
say time after diastole Ixipns." 

Any aioRle ion or sail is poisonous by itself, but in the presence of 
certain others Hiay be beneficial. This vi^ry interesting qtie^itiun of "bal- 
anced ion solutions" has been extensively investigated by Loeb and 
bis pupils, not only upon heart but upon skeletal muscle and upon lower 
medusa;, molluscs, and fishes. 

Even the mammalian heart can be readily revived and 
kept treating outside tho body if perfused with a solution containing these 
•ubstancce together with eodium bicarbonate (Howell) and saturated with 
oxygen (Locke's wilution,— NaCl 0.9 per cent. + CaCI, 0.024 per cent. + 
KCI 0.42 + NaBCO, O.OI to 0.0.1 + 
dextroveU.l percent.)- Itis necessary 
to maintain the blood -pressure at 50^- 
100 mm. Hg. and also ihc t^jmpcra- 
ture 36' to 37". Kuliabko and others 
Uave revived excised human hearts 
many hours after death. Fibrillary 
eontractions occasionally set in, but 
may be stopped by perfusing with 
KCI 1.0 per cent, for a few minutes 
instead of Ijockc's solution. The 
heart then conies to a stand-still 
and resumes beating under Lovke's 

Fia, B.— A[Ji»f»iu» for p<ir(uiiliig ihf msmma- 
lian html. A. iturirU; V, vmlridc: TAMH,, 
tAinhoiir; T//.. Uanrmometfr; MA?fm, <DUioiii«t«r- 
GASCII. tM eh«ki Ot, Uuk ot oxy^ta. 

The Study of the excised heart haa been very useful both in testing 
the elTect of drugs and in simulating conditions of disease; but the condi- 
tiiiQB of circulation are not exactly comparable to those within tho animal, 
ami the re^iilUi .■<huul<l always be carefully checked upon tho intact animal 
before assuming them to bo normal or drawing any cuncliuions as to 
pbarniacolof^cal aetJon. 

Myogenic and Neurogenic Theories. — Whether the salts or ions which 
maintain the rliythmicity of the heart*beat do so by acting directly ujwa 


the muacle tissue (myofrcnic), or whether the stimuli are first fiietierated 
in uervv tissue {neurogenic) and then traiwmitlefl to the niusi-le, is « 
question which hiis been disputed for centuries. And though the iM-ndulum 
hM rci>eate(lly 8wun||; from one opinion to the other, this question c&nnnt 
at present be anHWPrccl. It l» quit/- L-ortnin ihul all the extrinsic cardiac 
nen'es can lie removed without stopping the rhythmic contractions, nml 
tbut the ganglion celU may \k stimulated without materially alTccting the 
rhjthm ((iaskell). Rut the meshwork of muscle-fibres in the heart is bo 
p^mcatcd by a meshwork of fine nerve-fibres that it has been imposHJblo 
to determine whether the impulse arisen in the muscle-cells or in the nerve 
endinfo^ upon their surfaces. Wni. His, -Ir., huji inileol sliown that the 
heart of the chick embryo bents before ncrve-fibrcs have entered it at fill, 
but the possilnlity still remains that after once entering the heart rhe 
ncr%'ee may take the initiution of contraction away from the adult hearts 
muscle. Moreover, the recent experimenis of Carbon and of Alagnus in 
allied ficMs give considerable evidenc*- tliat sueh may be the ease; so that, 
in spite of its importance for Iwth the physiology and the pathology- of the 
heart, neither the inj-ogenic nor the neuwgenic theory of the hearl-lK-al 
has been finally proved. 

Maximal Contractions and Irritabilily. — As tlowditrh has shown, the 
heart Ulwrutes all it-'s iivailablc energy at each con tract inn. which resembles 
in this way the explosion of gunpowder or the liberation of a spring by a 
trigger. Like the power of the epring. the strength of the ciirdide contrac- 
tion de|)ends upon the energy stored up. This energ_v seems to depend 
upon the regeneration of the eonlriictilc i^ulistance mentioned above by 
Howell. When the next contraction, normal or abnormal (ex tr asystole), 
occurs soon after the la«t (early in diastole), the contraction is weaker than 
the prcceflinE, since it lilierates less energy, but the contractile substance 
is again completely destroyed an<l require* iinotlier pause (compensatory 
pauae , see page 09) to regenerate it. When it occurs late, the contrac- 
tion is of alnio;<t or quite original sti-ength, and the slored-upcnergj- U again 
liberated completely. Moreover, Krlanger has shown that the irritabiUtyof 
the heart inerea.seK progre-s-tively as diastole is prolongfnl and as the musch 
becomeii overloaded with the energj'-producing substance, 


The sinus as "Pace-maker" of the Heart. — In the frog, where the 
cardiac impulse travels slowly, it is very easy to sec that it arises at the 
sinus vcnoaus, whieli executes a contraction. This is followed by ronirac- 
liou of the auricle, the latter after an appreciable interval by a visible con- 
traction of the small ring of muscle about the auriculoventricular ring 
(Bond), and this in turn by rontrtiction of the vi-ntrielcs. 

It is probable that the sinus initiates the cardiac rhythm, because it 
is the chamber which, when isolated, beats at the fastest rhythm m the 
blood-«erum. and hence it becomes what Krlanger terms "the paee-makcr 
of the heart." ' Indeed, if the impulse from the sinus is blocked by crushing 

' Uixler patholoiEicsI conHitions and Mped»11y in the oxcisod heart the ventricle nrnj 
becotoe more irritaUe and maj' bcMnni: tbo paco-maker (rervncd ritythm). 


or by cooling the fflno^uricular border, the impulsea no Ioiig>T reach the 
auricles, which must tht-n conlrdct by their own slower rhythm or not boat 
at hII (niim-fturiciilar heart-block), 

AnAtomy of the Sinus Region in Mammals. — In niun and other mam- 
nalv llio simiH no longer exists m u separate ehambor, thou);h in the earty 
Fe[nbr}'o(FiK. 24:t, pa^o 125) its hamolopie, the mnuK rt>unit-iit<, i.-^ si-paratetl 
off from the rest of the auriculnr cavity by the KuHtschian valve. This 
aintM chamber receives the two vena; cava* and the coronary itinuK. In 
the course of developnu-iit the growlh of the fiinus ref^ion doca not keep 
pacv with that of the auricle, and it becomes swallowed up in the lattvr, 
HO that in the adult the sinua corresponds ruughly 
to the area bound e4l by the muuthH of the two venae 
eavae, the coronary sinua, and the interauricular 

PulmDnarr aolU or ulMy 

Ki«1ii miiHrl*. eonu* 


Kiwiachiui vBlva 

\ \ 

|>viitT<uinIi (vn-ivinjl Tla*ti#Bikla 1«ilm 

F>e. •.— Tlw BWltolu «n<l at ili« huauu liwrt vlcvaj Innn ib« debt. (Afur riBnod.) 

Comparatively little is known conceniiiig the structure of thi» impor> 
tanl region. The most careful «tudie« (Keith, Ketzer, SchOnbcrg) arc con- 
cerned morn with the structuro of ihe veno-auricular junction or the aino- 
ventricular connections than with the structure of the sinus as a whole, 
or the sinu-auricular bonier which is included within the hotly of the 
right auricle. 

The Vcno-tiuricalar Janclion.— iScliAcilwrc studk'il the miu-nuricular junction in a 
larf^c number oi Dormiil and .iliiiomul human hrnitu by nionnn i>( wrinl nation*, cueli «efies 
bcintc cnmiMwml of a(X> to WXl wciions. At a Icivl 10 li> 15 mm. nbot'c Ihc ciHrancw o( tlip 
Biipniur vcii« cuv» iiilo Ihp aurick- Utriuui) lie found llic u»uul iltuclun.- of vein wall. 
Bdftw ihu level IW nmlin » Councl lo conCnin icroiipa of ii1rin[«>,l munrlc-libns ivpamUHl 
fnioi Mie anolher by fat auil coniiectivc tissue, tiinav striutMl luuscli^^ibfCB arieo in Ihe 



vicinity of non-fttrialed Gbree but sre never ooncinuouB with ttwtn. Bundlw at iht 
fibres ) to I nini. in diiuncter run tnuutrenwi.v ncnuB thd vein tunnrd tbe nuricli'. gnuluallx 
convnrging into largpc biindlm, which are «ep3rjli»i ftflnu imip annlbpr i>y n liuiic rirb in 
lymph- uuti blood- vctacls. In tlie uni^le (huIcubI rurmi'il lM!l«««n the mirirle (atriuni) and 
VDnu cava Ibcae banila of xlrintiyl muitolc bccrawr nitich Ibitinpr uiid conlnin tiiitncmiin 
torluoilH fibres nswnibliiiK Piirkinje fibrw. In I.lil« rvgion rherr in n roniililprnble ilofovit of 
ful, lyni]>huid luid cuiuicctivi! liuiic. fonuJiig a tiiuiv or lest delinite horde r-tiiii*. I1u^ 
iniwclo-fibit'ii of Ihc auricle (nlrium) an; Insritcd in the connncliv« titouc hcrr. T h « 
connection between the muscula I u re of Ibe vena cava and (hat 
of the aurie1« in made bj- th« numeri>Uii mnall bundira of nlrinted 
m UHcl n-f i b roa lyiOK jlut beneath the endocardium, nluch pnM> arrrmK l.liiH junc- 
tion and end in the itbrw of uurieulur muscle. '"In the niacroecojiic prepa- 
fationc it in almnut nlwayi readily ii««ii that the *uleuaia 
bridiced at ils posterior lateral third by a tnii«cle-hiindle wliicli 
nNCendii upnnrdii Htid buckwards from the uuriele (atrium) lu the 
nupnrior vena cava, whttro it >« at rengt bencd by fibrca from t ho 

FtO^ 10.^ The 4taut ntton of the h«ftrL llivvmoAur^oulAr <ir VMIO-rtnal liuiiU^ »f xif^afnT nititH^ 
and til* aurrrutaiAiriuI'Vtatrifrular or Kitu-vmilriculur uiu«ulr buiidla. CSfihitiuTii-. r<inp-Tnif<iMl fmm tliv 
fitidinc* uf Knth» hriUHib*rc and R«lw,) A, fU«ii Irvtn ttw riflhl •4fT«, Th« riot(«l uvm rv|>rr«cii1« 
ilie •Iniu nttiin ; ili« niriir rvpiFaHit Ihi Vfcio-auricular mUH'lr itnindi. V.CtS., mpninr v«ia oaiaj 
y.C.I.. infrt'oi i-riiB An: Sf. coidquf)' •inut: AVO„ iutiFulu(fttHa)v«ntriin]Ur inufeln bunilli 
<Hii>huiiilla); TBIC, tricii>pid ralve; t'Af. pkiiillwy louwlc B. Thp nnir rtgion wMi Iron the front. 
SI I T. milnl vslv*; A O, iiDrta. 

circular musculature of lh« lower iiurt of the vein. Thin bundle 
ia alnu well neen inicftncopically, but mimeruus otiier .imuHer inimclo biindlos atv «ccn u« 
well. Il co(ttw|>ondii quite well wilb thnt domlird hy Ucith nnd Flack, and Wenckebach. 
8cli4nl)ert[ found ihai ilw reeion ut llie sulcus Im ).iiirtlciiturl\' rich in Derve-6brcB, 
ganglion cclln. blood- vrssels. and lympliuid (iBsue, and iit tbHcfore particularly liable to 
pathological iiifiltralioni and cicatriinlion*. 

rt iii woithy of note tliat tiip iiulcuit noted by SohOiilx-rir docs not n-pix'- 
scnt thv ifiiiu-iiunruliir junction but tlii.- vcnu-Mnnl jitnction. The Btranda 
of Htriated muiitrlr wlucb b« deacribcs are lierivod from ihc Binu!<. Thfl sinij- 
Huriculftr (.'<iiiii-atHul) junction on Uw oiIkt hand is ai-tually mtuated within 
the body of thi- aurick- (alriuni). 

RMe of Ihc Sinus In Mammals.— There is a conKidfrnblc amount of 
phyniolufiical as wvU a^ anatotukal i-vidoncp tbat in the adult mammal 
&B utII as in tbe amphibian tbiii id the iv-^on in ^s'lli('h tlio i;ni'dinc 
impuliM' un«-s. 


MftcWilliam in l$88 vrae ab1« to nbow ihnt ttiis in ttrrvtiiouB 
area was the only ro^iou n I which the Applimtion of hcnt 
tquiekrned and cold nlowcd tho hrnri r n C f. At)»in nnd t)i0 wriKr 
[ Here nbln to confinn ihis obtcrnition. H. £. Ilvriii;; lias aliuwii tliut this una U 
(rflMi lliP bfl lu crow cuiilnu'lion iii (l>iiie maounnlinn and hum.iii hmrtu, itioiiRh this » 
Dot itlwa>> the ciwr illirMhfddcr aixl I'lyiitcr). LaOKendofIT aikI L^hmatin uiid aJiM Leon 
Fnrderic*) slioweil thai evvu iu (lie cxcis«<<l heart jmrliuiu of Ibi- iiurictni cut off fmm thoii 
area (yrniml to hrat or beat at n iJoir ifaylhm, nhilc ihc^ which rpmaincd ftlUMrhMl to tite 
viii'ifL ivsfiuii Ix^ul H( uboul ibo biiititiul rut«. Erlnnjin' u.iul BliLCkiniuui were able tu {iroducv 
hnh-ins of ihc hwirt rate (niiu-Buricutiit block?) Iiy tomion of (hi* awa in the oxdiwtl heart, 
bill like nirwhfrldcr anil TCyntcr went iiiiabl«i tn prodiic* it by cUiiipliiu «xperinien(jt 
upuD tlic^ lu^iirt in eilu Ttic mcol (xincluaivi; cxperiincolii dfe iIhhic of LnhDUUUi who 
poi«mc<l the cp!U in lhi» iirvn by tiinvX nppticutiun of collnn ionkrci in formiUin, and 
fouiiil ihnt Ihc heart at once >lowc<l, aiiriclcH no longer (oilowpii ventricles. liiiJ the auriclw 
ond vnitridw b«ut BiuultaiMNWiBly luoiial ihyituii. see piif v 76). 

Course of the Impulse after Leaving the Sinus. ^ From the riniis 
region the ciiniinc iniimi.w Inivols to thr- wiilU of tliL- iiuritlfs aiid givca 
riee to the auricuUr contraction. It is aim propagated downward toward 
tho vnntricte^, which it reaches about one-iifth of a second lat^r. 

It L» a moDliy! pojnt at preMtnt whether the path from ribue lo ^■ontricle Is throu^ 
AuricuUr tiMue or whctliFT there ia u direct Kiiio-\eiitriculiir pathway, ua believed by 
Rflxer, who thinks thut the nitriclc in oR on a Mile palJi and contract* fiist meicly 
berjUM! It b BMnr to ibe uiuw than is tbo vsntriclc. nowevor. Bond's obwrralioiu 
on ihc rroR. nlwiinD!; thai lh« auricle CMilmots a ooasiilemble time before the inu»> 
ciiluluro of ihc aiiTiciilovcntricuhir ring, indieatcn that the impuW i>aMcs from Uw 
fonnrer l« the httter. 

Kent, His, Relzcr, Braeunig, Keith, and Tawam have shown that the 
cardiac inipulM- b prop»giiU-d from anrirlo,-* lo vcniriclc.-* ihroitgh lh« system 
of Purkinjc fibivs, which forms a i whose Hhafl arises in the right auricle 
at or near the .iIiium, rtin.« in the mentbranou^ .tepliim (aurirulovi-nlrieular 
bundle) tlownward to tho muscle .-w-pt urn, whore it divides into two branclica 
which straddle tho muscular septum and then pas-s to the right and left 
Ventricles, Within these chambers the branches) divide into numerous 
. raniificatiooti which lie just beneath the endocardium and pass downward 
as a nicahwork of lighl-eolon-d Iran^hicent strtinds tu the papiUarj- mu.-scles 
and walls of the ventricles. Occasionally instead of following the walls 
tliey cross the ventricuinr cavity to the papiUarj' mwRcIe as isolated tttraiuU 
{moderator bands, T. W. King, Tuwunil. In this bundle also the 
prfr^'iiee of numerous nerve-fibres (Tawara) and of ganglion cells ((lordon 
Wilson) renders it doubtful whi-lher the iiiipulsi' travels through nerve or 
tnuacle. The slow time of transmission is a little in favor of the latter. 


f Under all cirrumstancei^ (except those mcnlioni^ on page 67) the 
contractions of both auricles and of both ventricles arc absolutely synchro- 
nous. Barker and Hirschfeldor have ithowu that simultaneous coniraelions 
ot the two ventricles continue after the branch of the conduction system 
to one (the left ventricle) has been cut, and hence the coordination doea 
not depend upon the uuriculoventriculur conduction system but upon the 
ventricular muaculature. 



Anatomy of the Venlricular Muscle. — This ]» not Kurpriining, since, tut 
Ltiilwij!, Krohl, and .1. B. Ma<'('alliim have shown, each strand of muerle- 
fibrw passes from vcntrii-ic to vciitrieU-, Tht*so miiscle-rihren are arranged 
in thife (iislinct layers so plaeeti that they arc wound up like a scroll, the 
most suiK-rficial layer of th(? U'ft vcntricht penetrating to become the (lcc-pc«t 
layer of the rifiht (Fip. II, I, II. Ill), Bcaldes these MacCalhim haa de- 
i*cribed a fourth band of niuwele, iiidepcndpnt of thn latter, which sur- 
rounds both the aortic and mitral oniices in n single ring of muscle (mitro- 
aortic ring), ncrows whieh a septum of connective tisHue separates the 
aortic orifice from the mitral ring (Fig. 11, V). This hand is more or less 
homologotL» to the biilbus arteriosus of the lower vertebrates, and plays 
a most important rdlc in preventing leakn at the valvular orifices. 

Pro. II. — Arrmanninii of vanirttulir inu»lt-hbr«. (Attci MiiLf'ulliuu.t I anil 11. lupcrnvliit 
febfwtif (beldt vaKrldoud nuiu* lUiariiwiii : III. dntp Uyan u( il:<- li'fr -..'iiTriel*; tV, rinv "' uiuicl* 
nbOQt Uie ftortje ami milnl <irt/i<vv; V. (litmriiih H 'p r fm ^ littti Ihmr r^Jurnkn- t-AV, milrml qrififr: 
RAV, Uiempi'l arifier: P.* . piilmriniii) i"'!")' : ^O. mrui; CI/', imiirllm. imi-i-lc: AVB. mricain' 

SUioJvvttirioulAT biiDilLe; AUKTIi\ r\at uf uii««la-fibr^ «urrtiuniliiig bfjtli iLr Dikriic awl mjtrftt vnfice* 
■ItnMwnic rina). 


The Presphysmic Period.— The instant before the beginning of ven- 
tricular »y!iuilc the mitral and tricuipid valves arc open, while the aortic 
and pulmonic valves are closed. When the ventricular contraction begins, 
it at once* the preswure within the vetitriclcj* above that in the auricles, 
causing the mitral and tricuspid valves to close with a snap. There is thus 
a short interval, the presphygmic (.07-.09 see.), at Iho very beginning of 
systole, during which all four valves arc closed and movement of blood 
ceases in all four chambers. This perimi lasts until the prc-tsure within 
the ventricle:* riws above the arterial pressures (minimal pressure), after 
which the blood is driven out during the rest of systole. 



the Ttolridfa. VA lllttOM .. rtriiioiuttct. 

Meihod of RKordins the Volume Curve.— Y^ikIpII Hencicnnn hu reeonled tlui 
ifiii[i[yiiii: njiJ tiltiiiK of tlie voiilriclcM !<>' nicikua of n fpociftji.v cuiutruclwl vitnline i^ttiy*- 
rooRniph ur cardioriieitT like tliul cf Tip-ralwil and Jolmnnxoii. iltnilcraoii'fl canlioinnlrr 
HWi made- (ntiii un ordinary nibtxr bnil, out of which b \atjse iiindow wan cut luid then 
closnl lieniLi^ticall)' by coiiieiitiriK on a cur- 

(lUD of rublxT lloill. III tllC CCQlTf of thi^ 

rubber dum a hole wb« ciiI JiihI larjir cnoiijili 

torit lofilair-liglil in tlii-aiiriculoventrituliir 

ipoovc. The licnrt was ihrn pii«h«l in 

thmugfa the holt until ihi- rlam (.lipjied into 

thegnove. The cliiuiRw "f im'iwiirt? wifhiii 

tbosirtpociri^iirroiiniiinit thr hrarl. wrn'tMiiii- 

unnutBtiMl tu a nioonlin^ tuiibour thruu^li 

■ glsMi liibr rnnriilnl in (he o|>paaiii; iiirfaci! 

of the hall {Fig. I'J). Dr. C«ni«con and the 

■Tii^rhavt- fouud il inwit coiivKoieat toliavtt 

(he nconlitiK tnnibciur iiivprtnl, m that ii|i»lrok<!S record tiyalnic and dnwii- 

fiTokes (liaHlule. white a |;eiicral rlee in Iha rarve indicates 

diminution in volume, nnd a general fall iadieatea dilatation. 

Outflow during Systole— By thia means Hfinknton has found that 
during sy.-tolf ihi- viiiliirlo)' <!<» not empty thpni[<(-lvi>s with m rush «t tht? 
, bc^uniiif: of eyiitok-, but that tlic outflow contiuutit (|uiU! UDifumi throuffli- 
out at icaflt nini'-tenthH of (he latter period (outlaAtiiiK the rise of the art<'rinl 
ptibe^wavc) and bcgtuH to slow only toward the very end (slight rounding 
of the crest of the curve). At the cessation of outHow there is an instant 
(luring whieh thi: ventricular jircssurf is fnlling, in wliieh no inflow takes 
place, but thia is only one or two hundredths of a »ceond ami is difficult to 
estiniutc accurately. Tiiix iniUnnl. <-orn.-j«pondii to tho dieruliir notch upon 
the aortic pulae-wave, 

FlllinjE of the Venlrlcles.— The ventricles then begin to fill at a rapid 
tind imdorm rate until they are almost complett-iy distended. If the 
pulse-rat« is rapid, the next sy.stolo lake^ place l>efon- the filling in as, com- 
plete iM po«Eible, and cutting ifliort the filling diminishes the volumu of the 
heart; not only the total volume, but the amount of blood discharged at 
each syHtole (Fig. 13). 






FM. 19. — Voliinia rarrm of ihn miirirlfo at d'ApTHii hmi rsWn, 'Mnl'fini Inun ll«id*nen.> 
>i&OUad iw« thn«v hnv lh«nirvpof <h« (%pi<4l cydr may W lUiKfpoBoI upMii Ihr curt'v oorropoadlna 
tsdiStnat nt*. A, quol* ol blixid (oiovd iu b)' luriculu iiitolr. 

IMastole and Diastasis.— If. on the other hand, the heart rale is alow 

(Fig. I'i). n« after stimulation of the vagus, lh<* influx begins at the same 

Lrate as before and continues uniformly for about two-fiflhft of a second 

'(ateep iiscimt of the eur\e) until the veniriclei* an- dist^-nded, after which 

Hcareely any blooi) flows into the ventricleo uo matter how long the int«rval 


to the next beat . The diastolic- period is thus divided into two parts: ( I) the 
phane of diastole proper during which filling of the vontrielvs 
takes pluee; (.2) the pha»e of dinstaHiK in which little or no filliiift 
occurs. The slower the heart the gTCftt«tr in the disatolie fillinR and the 
lonfcer its duration. The greatest amount of output in 
unit time occurs at a rate which allows the phase 
of diastolic filling to be complete but in whieh the next 
beat oceufH l>efore diastasis sets in. Any rate above or below this brings 
about some slowing of the circulation. 

PofJiion ol Iho Valves in DlasloTc— BHUtiigBrUn (1843) ha* bowi abJa In donionBlrato 
upon ibc rxri*«l bcarl lliiit ihe cusps o( tin- mitral luid triciwpiil vdlvea jire lluattil togetlier 
by Ihe influx of bluod ami tlip valvoA cI'Mn vponUneously when the inflow cvn»o«. The 
writer IiOB lieeii abk- lo sbow Ihut ibi- ixeumnix of diiulocic is not necMHHrily ruused t>y 
thn valvm being rlnwd, but by Ihci fact that tlin hrart (ills for u lime before ibe wall* an 

Flo. M. — Ucihodi tor dtuodttntlac tht movement* of th* liwrt valv 

Baumarlcu'i method. 

A. GmI-i Diathud: B, 

ful Upon a stretch, and ihen tbe pa«iv« olasllcliy of Ihe irttllt prBveotfi furiticr lilling. 
t the vuiioun prcMure in niateriiilly iocmu»«(, furlher incrtuute bi volume then tokM 
plarc. The cioxurc of the valvra in cnrly clisntole depend* chiefly 
upon Ihe » u d d e ii n e h h both of the filling and of its cesHittiun. 

A very prcHy itnd iiintniclive ck>niotiattiilioii of llie oi.wiiiiiK !iml closing of the heart 
valvcA liafl been dcviiird by J. Gail by lui cxperimcnl ihciivn in Fig. 11, .\, which can l>o very 
uicely pvrfunned upon a sheep'H liearl an Iwughl at » butcher's Hhop. 

Tlie left Buricte ie cut away uiid tlie Imwt of a Iui^l- iliistlc lubt? lied in thn pinep by 
a circular li)t«tnre. A iar^e gbii«i lulie i« llinut throiiRh Ihe aorta into the ventricle and 
t>(!utured in place. Both the thiatle tube and the aortic cuiniula are ceiiriuctud with fuu- 
Dcls i>y mniiiii i>f nihbrr tiitx-s, and the diumbcni of the heart tnay l>e then completely 
Sited with uniri. Tlie i>|>tMiiiiK and elouiig of the valves niny Im broiiKhl uboul by raiting 
and lowcrinji one or the olher of ibi' fiinneU, and nia>' Iw wat«lied tliri)ii):li tbe nail of the 
bulb. Iiuiifliciency of tlie viilve may be produced by CUtlintc or Rlnil.chinji[ one of the 
ehonin- teiidinwp, hut after tlie expenment hna been rcpauted a few linieB ipon tlie tame 
lieart a cvrlniii amount of insiiincleticy imuaIIv »ct« in ■ponlonnoutlr. 'Die Kniindi pro- 
duced by the valve.* and blood alrMim iudependenlly of the eoiitrticlion can bo well studied 
by |)laclnK the slethoneope upon Huch a heart, proinded all the air bus been renioved from 
the cardiac cbaiiibera. In a similar niannor the phenomena can be obwirvcd in the ritcht 




bfttrt. The chMurc of ihe BOrtie or ptibniHiio vultva cttn nUo be duniooilmlcd by ilmwing 
tbe kIm8 tube out of Hw vmlriclc up mto ibn vc^mti, tying it there climo to dio vnlvm, and 
miling oft tlie uiJIb <>t Iht i-Mael ubot-o the li|:Hlure. 

Still nmplcr » the olibr mniboJ nf Hnuragnrtcti (1S4JJ of eutlin;; avny tlie aurictta 
to expoM llie valvM and Ibxn pouHnic In vatrr from n bonlur (PiC- ''i> ^V- 


It hsit been supposed by some writci^ that tlic diastolic dilatntion of 
the heart is brought about by some iictivc muscular contraction, eincc tbt- 
prcTiSure within both Vflntriples becomes nPRative, pven lo tho cxIgqI of 
— 55 mm. Hg. This iH-gativc prt>*iurc is of only momt'ntnry dumtion, and 
may be compared to that occurring within a rublior ball when 8r)u<;ewrd 
aiid let go. The walls of tbe heart are .'AifTiciently rigid and iLrt> emfficienlly 
l.provided with cWtic fibres to ivsume tlieir )«hapc like a rubber ball, and, 
I ou the other hand, the pressure in the eoronaiy arteries temin to hold them 
dtotcndixl an though by a win* frame.' 

The heart nmi^cle is quiescent and the heart walls are relaxed during 
the entire period of diastul(^ so that iioith^^r the mo.-<t rielieate retarding 
levers nor the most srnsitive palvnnomet^rs reveal the slightest Bigna of 
pontrac tion. Nevertheless, as will be seen, llie degree of this diastolic relax- 
ation of thv walls varies cotisldcrably under dtfTorent cireumstnnccs depend- 
ent upon the tonicity of the heart musele. This is shown by variations 
ill the length of :4trip» of ranliac muscle under a constant load, us well as 
by variations in the cardiac volume. 

Tonicily.--ToEici ty may be defined bb the resistance 
of the heart musele to stretching in diaatolo; or, less 
aveurulely. ns its rliastolie rigidity. 

The force which stretches the heart walls in diastole is the pressun" at 
which the hliMid enlcrs the heart from the great veins, nuniely the venous 
prrsmire, so that mih a high venous pressure (unless antagoiuxcd by a high 
tonicity) they will be stretched considerably (dilatation), while with a low 
venous pressure comparatively little blood will enter and thv heart will 
letnain small. In all cases filling will continue until an 
e() tii libri u m is reached between the venous pressure 
and the cardiac t on i city, unless the heart rate is so rapid that 
tbe filling is interrupli^d by the next systole. A high tonicity will, how- 
ever, antJigonize a high venous pressure and prevent overfilling. 

Moreover, Howell and DonahLinn have shown that the systolic output 
iftf the heart depends to a great extent upon the amount entering liie latter 
'irom the great veins, an<l hence, upon th« venous pressure. If the venous 
pressure falls below a certain h?\'el, the heart fills Incompletely, and the ven- 
tricles are unable to pump otinugh blood into the arteries to miuntain the 
blood -pressme at the usual Urvcl. 

Th(' rate of filling of tho heart ia accelerated (cur^-e of filling atcc|)er) 
-O^g. 15) when eitiier the venous pretwure U high or the tonicity is 
low; the filling is slowed (curve more oblique) when cither the tonicity is 

■ For a (l*t«Ued act«uni of the \-HriuuH tlimjries of the canllac rclaxntion, with fiill 
lUbUography, roiMiilt I-;. Ebslnn, IX« DJontole <lca tlerwiia, ErsebDiiMe dei- Phrnol., 
^xrt, IBOJ, iii 2AHh. 



btgli or tlu> venou8 prp^surc is tow. So that, as reRardo (iUiiiR «f the heart, 
n high tonicity ia equivalent lo » low v«iiou.s pn-sMun-, anil conversely, a 
low tonicity w etjuiviOent lo a hiph venous pressure (Kig. 16), 

Influcncea which affect tonicity may i>e Htu<iied objectively in isnlat«<l 
stripe of canliac mu.-tcle by means of their shortemng or )enf!:thciung. or 
tipon tlic intact heart by chaugcj^ 
in the volume curve. . 

Fin, IS. — VolunW onrvai •hnwilia llm «Hrrl 
of Wlallunn In VOMW pnanur* I V I') ami lu U.111- 
imly IT) upim thvMaal wliicli llis itiilneli»ani 

fillM during iUB>toI«> 

V P 5 tw. 

Fia. 10.— Volume rurioa aliuwiiii ilieaffectuf 
li'W vminiH pmwum or n' \*tgU tnnioity ijmn 1l>^ 
AUiinini nf blfK-l ^ntvrinc ilt« v«iitricJflf- (MoilLn«l 
Troifi V. If«id«r?ioD/^ A fall in ttipmiiTU* proiaut* 
i> viuivitlnpt tit an loervHifKl uiaicJty. C'Jf«raqti* 
invlHii of HfO pnnur*- 

The total volume of the heart at any pven instant may bo- n-gardfil 
as follow;!: 

Vulnni' «/ A/virt — voliune or heart walls -f volumenr blood withiucanline chiunbcni. 

Volume of walla — volume ot miun'In + cunmiiry blcKid ■!- lynipli. (TIip two lail*r 
(arlora vnry somrwhnl. llioiij(h rvlativdy Hliiclifly. ifie lyinjih 
incrv:uii[ig cmiKidmHy in cnriliii'^ sluaiii.) 

Volume 0/ Uood vUJiin thavibrrt — ciiii|i<i1. at nnch ayHtolR + tilocxl rvmaininx at end 
•if nystole (rcMidiial blooii). 

Residual Blood. — The rcsiduiil bloo<l undergoes great 
V 11 r i 11 t i o n a . In dilated hearts it may attain to several limes the 
amount of the .-lyKtolic oiit[nit (<■(. Kig. 17), while in small hearts it may 
be only a fraction of the latter. The systolic output, on the olher hand, 
may undergo equally large vnrialions. 

Ficj. 17. — Diacrani to illu>U*r* l)ae pli&iixni rn ti:»1lllilr ^r Ihn \'riitri<?l(y in N}-»I*>lii itncj djvlnl» 
•Hociftlnl frif h ^'arimiuiia m Itmirily <Tr anff ■>ntf>1i<i imlpul \fi.(I.K \. \ORU-, ntirma^; *. incna*Aj; 
— , diiuinlthfd. l«ns<1i o( heavy bl*ek Un* iodicatw iJtgrM ■>( uinint}', 

The changes in tonicity may be measured by the volume of the heart 
at the end of diastole, i.e. wIk-ii ihe hlliiig ix most eumplete. a liirge dtaatolio 
volume representing low tonicity (when venous pressure and pulse-rate are 
constant), a snudl voUime indicating a high tonicity. 

Nature of ChangM In Tonfcity. -^Porter has found that a slrip of heart 
muscle can bi- nuide to remain ehmgaU'd (diniini.-died lone), or can then be 
made to remain shortened when not rcpciving any stimuli whatever (in- 
creatNMl lone). Several degrees of this permanent !<hort«ning can be super- 



I on one another with (treat i*imi)arity to th(> tetantiR of skeletal muscle 
'("telaniis of toiw;."' Porter). BartToft ami Dixon have shown that the 
muscle when in tone Rives off mon? VA), than when at rest, further support- 
ing thw view of the rolo of incmisc nn<i tJpcreaw; in tone. 

KacliH-s producing ChanKcs in Tonus.~-t-'. H. Hoffmann has demon- 
)<:tratcil (hat I lien- atv two striinnite f«cl^ of fibre*i in the frog's vagus. Ouc set 
influences the heart rate only (chronotropic effect), the other increases the 
Mzir iiiiiJ force of ron traction (un;i;nientor ofTocT) and also increa«ics the 
cardiac tonus but does not affect the rate at all. This group of fibres ta 
fnund only in the interani'icular and interventricular septum (i«e]ital nerve^t) 
tn tlw frog. In other nnimuU- the two groups of fibrcv puKS side by side and 
cannot he ilissoeiated. though it i."* frerguent in weak stimulation of the vagus 
U" find one elTei-t occurring without the otlit-r, 

P. I). Cameron, id the writer's laboratory', has found that in <logs tl»e 
intravenouM ad minisl ration of digitalis, strophanthus. iiitmglycerin. aud 
calcium !=alta increases cardiac tonicity. The effect of small (therapeutic) 
dottfts of the«* dniRS in exerted Hlmost entirely upon the uinic fduvs in tlie 
vagus, and fails to appear if the vugi h»vc l>ccn cut or paralysed with atro- 
pine. I.arger doses, however, exert similar effecta by direct action un the 
heart muscle. Atropine itself Ulustral*-* thesic effects by cflu«mg a primarj* 
depression of tonus aa the vag^ become paralyxeil, which is followed by nn 
incicase in tonicity from <Iin?ct aittion on Ow heart muscle. Putaaaium 
saltn, asphyxia, formic acid, adrenalin depress tonicity, .\conite in thera- 
peutic do!«*s uffecij* rate more than tonus in the ilog. 

Since the exact volume of the heart, cannot I>e determined clinically, 
the area of llie cardiac shadow in diiistole fumislies the best index of ihe 
tonus, especially when combined with study of the venoim prc-wurc. C^jm- 
paratively little investigation has been carried on in this field. Moriiz and 
Uellen have shown that exercise usually inereaites lonu.-' in healthy per- 
sons. The study of tonus has niso proved of value in the study of exercise 
and in the controlling of hydrotherapy and drug treatment.-^, an well as in 
the study of myocardial insulFieieucy. 


The heart rate is determined by action of the vagus and accelerator 
nerves, and particularly by the tonic activity of the centrt^s near the cnlamus 
scriptorius of the medulla: the former nerve slows ih_ heart (inhibitory 
effeet), towers the blood -pressure (depressor effect), and diminishes 
the conductivity (negatively dromotropic effect) from auricle 
(fttrium) to ventricle; the latter quickens the heart (accelerator 
leffect). incrc.iscs ihc force of the contraction and cardiac tonus 
(augmentor). and improves conductivity (liaylisa and Starling). In 
some cases .stimulation of the accelerators may revive n heart that has 
oeased to beat (llering). 

Both vagi and accelerators are normally in tonic 

ifcctlvity. Reflex quickening of the pidw-rate, as from emotion, pain, 

'sensation, and other reflex causes (Kcid Hunt), and moderate exercise 

(Bering and Bnwen), is due partly to diminution of tonic activity of the 



va^. partly to direiit Ktiniulation of tbo accclcmtoni (Houkvr); while thv 
ncreleration afUr violpnt exerciflp is due to Htimulalion of the acreJeratora 
(Hi-ring, Boivi'iO. Acedcratiuii upoii mild excrci-s- tan also bo obtained 
in patients whose vagi are made inactive by O.-l to I.O mR. d Ju to j'a rf.) 
utropino (Hirechfclder). On thi* other hand, oxercise <;»U!*<hI no accck-ni- 
tion but a slight slowing of the pulse in a dog from which Fricdenthal had 
rcmov(-d nil iho cardiac nerves. 

rid. 18. — Orisln Uid wuneof Hi* nrdiie n«rvt*, uid cutuieoiurti'ixi.ijiiou :•! lin' •'r3rrr>tioDit1o 
liranrhm. tScli«iiMlic; molilleil troin OoujtiM Puw«U mul <iiti»oB.) MOT SK.\S. uuein o( ilia ifttroiil 
<ino(or> Bml ■Hi-TYni (•rnimry) lilim ol tha viau*; t' I, 3. 3. 4. A. iv. 7. 1^ ui^l T \.i.3, *.A.'\,?,K 
FcrvlFni und ihonrie I'llonall <piiuil Dcrvn kiid titvir r^uuiiwu* dinxlbuilon; SCG, tl(Xl. Il'li. «ipcr»>r. 
iiiuliil*. luiil itifnriur cervical cknclik; HEC LAH. rncuirent ItiyMsl otne; C PL, (orIiai^ plexui. 

The Miixle of uetiuii of tLe cardiac nervoa tuu t>e«n BhrouitMl in mjnt^ty, tspecUUr 
[hRt of lh(! itihiliilion by Ihn rngiu, Howdl nnd Uiikc in a niopt lirilllant ncrica of rntRnn-lini 
liiLve Bbnwii Ihnt pv t andi u ui is iKivdn off (rum Ibv lieurl mtixclo and 
can he found in iitorcnuefl c(uuntity in ibc iicrfuHioii liquiil after 
I h« T&Kiia ha* been h t i miilated. ConfroU vrilboiit v»|[iih tilimnlntion ahow 
no lucli iiicrfHBP. It uxiuld tliervfore appVHT llml viikub inhibition is a lrii« 
potrkaiium effect, n fact furtber bomi- mit by tlin close nnaloKy bctWL«n 
Uie »cli»ii of Ibia "leniMil nnd stiniulaliuii of the vaiciiti, an well iu> by iliir tniirLcil incn-flun 
in Uic action of llie vn)(iiH ufliT Ihf n<liniiiislrotiOQ i>f lar^ quunlititii of pottuuiiiiiii ur 
afWr intmiM' of [•otiuwiiini in ibit blooil. 

Tbfitw observer!! n'en^ unublt' to dt'nionstnle any effeot of Itic accelerators upon tho 
libcnttinn of calciiun, poCamiiim, or nitrof^ra. 





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Definition. — The blood -pressure, or '"iirtcrial tonwioii," is the pressiire 
which the Ijlooil is exerting upon the whHb of the vcbbcI in which it is to 
be mcnsurcd (lateral presauro), or upon the column of blood ahtrad of it 
in the direction in which ii is (loniiig (end pressure). 

The end prm«un ia oqiial to lateral premire - velocity head, but m e rule differ* 
by only * few itiilliDietnw froin the IntcnJ prenure. The cnil prvwiurr in llie brnnch of m 
veaKl i* ttqiiiil to the Intrnil pmaum in ih* VmmI (roiii whii^h It braiirhen. 

Fio. 10. — Cun* erf iiiWinntrmititt u»l imrtio pru—urMi (Alu™ Uii»rt)ilf.i ^.aurUrpmiim 
y. tntnvMtriguUr prunin): D, currg. ta.kMi with » itiHenntlkl muiomrirr, ihovini the dllltmim of 
preMurv betveai lct\ vetittitlr anil AortA. 

Pressure within the Left Ventricle. — It is evident that in a fn-ittcni of 
vlosttc tubes like the nrleries, the pressure of the blood in any a^ment of 
»rter>' is brouf^ht about by the tendency of the inflow (from the heart) lo 
remnin in vxee«s of the outflow through the rapillarie!*. The inflow to the 
arteries is maintained by the pumping action of the heart, that is, by the 
iniravenlririilnr presdurft during systolo. As shown by Hiierthlr- iind Porter 
the pressure within the ventricle rcumiiis lolenibly constant throughout 
Bystoie and takes the fomi of a plateau more or less indejx'nilent of the pul.'« 
curve in Ihc sorta (Fig. lil), though tlie floor of the (jlut^-nu slojws down- 
ward with peripheral dilatation and upward with conBtrietion. 

If the systole is too weak to open the aortic valvi-s, and the heart 
conlracto without chanRe in volume (isometrically) , the cuhf-c does not 
remain a plateau, hut has a rounded apex like that of the isometric con- 
traction of skeletal mueclc. The pressure within the ventricle when Iho 


nortiR valven are open is sUghtly in c>:c4ti>!> of that within ihc aorta, tliat 
is. v<;ry litllr above tliv tns\imnl prv^^uro as measumi in the latU'r, and tl 
rcRiaioa at ihis height until the end of syatoli^, when thi- tiunic vmIvci! cIuhu. 

Uuurlhle luid other* huve bImwh itiul ihe iniraveiitriculuT pnwiun; in not nlwayn 
PoiMUUit UirotiKhnuC sj-slolc, bur that u'lwii Uio |<rriplicr«! nounUincp ia v*ry low it tails 
toward llie vaii of nyiiude, wbik if the jwriiiberul nwislaiice ia very high it rim-* tamrH tlw 
piid of syntaio. • 

The Maximal, Minimal, and Pulse Pressure*.— A rcordi ugly, when (lie 
aortie vhIvc« open (.07 Uf .(W «H'onil) iiftt-r the beginning of venlrieular 
(tystole (see Fig, 45, pape 53), the preasun? in the aorta soon rises lo il» 
maximum, and from that limfl until the l>eKinning of thv next gyatole 
il (liministtcii ninir or l(!Si< gr»<)uully ae the vxcviv of blood ftowH out from the 
iirt4.-riul Inv through the rapiilarips and into the veinif. Th<.' mini in a I 
pressure is reaehed just Iwfore the bt^ginning of the next systole. The 
(lulse-prcssure is the difference between the mftxi* 
mal and minimal pressures. 

Characteristics of rhe Pulse. — ^It U evident that the mainU-nanoo of 
the cireulation depends upon the head of pressure in the artericfi. and 
uc<'ordinKly much .■ittention was paid by thL- older vlinicians to the " arterial 
u-uiiion " and the "quality of the puUe, " which they thought were mani- 
fesiations of it. The aiti^rial t^^naon wa^ judgeil by the force neeessaty 
to obliu-rutc the puW- at thi' wrist when the fingen arc preiued upon the 
radial art«rj-. 

A aliU more Mcumti; metlio<l of fm-linit I'le pu''* "" "> en>|ity ihe srt«ry fur a ffw 
COBltRICtn* hy "milkinic" uut Ihe hlou'l nilli lu'i> tinKm of our hunil. iiliik' ubltlFmitiiK 
U* artery ii)k>v«- iIh- wrist wilh liii- fiiisprs uf Ihi- oltivr tiuiiil. 'Hm- i>nv«iin' i>f ilir Inltrr ia 
ilmui ktmIiibUv ilimininhDd until thr mtitrn iif rhe pukr in frit, this iioiiit murkiriK t)ii> tiinxi- 
mal on>j'MOilic jirmsuiv, B.vftirvful trHiiitrig t>f Oie f*ii».-»lion* and cinii[iuri[i(( tho oliM-rv.i- 
Iron with thi- mult>uf n fiioii Kiihyj-mnniAnnmrlriF di-tfriniiialion inaite at Ihc istisiv liine, 
II KTral drKrpr of fikill in jiiilKirii: pn?T»iirt« nuy )>o uUAincd; one of the wTJU-r'ii tciirliPtu, 
whu hus euttivatml thin pcrreplion lo a mnarkabli; degcw, voicm tli^ jcrniral i'xt>«r>rnc« 
in nyinK, "1 con niliinatn thr hlnoil-i>rrwnin! HitJi the Hngcn bIuiip quitr ;icciinilt-ly in 
•lioiil einht CTi MB out ol l«-n, bul Ihost- in which it is i>f rottl imiiortaiicr arc alnuvk the 

Tita minimal pmnim may alM be judiced, but cvpn Iran aMiimlnly. by iwiiinikiinK 
Ihe amount of prcMun at whi(h the «in) of tlie fiulne just begins lo deoi«aMe aa mie raiiws 
the preatiuv in the artery. 

Dvlvrminatian of .Maximal Blood-presiture. — Instruments for detennin- 
ing the blo^Ml-ptTNuurp date from 1S5.^. when K. V'ierordt deleniiineil the 
weight that could be placed over the radial artery before the pulse was 

Mamy (ItTC) dcviwd ihe first useful apparutufi for Mlinutinj; the blood^reMUre in 
man. He pljici-iJ the- huiid in a pklhymmnKrnph connFctnl with a boiile for riuiiinK Ihe 
pirMDim nniJ n tp)i;'Knii>«popo Inmlwiir for recording 'he Mk of ihe piilw-wai'e*. 11c tlaua 
(1S7B) Ihul the niaxinml picBiurc muy bv dctpmiined as tlw point where the piilaatJan 
diaappcars. the iu> the point irherv thn ondllntinnn nrc InrRWt. It in worthy ot 
note thai Marr)' nan li>eiity-live years in advaiiee of the limes, aiul thai his tiielboda 
and ooncluiiouii are altn<»l exaclty thoic of the best modem metlunb (Krinnicrr and V. 
R«d(linKhai>Mn). t'nfoniinnii'ly. the work of Marey wh« lilile known, ami ilie flnt 
appaialUM to allaiti icciiend ive wajt (hat of v. Biach (ISH7), Unlike Uan^y. v. Biuwh 
aludied only the niaximxl proaurcB, but mueli good pioneer work nas 4oiu: with tim 



itutnimMit. 1l caniii«t(Kl of a miiiLlI rubber bulb fiU«! with wHl^r mid coiiuuuokaUiig with 
n tnctcixry miuuiDiPtrr. Tlui bulh <Ka» pi(«w>d itpon tbc eadial nrlcM^ until the piilM> below 
It u'Mi iibUtrr.tin), mid the pr««aure ueociMary u**!) nutd olT upon dm nnuiunieU'r. V, UiucU 
modiSfd lliv uppuruiuti luivr by iiKJiig a xpniis manonicter. nnd foinin nuhBlliijUvi] sir 
for watrr in the bnfi with an aneroii) hAmnieler. This nipthod b still aliiHwt uoivpniul 
ill FraDC«. but tlie poMJble ccrur with v. Utuvh'ii im well iia Poluin's [n(.-tli()<l5 is as ninth lu 
7S mm. Hk (Tigcnitedt). 

Riva-Kocci (1S96) and I>. Hill ttiid H. Bnnmni (1897) mtroduct^d the 
u«' uf a ruWtcr bag itbout the upper arm, surromidfd by a non-plactio cuff 
of «lk (Itivu-Rocci) or of leather (Hill hiuI Bai-iinrd) instead uf lh<' xniall 
bag that I'otain prcHscd upon the artery, and they 
coiiipn'j<j<tHl th« artprj' with proiwure from an (lir- 
pump or Davidson Bj-rinttc, feeling (he return of the 
pul»t; at the wrist aa thp air waa allowed to <^OApC 
nnd reading off the pressure eorrespondinfr. Theee 
are the methods now in most general use, ihe only 
modification being that the rubber bag niuiit not be 
Jess tjian 12 em. in diameter instead of H ent. as vined 
by Uiva-Kocei; for v. Rerk1inK;l>nu^n hiut shown that 
with narrow cuffs a great deal of pressure ia lost in 
Hquoezing the tissues, and hence the irndinjiM obtnint-'d 
with them are too high, but this is now remedied by 
using the broad cuff, Hiva-Hocci's niclliod was used 
only for determining the maximal pressure. 

However. M a r cy (I.e.) had g li o w n 
that the maximal pulse-wave was ob- 
tained when the pres- 
sure about an organ 
was equal to the pres- 
sure within the artery 
s u p p 1 y i n R it (t.r.. the 
ininininl preiwure — Howell 
and Ltrusli), ami this observa- 
tion furnished u basis for such 
determinations in mar. 

Detcrminailfln of MinU 
mal Blood-pressure. — Nu- 
meroua methods for deteniiining the minima) blood-prcasure have 
been devised, especially uf Hill and Barnard, and Mokso, but those 
which are useful and reliable in prartiro date from 1901. when Ma-ning 
began lo di-Iermine minimal pressure by the point at which the radial 
pulse M^emed to become largest. About the same time Janeway esti' 
mated the minimal prcsaure »t the point where the 
oscillations of the mercury column in the manom- 
eter seemed greatest. This i.-* a satisfactory method in most 
cases, but the judgment by the eye is sometimes difficult and in small 
pulses may be impossible. 

In 1004 SinutburgH ravlitKl Mtuilnc's tnelhod, as did »!»» SahU, wiio nconlnl 
tlip maximal pulsp-vavi? wilb a BpbvKino^Erapb nl thp wTinl. TF* lull*r mothnd in 
very eumberaoine. For pmellcal purtiuca the niethciil nf Mwdns and Strasbiirfer 

Fic>. £0. — Kiva.RcicM'i lilcwd-pr^vur* a|ini>mlij> ■* nimliffcril 
b>-atuliBi. iKindiisHof Uif A. H.TIiaiuiuCii,) 




«t fpplirnt Iho |>u1p-m in ltl.m»- 
□ul pn— un. 

b f«iriy talMfaetoT}-, piovid?*) > few pmcntition* ore takrni. FinI, It m normmirT' 

lo «t(^Tt an ultiolult'ly iiriitonu preatniro willi itio fiagtta tipoii (tii> rndial arlvry 

thn>iiKb(Hil Ibc ikivnoi nation. Ordtimrilv this ia i-cry diHicuU ; but if t h « 

arlcry lit pal|>atc<l ntlh the ball of ttie 

finger inntend at the finger-tips, nliile 

Ihi! finfci}T-lip* rrat dKniitRt IKp rndiun, 

AS bIiowii in lliv tiffin (I'V- 21), fiiiy chanfcrs of pn*- 

*urc by the fingcn arc cxprt<-(l iieaiiuit tliQ tMuu^ nnd 

iiot a^innl lliu art«Tj', anil n very uniform pmHiun? 

in «x«ned ui)on tlie lulter. Secondly, it is necnwary 

In nitf and Ihf<n jiniduiilly tftt oitt tlic prmiiirc frviD tlic 

bag while fi!<-liiit; ttii.- piilvo in ihJH H»y, in ordrr to 

■Miuniiit oni-wlf nith ihf chiuigi-a of pub* to be ex|jecl*il. 

Thinlly, it La nptmmry to rrprat llic liplt-rminalion 

four to six timed in cmler (O el>niiiiii(« tbc gn-.ti ilikrn'p- 

ancin that cmrp in when KiDgte n-iulitiKs are inu<le. 

All iIm iion-cuncnrdanl nvtilinp »hoiild be disttigurtlcil. 

In (hii wny fairly ncFunite drtcniii nations nf minimal prvamuw may be obtained 

(villiin !t nim. of thoM! obtstni'd by Llttanger's apparatw). 

Erlanxer's Sphysmomanornvtcr. — The mo«t scvurntc and sat- 
isfactory, if somewliiit Imlky, s phyf; mora anomp tor is that of Krianger 
with whk'h grnphic tvconis of both iiinxiniiil ntui iniiiimHl pres-turt-a miiy 
be obtained (Tig. 22). Kriangr-r'a apparatus dilTcrs from tho Riva-Uorci 

with Ri'i-kliiighausfin cuff only In 
th« ffict thill by iiican» of a T-tube 
the rulf is connected aUo with n 
rubber pri'Sfdiru-bng in it gltua case. 
Tho oscillations of prci«ur« in the 
cuff iiru thus L'omtiiunicfitcd lo the 
pressure bag, and the oscillations 
of this bag arc communicat^-d to 
the air in the glaiw case around it, 
and are rccui-dc<i by tin- move men la 
of n Murey tambour upon the- smoked 
paper on a smalt dnini. He is al«o 
able to let tht; prcMure Dow out 
very slowly by a scrips of capillar)- 
oiiliet!* of diffcn^nt boriri<, A rom- 
plicated Btop-cock allows any of 
these to be useil at will. 

with Hir*tiilri4*^ fh.lyifniili al1nrliifin]1. (Khid- 
•«■ ol »»homdM Br».l 

In iiaitig the F.rlaniEor appatuius, ooo 
liiriiB ibe slu[>.e(irk lo Ibc point rtuirked 
"In," tliMi minra Ihn prriiKiiro in Iho hnj; 
to well nlMive the nitiKinium arterial prn- 
sun.-. iind Itim* the staft-pocii, lo (ho point 
niarknl 1 or 'J. nlilch (yirn«|X)nils lo rapil' 
Inry outlets of itilTerenl niztw, 'flip prraiun? 
ill till? biift fnlU (irndiinlly, nnii 8onn miiall 
DMilhilioM nf tbn Irvrr an? Hrn.diic In the imparl of the rotiij>>vi«e<i urt^ry upon llie tippi-r 
biatitinof ihelxM;. A^iiddenincrpasein lhef>ieeuf thenewnvelFlaBounliLkcsplucRiindinarkii 
llie muuniitl prt-iHure. ivhieh i> rviKl off on llie nianiinirlM: it i» jii«t a Irifli' Ih-Iow the m.ixi- 
mal prennire thai tiii> firM [mUo-wsiw paatro <y>mple(4'b' tlinjiijcli tinder l)ic eulT and eniucB 
(be larijer ivave. U|>on which ulm h sinall •huiihlcr in iiHiiidly seen. B> tow thin paint thponeil- 
bi I iORR continue to increasicinsvcand thcnliegin to decrease, tlieuMinomoieJ lieliig watched 




nil the wliile. The paint at wlaicb ()ic oacillalioaii urv nmxicital ia the in i n i in a I or 
d t n B I o I i c MoTHl-pnuMUTv. Somctimni. r^ii^cialty in urlerimctcrulica, Ihn oicilliL- 
tjoiui (Ipcnwnc a Ktllf ami lUeo again incr^aM) nl nlintit tO mm. Ifiwcr [iivMiirr. In Hint 
cawi KrlnRgcc liiu iihann that the lower point or sccoiitl in u x i in ti m ut ohcII- 

IntioTw ia the one corricipantlin)t to ihv 
niinuiiHl piVHUto. 

Ill (inlcr lo Ju'cp lliLie rtcurda |*r- 
ntitneit Kontninn mnrka off on ihc ilnini 
tin puiiils s'liicti («rn»-|>un<l lu vtich fall 
of S or 10 tnni. Ug in ihc manuniclcr. 
Thcw msrkd an? nrndp by niMim of one 

Fn. 23, — Dijut^vii *buw'JE>K »rntninDml of 

Via. 2*.— Oiirvt Inkdi iritii the ErlnncFr 
birtcid-iirvfwtitii spmnitii". showing tho pcdntA of 

of thc< idinhoiirs upon the polyifraph (IIir«chfi>Ulcr) iiilui^hincnt which ia cdiimkI to 
vitiralc bv aiiuwiiii); a Btnal] pipeltc inscrtiMl inlu the lun^ ni)<b«r tube. 

Tliia ii])iMi[atua lina licru rurpfully Imlnl, both upon uiiiiniili uiil upon niMihanJcal 
iriudfU, aiivl Ikm bwn b>ii>U'I1 lo jcivu accuntlo rcmill*. Of ci>nr« it cannot be iiwil unlcw 
ihc inmtcl™ of (lie arm un.- nt teat, but ntilher ciia any olht^r nphyiEinuniHiioinetC'r, uilliuiit 
JnlrmlnciiiK a lnric*tiTor. The rrailinpi ol>- 
Ia.iiiiM.1 in lietonuinin^ both inaxirtial utui miiii- 
mnl prrsmrea in urteriasclemtlcs nm too liigb, 
but (liiit frn>r i« nl»o univrrHul and at pn^seni 
unuvoiiliible. Al tini™ llii- systolic intrrosp 
in Htxr in not iiuii<l<-n, bui thin can iiaiially hi- 
ivm»lipii by I'rwwiiijf (lie iever a little inorv 
lishCiy than Itcfotc iiguinut tlic dnun. Oeca- 
uonally a luriter or sioaller capillary oiitlel 
in reqiiirpil and these may Imj rpodjumwi. 
Tho rcnilinsti oblalnnl by ICrliuifirr'* method 
un-, as a rule, about ^ tnui. hichtr for the 
maximal (systolic) prmaun? than by Ihr 
broad culT Riva-Rooci, and for llie minimal 
(diavtolic) witliin aliuiit '> tti 10 iiiin. of Ihc 
IVflidinei by Thir TTu-thod of Mni>in); and 
Strasbuntor ai( modified by thpiTiiorlHitflch- 
feldcr, also Bruftli). Krlaiiiifer'B mi-lhod 
jclvcf rcBUlta auRiclr'nfly nnnpiivocnl to 
form Ihe ba'-ix fur a reM-urch. ultiiou^h the other method la often quite axUafaetorv. 

V. Rcchllnghauacii'i SphygmolonomelcT. —■ Numerous other apliyKinoinanomeipni 
Iiai-u be^ri dc*i".il uf latp. tiutiibly the it pbyicnioaenp<: of Pal for ileter- 
loination of pmiuiv by thc^ mo\'pmeiil uf a drop of colomi lit|i,iid. and the vimuil 
(tonomrtcr) anil jcrapbic (lono|traph) mnthodii of v. lleckljngbauacti, uiion the: aamc 
ptincii^tr as ErluuKer'ti, but they do tiot jxitwciM any apocinl advnntjij(<« ia their rrapeclive 
aphcrcs of iiacfiiliiMw over the methoda given above. 

hi*'.. 'J5. — - V. ttcAklinfthaUHJk apparatus. 

i.Mlet ». Iletkliiialmu*™, ^rr*. /, «piT. Falti.n. 



AuKuIlnlorj Mclhud lur Dctermlnjidon ot ibu Blooil>Pf«astirM.— A wry iugtuiioiw 
■ui'tliod fur (Inli^riiiiiiiiiK Uk- mnxinial and initiimal bloucUpiciiaiimi vnn dcvtand by 
Komtkoff La 1905. If tlic {inissure in a rubber cuff u)K)n Iho u|>|i«r nrtii is ttllowm) to 
[all fnuiuklly from ■ )>oint above tlic mnxiniBl urtvriiil pmHsurir, vchUe llie olmervcr liaCenv 
vrilti a HWtboMOpe |>ro»e<l upon tbe l>rachinl artery al n pnjnl alioiit Inn mntiniRtoni 
below the lcm«r bonkT of the cilfT, do imiiikI will bo liearU iinlil a» Huun >9 (lie preatniro 
in th« eitff falb briow llic maximal itrtrrial prRuiire. An the niinimuJ nrltrruit jtrtwtun: 
i» iippr««ch«<d, ttii' ureund nu'ind alw) l)ctt>nir'H louder, rriiirhtu Its niiixiinum at thp 
rmiumal arterial |)nntir« (wiifre llit-w i.i the grL-aUwt alternate t-'Xpnnsiuri uiid coti- 
Iracllon of the nrtery), and dimpprani r.ipi'll/ wbrn llir prrasum in the cufl it a trifle 
btlow tbe miniiDid (<liaxlulii'} prvMiiiv, liidt^il. Ffllrit^r liiu found ttiio iiicthod aecumlp 
ta«-ithin5-t0nini. Hgot the rvuding* wiib tbe v. Hetkliiiglinusi'u nptmnilus. Mins Alli-ti 
and Mr. IJiicIf, in Oii* •didy of tbe bbKid-prvMvim* of 3!i )inlim[>> in Ibi? Jiibim Ilopkin* 
Huspilal, fuund tbut ibu irailiiigs by Ihia luetJiud novrr difren>d mun' Iliuri 'J-ii iiiiii truin 
control dctrnntiMttnna nuMJoat ihn nine time nitb tbf lurUngi-r npimrutuo. lliougb ihey 
look the mtiiiiiial )»«Mum »> Ibc pjinl iit nbieh thniH'e.«idKfiin'i iibsolulely <li«appe-arwi. 

Tbe Dkclbod Mmiu Ihemrurc to l<« unu of euiuideriililu accuracy, tliougli tii peiMIW 
vith my small vomoU it ntay tw dilfieult or impoiuibk t« uar. 

Pocket Form of Blood- PrcMurc Apparnlu*.— Tbe exigencieji of Ibe busy prarliljoner 
dPtnanii uii upparatiu lo uociipy biiiilII ofiiicc iind yet 1:1^^ miiiltH uE retu<L>ijalili> uccumoy. 
To thiji nmi I'otnin mode uw of n sniull .iinl ujxin whicb tliP pnaaiii-e wnn shown by tlie 
cunipr^s^lun of 11 uprinc «vl»brBied in ocnlinn'troi of mnreury. Morv n'et'iilly a niiinbcr 
of sueli (oniix haw IxiTn di'viMHl iii which tin! pn.teui« cbuuilvr is (.'uniieoted wilh tliu 
usiiiiil Riva-lton-)tccklmKliaiiwn cuff. Thn Tjrxu appiirnma rrpn-'Brnta one of Ihe moat 
eunipai-t u( tbme. It i» praettnilly a. ininiaturn v. Reckhn|{hniUM-M «j>byieiiiijloiitiinetpr, 
puckcd BO BDiall Ibiit it nwy be carried in llw- poeki-t ivilb «nw. Tbt- rL-iidiiiga luc luude 
by ibe Kunc mclbod :ui upon Ihe v. itprklingh.tiinen, but the cxcunloiu nrc mui-'h iimaII«T, 
a (acI wliich oflci) irilprfen'M nith the dvi'^Miiii>iilii>n of niinimnl pirs«iini. NeverlbeleM, 
UcBrH. Kngin und Damly, in ihe Johns Hopkins Jli-ibtal flinic, li»v» found that liutermi- 
naiions <ritli thin spparatnK nsvialty iipproiich within .'> 10 mm. of the delefniinalion» 
wilb Ibe E(luii(^*r ap|>aru)ii!i, 'Hub error is iiamilly due (o tbo fuet tbal tbe m-iximnl 
ptnanim in dcteiminHl by digital palpnlion, in uliirh then; \* uii inhemnt error of nlmut 
I this ainoiml, rvK»rdkw8 uf the form of apparalUH uned. The detertuinatloiM of inlniinal 
I pn»iun! UBUally fell wiliiin 5 mm. of tiuw- mode with the ICrltuiger. 

When the rradings wctn made by (fie suneiiltatory method Jl was iMimible lo n^n<-h 

i sbaoluie aecuraey in many cilmw with Ibis puekcl fiirm of appunilus, l^ttr all spring 

(nnuiire gauscn, I bis iprins in liable to wror out in time, bo tbut it aboiild Ite controlled 

every few monlhii by mmpnrison with a mercury manometer at rnrioiM poinlJi ihroiigli- 

vut ibo Riiige ol pu'wun'. 

QbMn's SphytffiamaDD meter. — t^lill more r1^eently tiibaon and HnUi have dciiMd 
an appttratiui Mmilar to ICrlnn;;er'f but rveordintc the oxeillaliorw of the mercury nianoate- 
lent dirvcUy by a float instead of by tlie Marcy liunboiir. Tbeae iiulruinenl* ^m nsullji 
fairly eoncordnnl with Ihe Krlan^er and have the advantaj^n of reeordinft the CormipondiiiK 
|irc«Hir« diTvclly in absolute fiKiireif. 

Normal Blood-prvMuren. — Fur youns iiervonA (19 to 25 yen™ old) in Ibe reclininR 
poatore the awrnjte bloo-l-pn^scure aeconljnjt to Krlanjccr in maiini*! DO mm,, niiniiiuil 
65 nun., pulse- prwaure 46 iiiiii. liiK^nenil the liinila in normal indiriduali at n«t are 
niaximal 110 to 135 mm., minimal AO loOO mm., pulac-pmintro 30 to 4JJ mm. In the 
experience of the writer a niaxInvHl priMturv of 1 15 to 130 aim., with « mittinial of 75 to 
I 65 mm., pulne-pnvaurv 30 to 10, i* mora caminon. 

uecRAXisu or the circulation. 

Pressure in Different Paris of llie Vascular System.^ — Dawson haa shown 
that the mean pressure is ver>' constant throughout the arteriKl 9}'st«in, 
while the niaxiiiml presiure fall» greatly as one approai-hi^ii the periphery. 
Tlie tuinimal piTSHiire is also quite ronBtant. As one approaehea the periph- 
ery thf niii\iiiiiil pressure falls quite rapidly to invct the mininiul. and in 
the smalWt arteries they are practically equal. Hence the presnure 



in these arterioles docs not differ grefttly from 
the minimal pressure in the aorta, although it is L-crtititily 
a few millimttrc* less. The minimal arterial blood-preaa- 
uro therefore represents the peripheral resistance 
(vasomotor changes), while Ihe maximal pressure approxi- 
mates the intraventricular pressure. Mart-y (1. e.) has 
shown that lhi.-< approximation is eloaest when peripheral rcsifilancf ii 
high. Accordingly the pulse-prcssurc, or dilTerencc between the two, 
rt^prescnts the head of pressure i«ndinR to drive the blood from the heart 
through tht' aorta and large arteri*.s onward into the peripheral aiteriolea. 
The fali in pressure may be compared to a ens cade 
whoso first descent i.* from heart to arteriolea, 
whose second from arterioles to capillaries, and whose 
third is from the capillaries back to the heart. The 
actual hcra<l of pressure at any point in the arteries is never equal to 
the total head (maximal pressure) which would bo active U the fall 
were uninterrupted by interposed resistance, but is more nearly equal 
to the puUe-pressurc. 


The fall in bloo<l-prcfuiure <luring diastole continues until the next 
systole takes place. It the pulse-rate is rapid the diastole Is short and the 
blood-pressure has not time to fall much; hence, other tilings being equal, 
minimal pressure rises and pu I sc- p r e as u re falls as 
pulse-rate increases.—Ditetua itii!win|(li*pukxiin*lwiil DlDlmBlpTieHura tn nrloiupttrtiof Ihe dr«ul*torir(yil(ni. 

Eriaoser and Hooker hai-c cbiined lliat undor orcliaary condlliona lb« product of 
piil8«i-prciisur« mul t ipli(!<l liy pulK«-rat« ii toternblj: conttant, 
uiid repreoeiilB roueKly Ihe velocity of blood Row. slihouKh Y. Itpailpmon, tlio writer, 
and nthen bnvc proved that t)u» ia very iiinccuraie and oiay iavolre an error of inotv Ibaa 



50 pef ci-nt. Tlie curves uf Dawaon and Gorham, who cbim ilut the paUc-iirtsiure iit a 

L"»»lijil>l<! indc«" of th(! R)«tolJc uutpul (per beat) ol tlie vetitrieJe*. iiidicAic iliai thcw: 

KriU-ni refertwl to (|ualll«live rolhor than •,iiiintitali\-c ctiiuiKts. ileiidcmon hiu iihovi), 

Dwevnr. tii3t within ii cvrluin nage at pui«^rul« tlie vcnirlrtilnr ntilpiit pr-t bcnl varioi 

■vvncty a» the piiliw-ralc. W'jlhin IhiH. the usiinl, miigi.' the vclwily of blood flow Ih 

'KnuUBt. At raU* belovr it (imo U Iwl ili;riJi|t the i*rio<l« of ilin8t,i*i»; oliovu it llie «iic- 

tcmivc; lynlolm enrmach iipmi the pcrriwl uf t*eiilrii*iilar lilliiiic ami ciil ittiott ihc inHciW. 

^Within the limit* in<iicitl«'d by Ifondeiwkn, RrlanRrr nni) Hooker's index of veUwily tnaj' 

Hea be carrcci, npeciully nliwi then! an- iiu i;itn-iiii< vasuiiioUir chaneiw. 

F(u, /T-— Di3V«Jn fhcivrtria ^ffH-t^i^f v«jvmiiv1rirli{jn, vjuoiiliiljoij, ji»cr«k*nl xiid dt^trvuvl Inrr* 
ol vculifcular ivntnciion upon Ihi nuuimsl ■n'l Riinimal blood-pmaurai kiid uptm (liv (inn of tht pulse. 
£l'.<i. lyiiuir: D/^5, iliululc: .tfir. lunee Mt«n«: .lU/., artCTiolia; CH/*, cap I Hum. 

If the peripheral veiMclii dilalc, taote blood can flow throuitli in the »aiiio time, anil 
faonoo when the pular-rule !■ conalniil. vnaodilutioo bringn about fall id 
Blioiiiial prcagur^, riiio in piil6«.pro««urp; vannt'onalrictlon 
brings abutit rise in ininimul prUBHUn, tatl in pu l«r- prvmure , 
but a chaniCT^ in mnximnl pmwurr following the ehnngc in nubininl luuiilly occun roflcxiy. 
Fi|E;urv 26 nhuuv (Ik> varioiiH rrlationa of maximal, miniinalj and piil»r-pn«»;irca to tbe 

^-jAat« of ihe iiitniv«nlriculur praBUre. 

Krinnitpr and tlooter ^vc Ihc followinft tnMc lo imlicatc the (■cinititioni prriu'nl In 

^llie circubiory i(}r«teia: but owlnn (o th«i luacciiracy of the calculatJoiw this (kiriii»heii use- 
ful information only when the cliangcn are extremely nwriud. 


PullMMVHUI* K pUllV- 

r*(D vrlmjiiy. 

Ehersy <■' he*rl. 

PeripberkI na'xIiwiM. 



Increased .... 






l.'nehu !«>.■■ 1 . . 

Incn-iun-d . 





I ncrra*ml 







UnchaiiSP') ......... 

UiiQiTiishiti . . 


Incrr'ajii'i 1 . 

Unrhanjtcii . . 




ClioncM in the pcriphnal vsmpIs can be n?«orded ti.v placing the patient's liawl in ■ 
plelhy«i»<i(^pli (Fij:. 28> which la sviilnl hernieticuJIy nhnut the forenrni hr miMinf- of a 
rubber ruff. The fret- miaee in Ihc pklhycmoKniph 'u filloil wilh «aler. which runs in or 
■ij>hoiui out of u iiibo le-juiiniE !<■ a movable ital-iulje. Changes in volume of Ihc ami are 
tvconidd by upward or duwnwunl niovciacnla of Ihc text-lube. 



Work of Ihc Heart. — Since the intraventricular pressure ia'almoat ron- 
.itant ihroiiKhout i<yritole. it is cvirlcnl ihat the work doii« by the hcnrt u 
tulembly curiKtaiit throughout this period: anti since no work is 'lone durint; 
diaiitole, it is evidt-iit thnt the work of th« heart per initiuto inuy Ite csti- 
mut4>d, at li!a»t roughly, by the product of intraventricular prcsauri.' X dura- 
tion of syatole X pulee-rate.' 

Fh>. 1S> — Homo plttblWDacnvh. (AfMr llDwrll) a. ey\UnWi c.l i>lFi)i»mnanie)i: r. tntlnr in 
■■Mr in I St ft conalant lartU; p. point rcoordlng Ihc ncunioni of K^vtubc t. 

The VAlufr of li!ood-prc'!»urc' di'tcnniniitioiiM iw an index of the func- 
tional power of the heart will be discussed on page 142 in relation to exercise 
und cardiac overstrain. 


I. Change ot posiiion, Erkinicer and Hooker liuv^ sliuwri tliu! ilif iriiuiirinl 
premiira nwinlly riw» cousidrmlily uud 1 li c p u l»p-pre»» ii r« nlwn>ii dpcrnan** 
upon sLandiiig utler hax'inK lain rfown. Tlip puluc rnlc inrmaiva aretntlingly. They have 
)>bo>i-n (but thew eff«ilii *ns erilirely due lo I In- ml*' i>( jtravjly. 

'i. ATior mcalti the maximal prciiiiutc nnd pul>o>pr(iiiiuf« ar« 
inrrcimcd. alnu iLp pulsi^rate, am\ iho mininial pncMiiro niay b« iDcrasMd but Iv a 
Im pxlent. The citriiinlion is BN?(^knttlMJ. 

3. AfliT «x«rciar ihvf'IToct iolliriuunn.v ndrr mrnUrOnly n)nrf> niarkni. tVlieti 
exertioc if continued to tlip jwint of,faliKUt> tlie prtiwiiirv» fsll. the pulse-nitp faUn bIbo, nnd 
ibe cirtulatlon is alowcd (ikhott. Hnaing. Cabot, Bonen). (See page 131.) 

■ For moiw com plica ti-d und |>erluip« more accurate fonnult^ «f. Ti^nt(«dt 0-C.). 

_ . PiiIms prrMurp „, , ^ . . , 

Tlie ratio .,—. ,— ; — —iT-^ ot BliXKl-prcfwurc i^nrmciciil m lined man t>T 

Moxunal (nystobc) prmsurv 

ItMataii iudexof circulatory condllioiu. IlaBigni(ica^ct^^lny bi- givtn as rollomii 

P. P. X P. n«t«-Velocily > -._ , ,. ^ , , . ,. 

i, i--i. „, , !■ — triciency of bvart as • pump, la a oomuu uuu- 

Syiit. P. X P. Rat* - Work f ' *^ *^ 

vidual thi» coalBciem i« 25 per cent, to 35 jwr wml. 



4. Upon Dcntory «iimulatlon the nuoir-oior oeiiii« In the me<1ulla iwu- 
il|7 rORpondc by conslrictiDK Ibp (wriphc'ml vemcU, and the pmnurc, «s|M«iiiJly llie iiiicil- 
tBal pNttura, rues- The pulM>-raio ibUHll.v iinickenH aim. Hicff ttnt K'^^' viirialioon 
in the rcBpcin« ol <lilT«Biil huullhy iiidiviOduIn lo puin Kliiaitioiiii. Ih. A. Uerg, iin<lor ihr 
ivritcr'adirrction. hiuilf«(r<lllir'rlTrcl(if plnc-hinK ihenr upon the NooH-pmBurc of tiFultlij- 
iiiiliviilujilK, bikI luui fmini] in Buine )«n>iiriB u ri«e of lilood-preBHU re amoiintinit 
to 10 to 2(1 mm. )l|r. In nllipni no i-ITcct, in ot.hcta n full (if Blioiit 10 mni. Too jntMiiie 
, Mlmuli prolutv vliock. Menial oonion ha* a similar «:|Tt«l — a <lfflnit« vaxoRnn- 
I at rid ion wiling in. wlui'h is shown by llie sfamikage of llie annin u plelliytunu^mph, 
fi. In ii!«rp ilii' oppofiit*! rFfrctii atv unrn: them U a i^nenl vaaoili lation 
nnd H fall in mininiiil b looU-prpstt n re (Iloufll. Briub, and rn}vn>Y«theO- 
Tbcrr if jirobal^ily nlao a vIikIiI full in nmxinial pn-wnrv. 



When the heart faila tlic oirciilatioii is tilowecl, and th<- blood becomes 
in com plot fly ai^ratpti and overloadrd with CO, (f. Bohr). Thrso windl- 
tioDM clotwly «niul»tc thi' eonditioiw proci-nt in awphy.xiii (Trmibc). or after 
breathing an atmosphrre overladen with CO, (Klug has ehown that tlio 
cfftfl of tliew is (iiiite similar). 

Expcrimcnial Aspliyxia. — The 
conditions n.-« ol>;4i-rvt'il in exixri- 
mental asphyxia sonu'whnl fore- 
shadow those due to accumulation 
of CO, from heart failun-. The 
blood -presttu re chanfces ill asphyxia 
have been moift earefully t^tudiod 
by Konow and StentKck in Tiger- 
stedl'K labornloiy, who found as- 
phyxiation in rabbits resulting in 
the following series of events: 

1. At ib(t bcsinning of iwphyxis iho 
vast) mot or and cardiac ccntrm 

.in the Ripdullu arc si imululed, 
as is abo the inliihilory nrnlre. Olooii- 
prcimure rlneii und the puliir in 
■ towed, ({'omeron luw sliowa ihui, on 
tlie other band, the 1 1> n i c i i y of the 
heart niiiacle pnimptly .dee r cases 
with l!v^ fint dnttr of ii^phyxia and re- 
tnuins diiniiicihed ihmnjchrail.] 

2. An Bipliyxia couiinunt. tlie elTecI 
ol alowiitiE of ihr piiliw exec<^ tluil of 
the rise of prueurv and the blood- 
prcKsurc full*. 

3. This mndiiioii slown the cireula- 

tioR itiU laon, CO, aceuniuliiUvi in tlie blood, buthing the vasomotor ceoti*, the latter 
.MimnlalMi die tirtettal>« to utilJ further conalrietioii. the xagiut can nu loiiKcr overcome 
'Ih^effrctK. nivl in spite of il» continual action IliepuUn quiekcna and blood- 

prcssurD nitnin rise*. 

4. The adiviiy of th« vnsonmtor wntte diminishoi u*hil« the \ig|ui centre rcnuuiiB 
at nuximnl activity, and the pulae-rate again slows and t>lood-pr«** 
sure afui n falls. 



















-J —1 





/ 1 
I / 

\ \ 




1 y 


— f 









Fio, ;n,'— [>iiicnm shotting (be curve »f hkinH- 
tkf^tuir rlunnc fttpbynim. (SdieruArio. illivtrmiinc 

lh* rviiitui uf Uunuv ana Slenbeck.) JV, nwtoal; 
#1*, bU>ci-L'pf-iBviirv \ PR. pultivnic. 


5. The vagus centre fntiguen, the ncccnory vwaniotor oeiilicH in ihtr xpinal conj 
an axnln ittlmti]al«<d, tui'l blooil-prpMsii r« anil pn I«d -rntc aRnin rise, 

fl. I'^ilicltictivil]: of Tlio lieurl (liuiinbihcs, uwtuiioiiat bcutx uni ilruppnj by tlie vni- 
lne\e. blnnd- prr»uii rR nnd pulne-riitc fall, anil the niiimal dim at this 
BlAiei> uuliiM respirutioii is piuiiiplly reiitomJ. 

UccAaioiiuily in niqihyiia periodic cbnnfps in rhylbm of thn hpnrt orcur. burH iui havo 
bMn dbsnibcd by Lucinni in f ra^ utid by I^nKO"<i(>rfr in onM. Tlimo iirpffulAT^tlofl occur 
whon the viLfn«mievtionc(lii« well nn when tlicy urt.iclive; (htsulsooocuni wlirn thciuitinn] 
in miulc l» lirratlir aii piccnw of CO, (Klujtl- Whrn, howntTr, thr vaiP aiv inflrlivr (ciil), 
llic ri»i> id bloutt-juVBHUre in uapbyxiii is FontiiiuoUM fnini (lip un»et until Ibt- rasaiiiolur 
eentrw foil (I'.e., in the fourth ■tatc^). Whrn Ihn ecrrirnl npr\Tii have been cut nnil Ibo 
vnKi arr aclivv, tlter« is an iniiiMntiule fall in both blooil-pntwuro anil piil«if>-n)l«- the ritm 
ill blood- prvMiire acla iu much lulcr wlicn Ibe accMnory vnamnotor ctMitrta bi lb« spitial 
oortl arc ■timulaicd, or iVie animal may die if IIkmc fail to rmponil. 


Importance of Determininf; the Mechanism Producinc the Change. — 

Variutimis in blood-prrsfiurc orcur not only in conilitiunH of lu'iiltli but still 
more uiKicr patholn}0''nl conditions. Asf will l>c seen, the mechanism which 
brings Iht-M- chnngi-.s ubout is not alwjiys » simpU^ one, tuiil llu- ciiusjil fni^tor 
may not hv Rffected by merely ivaartmg to therapeutic methods whieh 
lower a hijih l)I(ii)d-pri-MSiire or riiija^ tt low ono. Ii is theri'fort^ nccoiwiiry 
for the elinicrian to investigate a* fai- aw possible the condition of the vaso- 
motor nervea, the strength of thd heart-heat, to determine also whether the 
blood h* properly aerated, and learn whether the kidm^y:* arc performing 
their function properly, before proceeding to symptomatic treatment of 
high or low blood-pressure when the cauoc is in any way obscure, . 


The following represent the typical blood-pressure findings in various 
dJscaaeit. In exccptionnl tases more extreme variations are «een: 

1. NephrllU, wpocially tliu cbronic forms {nuKinW preseiitc 160 to 220, iniiiiniaJ 
130 to 160, pi I Im;- mil! SO to SO). Ilifih blood-proBure is common iii iHith panMichymntoua 
and rnv". I'JiwIcr an'l lleini-kc fnunit thai in .ininiaU from whicb .'vlmosl all the 
kidney 8ubiitai;CL- UmI bi-en ivrnovotl. bloiHl-prensure rose puri paii»u nvith the occurrvuoe ot 
sigiiB of n-iml iiiaulEcicncy in thn mcluljolL-iin. 

Excellent reviews of this subject have recently been published by 
T. C. Janewftv and by Pearcc, There socms to be a i^triking parallelism 
between continuous high blood-prcseurc and ovoreccretion of the adrenals, 
usually leading to an hypertrophy of the latter (see page 208), ■ 

In acute nephritis llie b1(>ud-pn'Mtun> may not ariw. but Builcnnaiin r«pon« 
a aw« of BCartuIinnl nephritin nhcrn » ritv of 50 nun. lu^mlilcKl ilie onset of ibv nepluitii. 
Here it in of dinj^noatic and pmenonlic importance 

In uraemia blood- pmBiira rises nt tlie be^nnlnx of ihe attack, but may grad-] 
UiUy fall ■ tew duji before a fatal tftrmination (Laqueiir). Craduul fall in blood-jutBaure 
also ncconipnniM amdioralion. Ehipl timJA ibnt ibrn^ is no riir in the mildnit caivii of 
nephritis, but iliat ibu riie of prtuun.' niiu parallt^l V> the severity of the disease until tbe 
t«nniiiul fall nets in from cardiac uvaknru, 

2. AricrioscleroKiK.— fncwascd blood-premiire (maximal UO to 170, minimal 110 
to 130, piiW fiO or orvr) ii the mlo in nrtcviaeeleimiH. IboiiiEh then are OMadonid excep- 
tions where the nuaximal prMH»» docs not exceed or e^-en reach 110 nnn. (Israel). (See 
also chaptex on Arterioaclenxiis.} 




with tiitrtlcH or other vuaoconii trie tor* or liy veiK-nec tioti only 
increasp" ihp I Auk o( the hearl. Thp only mwlical irwilmept whjeh n ids it 
ut nil in adiiil lustra I lou uf ultupliie lu punilyzc tht vsp. i)uii<kiTi the liturl, ajiil fvriml ihv 
preMUrc to Hue lantt^ mulily. I.iiinliiir pimrliirr hclpn Kimpwhnl l>y rcmiivinx tht^ rxccMi fif 
tntracnuiiKl fluid. If tliU dix» not nulliet*. L'usliiiig ailvinB Burptal iiilrricrviict! in many 
CMM, — »9djio( theikuU iiehig lifted Itrmpomrily in order In n>lirvr Llir intrncnmlal lonsion 
and to ftUott l>ie bloocl-prfwiire lo fall T)iiB |>ro«Mlure m [ilrrioal <levuid of dangvr in iho 
hand* of n Hur^on H'tiim.- lur^wiK in prrfi«t. but very dHnf^roiw if it in impMf«ct, nnd thi> 
point alonp irill iiflf-ii doi>idi> lliir MdviHiibilily or insidvisaWlity uf the operation. 

7. AlUcks of ittlopaihic Bplkpty ore oHociatcd with very higli blood-pnavurc 
and dmr puUc. The blood-prvuiirc sitiln vithin a fow minutes after the fit, which aiwlds to 

, diffenntlalo it from iira'Tiiia (Pilcx). 

ft. VkicnUr Crises. — I'lil hrui <(cMribc(l nn imjiortatit K^^P "f cases taiOciaUxl with 

' crisM of high l>lofHU[irpRfliin:i due lo vtuwooiuit fiction. Anions tlicap ho HiMsee urinmia, 
eerUuii cuaus of itrtt^riuavlerotuE. tsiiwiuJly with iitHlomiiuil uiid lurdiiLC syinptitnui, luid 
mpocially the tnliclic viscc^rnl erism with inU--iuv pain. Iln hnn ihown that these na well n» 
fttlMluof tlxhtning piunH arc aMorial^ with inarkeij vasooonstriction and rise in bloi>d-]>i«»- 
nuic. and vlalo lliiit ihey lire e\'en relieved by the ndnuniiitTvtJoii of iiilTOglyecrin. He aliio 
clamcs ansinik poclonn. intrmiilli'iit claudication, and ItAynniid'H discaac undeir thi* head. 
'3. Aliacks of Anxina PectorU. 

IQ. Some Cose* of A(lain»-Sioke> Dii«aies bctwecfl Attack*. — Gib«an reports k 
caac willi maxini»l ptVMHizrc ;!70, niiriirnnl i>re«*iirc 70. piilsc-ratc 27. The proffun; may, 
liowuver, never riae inalcriBUy. During the attaoka it always falls almost to wro (tee 
page ■IfiO). 

11. Exophthalmic Oollrc (Graves's or Basedow's dueaw) i» nfien accompanied by 
hypertrophy of the heart with iiicrewed nuuciautl, HO to 160 inni., miniiual 90 to 110 
mm., and piilac-prcMUm 30 to !'0 mni,, pulM>ratc aee«lerat4sl to 120 nnd over. In 
Home vanes til Grav«a'(i dioeaMe the prenurv rHtnaina low (maximal 120, minimftl 00). 

12. The End of Presiuincy, the on«el of Inbor. and the puerperEiun are accom- 
panied by a slight (lO-lD mm.) rioe of maxima) pmsure tvith httle channc m minimal 
preHure (Slnmoii* nnd (i<)Uliibi)rough; we IHrl III, Chapter IX). 

I'i. Chronic Primary Polycythiemln. — The increiucd number of red oorpunflea 
iaereaaca the viscuBily of the blood, and thereby the work of the heart, bcnidcx nrlxKnicle- 
KMii m uiufllly nwocisted. On the other Iwntl, aa shown by W. £rb, Jr., iiicreuoe in blood- 
preasure causes liquid lo leave the vetwU and thereby incrcawa the viacnsity of tlio blood 
ftirtber — iDlradueiiig a viciouB cycle. 

14. Cjanoilii In Heart TalJure with Broken Compenution, irhicli occurs al some 
■ta^ in almost all failiiiK hearts. The blooi) liecomm overloaded with CO,, and vasocon- 
1 «tricli(in pluB augmentulion reoulla on in tuphyxia (»ce |>ap! 237). I'tiually the pulse i* 
qtltckcncd, pmbnbly from fatigue ol the \ag\u centre. Thla condJlioQ in of ]t;reat clinical 
importance, since tlie hlgli blood-preaiiir« incroasca the work of the heart lutd occelerBl«i its 
failure. Venraiection. nifita, digitaliii. snytlung which ac^eleratm the velocity of blood 
fh>w through the lun^, l>rin^ about impnn'cmcnl anil lowering of the blood- pressure. 



Although tho occunrpiicff of Inw blood-pressure is usually associated 
in the mind with the idea of a diseased heart, such is, im a rule, not the 
case. In fnot. in moBt chronic diseases of the heart the maximal prciwurc 
is Increased rather than decreased, an has been shown above. In one case 
of aortic insiiffieieney, for example, the writer found » maximal pr<-iwiir<! 
of 150 ami » inininiHl prejwurtr of 1 10 two minutes befort? death, in spite 
of intense heart failure. 

A low bload-prciBUTc i* more commonly an index of fail- 
ure of the vaaomotor ccntro than of the heart, and occurs in condi- 
tjon* where ibe strength of the heart is uninjured (Romberg and I'teiler, llnwafeld and 
Fencvewy, Crilc!), 



Condiiiooii in which low bloMt-prnwiira ia fount! an. 

1. Acuic Inlcctlous diMatct, exoept mpninifiti)) (where the blood-pTfwniM i* Ugh 
from iocreMed intmitiuiial t«iiuo(i). KomtnTg anil I'iiiwipr tuive Bhown llial iMctort*! 

QM diininuh iJir: trniic aciivity of the; v.vomolor criilir, ancl miyot'vn pnralyic 11. 
! Slrangtb of the heart is showD Ut be undiminished if the va»oililu1ioii i« couotenoud by 
a, eam|>r«i»ion of the abdominal notla, el«. 'ilia bluod-prvuurc fuJlM betniue tha 
rjolM MP dilatrd nnd the aiilflnw trom the artcriM ia too ni|>ici (miuiinnl pmuurc W to 
''ill), minimal pn-wur« 60 to 90, (tube-rate Incrrased.Me table, paRi' '2y). 

Tlip Iciwfsi litiKxI-pnwure i« in typhoid f i- v e r (Biirachi und p c r i I o n 1 1 t «, 
where tlie dilalntion ol sbdnntinid vcmcI* from thr local inHnminntioii ndil their effect to 
Uittlof the cuiuueuuit vaaodilatlon. In typhoid fe^-er the n'rit«r Iioh Hecu inuximal pmitiurM 
i low M fifi miD. !lg (Rivn^Rom), nltlioui;b tniuciinn] 100 to 120 with miciiDul GO to DO b 
I COORIon. Crile rikI llrimcn hnvn drocrilx^d rinni in blood* prrmun; at thr oiwct of pnr- 
illoji due to sploDohnic Hiiiiiulution, but the writer haa had two caaes (one of which 
ia itictitioiml by Brtggii) in which inactivity of tlic vnnomotor centre prevented thi* riw 
from occumnjt- 

III pncuinunia tlie bUNxl-preiBiure may not be cliaii£(T<l much (niaxiiiial 110 to 
130, minimnl DO, piiticmtc 130); it may rine ui mild acphyKia wita in, or it may fall v»ry 
low from vasomotor paralysis. 

In diphtheria, scarlet fever, meksles, acute rbeumalism, and 
I in fact in nil other ociitr infectious diRciiMs, the tnaxinial |>itiMiiin! unuotly falls below 
100 duriiif; the htright of the fever (Wei^rl). 

2. PfclUaU. — In this diica«c all ranges of blood -prciBure may be found. John, 
Naumann, Burckhanll, ami Slanion haw found unifomdy low prCMures, 90 to 100 mm. 
with the (ituirtner and Itivn-Kocci ujipuratiix, but thla may arise frum the pallor of the idun. 
Jancway foimd that variationa of innnimnl prruuir belwcrn SO nnd 120 ram. lie are 

onunon In ihir mumc patient, and IImi writer's experience beani this out. The puW-nte in 
BuaDy rapiil, S(i to 100 jicr minute, feiem ftads (hut tliere ia uauolly u rise of bl(Hid-i>rrh> 
sure wh*Ti improscnienl sew in, snd a fall whc-n the cjum iii tcnttiniE wome. 

:t. Shock. — ('rile ho* ahown that in Kurfcical xhock froio injury or pain there is loss 
of tonic aclivilY 111 tlit> vsMimolor centre eisclly an in aciitr inff^liniiH rliricawH. Syncope 
from emutivnid excitemrnl. etc.. Sa of siiniliir oritnn. Crile coiml«nictB the viuoiantor 
pamlyxix by puttinfi n iloiiblc-wallcd rubber xuit upon the patient unil inflatintc the chnni- 
bCT ljet«*«i the walls until tlie prf«*.ur* comp*n»a1e« for the loss of vascular tone. 

Ilenderion. nhile conlimiiug t'rilr's olwervatioiu u ivpirdB the pomia of the vaM>- 
motor crntrr. bflievrx thnt this is not the primary phenomenon. He calls atl«'nlioii to tlie 
(riniilarity betwtr-n the phenomenu of ehock ami those of muuntuin tticknesn. wLicb Mooin 
hasflbown to be due tna lowi'OjCoiilrnt of tlw blood (ncnpniaK Hcudprson IwlicveA that 
tlwi Boedianian of the ttvo conditionii in Hiniibr and is able lo iiulMlsntiate hlx claim by 
(mxliKiDg aliock ex pprimen tally under nil conditions in which ('O, ia mode to eMnpo 
npidly (mm the blonl, cither ihroush rnjiid n^rniion of the Iiinfc* or ihmutch exposutv 
of tli0 liil(MineR nnd iiienentt'ry to acurrenl of wnrm nioiat iiir. He Iiaa aliown further 
tlial CO, ia the hormone which pm>cn-m the tonic conlrnction of tliewnllsof the >'cins. 
Bojicro/t hsx nWi shown ihul llwue are undpr nervous control as well as the arleries anil 
that llieir nerven uriae in the name re^oiis an do the viuioniotor nerves to the latter. 

Aeeordinff to llcndrrwin the aiwiiiencc of c^-entji in ahock ia aa follows^ 

(1) Psin or emotion; (2) hyijerpnnea: (3> overa^ration of the blood (lowerin): of tha 
(X>, cuaiteui, acHimia), dilotBiion of the veina and accumulation of blood in the l»tler, 
lowcrinft of the venous prouurc (and hriicc diminiiihcit entry of blood into the lieott); 
(4) fall In iirlerial premure, uccumpanied by Iuim of arterial toiw (vaaodilataCioti}; (S) 
eerebral luuttnia. 

Thrre it nn accumulation of blood in tlie veins with deptoiion of the arteriM (an 
art«fial iniemia). 

In fevers the htith temperature fi\f» rise to n sliicht polypmva and also favora 
the eraporation irf IT), from the hines tleniterson believen tliat ihene factor* «oApef»Ie 
with the loxini in prodtieinft the vaMuniitor immiRi of infcctimia dinenses. 

It will be cevn ihHi in many of the functional cardiac diseases aociuntiUtiOn of blooil 
in lite %'eins with dejilelion of tlie arlerin ia the mot<l Btriking disturbance in llio circida- 
lion, tuMi plays on imiwnant rUo in producing the clinic«l picttiro. 

^ disp;ases of thk hkart and aorta. ^M 

Whether nn orcnsionil wliiiT i>f CO; or niereiy occasionally holdinit t.lie brwitli nifll 
tvlievu lln? iLCu|iiiiu »»■! resMrV' tlie vuflculur [uiirr in such caava reniuiiia ta Iw pruvcd. 1 

4. CalUpM frotn vaniiun jnisotui. onriioliA and Mlicylic- nrii), nnvnic, phcwplionu, 1 
drug* of tlic tiniipyrv'tic xericM, oK'., t» Uue lo ibu «aiiie cutLsc — lailure at tlie vitaocan- 
«trictor CPiitiv. — unci liki-nise is acconipunieil by low Mooil-pnsBurc. 

A. Aftitr cxtirniivc hemorrhage u, Cnll nf blood-prcwiiire teW in (except afl^r veiie* , 
SMlioD in ooin^ ca«ai> wliere a fuiliiig hvarl in relieved), owing to luck <■( blixxl lo fill out j 
the artcriiTs. Tliis in usually rplii^vnl liy subculoiicoui or intrai'onoUR NaCl inliuion, orl 
cnreii by liiitiot iir1i?nal Irani-fiikion (Crik')< I 

G, lu diarrhua. dywntcry, cholera, ur nfter proftuw mm t ti ng , aa from vanoerl 
of *Uimnch. ititiutiniU nhNlnic-linn, prrilnniliH. etc., when larg^ HmounlH of fluid have 
lefi Itie t)i>dy, tlii' artnnvi may sloo bf di^jilete^i of fluid and i^ very loiv blood-priMiure J 
ntult. Tlii» is iilsLi ri-li(>v«i hy infusion. 1 

T. In pkurliy,eF-|>eriHlly plenrigy with effusion, blood-preMiiwiBunifonnlylow. 1 

5. l>oficardilis is ju'i-ompaiiied by Ioh' bloiKl-proBurv (m.ixiniim) 10(1 U> 120, ' 
minicniim 7(1 lo !)0, pulsc-r.ite iiirrcascrl) unlwa con>plicnlc<l by hypcdrophy of ihc heart I 
or Boiiic olhor fiiciom. I 

e. Acute cardiac diseaics of nil (y|i«(. which hnt^ not lx«n prrccdni by chronjol 
prooCMW ami arn not iixwwiBrpd with iriarke.) cyanonis. Hero the aUive-iiientioneil toxin 1 
nelion oii the vuMiniotor ci'iilrt^ in uHuully pniwut if the rtidocurdilix is of the iiifectioiM I 
vnrifty, nnd linidcs then? in Home weakeninK of the heart. The qiiiekMMd ptllH-rM«'] 
prf^entBCO, from aeeuriiiilaiin;( in the blcxxl and the asph^iiial rise in prmrure dow not] 
occur. K. WeigiTl wj.Kir(K nil r:iii;ri's uf prfsaun? Iwtwii-n OS imd MO ram. IIk- 1 

10. In chronic mJIral ntcnosi.i the mnximnl and minimal prpuKiinw are usually I 
Dormul or a little below normal, when the left ventricle dom not bypertrupliy; hut lliia I 
may vary eonniclcriibly. 1 

11. Chronic WRiiln^ dl*cA*c*. eanner, ehronie phtlmis, anu'iiiias. ele,, are twwoeiaied 
with brown utruphy of tlie lit-art niiiBele (nee puf^ 211), willi wi-iikened lieurt action, 
h«nce iril.h lowcrcil blood -tircMurc (10 to 20 mm. lower than normal, puUr-mtn luuallyj 
inereaaed). J 


^'a^io^l« mt'thotls have bwn drvised for the determination of tlic venous ( 
blooti-preshure in tiian. the fii^t bi-iiif; int ivtditertt by v. Uosrh nod beinf; 
but H nlijjlit vaiiation of hix arterial sphygitioniunoiiti-tcr. 

A very mmilar apparatu* has Iwon conol nicteil recently by Scwull, but this ^ve* 
rather unsulisfaciory rwiiiltii in ])raetiee. \'. Kri-y and lnl*r tiiiertniT also det^mlineI| 
the ppRHiurr by coniiidcrJiii; it nguni to the height abo^-e the angle of I.iidwix at nhicH 
the ^-ein* of the hand eoiild lie >.oeii to eollBpne. This inel.hrjil is not 'piite as jEwd ua the 
formrr. A eonsidpnibie adiiuiee wiw niiide by v. llMkliiitdiiiutv-n, who comprt'iaed the 
vein by inHalinK n nmnll niblirr rapsiile pmviderl with ii g\iu# window in the lop and a 
niblier-diim lluur havirit: a liule in its eeiiln.', Tliis dum wus cuuted with glycerin so iin to 
innure perfeet coiitnet. It is llicii plnw-d vvrt a vein, preferably upon the back of the hantl 
or wrist, and the 8y«lem blown up until the vein can be ee*n to <liMkppear, ut vrhieh point 
the prpHsurr is read otT (ijion ii water iiianuiiivlcr, Eynter and Honker h^ivc^ niodilied Ihia 
chamber hy eonslrHrliiiB one of aluminum with the entire lop of fctla** and Ilie twn enita 
concave no us to avoid presniire ufHin the veins, and their upparaUis BCeriis to K've multa 
eoneoni.ani within 1 cm, H,0, Tliey find tlim the norninl ^■enou« preiwurr !ii the i-lrrno- 
xiphu-d arlleulauon i" •') Itl em. il,(].' It in increased by exercise and in eiirdiae case* 
U'ith broken eotniK-nsalion, when it may rise lo 27 cm. or over. When the veins nre not 
BulRcienlly dislendtTrl at that level the hand may be lowered n known distance, the 
prsBUiv read: and (be ihNlnnc loweml tuibtruet*^ from the amount uf the readinjc will 
npraMnt the venuun pnmiire. I» catmi where jihteboeclcrosia Is pnacnt no aatisfnctory 
deUmit nation)) could hi- made. 

' Time figiitea axrw well with direct manometric determinations rMoriily made in 
man l>y Mnriti and v. Tabora (Verfawndl. d, Kong. f. binere Med., 19W, xxvi, 3n). 





lips, muy 

Th*" prt- spurc- in llie cftpiilaries of vascular areas, specially of the 
bo (loU'rmincd in the Hamc way, uving the jioint uf blunching a» the 

The »ttuly of the venotiti pres- 
sure ix of uudoubtcd Jniportuiicc 
as an index of aceum illation of 
the bluud in the systt'mie cirru- 
lation and thus as an index of 
heart failure. Mon-over. it in the 
most importaot physiological 
faelor bringing nliout varialioQa 
in the volunK- of the heart: a high 
venous presHure causing dilat-a- 
tion. a low venouitpn-jwure eau.sing 
diminution in volume (insufficient 
filling). Thi.-* intiy prove Ui 1)0 an 
important factor in brtngingabout 
certain eonditions in which ihere 
18 "aru-rial anu?miu" (shock, car- 
diac neurosis, etc.). 


Beforc birth the redftjince id 
the vesftcU of the collap.-ieii Umg U 
[■at*r than thai in the systemic 
^kfteries, and h<-nee blood passes 
from the pulmonary artery to 
the aoria through the ductus 
arl«rio#ui) (Botalli). 

Kio- 31.— Hooker anJ E>>iei'i mixlIGcaXiun of 
A> tke blbCNl-pitWUre in y*HtOg v. RvtklinBtuumi'i iualli»] uf .UcrmmimK tt"< vriou* 
' infiuiU i> so ami. llfi (Tnimpp), U miat P«-«i» m mw. 
bn oMnanfl Ihni ihe pulmonary [irc)«i>in> 

(Miniewluit |;i««tcr tliaii Lhis. VVliL-n (lie arat of lUDK capilUriua URlnm nitli ibe Gnt 
RpiniliiM), Itu! roUUincF in ihr piilin»nir>- vrm#Iii dMrnoM;* vnty niark«i!y. Ttiiic 
'(lccn>:w««> rontlriUm iliiritiK Ihe period of infancy unlit tlie hinfC is ftilly cxjianded. 
.AftKiniiDg lu a mimhi-'r of oboervera <Btulnt-r. Uchtliclm. Opuothomiki. Uriiilfonl mid 
DvHn, niiinii-r), the mmii piwwiirc in the piilmonniy arlt^ry of mbbilH, cut*, tuiil dogs 
vnriM tTuin A to :iii ii>ni. Hk- II iiia.v be said to Ik> uppruximutvlT Dlie'tliird 
lliBl of the aorta but cubjrct (o maaidenble variatioDH. H^nitHlt Iibji found 
that In rabbit* aSili 14:^ mm. prmmiro In tho aorta tho prmsiitv wiiliin t)ie risht ^-cntricle 
i* mticb xtmlvr tlian Ihia. 

The putse-prcssuro in llie pulmonan,' arten,' is much smaller than that 
JD the Aorl4i, probably alwut 0-12.5 mm. Hg in small animals, and iu 
man not far from tbcw figures, 

Work of the Kight Heart. — The pressure within the pulmonary nrt«ry 
und hence the work of llic right heart varies within wide limits under 
frxpt^rimental eonditions. 

These variations are in part pas^ve, due lo pastivv .staius of blood 
within the pntinonar^' vessels, and in part may bo tho result of vaso- 
motor chungeK iu the pulmonary vessels. 


The conditJoiiii in which the changes in pulmonary prtssiirv arise 
pasavcly from changes in ihc left ventricle are the moat common and are 
cJinirally ihe most important. 

IncrraMHl tnfan pulmntinO' piVMurp may arise: * ' 

1, When Hii increiuied omouut of blood unt«n the right heart from the retna and w 

expelled into Ihn pulmonary nrlcry. 

'i. Thp fitilinonury blmxl- pressure a]8u uii<ler^u«( rlirltiiiiic vuriBtioiia. falling duriug 

iimpiratioti ua u ruiill u( Buelioa (ns nhnwii by dc Jtifyt) niid [ixing <lii[in|t expiratiou. 

3. When the Icfl vci.l.riclp fsilii lo pump an etjiial aii)oii(il onward into tlic aorla... 
«MiiInf blood U> uccuiiiulule in the pulcuuimry cupillurics uolil Ihcsc are overfilled BrHl'l 
•id in increwiiog Ihe remnlnnce in thi* circuit, (ilie left *icnlricla acl« upon the puU 
■nonary eireuUtion a« » suction pump.) 

4. Probably TroiD voiuitrictton of ibu pulmuimry arteriea under the inHucnm of 
vniKimolor nnrvcii. 

Pulmonary Vasomotof Nerves. — The existence of vftjtomotor nerve* iol 
the pulmonary art«ry, first Buggcstcd by Brown -S(5quard (1S70 to IS73) ant! 
later by Badoud, has been much disputed, but seems now to Ito proved. 

Francoin'FRinric hnii (hnirn that ititntiUtion of the lon«r cervical And Upper five 
thomcle j^iintftiu in llit: do^ unifonnly euUB(^d a ri«c oS blocMl-preaBure in the pulinormx]' I 
artery, a full «( prraiim in (lie left auricle, and an increaac in the volume i>f the lunj^J 
I>rotialily ibie lu iicciiniiilnlinn of blood on the ari«rial dide of the capillaries. This rite in 
pulnionury pressure bore no tonaluiil relutiun lo the prwHUrv iu the fetnorn) artery, which 
RomelimrK row nml iiomelimrii fell. I'lii^ evidence >itrant;ly favors the exisWDCS of vanocon- ' 
Htrictor fibrvs. Fmncois-Friuiek tJiowetl liirllier ihHt Ihew nunie etiangea tn pulmonaiyl 
arterial pnw:ure. left uuriculnr prmaure. and lung volume occurretl relie«ly when the central I 
eiiii of the femoral nerve or a proximal hmneh of the Kolnr plexn« wax oliniulalrd. ThiaJ 
reflex, on hi- nhowB in u subsniiii-rit jiuiier, may Imve !i!i[)orUnt beoringi in tlie production ' 
of certain cardiac dymptoiiix aiul in influencing; the courte of rardtae (IlHcafics. 

Action of DruKS on the Pulmonary Circulation. — Fran^oiif-Frftnck's ri- 
aearches are very ronvincing. Thry have been confirmed by It. C. Wood, Jr., 
and ulbor.'*, amlurc arci-pli'il by as keen a critic as Tij;er8ledt; bnt Wood, Jr., 
and also I'ctitjcan have found thill all drugs exert ii muvh losn 
marked effect on the pulmonary circulation than on the 
systemic. It miut be admitted that acceptance It not universal. Thn 
clinica] importance of the problem renders it a matter of universal interest, j 

It may be considen-d proved by Frangois-Franck's work that sensory^ 
stimuli, stimulation of the sympatlietic ncrve«, asphyxia, etc., may cause 
the pulmonary arterial prettsure to rifle to about double its original heif^ht, 
and hence in chronic conditions may play an important ratio in briuipng 
about hypertrophy of the riRht ventricle. Moreover, changes of pressure 
which are relatively small when applied to the left ventricle a.-wumc much 
greater proportions when applied lo the weaker right ventricle, and appsr- , 
ently ititglit changes in the .Htrenglh of thiii chamber may then be impor- 
tant factors in the mechanism of the eircuUtion. 

Tonicity of Ihe KizhI Ventricle. — More important than the changes in 
pressure in the pulmonarj- artery are the chan^t*^ in tonus of thi- right 
ventricle. Owinjr to the thinnej« of the wall, changes in tonicity affect 
this chamber much more n-adily than they do the left; oversl retelling of 
the fibres seta iu more readily, and weakening of the right ventricle resulUi 
more readily. Tlie^ changes may have do direct relation to the changes 
iu pulmonary arterial pressure. 





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sriii Shack, ibid., 1809, xxiii, .^5. 
Dawson, P. M., and Gorhuni, L. W.; Tlie Pul»e-prniaure na »□ Index ot SyBlolic Oulpiit, , 

Jour. ExguT. Med.. N. Y. nnd Ijineiulcr, I'JQH, x, 4S4. 
Cohnheim, J.; Locinrfn on Gonerul Putholugy, L,uiiiion iNrw i^ydenham Soc.), IBSS. vol. t. ! 
Scliott. Th.: UeutAcli. ArcH. f. klin. Med.. Ldpz., 1902. Un Bluod-prvwure undpr iha 

Influence of .iriil^- Ovr rat mining of ihr Hpsrl., New York Mod. Jr., IIKK, Ixxv, TOfi. 
Cabol, it, (.'., and Brucv, R. B.: Ou the M«uiin>itieiii of P'unctiona] H«art Pou'er. Tmix. 

Aimc. Am. Phy«., 1907. The l-jiiitn.iijon of the l-'unctionnl I'ower of the t'urUio- 

vanculnr AppnrndiN, Am, J. M. 8c., PhlJa., liMjT, ^xxxiv, 491. 
Boweii, W. P.; Study of the Pulse-rnti! in Muii lu Modilied by MtiBCuUt Work, Contrlb. 

W Mrd. Rt-search (VniijihnnJ, .\tm Arbor, 1003. p *^. i 

tlvwel], W. li : \ Coni ribulioii to the Plivsiolojo" of Sleep, Jour. Exper. Med., N. York, ■ 

ISU7. ii, 3i:i. 
Brush. (*. K,, luid rayerwesthrr, R.: ObwrvstiOR* «R the ChAnjceo In Blood -priMium 

iliiriiiit Normal Sleep, Am. Jour. Physiol., Bosl.. IIHII, v, ISA. 
Bohf. Chr.: 1'hyBJologii- dur Almuiig, VV. Nngirl'ii Hanilb. d. Fliyniol. d. Meiwcheii. BmiUI- 

iirhn-riK. lim. Bd. J. 
Traube, h.\ ^'on den Emcbetiiuii^-n, Wtlchc mau atn (.Irvulalioimupfinrut. boi EinblaMib^ 

vou Waanenitoff odcr von Siiucriloft oder einos CiiseemeuKes nus Kohlunaflurv, S«i4er- 

ctofT und Slicksrnff hrohiwhinl, t!i«. BeitrAKii itir Pathol, ii. I'hv^ol,, Bcrl., ISTS, 

i. 332, 
Klug, I'.: L'ebcr ilen Einflun der KohlcniRlure und dra SauereliifTa nuf die Function de« 

SAumlhierherM-nH. Arch. f. Physiol,. Leipi:,, ISS;t. p. 134. 
KoDo«. H. (!., (Uid -Stenbeck. Tb. : Uelicr ilic Encheimmgen des lihitflrucko bci Eratick- 

un^t, Sknnd. Arrh, f, Pliysiol., Ijeip*., ISW), i, VXi. 
LAntcendoriT, O,: irnlvrsuchun^-cn uelier die Natur die des periuUiBcti-iiumetxeuden 

Khjihmiui tmliciiondt^rc des Hcr^iiTui. Arrh. f, d. grt. Physiol.. Kacu. 190T. cxxi, 54. 
Puittitr, H,: Tcbcr die I'rsacbe und Bt-icuiunjt 'ier Henaffeklion Nierrnk ranker. Stunml. 

kLn. Vorlruee. U-ipi,, 1906. Inn. Met!., No, 12:^, 
Biitt<;miann: ICiiiitte Beobnclitiinttrn iirbrr dm verhiillrn dee Bhitdruckcs bci Kmnken., 

Doul«cli. Arch. f. klin, Med . Leipn,, 19(r2. Ixxiv. 1. 
Jnnoniy. T. C: The !*uIh<JoKicol I'liysioloiry of ('lironic Arlerinl Hyperteimion and iU 

Trenlracnt, Am. Jour. M. Sc,. Phila,, liW'. cxxxiii. .W. 
I^r«e, R. M.: The Tlieory of Clieniicul Corn-luliou lu Applied to tlie Pathology ot tbe 

Kidney. Areh. Int. Meil., CTuciiko. 1908, ii, 77. 
liqueur, A.r Ziir Kenntiiiw ureeinlsclier Ziudflndc, Dnuitwh. mp<i. Wochn»chf., Lclpt., 

IttOI, xxvii, 744. 
Enget, H.: I'chcr den Wert, dcr B]iitdnieknir«iuit( bci chroniiiplier Nephritic. Verhnndl. 

d. deiitsch. Naturforsfh, u. Acmic; Zcmralb. f d. (tcj". Phvsiol. u. Path. d. Stoffw., 

Berl., 190S, ui.SM. 
lararl. A.: Klini»ch« Beobni-htuntirn iirhnr da» Symptom d<-r Hypertejution, Sninml. klin. 

Vortrflitt', Leipi.. 1907: Inn, Mwl No, I3."i, 130; and In, Di«s,, ^traebuni, 1907. 
Cuihinf;, H. W.: .Same Expt^rimenlid nnd ninical Observutioiui C«ncenuuE Slatm of 

Incpca*"! Imrncranial Tciwion, Am, Jour. M, Se,, Philn., 1902. exxiv, ;S7.^. The Blood- 

prewun- Itcaetionuf Aciile t'rrebniICV)m|>r»Bion Illustralvd byCaac«<of AriileCcr^ral 

Ilemorrhnsf, ibid., lUOIf. cxxv. 1017. 
Hill, I.. Th<' MeclianisTti of the rirciilnlion. $chftfer'« T«:xt-book of Phyniol., Edinb. ftnd 

liind.. 1900, ii, 1. 'nil- IV-re-bral ("insulation, Lotul.. ISIlfl, 
Kocher. Th.: IlimcrschuitcninK. Hirndmck. u. ». w. Noilinjuser* tinndb. d. upec. PatJiol. 

\i. Therap,, WIcn, 1901, vol. ix. iliHT Theil. iil* Abilicilung. 
KIm, a.: t'ebi-r einige KtRrbninw von BluIdrucklu«HHungen bei GeiaUiikrankMi, Wten. 

klin. Wochcnwhr., Wicn, 1900. xiii, 270. 
Pal, J.: Die UvfJUukrtBea, Leipt., 190;>. 


Gibmn. «. A.: Ueort-t.tock. Bnt. M. J.. Loud.. 1906, ij. 1113. 
f SUtnona, J. U., and GoUUbnrnugii, F. (.'. 8or i-hnpirr on rrccnancr. 
< HaKfifehl, A., and l'enev«»tiy, 8.: Ueber die LelniuniCKfaliigkeil d<« (ettig LiiUrtclcii 

Honuw, BerL klin. Wdtuachr.. 1899. sxsvi. SO. I3S, 150. 
Crile. C: Tlio Blood-praMUic in Kutsery. I'hila., IfHU. 
Iteudnauii. Y. (wilh ibe ptJIulioniliiMi of M. McR. Smrborough, F. P. niillinTWorib, fuxl 

J. It. Cofltiy): Acapnin mid Shuck. I, ('uxboo Dioxide an a l-'aclnr in Uie R«xulation 

ol tlw Hrart-rute. Am. Joiim, I'Ii.vmoI.. IIohI., 11)08, xxi, U6; P»rt II, ibid., 1900. 

xxiii. »,S. iu»t I'nn III. itml.. IIKHI, x%i\. Gd. 
Mo«ao, A.: Sui rapporti 'Icllu reHpinuionc alKloiiilnal o loracica.. Arch, per bt Mi. med., 

U7!i, PiMolagia dcU'uomu sulU Alpi, -Jd mi,. 1KS8. 
MoMo. A.; Id rcxpiration |>i<'ni«liqiir (phfiiorncnn dc nic>iie-.*»Uik«) trile qtl'elle m 

prodiiil cliex I'honiiiiu sur Ins .Mjvs par I't'lTi-t dc I'licnpuir. Arch. ilii). dp btui,. Turin. 

190.^, xliii. Kl. UifFi^rciiecs iinlividiirllc* danii la rmiiclaniv il la pmwion psnip le dc 

I'oxyiCttne, ibid., ttHlG. Ixiii, l!)T. DeinoiiBtralioci dco cvntne mtpir:ituimi spitiaux 

au nioyi-n dc rncupnie. ibid., 1905, Ixiit, 2111, 
Bamch, J. H.: niood-pramun Smdiw. in Typhoid, S- York SI. J.. 1907, l«)cvi, 348, 
Crite. (.!.: DiscnuBtio Value of BkKMl-pmeurp DelvmiiiLuliuiiii in ihe DiagnotuB o{ Typhoid 

IVffontion, Jooir. Am. M, AiaiK., ilhit-jifpi. 190;(. xl. 1292. 
RriKC«, J. W,, aiid r«ok, II. W, : Clinical ObecrvuiioiiH on Blood-premure, Joluw Ilopkine 

Uo.p. BuU.. Halt,, t!)03. li, 151, 
Wtajccrl. K.: LVIkt dun VVrluilU'ii de* artprii'Upn Bhitdnickii hri drn akticcn Infoctionn- 

krankheitrii. Fsimnil, klin, V'urlriiinr, Lfijix., U)07. Inn, Med.. No, 13!S, 
John, U.: ticbrrclcnattcricllcn Ulutdruck kici I^thisikcr, Ztaehr. (. iliat.u. pbynik. Thcmp., 

LHpi.. 1901, V, 'JTJJ. 
Nuunann' Blutdmekmununin^n an Lutigcnkninkcu, Ztachr, t. ISibt^rkulumi ii, IIeili>LA(< 

IPDH., Uip«., 190). V. UK. 
t^iamon, W. B.: The Btood-t>r«B«<ini in Tiiberculcwtia, InWmat. €Un,. PhiU., 1907, 17lh 


I'eten, L. 8,: Blood- pnmturv in 100 Casw of Tuberculoftift at High Alllludea, Artb. Int. 

Sllld., ChicnffD, [90K. ii, 13. 
Crilt, C.and Dollpy. D. II.: A Method of Ticalmcnt of Ilemorrhn*^, Jour. Am. M. Amoc., 

Chicu^, 1906. xlvii. 180. 
v. ReckliRxhaiiarn, II.: UiibluliKc BluUlruckmciKunK, Arch, f, cipcr. Palb. u. Pbarmakol., 

Leift.. V.K>&. Iv. 
Ilookcf. l>. H., wkI EyBrer. J. A. K.r An Imlruinent for the Helenninalion ot Vwiom Prra- 

■ure in, Jolinn llopkitu lloup. Boll., Bidt,. I90S. xix. 27*. 

PituiaxARV CutruwTiwt. 

Trumpf). J,: Bli;idnicknietiF'iin)n-n an |ci»uiidcin tind krankm Ssniclingen. Jatirb. f. Kinder^ 

hnilk.. Hcrl,. 1906, Ixiii. 13, 
Beutiier, l.iehlhrini, Opi>ncho«-*ki. Bmdtoril nnil tJenii, I'luniirr. qimtcd from Tip>"ledt, 

R.: Uer kirtntt Kreiiilauf, Rnfeb. d, Phy-ioloicif, Wle«b., 1903, ii, 52S (in wliicli u cam- 

plrt4> summary ■>' 'btr lilcraturt- (u tliul dale is tu be fouml. with an excellent r^iun^j 

uf Ibe facts), 
Ke .fnorr, S.: Uetiv den Blutstrwn ia den Lungen, Arch, t. d. gea. Phyniol., Bonn, 1K70, 

xxl, *m. 

Fnuii;<a>-Franok, C1i. A.: XouvelleH rt-rlierrhex Htir I'HClion VHHU-oonHlncttw p(itiou«iair« 

du grand nympnlhiquc. Arch, clr physiol. nor. M path.. I'ar.. 1305. 5 Utt.. vii. 714, SIS. 

Elude criltiitw rt «xi>^rimeTiisle dc la rimnroniKriction pidinonaire r^tleM>, Ibid.. 1896, 

« 8*r.. viii, ITS, 193. 
Wood, n.C, Jr.: .K PhvaiolofcicAl Sludy of the I^llmo1lary (.'irrulalion, Am. Jour, rhysiol,. 

Bent.. 1902. vi, ■£i:l 
IVtil)mD. r..: .Action tie ijuclinie^ mimit'uiiienlii vsaomoteurv (nitrite d'amylp. ndn'nallne, 

prjEOt dc wi(le') Hir U t-Irvulalion pulnumaire, J. dc pliyniol. ct dc path, ||;dd,, I'ar., 

leiB, X, 408, 



One of the moHt importunt fnctors in determining the work of the heart 
and the nutriiiR-ril of the lijwui-jt is Ihi- vlscosily of the blood, — that i». tlic 
friction which iti^ molecules exert upon each other and upon the walU of 
the blood-vp»seU. 

PoiMMiillft nnd later Arrbeniun intro<liim<l n mirthiyl for ilnlnnniiiinfc visconiCj^ f{iiBn- 
titalively Tor Indifferent fluid* by obeerviriK ibi- tiiiiv taken for a iu:ii'('ii tulmiiv ut nuiil to 
flow vprlicall.v ilowii ii givi-ii k-ngih of npiUiiry tulie. Tlip liaip taken by water to (low 
iiniiler the Ramr conditioiui wjui iMctl njt unit. Poiiwciiille found 

(^uaulil)- of blood Houint! in ^i\-en time ^ vi(;ciHiiI}' ciieflieieal X (iiianiel«r at 
captQiuy)' X height of pruuiuru : l(-nglh of tubd for dialancc of Row. 

Hiirrthle found ihnl PDiiwciiilli>'i> Uw alao litid for pulsating fluids and in«>aund the 
vi«co»it>' ut ttie blood in tlie living aniitiul by compnriiiK tlic outflow of lilood from a napil- 
lary tube introduced into thn aorta to tho (ititllow til water under the •amc canditiotm. 

ViMMHity eoelIici*iiL (water) -4700 
Dog'ii blood -= 1«4S 

Dog's blood 

4700 , 
10l3 "*" 

ConlHcient of viacomty. 

Apparatus for Clinical Dcterminallon of \'bcosity. — \'arious forma of 
apparfttu-s hiive been lieviwd for iletennining (he vi.scosily fliriically, niont 
of them depending upon the time taken for a column of blood in a given 
j^ capilliiry to Iruverse a given distance 

or to flow out of a given orifice when 
Hubjected to the presaure exerted by 

a constant column ot water. 

^?nSi ....••CL 


tla.33-—Oel.vnvanu\ a]<['iirmtiu lor ilrMnainin* llrp i''>ni>ii>' o( thi- hlonil, lAOtt Bni^oli wi<l 
SohitunlitiEni-f A. Ap[f&riLtu> at rt«t ou jtn vljknil. fiivulnlou llie TliermonLel^r and (he handle mut iiKt». 
In Oiv iilnii<l*r*aHvlii( lulw williin thr «niW(-jiiciu>t tt—df, ub— aJ. U. UeUud ot tjipllistlou. (Afler 
lirusur-h uirl KFhiitvnMm.) 

Such iippuniluK hiui been ile«cribcd by Huertlde. Burl4>n-0pH«, HirecJi and Berk, 
Dclirnnann, l!r«>i and nlwi MoTiuikpy have deviacd VPty aimpb form* of uppumtua iji 
ivtiich Btielion froin a riil>U>r Imili lb used inBt*ail of posiliTe prowupc. C. R. Amtrian in th» 
Johnii tlupkiiiB MihIicuI I'linic liiu found Ihal Ilie Hem appMralus gi\'«i rm\ill(i willi tiomial 
blood wliioh tall}' well uilli the hlooil roiinl, and whirh ihcreton! »cem ipiitp Biijafnelorj'. 
De te rni 11 II II 'n newer u p pii ra I iis {Vie.. 'Xi), howp»Tr, cnmbiiie» cUnicid 
llwnicow wilh uccuracy luid i» prolinhly ihf iiiorit saliafuctory now in u»e. It eon- 
Bt8 of a rupillary lube Mirroutided by a fininll cnndcnMr^jacktt of tcl)U» contaiiti&x walnr 
at 38°. The jacket bear* Iwo side uraia wliicli rest in ihe torka of two iipriglils bo rhiil rhe 



MURip n vftrtickl pontion. The appantu* i* token up lu a whole and (ho 
up lo a nwrk on the capUbry. The appai'ulua ia thrn placed hack on ihn 
turkv, a&tl Hit tittip lukui for the blixMl to How ooit unlil it rcHcbe* a aeooud (lower) m.irk 
ta noti^l. (Thw i>huul(l [pquiro 30-40 aoconda.) A aJcniUr det«munatioii is mailc with uat«r 

In order to keep the blood from clotting, n tjltt« hinidin may be placed upuo llie 
ear before KlabbinK it. This does not Bll«r the viaooKlty as do addlns sodiiiin oxalnti;, 
laltiog. and delibriiiation; and keeps the blond from clotting for 20-30 niioutva. 

IhrU-miniin flbtains a frw drop* of hlnod quickly by liaviitft the pstinut cxcrt a forced 
cxpirattun Willi ibe gloltis ctuoed (Vulsalva'tt cxpennieut). 

Factors Influencing Viscosity. — Ilcubnor, Detcrmann, and others li«vp 
that the chipf fartor in det«rniininR the visnosity in the viscosity of 
: lod corpiisclfs. to which »l)uut two-lhiriis of ihc viscosity of the bloo«l is 
due. Indeed in many caees the»! observera, and also Austrian, have found 
that the hlood-counl and the vigeosily furni:4h accurate controls of one 
another,^ though there are exceptions undnr patholopca] condition« 
(leiiluemia. etc.). There is little if any difference between the viscosity of 
the Dormal blood in the arteries. capillariCH, and veins. Bui in venous 
stasis the viscosity increases tremendously. 

In a poly cy t h acmica with 11,000,000 red corpuscles the vis- 
cosity may be three or more time,i the normal (Stern). 

On the other hand, in anaemias, fcvwr, the liydraemia 
which is associated with anasarca in broken compensation or exudates the 
viscosity is uniformly greatly diminished. 

Burton-Opitx found that diet exerted a considerable effect, meat 
raising the viitconily, carbuhydratos and fat 8 I o w e r i n g it. 
He also found that hot baths lowered viscosity while cold baths increased 
,it. Hot-wr baths m-em lo have Htlh* effect. 

In compensated heart disease the water content of the blood does not 
ohanKc (,\skana'.y), nor docs the viscosity, but Ihe water i.t increased and 
the viscosity diminished (3.74 to 4.21) when compensation is broken (Dctcr- 
mann). In bronchitis and diabclej< it is higli (o.o). 

Detemiann cannot confirm the findings of Otfried Muller and Inada 
that potassium iodide lowers viscosity ; and indeed the chanfces which they 
obtained wito h-j*s ihnn 1.0 per cent., well within the liniit.-i of experimental 
error. Their paper, m well as those of Hirsch and Heck, illustrates the 
tendency of workers in the field to draw too definite eoncluMona from too 
small variations. 



lUaieaUle; An ilc chits, i^t dc phm. Par.. I)vl7, -toAr., i, 21 (quoted from Hinwb und Beck]. 

Arrhmiiiu, 8.: Innore R^lbiiiiK wiu«eri^r LOttunpn, Zlacbr, f. phvalk. ClKim., I^eipi., I>Ut7, 
I. 2S». 

tiuorthlc. K.: n'identnnd dcr Bhithnhn. IViiIneh. mrd. tVoclipniwhr.. Lcip«., 1S97. S09. 
Uab«r tiUK Meikxlc tur BentunnniuK der ^'iAkueilJit den lebendon Blulm iind ibrv 
BtgdmiHe, Arch. f. d. gi-t. Phjnial., Bonn. 1900. Ixuiii. «t3. 

Buitun-Opiu, R.: t.Vlwr ilii) Wrilnderunfc <ler ViiikoMiai liea llhitrH iinirr drm f^nfliwa 
vtmctilMtHiM Endihruiig uiid pxpcriincnteller Eiii^rifTi-. Arch. f. d. Km, I'liyniul., 
Bonn, 1900, Ixxxii, -lir. Wrxli-leh dcr VUkoaiiAl dc* ntirmalcn mil dct drs Oinlnl' 
blutaa iiiul dm dcflbrinirtcn Bluieti viiid dra tUutaCTUiiui bei \'cn!chicden«T TeRipera- 
tore. iUil,, tUUU, Uxxii, 464. Wciten: ntudicti ticberdie ViskuHiUil dw Blutca. tbidi 


1906, cxii, 189; ftbo Am. Med., 1900, vii, 111. The Effect of Changes in Tempem- 

ture upon the VUcoaity of the Living Blood, J. Exper. Med., N. York, 1906, viii, 59. 

The Effect of Intravenous Injections of Solutiona of Deztroae upon the Visooeity of 

the Blood, ibid., viii, 240. 
Hinoh, C, and Beck, C: Studien lur Lehre von der Viscoeit&t (innere Reibung) des 

lebenden menschlichen filutea, Deutsch. Arch. f. klin. Hed., Leipc, 1900, Ixiz, 503; 

and 1902, Ixxu, 560. 
Detemiann: KUniache Vntersuchungen ueber die Viskoeitflt des menschlichen Blutca, 

Ztschr. f . klin. Hed., Berl., 1906, lix, 283. Discussion upon this paper in the Zentralbl. 

f. inn. Med., 1906, xxvii, 519. Die Beinflussung der Viskoaitftt des menschlichen 

Blutes durcb Kftitereice WAnneentziehung, Wfirmezufuhr, uod WAnneetauung, Berl. 

klin. Wochnschr., 1907, xliv, 687, 723. 
HesB, W.: Ein neuer Appsrat zur Bestimmung der Viscoeit&t des Blutea, Cor.>Bl. f. scfaweis 

Aerate, Basel, 1907, xxxvii, 73. 
HcCaskey, G. W.; The Viscosity of the Blood; Ita Value in Clinical Medicine, J. Am. M. 

Assoc., Chicago, 1908, li, 1653. 
Detennann; Ein einfacbea, stets gebrauchfertigea Blutviskowmeter, Muenchen med. 

Wochnschr., 1907, liv, 1130. 
Heubner, W.: I^e ViskoutAt dea Blutee, Arch. f. exper. PathoL u. Pharaiakol., Leipi., 

1905, hii, 280. 
Stem: Discussion of Determann's paper. 
Askanasy, S.: Ueber den Wassergehalt des Blutesund des Blutserums bei Hrmalaufstarung, 

\1. B. w., Deutsch. Arch. f. klin. Hed., I«ipi., 1897, hx, 385. 


HUlorical. — Obnervatioo of the uioriiJ puUc bcgitn nlmosl ■j-nchronoiudj:' vtth the 
>JtOC»rar« ohmrvation of dJarw)^ in (cmrml. Ilippormtra (B. C fiOO) noUxJ the infirk«(l 
pubntliMi (('V<7p>c') '>' ll>*^ arlf-rira in cerluin diBFami. bitl ilid nul iuaociat« It »itli the b«at 
of IhebcMI. HrrophiliM iH. ('. 'MIO) nbacrvcd the fclati*««ynchixiniiimaf tbtoi.' twoni-cnt* 
■ad apeaku of the i^uii^t |iii1im> in health l<ivi-)fi6() Id oontnwt Ut the marked pulMLiun in 
<lii«iMe <lhe itar/idf o( Hipfxicraloi). Krinlntiu <B. C. 2S0) iihowecl Ihut tlic artcricn nntr 
the bearl hr-nt bnforr iHr »rlrnt» morr <lwT:knt trwa it. Ariatotin and Inter Arcliijtrnoe 
<firiit(Vnturv after ttiefhristiaii enit mudu auniprouHobBPrvaliiMuiupoii the puL«iii variolic 
■liwmc*, and The Iiitirr ilcscribcd and fcovr the natnr tn the lijciotic type in MM* 
ot fewr. altlioutiti he wiill believed that the Hrtc<rle« were fille<l with air. (inlen {A, D. 131 - 
2(K!| dcmoiutlrminl Ihui ihe nrterica were nilcil with hlontl and itiidii'd the iiifluuuM of wx, 
niX, rlioMiK'. iiln>|>, hot ani] mid hatlw ii|inii The ihyihm nf the pulx'. 

The old ChiueM phyalciaiui alno ducribed the pulse and evni made drawing lo 
Qlustntf their iieiiBorj- imprcaiioiu — a pntcticc whirh did nnt hettin in Eiim])c until the 
time ot Henri Foii<iijet in 17(17. After llanfyV <lcriior\siration of the drciilation of tlie 
blood ( ltl2K). the study o( itic puUv wiu roumed with renewtxl vigor aud bu« conliuued 
to the prcocJit day. 

Examination of the Pulse. — ^The rharacUristici of the pulnc-wMt! are, 
a» 11 rule. dot4.Tiiiinvd upon thv rmltHl iirtcr>', in which the nrtcriiil tension 
may bp pstimatfd as (tescribcti on page 19, 1 ho wiiU «f tlir ailery being also 
rollptl umltT the fingt.T while th« nrU-ry !.■« ompty. iinii lhii« Ihe prescnirc or 
abeenc« of arierioeelertisis notett. Thi? walls of a normal arteiT,- are barely, 
if at all, palpable; an tithpromalouf iirtprj' may feel liite the trachea of a 
small animal (goose-nerk) ; a difTusely sclerotic artery fcoU like a pie(.>c of 
thick •wallet I nibber tiilie. 

It is important to note the palpability of several arteries, since one 
of them may etwapc a xeleroUc proccKs. All the blood mu^t have been 
picssctl out of their liunina and of the vcnic comibM that nccompuay them 
before palpation is befiun, or else normal arteries may appear to be 
8ch.>rotic. The pressure is then relieved, and the tips of two or three fingers 
are praased upon the artery until the pulse appears niaxinial (at about 
the minimal pressure), when the following charaeteriBtics are noted: (1} 
whether the artery (beoccthe pulse) feels large and diluted (pulsus mag- 
uua) or small and eonatnctcd (pul.tits parvus); (2) whether the 
pulse is harxl (pulsus durus) or soft (pulsus mollis), — t.r.. whether 
the minimal pressure is low or high; (3) whether the onset of the wave is 
sudden (pulsus rcler) or gradual (pulsus tardus): (■i) whether 
the wave is sustained (anacrotir) or subsides suddenly under the 
finger (eol lapsing, wa te r-h am mer, or Corrigan pubc) ; (5) the 
rate of the heart per minute (counted continuously during at least a half 
minute); (C) whether the rhythm is regular (pulsus rcgularis) or 
im^lar (pulsus i r r ■■ g u I u r i .t ) . 

Clinical Sphj gmogrnfrfis. — An ioEtrutnent (spbygmogr&ph) to 
reeonl th« pulse-wave graphically was first deviwd by K. Vierordt (1S&5), 




but It waa not until ISfiO that E. J. Marey deviitcd a thorouRhly practi- 
cal and accunitf form, almoct devoid of error, which is still in use. 

Mnrry'8 ri[ihy|[iiKi|;ra)>li coniiiiiUi nf a bultoo (pctntlc) pmutetl i4(>Lint>l the skia over 
the urUry b)' ineutio ut u npriii^ su lui to receive (ho fiulHiilJoriH fniiii the Brlvr>'. It u held 
in place by a Icuther cuff, mid it « monl important Ituit Iht- fwlcitlr rpm.iin c-xactly over and 
tiot to one «ido of the iirtpry, TVic pelolw in snrniounlwl by ri vorliciil rod or screw vtliich 
artimlulw by u movaljli- joint with u Ioiik "Tiliiig lever, 'i'lie writitig lever n«ord* tha 
mstsnilird puliu: rnnvrmenlji upon n turfiirci nf Hinoktij )>apcr held in vertical pooltioit by m 
briuw upriiclit und driven by u vniull piece of elock-work. 

A more totiipuci luid eimvfiiifni lonu i>( Bphygmogniph in of Diidj[pon, in which 
tlie St nuiiht lever in Niippliiiiled tiy .1 iloii bio- jointed one which wrileo on u tiuriioultd iuitcBd 
of a vertical strip of smoked paper. The tension of tiiu sprii^g iinssing (loan the |>clotl« 
U roiifthly adjtiatable. which •nllowi' some v.triutioa In the pnmuro over the artery. 
V. Jaci uei ha« inipraved nud)eeon'o apparatus by odiiin); to it ft amall time nutHier 
recording IKihs of u second. 

Another eicellenl fnnn of sphygmogrsph Ih that dcvisc"! by Roy and Adaitii, wliicb, 

by meuiti of a delicate adjuHtrneTit, eiuibles the olwerver to obtnln u ptilsc nieord at 

uxBCtly ilinjitolie pmuiiin-. trtiforlUDDtcly, it has never heMi plneed on the market, and 

, hence Uat mil. been aulijecTed to the toit of 

gencrul um:, but any one who in intcrroled 

in HpbyKmoKraphs nhoiild certainly familiar- 

iie hiiniieU witii their obtiervBttoiui. 



Fi'i l:r , 1,1 ,1 |,<.. r ' 'ikm willa 111* ErLnujittr blituU^ivnurf uppuntrop* front ihf knn* 

trf two pBti^'ir t !■, . .r 1 1.1^ 111. ■iin- m i.h» fud. Tim Tiitiimi iiiiliniln iho prnmirra Kt hIiicIi Ui* 

eurva are ULeu. Huac uuilctliacij unItualiDi nuilnutl Bml miniin*! preuurc* rsfpn-tivsly. 

Errors in Sphygniography. — Tn spitf of the existcnrv of th^«> fiiirly 
satisfactory sphygmograiilis and of their wide use, discrcpant-ies between 
the clinical ol)t<crvAtioiii4 and the tracings obtained are so frreat that CalK>t 
refers to the sphygmograph as " an interesting liltk- toy." The r<.'ii«on that 
it 'us not <if value niii,-*t he cither that the apparatus itself is subject to 
inlierent errors, or that, as Mackenxio .itiitcM. " it wa.-* expeclerl to give in- 
formation of a kind that it was incapable of mipplyiag." Unfortunately, 
both are the c&«e. 

AtJiiuuwiu. ill iiivealijeutiiig tlie aceiiracy of eraphic rrcordinf: ilevic««, foiULd thut all 
8phyfau<i|traphii which innKni<ied the mo»-cmcnt timre lliaii tntnty litiiea intntduecd a 
lai^e inherent error. Ilml <if nil the (omm in line Morey's introduced the leani error, while 
the Dudgeon appiiruliiH niid the Jiuiuct inufcnitied it 130 tjmei>, inlruUucinx tTem«iidoiui 
distortion from liin^inK iarfir. puUelioiia. 

On the other hand, Ihc writer, D. Gorhanll, and Sl*wnrt hare been able to riiow 
that not only the »i*e lull also the entire type ol the piili<e-cur%'e ohtuinei.1 depeuds upon 
tlie prenure excn4>it upon the artery and other similar fuelun: the true form of the pulse* 
wmv» being obluined only when the prewiure enerted by the iphyKmoKraph i« exactly equal 


to tbe pnm^iiv within the nrbery, Fortumilely, tliis is the point nt which the piilw excur- 
•Ion b miLxima). lunl iw all ohBcnTm nirivn for the Inrgusl excursion, it is probable that 
most »iphypno(tmpluc iworda art takpii at altoiil lhi« premure. The ideal ap|>aralu» is 
Iht^ one in which it is not mcirolr probulite but certiiiii. naA 
hcncr thai of Kuy anil Ailami i» Ihe only one wtiich Bboo- 
)u(«ly fulfiU ihc rofttiiriMDetiis. 

The Absolute SphycmOKram. — A wrj- con- 
venient and iiiat ruftivc iiK'lliod of recording pulsp 
tnirifijt'* ha« been introduced by Sahli. Sithli 
transffra the pulse - ciirvo to cofirtUnate paper 
upon which the oritinatea represent milliinelros 
cf inercur>- nn<i the abitriiwie n>prei*ent fractions 
of a aeeond. The lowest point of the pulse-curvt- 
he marks at tlic U-vcl corrf.spoinlinjt to the mini- 
mal blood-presHure, detemiitied at the time with 
the aphygmomuno meter; the highest point at the 
level correspondinK to the maximal pressure; and 
maps out lK'Mdc» this the other main points of 
the pulse-cun'e (pretUrrotic fall and wave, dicrotic 
uotch, Mumnitl of iliri'otic wave, etc.) at heightii 
and difitances proportional Ut their occurrence upon 
the sphygmogram. hut translated to this new 
scale of presEurc and timo. This curve he terms 
the absolute Bphygmograra. 

Fill. S4. — Abiniula 

tormpoad to the ndl^ (m^- 
Ini aliovo. The fituro to Iha 
Imlt indiwU pf—mw Id 
inm. Dn. 

Tbp nlmoliHu Bpliygtnognun (an ulso he read off from 
tb« Dntlnnn- i>|ili>'Kincigram by uning ihR lowtst point on 
Ihc Iruciofi as Uie ordtnute or niinjnial prcMUrti ;ind an a bane litie for det«muiiin|t 
ihn pfnnure at oUicr pointti, sod ciilculsting ibcM! rrora the prDportioii 

Oidinatr of point : Total height of puliie-wave — 
Prcwure at thai umtaiil (iil>ove niiniiiiul urtcrinl prcawiirc) : PuliH>-pntMUre. 

Discrepancies between Feeling and Recordinc the Pulse.—Xot all tbo 

di»crep«nctefl between ."iensory inipre.tHion and sjihygmogrnm are the fault 
of the instrument. In the first place, there is no ab>-oiute uniformity in 
tho minds of physicians as the staiulanl to l>c applied to the intUvidual 
pulse. TImx, th« writer hajt i»e*n one eminent clinician dictate a not*, 
"pulse not collap^ng," and another a few minutes Iat«r slate that the 
samt^ " pulse is collapsing in quality." Tlic pulse had not changed, but 
the eubjective criteria of the two men were slightly difTer«nt. 

AjEiiin, bdwrca pake palpation unil KphyjcnidKrani there it a difference. It la very 
dillicull, alino'il imjMMalble, Eu determine jtiBl how ioiig n puloe is fliutuned utiii bnu- quickly 
it falb, iiiioe ititwr iftdipntnU arc liiiai?<I upon n lojupncci of cvcntit ia^tinx for an interval 
ot about onc-lcnlh nf a iwconi}. tiii<l chnni[r» both in lime and in piv«urf itivinl be con- 
*ideivd nithoLiI tlie |>rvwn(« of an>' niiniilluiiwiUB Btsndanl for fionipariKon, Pvwliolojiic- 

' ally, lurb ciuupiiwunii miut be very fnlUblr. Pnurtically ihey are not a» fallible lu tliey 
appeitr, for (he juilicnirnt io luunl not ttpon fomi or duration, UhIoib Ihf nbuonniilitim am 
loarked, lu much as U|kiii obuipa of pirwiiire. What one i^ly apprecinlra moul in feel- 
ing the pidac u the lunount of minimi^ preMure ("lianlneM" of the pulne) and the lunount 
of the jMibe-pivwiific (fiat <rf piibc). and oidy to a loater cxti^nl thp (liirnlioii of tlip |>iilw 
wavu. UciKv. the aeiisalion due lo a hij[h piibic-pre«»ure with a n>oilernt<' diaxlolic 

|,|mMnin: w ofli^n niuluken for (hat due loa collapsiiv pulie. tliough iIlc [onuof tlir ptdse- 


1 J, Inflow Intn tliorlfry fniin hrarl: O. nutfliiw 

u'livt' inuy bIiow ihnl if inqiiitr' woll tiialninpi). In roniparing ihc |>iilw wnttation nilli tlie 
KphyKtnasrani, onu ia (lieMoK cuiii|juriiig two sunienlial iJiSercnl ilnndanls, and thui 
inhen-nt cliflftcnce miuc be tAken into aecouni. 

Significance of the Pulsc-ctirvc^Assviiiiing. however, ihal one hiis ob- 
tained a correct tracing from ihc arlery. what deductions are allowable? It 
ia evident thai the arterj' expands somewhat tind4>r an incnMuie in preioture 

(cuuKing H riiH! in the piilse-wave) and 
fontracts whfn presanre dorreases 
(eaui<ing iv fall in the pulse-wave). 
P'urther, the preitsiins in the nrterj' in- 
DrejLsen or decreases, depending upon 
whether more blood entera it than can 
k-«ve it at that iu.-slaiit (Kig.35. ]>n> 
or whether the reverse is the case 
{I<0). When the iiiHow exacily 
equals the outflow (I""0), no change 
of pn>8tture oocurit and a plateau 
resuttH. The pulse trticing is merely the record of thew event* — th« 
reconi of the ratio that the inflow itiio the arterj' from the heart bears 
to the outflow toward the iieriphery at ench inriliiiit of tin- canliac cycle. 

The normal pulw-wavc hiw the 
following forms: an upstroke more 
or less steep (percussion wiivtj, ii 
rather acute summit, amt sudden fall 
(predicrotic) followed by a very srrmll 
rebounding wave (predicrotic wavcV 
then another more (iradutil full tiriiii- 
nntinjiina.imallnotch (ilicrotic notch) 
which marks the end of sycilolt^ 
(Man-y, Huerthle). then a gradual fall 
during diustolc. In the aorta the fall 
in waves is not as steep as in lh>- 
rsdiai artei^-, which indicates thai 
the former reflects the conditions 
near the heart, the latter shows the 
conditions lit the (x-riphery (Slaify) 
Relation of Pirtse Porm to Peri- 
plieral Resistance. — There arc tlm-e 
general types of pulse (Mnrey. Ilirsch- 
felder) which may occur without any 
heart lesion whnte%'er, nnd even in the same individual at the ."Hinc m.i\t- 
mal and minimal pressures, though usually the maximal and minimal pres- 
sures vary with the:*© ronililioiui. (Fig. ;j".) 

Type I corresponds to marked peripheral dilata- 
tion, as after exerei.^, after meals, in sihock. fevers, or in some n< rvnui* 
individuals with vasomotor instability. This is the collapsing ty]x- of pulse, 
rapid rie* an<l rapid fall sometimes followeil by a large dicrotic wave (see 
page 45). The risi- is, however, about two hundrv-dths of » weoiid slower 
than normal, but this difference is not within the limits of perception. It 

I'K. .ih\ — iJiiiyriHiii -Ilj-a .ri[- l!'.' riliir rrl-i- 
Imn' nt Vr^lkini^ulnr ViiUlTLL. I 

(*k«i Willi liigh pn-ipliml iwruiint. 



fwis mon* sudden b<'<'Bu*<' it is itharply followed by th^ midden fall. The 
fall io this type of pulse is »lmoBt roinplotc before iho end of systole, i.f., 
before the dierolie notch whieh markt< that point (Marc}', iluerthlc). 

pM. 37. — Thnc typoi «( ■firnil pulw-rurvf «im«pon(lln< (o Ihr mnt pulif-pmaur* and «inr pijli*> 
nl*. iJuhua Uqpkiui lliup. UuU. mill,) I. vaudiliiiiiui; II, nonunl: III, vaMWKnirieUciD. 

InTypc II only about half the fall oeeure during »y»iole. Thw 
eorreaponda to modrrale degree of dilatation and in 
the lyix- pni*ent in normal individuti!!<. 

In Type III the wave soon rises to the summit and remains there, 
forming a. '^uiituineil plateau (out How = inflow) until the end of systole, when 
it gradually falls. This curresjfoiids 
to peripheral conatriet ion. 
preventing the outflow from the aorta 
from exet-eding the iuliow into il. 
as Is -the riuie where a normal degree 
of dilatation is present. The normal 
puWin man may be converted into 
this type by eompresaion of lioth 
femoral arieric* (Marey) or of the »b- 
donunai aorta (Stewart), The men- 
inereoae of the blood-pressure U not 
a eauHe, Ik-cmuw after exerei!<e the 
blood- pressure is inereaped and yel 
the pulw beeonie.-i more ri)ll.i|i^iii^ 
tbao before. 

Pill. M.— Kir«t ql mhilition ol taifi nitrite 
upou U« pulM^lomi. 0^ft« 1'. Ktifa.l Curvn 
laitcn 111 xifi-RHJuii, Vitxidilaljfin r**rhMB ilr 
iniiximiiiii nr t snil (luiiini-kit-> hi if antl r. Well. 
mailivd ilitmiinn at d. A iii'l ' Luiiloil* mrjiuI- 
mwf mw 4u« ID dutMIr <*( tha •rtco'. 

Hime ptfwnl ouiliuei uT I he pulst^ 
mtvM Rfr fimhcT niixiilit^l l>y ^mjallRr wavr^ 
eiadue to ihoebaiic vJtiRiiioup u( tturanery 
II. or to the Rbound of ibr pmusiioii 
mivc :it ihr perijihrry (v. Kri«). Tlif m<»t iini>onai>l of iliw*e in the dicrol ic wave 
(otluwiot: imni^iluil^y ii|k>ii iIip elueun? o[ llie nurtic vdIvh boiI diic eilliur to 
n centrifUKal vravc ftum the hiaod im t>inK>i>K nKainiit tlii-ni, or IO 
a rofleelrd rani>l|>i>i3l wnvc from ilie peri pli cry luward ili« 
heart (v. K riea >. Wliiclievt-r ihi-orj- iiitir Iw c(irn*l. Ilie nspnlUI fad rciniiin* tliat 
tJiD dicrolie m^v is o iPcniKi.iry nnr nn<l ix <)p;ipn>jrnl upon nni'riiU rlaxlieity, \. Krina 
^'has ahornii lliat llie ilkrolic v'-jii-i* is miwl iniKkiMl wlit-n itic prriplieml vi>ib«;I>i are coiuider- 
Hj dilated, but not vhen llipy ai* ilibtod t« IhHr tuIWi rxtirnl iKijt. SS). 

TXv nilwr «nvn may ocruf ii|ifiii pii)ii>r ii|iBtn>ki> i»iu(Cfn(lc) or ii|>iiii the doniiBlnilce 
(katiMrulic, tig. "Xi, a fi) and ak divk^uuuxi accordiiij^ty. Small sccuixlar}- u-avEs of tfaia 



type are mosl marked wlien the pmniTe ia bigli aui) the limit luUon vtroiiK (<.|7., {luloiw 
lijiiferietw), Ijirt th»ir oociirrwicc in oft<!ii dun to tinichinjt vS Iho t^nilonB near Ihc prJi>tt« 
nf iho sph,vt:it>OKraffli, and loo f;ivat weight iniuil. nol be uttuclitil (o llinn. 

+ _ + + + 

J)*- 3)+ JD+ 

Fio, SV.^Mcreur)- Runmmrtfr imdnK (riri the eauvlid urury of ■ das. ihcwinc iVi>'tlinilv cuii- 
tioDK la blood^prcBun KnJ rliytliniic iDcrouio In dlcFoUnDi. <KincInai* of Frvt. Abvl ■nil !)r, lii^nnitM ' 
'HitidicnHiiiM^tv'inftrvAiiami lijapmHUfO-^jal which Ui«bkKfcl^p— ii r^iwloTifBtt('~f>n<i tbc prnphenJ 
ktMftsanxiiUUil. Hin« in trfondt. 

Too much informntion should not bo sought from the Hphygmogram. 
All that should lie 1ook(.'d for is whether the upstroke ia sudden (p. celer) 
or i^adual (p. tardus) ; u-hother the main fall in the wnvc begins early or 
late in t^y^tole, or not until the bcgiumng of diastole; ahio whether the 
fall is quite or m-ariy complete before the end of systole. All positible 

ini-ntid n'scr^-atioiis should be made 
for Oing of the lever, incorrect nppli- 
lations of sphygmogrnph, etc., before 
H judgment is made. 


The normal pulse varies consid- 
erably in different indivitiuals, being 
in general more rapid in thoBC of 
small stature and slower in persons 
(if lariiEer staturi-', hence, more rapid 
in women than in men. It also 
varies considerably according to iige, 
l>eiiig dependent upon the relative 
tone of vagi and accelerators. The 
pulse-rate is also more rapid (tachy- 
cardia) in fevers, varying in general 
according to the t^nipcratuR- — each 
degree Fahrenheit increase corresponds 
to an Rccidcration of about four to five 
beats per minute. C, D. Snyder, m 
the result of a long series of experi- 
ments upon the heart-rate in dillcreni 
vertebrates, finds that the rate is 

influenced by U;mperature in the same degree o-s is the velocity of simple 

chemical re»etion.-4 and follows the loRarithmic formula 

fia, 40. — IWnariira nhuwinB ynnnii" fiiniu 

pnrLion* nf \hri c?tin**"i uiide'tiaod. tlYPSii- 
DICROT. hjiwr.lirmiK'. 

2 MJ!L\ 

In typhoid (*vpr llior* u often on BXfwptioo, b «emper*lUPe of 103" lo 105» twins 
nemimpaiiied by u pulM>-raie of aihiut IMJ per minute, owing tu a t<ixi« ■timulnlion uf the 




The following types of pulse are associated with various pathological 
conditions and corresponding states of the heart and vessels. 

of pillH.' 



Kofviau . 

Tknliu, , . 


Dinotic, , 










ChAT«eteriBti« ■ 

Sudden risB. shArp 
■peic. tA.Mil prr- 
dicrotic ful; tJien 
bIov fail, smtU 
dicrotio w & v e , 
tndu*1 f«It in di- 

Sudden rise or 
fllifhtty round ed 
plat«au top Ufct- 
ing nlmost to di- 
crotic notch 
irhich » BDiaJl; 
graduAl dimfltolLc 

RexembUne uu- 
erotic «xcftpt 
th0t (lie BHiall 

iiredicrotic ial\ i« 
oUoAed by rJH 
equal or above 
tut of the per' 
cusflion wave, 
makioE the sum- 
mit biiun-ate 

Gtaduat dow ri««, 
percunioD vave 
oblique, Humtnit 
round, cradual 

Steep riPT, apex 
sharp, sudden 
Dtcep fall, di- 
crotic notch in 
Jower half of 
curve oft«n level 
after the predi- 
erotic ftav« 

CoUapKins !n qual- 
ity but dicrotic 
wave very pro- 
nounced and pal- 
pable, as a nnall 
Wfivfl regularly 
following eoon 
after the percue- 
juon wave 

Dicroflc wave OC' 
cura at the foot 
of The a*wend- 
inc in^vlea^l of 
de^cendine Umb 

ClinicAl condi- 
tions in which it 
is moHt fre- 
quentJy observed. 

NojiDal ladivid- 

SomA oaMs of aor- 
tic inoufficienoy 

A few oases of 

Arteriosclerosis ; 
chronic nephriti 

Boron cases of aor- 
tic insufficiency 

Some nonnal indi- 

cbrouic uephntis 


h«an acting 

Aortic stenosis . 

Aortic iDBuffiden- 
cy {water-ham- 
mer or Corrigan 


Norma] individ- 
uals, nquras- 

Some oases of 
Basedow's dis- 

Fevern, especially 

Normal Individ- 
uab during or 
after exercise 

after amyl ni- 
trite or nitro- 

Any of the c<mdi- 
tinnp in which 
dirrotiam ma v 
occiir. but wjih 
more rapid pul^e- 

Blood -pressure aa^ocialed with it. 

Maximuuk. Minimum ^ 

Noimml . , 


Normal or 


Normal . . . 


SUghUy or 

Normal or 

Nonnal or 


Noimal or 


Normal or 

Normal or 

Nortoal . . - 





Low or 

Normal or 

Normal or 

Slightly in- 

Normal or 

Nonnal or 

NormaL . . 

Normal., - 



Pulse -rate 
qu i e k- 

Slightly in- 
or u Q - 

Slightly di- 


or nor- 


Normal or 

Normal or 


Normal or 























■For forms of ii regular pulse see page 013- 



va([iu: while In meningitiH the high intmcnuiitil pkhhum aiay briug the nit« down to » 
Kieul ileul lavn-r (SO lo 60) ntid may eautc Jrrcrgulurit)-. In lubnrciiloiufi the piiW is rajiiil 
F\-rTi ill ihp cjirlr "lafftw. The pnliw-rnU' is ulwi «cc«leniC«id ill llit' hiiu-iiilub, in iieunui' 
tlii'iiia, tiruvui'ii (hwiuK-. hyBlcriu. nhoi'fc unil cullupK. alidcinitnnl dinteiiiioii, [irriuiiiilin 
unci oihcr ihwaw* of ihc abilominiil vinrara, nnd in niuncnuin ciiniiiie <li>icaw>i. In (evpni 
sni) in niiuiy ulhor ouiiiIiliodB of iicccltrrulion llie ]>uls(? Im-voiiiw vxlreinvly unoll mid 
bnrcly piil|niblc on Ihf one bund, iind rxirpincly m|jiil, Iwrcly countable nn ihc other — a 
Hmnll »n(l "ninninx" piilix-, Pultie-nitM of uver 100 \»t niinuie atv tiul uooouunuii in 
fi'vi-m, while 200 or rvcn :100 m rcuclied in iinroxymniJ tachj-curtlia. At llusc gtval mtra 
tlic! dur»tinn of syiitole ia markedly shortened, mi well a* clmt ol diiwiote (the peno<l of 
systolic output falling fmn 0.3fi sec. to 0.2 or vwn lan>). 

i%iw pulw> (bRidyntrdia) (bnlciw nO per minuti!) i* ohwrvibd iwiinoially in conditions 
with intracraninl t«nHion, in meningitis, in dimtalla poi»onin(!. phronic nephritin, chroiiia 
myocurditin. in coiivniiwwnci' froin sonic tpv*t». «p«ciully diphlhcriu und iiiflufnin. and 
in Ariamit-Stokni iliwaw. In thr Inllrr iN>n<liti(in thi- auriclox niiii ^Tnt^iclcll aro heating 
IndepMidently (M<e cluipter oi) Aduins-iitokes diaevw). 


Harvey, W.: Exercitailonea anatomicae de niotu cordis et aanpiinis citrulatione, lUiteio- 

dmni. 1871. 
For hintorical r/iiiimi< ef. Morrow, W. S.: "The PuUr," Roferrncc Iland-hook of the 

Mwlicul i^cienow, PUU„ IS03. vi, 7»7. 
Vierordl. K.: Die U-'hre voin Arterienpuls. BnniiLirliwpi((, IS.Sa. 
Marpf, n. J.- Rfv hnrrhr" mit I'^it <li' la rirtriiiation il'aprfe leu ritrari^re* dii ixiuU foumia 

pur lui Quuveuu sph,vKnioK'''P''*'- -fuuriial do la phyaiol. tie rhumnie. I'ar.. IS60. iii, 

V, Joquei, A-: Studieii upb*r gruphinclie Zeilr«KiBlrinin|E;, ZtBclir, f. Biol.. Muenclien a. 

IJiipt., ISOl, xxviji, X, r. X.. I. 
Roy. C. S., luid Aitami, J. Li. Heart-beat and Pula^wave, Prartltloner. LoniJ,. 1800, 

xKv. 81. Irtl, 211, 3-17. <I2. xW. 20. 
Athana«iil, J.; Methode )[raphii|Ue, Trar. Amim. dc I'lnotiliit Marcy. I'ariii. I90<^. p. 3!>. 
HlrachfcldiT. A. U.; Gnipluc MclhiMls in the Study of ('urdiae I>LMaM«. Am, Jour. H. 

Sci,, Phila.. lOOfi, cxxxii, 37K 
Gerhiinil, 0.: Bcitnkx<^ Jiiir I.ehre vom Rliitdnipk, Rindflriwh Fe*l*chrifl, l.i-ipi,, IflOT. 
Stcwnrl. II. A.; An ExpiTtinental imd CUnirol Sliiily of tlie Blocxl-prt-wurv and Piilt« in 

Aortip Inaufflciency, TliMia, Edinb., 1007; aliui Arrh Inl Mm!.. Chimj^. IflOS. i. 102. 
Sithli. H,; IVIwr daa alRoluIr SiihymnuKruni and seint.' kliniachc BcdeulunK iieb«t krili- 

when BomirkunKrii nrficr einip? neurn.- ■phygniagTiiphiacbe Arbtilen. Dcutvcb. 

Arch, f, Win, Mi>.l.. Leljm . i!KM, Ixui. 49.-1, 
Mumy. E. J.: I.a eitrulatiun ila naag a I'^lal phy»i<iloKi<]iip et duiin Iw nialudim. Par,. ISSl. 
Iluert.hle, K,: IteitrlW^ inir llarinmlynaniik. Arab. f. d. koi. Phyninl.. lionn, 1891, xlix, 29. 
Hinc'lifi'ldiT. A. U,: Sonit ObtMTi'alioiiB <i))oii Blood- pr«a8Uro and PiiUc Fomi, Biill. Joliiw 

Hopkina H.wp , llaltimon-. 1907. xviii. 2fl2. 
V. Krim. J.: Sllldieii J.iir PiiUlclir.-, Frt-ibiirjt. 1S92, 
iinydcr. ('. I>.: Tbi- InHuenirt: of Tt'inpi-ratiirv ii^hhi the Rale of tlie Heart-I>eat in the 

Llxhi of the Idw for ChMolaal Itcnction Velocity, Ani. J. Physiol., BoHt., 1000, 

XTU, 3S0. 



As hns bvon wen, t1)o study of the- blood -pressure and of the arterial 
pulse conveys iDforniation regardiiiK th<? strength of the heart-beat, tba 
condition of the peripherul nrtr;ri«», and the velocity which the heart U 
im{>urting to the blood stream. But it reveals the action of the left veo- 
tricle only, and what occunt in the other chiimbers of the heart must be 
sought for eWwhvrv. 

In studying the heart from the four atand-points of Engclmann, 
rhythroicity, irritability, conductivity, and contractility, 
it is Dcc>e«sary to obtain a knowtedRe of the origination of the impulses 
in or above the right auricle (atrium), of whether impulses othtir than 
those cauung the normal rhythm are acting upon that chamber, of whether 
the right auricle (atrium) is it-self contraclinfC, and of whether uU the 
lnipul«GS are being properly conduett-d to the ventricle. Our knowledge 
upon these points has been derived almost entirely from the study of the 
pulsation in the jugular vein. 

Visible Pulsation in the Vdns.^ — Fuliiation over the veins is visible in 
80 per c<-tiT.. of lK';ilihy iiiilividunls {Hewlett) and is a» pronounced as that 
over the arteries, but it is different in character. The Iatt«r xhowx the force- 
pump, the former the suetion-punip uelion of the heart. The pulsation over 
the artcrii'H is quicW. sharply localised, easily palpable, and the i^ 
, more marked than the <'ollap«p: that over rhe veins is <)i(Tufie, wavy, rarely 
'palpable, and the collapite is more marked than the im- 
pulse itself. Further, the puLialionpi over the vein under normal con- 
ditions are exactly twice Ihe number of thonc seen over the arter}', and the 
Bret of the collapses ia aynchronous with ihp impact in the artery. Such a 
puLnation over the win is kniiwii a.t the "' physiological." "negative." or 
"double"' venous pul«, in contradistinction to the other type@ of vcnow* 
pulse to be described later. 

The puliation over the veins is not. like the arterial pube, to be seen 
In «ver^' vein in the body, though Morrow ha.4 .shown that in dogs it 
can be detected by means of delicut« manometers. To the eye and to 
the recording apparatus available upon man, it is appreciable only in the 
veins near the heart, the external and internal jugular, the cephalic, and 
the axillary. Occasionally it is also to be seen in the brachiocephalic and 
other veins in the arm.' The site where it is most easily and uniformly 
[ seen is in the right supraclavicular fos?-.» , either over or just to the right of 

' Priedreicli (liuuehl that tlui puisation wiu trnnnmittoil from tho Krlericti Ihrau^ 
the capUlariea to Ihr vein*, but micU lr]inHini<wion prubabjy nevHr laltitB plivoe and i>tbar 
explaiuiiioiw must be sougl)!. - ■ - 

4 M 



the ori^n of tbe stcmoclcldomAatoid. Sometimes it U a little more mnrkeJ 
in the supniclftvii'ular fosaa. at about the manmiillary lini! where the exter- 
nal jugular vein ontcrt; the Kubclitvian. The normal venous puUation is 
raroly to he seen when the subject is standing or when propped up high 
upon pillowB, but is mo!<t di»>tinet after he ha:c beeti in reclining posture 
for »ome minutes with a single pillow under his head and neck. In patients 
with venous sts.-'iM, on the other hund, it may be neccssury for the patient 
to sit upright before any undulations appear. 

It must bo borne in mind that the pulsation iieen and recorded over 
tbe veins represents the alterniite filling and collapse of the latter. Tbe 
eollapne, that is the obliteration of the lumen of the vein by the atmospheric 
pressure, is uMuuUy the most important fitclor. It is evident that s wave 
will occur during those periods in which the pressure 
within tbe vein is greater than the atmospherlv, and a 
collapse will occur whenever it is less. If it is permanently teas 
(negative) , the vein will remain eollapsod ; if it is permanently a little greater, 
the vein will remain distended. In neither case will a pulsation be seen. 

llic Donnul pulsuttuu in tievl wien when itie pnsaiurv in tlie jugutur vi-in is itltomBting 
between a poail.ivn and a ncgaUvt )>rciiaurc during the difTcreot phnum of the cardiac 
cj'cle. Tbe cliwtic dlKi^nliun of th«i vi*In b not c-aIIocI into ]j1ay. "Die vliuitiL- distraCton of 
tlie vein lit syilole occurs only ul n much liighi-r vmioiih pnaBure, n* in Iripiwpid Jiunffi- 
cicncy. OcciwioriiiHy, cupuciftlly in chronic heart caaw with phlcbonclcrosis. the veirmBtand 
out like \arT^ kiiouy corda, but no pubatiuri in to be diweraed in thuui at nil. The knotty 
nppcnrnncc (I-'ii;- U) <9 dun to the cloHuni nf the vnlvca within the veinn, the dilntation* 
«|>peariTie just libovc the valves, ["erliaps iheelosurooflhc valvre prevents urduinpcus tbe 
puUaticin, or pc>rhii{ia thi- rigidity of the venwl wall pi«v«iiti it from eollnpsxntc and lillinR. 
Normally the valvee in the jugular ilo nnt close, but thje closure \» brouiiht iilnjut by chronic 
voooUK etABis. juat as it is in (juadrupcUB w)u>rv buck premurv rtuulM from Ihi.- hi^nd bcing^ 
dopcodont. In euch cnscs it a iin[>oiuiil)lc to obtaJQ anv idea of the undulatinui nearer (he 


A far more exact idea of the nature of the jugular puliation eao be 
obtained by recording it grnpbioally than by mere inspection. With proper 
apparatus this is not accompanied by any difficulty, and a satisfactory 
record of both venous and carotid pulsations can be obtained in about the 
same time as a radial sphygmogram. For the interpretation of the venous 
tracing it is neceasar}' to compare it with the other events of the cardiac 
cycle, which is accomplished by using the puUte-wave from some artery 
to fix the standard of time. 

In order to interpret the waves upon the venous pulse, it is necessary 
to record simultaneously the venous ptilse and either the arterial pulse or 
the cardiogram, and to see at which point in the cardiac cycle each event 
will fall. Accordingly, all forms of apparatus (polygraph) for obtaining 
sueh records are arranged for taking at least two reconln simultaneously. 
In all of these the puLsalion from over the vein is received in the same way, 
and the only dilTcrcnce in the various forms of polygraph lies in the method 
of obtaining the arterial tracing and in the form of kymograph used. 

Application of the Receiver*. — The piilnaiion in the juf-ular vein in recorded by 
holdinftover tlieskiii above it a snudi (cliiai funnel on apcdiU receiver (Fig. 41. r), wluchia 
connected With a Murey reeatdicK kfinogrhtth (i>inbnur. The inovemcntii of the iikin aro 


tninmulted at once to the kytnoer^h tambour and recorded by the lever. Aa a rul«i. tlw 
^BKMt fuvonible cunditioim uro ubtuincd wbi-n llie patienl b lying with head and nedc 
Rupportod on n sinicln pillow Ihnl rslcnds doirn )un to the iilinuldvra. with liis lu«d turned 
well lullie riiclil luul llio ni«k dcHiiiteily llexed. In Ihunny the riglil ulrnirK^leidomastoid 
M rdnXL-d lUiil a Inicinfi ovrr cliic pulautiun rtnm hjuw of tlir iiilrnul jiitciilnr vna J* trmn>- 
iltted to the skin. Wh«<n tlw i* not nhlAinuble ibt) junotion ul tlir uttcmitl juKular vein 
ritli Ibe •ubcUvinu iliould bv trit^ iii the nutnc way. Thr funnrl nhoitld t« pnwm] ■gainat 
■okiii jtul cnoii][h to miike thtcontiict Dir- 
fUfcht u'ilhodtuilectiiiKtlivpulMiliuR.bul Ihls 
1 pffectiii niUioul nny grpul dL-Jtltrily. and 
Mtf-itluliifiu) dilc (o Ihi^ holding of thr rc- 
ovivprrsirly ap()i->r ii |»n the Iruciriji. ^^'hen 
Uic.v iloflo it in in ihc fomi of Tinr <»rtUiitionii 
brvrinK no relation to the raniiiic cycle and 
hnving ■ rutr of fruoi four to eiithl ppr 
ncontl, in oontmul lo Ihr Riiieli iilovrcr and 
larger moreincotn in the vcin>^ Such 
ttkcitift* ahouUI bo dincanlnl. 

In many ciMen the umple kI''"' ftiond 
ia not an cnlinftictory lui u receiviii)!; de\ioe 
inlmdiicml by Mackr.nxin (Fit;. 'II, 0> <^"' 
wtinK uf n xhallow inetMl paii :t cm. in 
(tiIlJnnt(^^ with u tube IcmlitiK oti from it in 
the fonn Khonn in Fin. 41, onr jKirtion of 
thi' circimifen-iiou lieiiiic flnll^rici! tnatcai) 
ol rouoil ia onlw lo fit clowly above the 
claviole. It is conTviiietit i<i have a iimnl] 
bole in the top of the imn ao that it may 
be adjiisli^ lo the akin without moving 
the rMnrding lever, and aft*r atljuntment 
la complete thr hnlc i* cliiaril by placing 
tht linger over il. 

TIm; tmciDK from llie corotid arttry ii 
ohtaiiied in n <tiniiUr wiiy, i»iiiK for a 
ivccivet a mduII lambour sunnouiiled by a 
button to fit o\rt the nrterj- (Kig. HI, t>). 
A eoMll hole in the top of (hin laniliour 
the aonic puqxjie an befom and U 
•(ofipeiJ by rovering nith the linger, 
tlw ■ler(io«'lei<loiiia«toid when Ihr 
the imlaatJiHi buiug uuwl marked when the t«oei^'er ia preened heavily upun it. 

ComparLion of Carotid and Jugular Putsalion.—Sinrc the jugular vein 
and llie riLrutid Jtrk-ry niv ill itboiil the siiiiii- tiiiitftm-i- from thp iH'ftrt, the 
trncinKti frnin tlie latter must always he rotii pared 
ilh tlic form IT in i»r«lor to exclude waves which might havr been 
lrati9itiitted to it from t^K' urlcry, and also to iitdicutc the rolAllun» of (he 
venous waves to the rardiac ryclc.' 

Hii* cMapariKOii iitay tie made by tAkiiin; the juKular and the enmtid Inicinga iiiniill- 
MlMnutly and comparing tliem with cncli othct 'litrctly.' or, fur thr mkc of convtuucnce. 

Pio. 41. — S)U> (nr reeonllnf ilie Juaular and 
(■roUd piU^tioiw. .1. Jl>(r'iliuti>iii ul llia ran* 
t*luHl«d la bl««k}, *liuwiii« tUriul'* lurafipiyLnAthtf 
iii(uUri*(«var<U<iiinti(al)iinrl ihf »niU<lrHwlnr 
toonocilric ttrclc^^ S. appiAratico of Uib vhIvvb 
WEtliiu UlD iUKuUr vein wlirii rlu-nl hy hmgk pnm^ 
«ur*; C.pHitivn'rnrjuaulHrvfLjk; /J, firtnc IVBtwar 
(or mwnliiia Uip tnilwl'nn over the uraud arory. 

'riie cutotid urtery is next lo ilip »kin jurt 
bca<l ia tumcii towanl the corrrapondiiif; 

' Where grait Mountoy ia neoesMry the onaet of the c wave mu«t be ernnpuvd willi 
tJiU of 1Im> apex bml. 

'It in not neceaeary that the levers bo exactly auporpoae't. but it in prefer»blu to 
urn off tbe iliHinnee of the giwii point huriiontully fnnn the arc docribod by the 
ver at the beeinmng of thr (ruling (r,^.. Fig. 41}, Thin dialancc ia then laid off u|M>n the 
oilier curve it> tlie mune niujirieT. Whctv^'er the e»rv« may begin the |MipeT truversee the 
BAine diatanoc uimn both curvua iii the BUiae tiine. 



Pra. 13. — AppuBiU' fur rwnnlinK th« ropirmlloD. 
SVB. rubber tubt; GL. ■■»• tube. 

a carolld ftDi) A brachial or rtuliol trociuf miiy be nuulu Muiiiiltaiieotisly, luid the point at 
which the can>li<l whit brjiinK niarkod off iipnn the latter, llicn n jii^lar nn<< a brachial 
tnuang may be ruuIr. and the timrr that ihv curoiiii wa^f occ.un before the bracliiul luurkpil 
oR bcfnit) rnch hratchial nnt'e in thin tmcinif. uiid clinw poiriia ihcn mcusurcd uff upon the 
jui^uiur tracing. 'Iliiii ii tiltea the siniptMt and 'iiiickrxt procnduro. 

Respfralion Recorder. — It is ofU;n of importance to tlctormino thv 
relation of »n iirrhylhmiiii to the phases of reapiration. The Mmpleat device 
for K'cording the latter coaaists of » pier« of robht-r tube (Fi)?. 42, 

Kin) contifcted with the tube to 
the recording tambours by ii ^hort 
Lishuped piece of gliiss tubinf; 
(ui.). A piece of atriiifi or tape ia 
attached to the rubber lube, 
another to the glass tube. The 
apparatus is theit put on so »a 
to cncirclG the level of the nip- 
ples. The stritiKH are tied lightly 
enou|ih to just stretch the rubber 
tube ihirinfi expiration. Inspira- 
tion then causes a down«troke of 
the levera, expiratioD an upstroke. 

Fornw of PolyEnph. — Srvrral !ann» of pol>xraph for cliiiienl purpows hnve bi*ii 
ilcviswl lo tvcorrt (li'w? curves, Thi-ir relulive value .inpcmla Ur^l.v iijioii (he delicacy of 
ihe liimlraum. The ulilnt form i» the polj-tcmph o( Marey. coiiBiatiiij; of iiii onlinarjr kymo- 
Krapb drum urrajifreil lo rotate borixonlidly 
with two .Mnrcy tamlmtin to write upon it, 
fO aa iKi rccijrfl Himult:uiMiu»ly ihp curve 
from the jiiRulnr and curutid or jugiilur nud 
cnnliuenirii Thii- ia fnirly lutliifiiclnry, hut 
in mcchuniciil perfcvt iuii bduw olhrra uiv 
vuperior. Mackcniic lin« <lcvi«eH Iwii fnnnii 
of |K)ly)^rnph. Tli(< tuvi, » Mitiple Ja<|uct 
sph.vxiiioKTnph u|K)ri which o Murry liunbuur 
it mount«d ill Hcldilioii «o an to rrconl ilie 
raditJ pul«c and jugular or carotid, etc., 
IJmtdtaiWOUily, Ibc time iK^inx ninrkcd off 
in i teotmd* by a siiiull clock-work Ms wvll. 
In tlie improved fc)nn of .Mackcnxii.- ptily« 
gmph. the levers Ixwr ink priw and write 
upon an endlew rutl of wlilte ()U|wr, au ihul a 
very lotiK *i>rip» can Iwobtmned. V. Jmiuct's 
carili(«phy^io|;raph dLlTent (mii) iho tcimplc 
•phynmngmph only in lieoriiig in addition 
two Miirey luTiilwiini nhoM! double-join red levcfn wril* jiiHt ulwve the lev*r utloched to 
the railial pelutle. Both MHckcniie's uiid Jiuquet's nieihodi siilTer from the inconi'iMiienc« 
of adjUMlnic the nphyitniogmph to the radial artery and keepintc it ailjml'^l liiirinfc ihn 
mtifB ahierviilioii, a factor which in vory 'liBCLiiiccrtiru; lo iHith patient and phyxicitui uikI 
which prevent* niuny ini;K>rtunl ol»er%--jli<)iui from liein^ token or rcatlnw pulituils. 

lliiB dilRcnlty is obvintf-d in iho writer's moilif i ealon of the Er- 
laiiiccr blood-prt'BflU re apparatus (fig- 22, pu^ 21). In which two Kinull 
Marey tanihount and n limc-m.irker am armnftnd to yrnUt above the lever of tlie hlood- 
prmtuc appanttuti, ^V'lle^ ihe hn|[ 18 inflated upon the antt, the brachial puW in recorded 
by the lever ol the blond -prmsMrr nppamtua and uned as tlie ntundard iiii<iea<l of the rndiiil 
puliie. Hub enC&ilw no tmiihle and no rxpphdiciire of lime, Ther(>by tiuviiiK iiiiirh of th? 
trouble Riven by the oilier inelhodB, and peniiitH a set of recuitis to !« oliluincd very 

fKindn4iu ^f \. IT Thinim- *'■>-) ti. imi' tutitkwr 
(i i*e V t. *. Icvt™ of tftTiihmi** tf*r r«onJinr 
van(HI> tr^ciuiL farotid ^uL*r, i^r curU^ogrnn,. if. 


quickly. It m ulso ponible (or ibu opemtor lo work with one lian<) Inn aiid tliua nv« the 
MMlty oT nil anuaUuit. The curve Ibun olttnionl from ilui jugular vein ia nhawii in 
g. 44 mid its nilaiiun (o ilie oilier «v««ta in the cardiac cvcic (■hovn in Fi|[- 'tA. 






_i ftlit' v>.Tiit'nl lifif *: rrprf^mriiiji the br^inhm^ of liipnmti'l piiUe-wa^r!: i^ tb* 
■ IBHlA^niloIi'' rulUtur-, 'f limi' •>( diFnitii^ iH'tcli in ilia «niii<l; r. wave at auS of ■yiuilr; 
H, hollRw St Ih* mil of i.h* ;iiiKl.<)nlolio cnlUpxv: t, d (Ann/), trlHyiinlie *nil ptDtvJiwtolie itsrw 
dtcfribvl b)- Danl. (Thr i ami ii dcpnuloon u* nol iMteral «D dll tnum(».) 

ficcenlly, Uakoff liAs coiutrut^inJ 

K very coni|inct form of thin nppam- 

tw, b««riB|: an Erlaniier bloml- 

prannire a|>par!tttui. a tambour for 

monrHinx the heiiiht of the lilooH- 

prwtnire objective]}', n lambour for 
[kpc-x or vcnoua or earotii! tmcinite, 
[•im) an cxcrilMit lime-marker. This 
[itMini tob« k very |;dck) iiiiitruiiient of 

wide applicability, tiuitable l» all tbe 

iwmlBof ilie practitioner. 

The choice of apparatus 
(lepemU chiefly tipon the ilt'li- 
fftry of ihc tjiinboun< and upon 
the portubleness of tho appara- 
tiui. In thi! latter rt^'ganl ihc 
Jaquet cai^Jiunphygiiiogruph is 
particularly tiesirahle, but in 
tilt- ffirnicr it M cxreilcd by 
many. The possession of 
extremely fli-licnU; tauibuurK 
onablcs the (ihs<Tvcr to proceed 
rapiilly and to obtain beautiful 
ani( accuraU; records which 
would Ik; impossible with ordi- 
nary apparatii!*. The horixoii* 
tally writing tambours of 
French manufacture are partic- 
ithirly delicate. 


Fiu. 4.'i,— l>iiicninr<g>r««liD( (liev&riaiu cnnu i* 
k ninliM cvclr. l«U*n aa in previuiu riEum. Taao ia 
f, *HciiiiJ> (v«ti«kl liuciX DuIUd linw npm*t>t ourvan 
odiALTiviJ wlii-n tJib pirtiphrfiii rvaictuiM i* hifb. The 
r>uW b<K<iin« vacmii<i unit lh» lalimTMtrieular Ine 
luward llio buiI of •Jnlolo. 


The curve of vonoiLH preswure obtainod cliiiiciUly uud in animals (fred- 
Ferici), Morrow, Hi-riti)!, Thtx^fwld) corresponds exactly to IhotiL' obtained 
rwithin the auricles (Cbauveau and Marey, Frederieq, Porter). The first 






wave (a) 'in the venautt pulNf i^ Hue to the con true t ion oT the right 
auricle, uiid diMitppcars when tht- auricle 'm paralyztnl. It occurs tiliout 
one-fifth second befort* thf coiitrartion i>{ ihe vcntriclp. The onset of thu 
Vf I) t ricu Inr contraction ia murkoii on thv v('Qout4 trarinit by ii| 
small wave (f). caused in part by the piishins up of the tricuspid valve 

whi-n thi* intnivontriculnr prcsaurc risen 
(llirschfelder, I, c Bard. 1. c, Morrow, 
Ousliity iinll (rronh), and in part by the 
How of blood from the coronary veins, 
whieii, «.t Porter ha.t tJiown. arc forcibly 
emptied into tlie uuriele at Ihix ioKtant 
(Sewali and Ilirschfeldor). Mackenzie 
tliiiiks tlial it is duo only to the earotid 
piilRation tranamitted to the vein, but 
Morrow hsn obtHined it after ligature of 
the carotid in animals. Reside* the wave 
appears iibout Vo second before the ca- 
rotid wave in many ease:* (Hirwclifelder, 
Bard). When the tracings are taken from the left jugular and right 
carotid, the e wave in the vein may be later than that in the arterj-. oninR to 
lonfcer time of trannmiiwion. The c wave is almost always pre«cnl; but, as 
Bard ha« shown, it may be very small or enliiely absent in hearts whose ven- 
Iriclea are faihnK (Vig. 46). The rise of the c wave is followetl by a I a rge 
fall (x), which may be the largest fall of pressure in the whole cardiac 
cycle. The exact mechaniwm by which this fall of pressure in the veina 
(and also in the auricles) is produee<l. and c.i|>eciaUy why it should snomctimea 
represent the larjjesi fall of pressure, is not clear. It h evident at this period 
of the cycle that wveral events are taking place: (Ij relaxation of the 
auricle : (2) a certain amount of downward pull which the papillary muscles 

Fiu. 40. — V#n"UJL tmcinc >hi>wmi| %h^ 
•flDflu erf tb« r wave in a nw iif bmrl bHi' 

JVa,. riaht jiiRular vein; VAH,, JeTl r±- 
ratid ftiny, Tiut in ) ■wonili. 

-A. VoHnu ifbOjQC «howLnft lUficuUi pii(nl>-)'i]i iiLjiw^e--v uf a wavi:j «ilh itJtt ix^ JaiirBB*i<MJ 
ilurina T*ntricuUr >yvIolt brtwriMi i snil r H. Sum* mrini. Ituln ipMil. 

exert upon the tricuspid and mitral valves: (:J) at each syfltole, as can be 
seen when the heart is exposed, the movements of the latter within the clw«t 
are exerting ^a pull upon the vens cavie, thus pumping their contents into 
the auricles; (4) tiie outflow of blood and the decreaae in .lixc of the heart 
during 8)'Ktole cauxe a slight increase id the neg»ti\-c pressure within the 

'Sincp Mttckfnxip'H first, nomntic-lnliirv ami IcIwriiiK ol llie h»\'«i was inlroilucwl, a 
glut variety of I«lt«n[t^ uiid uF ilmiKniitioii hy nunii-ruls lius \>wn \isttS liy (lifferciit million; 
but thMP acrve to coroplicnU! rothrr dinu lo nmptify lb« iiunljon. Tlic li-tl^nt or niiikibora 
are Dieroly Bjrmbols, atid a nugle unlfomi Hysivm would be belter than h liitbel of terms. 


thorax whicli may be transmitted to the thin-walled veins. It is probable 
that ne-ith«r of thest^ factorH alone if reeiponsiblc for |hc fall (x <)eiireit8ion) , 
but that each 1^ active. Ccrlaiii it i» that iiuricular relaxation is not tho 
|.9ole cause, for ua shown in Ft);. 47 it may still be the lar^^si depression in 
caaes in which the auricle is paralysed. 

Or. PMboHy ha* callod th« wri(«r'x nltctition to n ninntl wavo ■rhi<Th is frrqumtly 
M«n dtirinx Riidtytttnii^. repeciiilty in IrBi-inm ttom I'ixorouH heartn. occurring juit ul the 
lase of the i ilrprrsAao, iukI nliieli i^ iniiny cunm CDiinol tn- <liu! to lliti)! of tlie Icvw. 'Fliu 
orixin nmJ litCoiA'^"^ ol lhi« niivn utv cxtn'inr^ty unnortnin. ll nuiy Iv really traiuunJltiNJ 
frotu Ihe arlery; ur. tn Dr. Pcatiody HUiocMta. luny Iw dw U> >Liglil iiimifficiuDCy of tlio 
I papinnry muauW uludied by SewoU, 

The fall which Icad^i to the -x depression usually la.'rta until*about the 
end of ventricular sj-stole, d (instant of the dicrotic notch), after which it 
is followed by a targe riiw {diastolic wave of Porter; v or ventricular wave 
of Markcnzie; tw. ventricular Ktagn.ttiun {Vcnlrikclstauunp'welle). lU-ring; 
telesyatolic wave, (, Hard). This wave is very constant in its occurrence 
and is usually !>up])0«ied to rt^present stagnation within the ventricle lasting 
from the en<l of aystole until the tricuspid valve opena; the fall v-y indi- 
<:at«H the opening of the tricuspid valve. 

I As Bard lia« aliown, two lUKlulstions ate oooasIonaUy found ((. if; I, leleitystollc, 

poemning at tbc end of ayvtole; nnd d, ptDl4Mliiu(olic, otxrurriue it tlic vpti' begiiiiuog af 

' diartol^). Bftrd otatas ihat the wairc I i* cninridcnl with Ihn Unt Micondnry < prndicrolic) 

«-afv of llie Hrlerinl fifdae. ihe second ivilli (tie vibrulloii of the \'«iilricJeH due to the cIok- 

utv of tbc aortic vnlw*. hut ihiM in not very Mitiiifiuiton-. 

Sewall beltevcti Ihal iliu Kiuguatiun &t the md of systole (w)ieii the u)«tn>ke of llie 
»or 1 wave occuni litfom the rnd of ni-ctt^R) ia (hic to n fatiguing or ninHclung of the |Mpil> 
iaqrniaKlcM.c-Hiiurix » «littht ln<-ii»piil ivmiixiluli"" M that insljint; hut in cafim with no 
mumar in lh« Irit'iiajiid ivgiou tliis exfiluliulion inMrds PKiitiniiatiDil. 

■ The rise upon the r wave outlasts the end of 8>'stolB by about ("j aec, 
whinh probably ivpresents th« tini<t reiiuinnl In transmit this changti of 
prcsaurc to the veins, 

Uoiit VTi(«ni fnllnw HnckttnxJe in bnlicving that the upatrokc! of the r wave mpn!- 
kvMits stasis within (he ventricle laMticiK until tlt« tticiwpid talv* opens, Inil cardlonieler 
I tnuiii)(a >huw thai lillitu; uf ilie v«iitrick'a. cir at ti'iuit diUialion, t)^D* at llic inBtiuit 
[ ayntolc cimU. Chfliivmii'i tmrirgcH of ihn ini>ii~ni>pntt> of the hciirt vnlvrn alm> iihow Ihnt 

■ Uw trisoupid t-itl\c ofK'iis tiefore itie time ut which the cmtt of the r wave appears, mt that 
Et i* ])rabiil)le that this wiive doc< not rcprmeiit Ihr very iruHaat at which tb« trictuipid 
valra opMw, hill IhHi wlwn T.jie pcrio'l '-i' cxoeetb' the Iransniisslon time the interval 

\ RfMtMtDts a pvriud iluniig which the vniouH prvrndnf mniiins pmit«r tluin atiuoBpheric 
I prewure. Or It may hut antil a nifEricnt mnoiint of hlood hn* entered the ventricle to 
[ bave rclieveil the venous eitjeorsijmeat which followed ilie i»a«aliMi of the factor* whicli 
r bad pnxlucrd tlic x 4e^¥ntaawi. 

The di>scend)nK limb of the v wave continues as lonft tai blood is r^ishing 
in (o RU the ventricle (Henderson's period of diit^olle Riling), after which 
there is a gradual iiltin^ of the vein and a rise until the next auricular systole. 
In slow hearts HirHchfi-Uler and .\. (•. (iib.ioii have shown that the inflow 
into the auriclcis ami the filling of the veins is no longer unifonn hut ih inter- 
nipled by a well-defined wavelet (A, Hirschfelder; h, (^ikton) which follows 
the I' wave by a deBnitv interval <Fig. 48, A). Both these writers indcpcn* 



dcntlyascribt'd this wftve to the snapping together of ihc uuric- 
ulo von tri cular cu8pi< at tin- end of ventricular fill- 
in g id middiMtole, and the former called attonlion to iL» correspondoiicc 

PlO. 48. — Vounu UBcina Irom ■ vpry kIdw hwit, viih Iniut lliinl h«krt miiinl. 'hnviiia I'l" prixair* 
'of tilt h nv*. Mat. oiulnul blooil-fin«ute: JJin. mlnlniBl bloidipmrnirc, 

with the onset of Henderson's period of <li&8tii8J8. Thin fact is further borne 
out by the preaence of a corresponding wave upon the trHcinj; from the 

ce9ophag*i» (Kir. 54, h). Thia wave 
disappears when the pulwvrat* be- 
comes more rapid CFif;. 49). 

G. A. Gibaon, Kyit«r, nnd the writer ' 
have orcaainnnlly *ppn a wave tcln IntrdLimtolc 
uf nluw |iuls(- |irMv<.liiig the vavt' of iiunculiir 
coiitrueUuii (a wuvp) by u lutlu-r dcRnitc 
iiiMta-.-lI (Fix. A(l). The ctlatanco (mm tlie k 
wiivp (urii^s. T)ii» wave in asauiiieO by iho 
tottnrr writer to rcpfewnl a miilnu^tian orip- 
nutiiii! ill ilir NJiitis ivgioBi of the hearl. Since 
tlie remnant of the embryonic riniw in nctuntly incorponiteii within the body of the muiicle 
[atriuni), ihlii view in quwtionable and roquinw experimental conlinnation. 

one how LuK'r. Afl'r K^viiiiEntrapibii iiii*! ijujck' 

Pin. X. — ShoiilnK k nxt u> o«currinB ■hoiily btion the a nvt. (From > IrMlu Ki*d« tu rsllxbonlliui 

Willi Prof. L r, Uuker.) 


Some of ihoito events in the cardiac cycle may bo clearly diBtinguiahed 
vitli the naked eye. L'pon looking carefully at the jugular pulgalion in a 
normal individual and placinR the finRcr upon tho carotid artery the vein wiil 
be seen to fill Iwicx.- (a wave and v wave) nnd ti) tolhtpse twice (x depn-SMion 
and y depression) for each beat felt in the carotid artery (" prcsj-stolic-dia*- 
tolic," "physiological," "negative," "double" venous pulse (Hintchfelder)). 
Theao wavca may be timed lesa accurately with the eye, but, although, as 
Mackenzie stales, visual examination may save the examiner many unnec- 
essarj' tracings, it nhuuld iml be relied upon in doubtful caws. For c\amp!c, 
a simple mesosystolic collapse ^ike that iUiown in Vig. 44) with absolute 
poraly^ uf the auricles may mmulule a normal venous pulse. 




Auricular Paral>'S)ft. — Bo^dcs thi:t normttl (ufgative or double venous) 
pulee scvcml other tj*p«s of venouH pulm arp seen. In venous stasis and 
riinliac failurp the auricles amy noon boeoinu woakvneil taiti ihw a wave, due 
to their co&trMtion, muy (Usaijpcw entirely (1-^. 47 and 51). This phe- 

a nva. Vji>. ri|hi juaulu rtin: ACS. Icfl «n>tid •rtoy. 



nomciion is readily demonstrable in animals (v. Frey and Krehl) and need 
not be accompanied by any cliiingf in heart-rate, though iirrhythraia is fre- 
<]uently present in man. In animals auricular paralysis or marked wvakea- 
ing of thv auricular contraction may also occur as the rusutl of vagun stimu- 
lation, so that the pm-etncc of pv p 
this phenoineiinn alone is not 
always a bad omen, though 
usually such is the case. 

Positive Venous Pulse. — 
When the iiuriile i-i paralyzed 
or thor« is a leak nt the tricuspid 
vftlvc, the entire form of the 
pulse-wave usually changes. 
Tlie collapse during ventricular 
«y stole di.-siippcur!! and is replaced 
by a systolic plateau, or more 
usually an ^/-shaped wave with 
an eariy syirtolic wave c or p, « 
niiiUystolic depression, and a 
Iclesysloiic wave v (Hewlett). 
Mackenxie believes that th« 
lint crest of the if represetits a 

contraction of the auricle Mmultancous with that of th« ventricle, and 
that the depression in the middle corresponds to diastole of the auricle; 
but this form of curve has been obtained by Knoll and Thcoi)«ld in 
animals when the aunclcs wore stopped by vagus inhibition. This form 
18 known as the ''positive," "ventricular," or, from the fact that it 
appears to the eye as a tungle wave, the "single" typo of venous pulse 
(see chapter on Tricuspid Innuflicieney). Though the vejitricular type of 
venous pulse occurs in iriciuipid insunicieiiry, it i.-< nut pathoguoinonli; of 
the latter and may indicate merely paralysis of the auricle. 

^'Kl.5S.— P«i»iln-rutnnlrirulart»v« utymwu pill** 
ID tJimiBpid mf>iiHii?irric]r. i^Kiirjjta ahanic* uf tii* u aiiv*. 
JUG. tisht iuvilu vsn^ BIIAt:il, r>(hi bn«hial UMO'- 



Informalion furnished by the Venous Puliic. — It h apparent from the 
alrovc (tv^rripiioii tliut liie fulluvviri); fucU arc to bo learned from the iiormiil 
venous pul»e-ciir\-e : (I) whether the aurirle (atrium) ta conlractinR, and 
whHhert-aeh auricular (atrinl) contnictiitii i« followed by u vcriinrniiir ron- 
trnctioti: (2) the time roiuired for the conduction of the impulse from 
auricle (atrium) to ventricle {ihv int^rvtU a-c on Uii- tracing, about \ second 
in normal individual — voniluction time); {3} whether or not the tricuspid 
valve Li rloitin); |jerfeelly (shown by the fall of preiwiire durinR systole 
iin<l ihc MitjwHpieiit v wave).' In irregular pulsct) miiuy niori.- important 
faets are to be learned from the venous pulaes, which will be diacumed in 
eonnection with thia diuturbanro of function. 


1'be 1,'Miouii pulse tmciiiR revKols tlit^ coadiUona prevniliBK ia the right auricle (atrium) 
ami the olaie nf tlic Iriciwpid valve. A cormtpondintt jiit-Mtixniion of the i-UM of the 

left auriolc (atriuiii) unci of the nutral valve 
waa mucle poiHLl>li> by it iDi-thud ubmI by 
KmJi-rie<| in aniinalB and introduced lata 
rlinicul itM.>dkiii« l>y Mmki>wi«ki. UiakowHlii 
cnlU nltmttuii to Ihc (act ilial al ibc Ie»-el of 
the scNXintli to (he ninth lltorncic vcrtcbRr 
(about 35 to 37 cm, fmni Ibe trMh) the left 
auricle i* in eonlnct with the iCKiphi^[u«. and 
wlH^^ one iiitnxliiceM a i^tomach-tube to thia 

\pvtl il rt«ei»-c« iiiipuliicB from the left auricle 

I I /jffMHB] I .ilone. Acronlinuly, an anlinnry iloRUich-liibe 

1 n I (LV iVBr / I '■ capped «ilh u tlijn rubber linger cot, aud 

' ' iTjUfcW I ,(,p (alter sociiiml by vtindiiiR a »ilk liitatiiii; 

sp\-crnl tiniMi uniiiTid it. The MoniAch-lube ia 

i~r ^iiifij/' ] ili^n BWnllowixl hy the patieat mitil it cxUinda 
i=ii=J — 1 1 iluH'ii t(o to XT cm. from the teeth. It in then 

connecteil with u Marcy tambour whoae oecil- 
lalliins Ns-«nl the coiiliacliuD of tlie auricle 
and ventricle (I''i|». A3 luid »l). Tha (aO in 
ihe H-Rve Dccum when llie auricle moves anay 
from the (mopha^cus. ibc rise vlien it ii 

prmeed against the hitter by filling with bloi>il. I'mlef onlinnry rinMimstanoni veo- 

Iricular BM well a* HurkciilHr tijitinle ilmn-H the iiuricle avay fruiii the aasopbagua m» 

lluit the falls nn-l ri»ni cormpouil lo aurictitar anil vpntriculnr s>ilolc napectivdy. 
(r^ofhnKcfll TracloE fn Mitral 

Inutllklcncy.^Whcii the niiiral vulve 

dot* ni>t cicnc (mitral insuHicicncy). 

blood in f>)rceij back into tlio auricle 

<liirin}: ventricular nyvlole. uiid, iiikIcikI 

of a Fall, then' in ii rise during »ynlolc. 

MiakuusklV mctliCHt furniHhcK the 

nicjirii fur obliiiniae llic miwiiiK link 

in our knonleiip? <if the cardian inipuUc 

sail the nicHiiiTiK uf fuiictlriiial niummrR, 

bul unforlunntciy the iinalloviuK of llie 

stiimacb-lulio i» tio diKi^n'R'ol>le to the ordinary patient «Ti(l w> danf[erou» in oH T«ry 

■evere ouoi as lo prveludo it8 aitofilion into Kionerat use. Puticiila can, however, often 

be irainci] to nwnllow the i>tomaaii-lul>e without dilllculty, or a niblvr lulw of vtnall boti; 

may lie aubailtulMl, and then wry Mtiafiictot?- rwulta may be ol>lainod. 

' Thia, aa hua been lAowit by Mackcntie and by Riht, m not abaolute. 

the tftophpcu^ lo <how Uip cnnltactiuEu of 
(he l«ft auriflv. Thi« amrw pninh u> thp thin 
rubber hiilb *l i)*p «n-J nt Ut« wph«cni tvbv, 
HT, ■idiumIi . 



Pm. S4. — UiMipliaCEul an<l caroUU lr««ing> from a 




I Kr >'A«Hij 

rio, t> . fl I n ip U gt fciFtn <d Dppttntnr for rvconlinc tht* «Iw^jiH4nlici£run anil CArdlocrkm umulTAncoiulx* 
LMPT WOffr.juiAIUdiritliiialODlutlon to r*wv« ihvirttuil nglit bamli mpcclively. 

Pm. H. — Palint iriih budiluuiiii pUred in 
>u« of Hit mtulion. mdy lot takinc •liclmnnliii- 
■nan. (Aftw Elnikom.) 

Fhi. ST.-'Counc a( Um d«iri«l nils iSaoi d«> 
lolholi^rl-bnitiniiiau. (AtUrVKllrr.: i-r.miinr 
(if lh<n*^tivi>wat-fifroinftunalwiovr»ih<ilc*; b.b, 

llwuuncaliir ■>>r'>lf'^tr,D, vjiita about tTlB^tdlricLB* 
bKUj]iaiKtLtc*l-ivi JujitMtviiDtricu!*r mxniolw^ 


th> tim* I 

I >.c vtnoun Uld oUDtid pu1i«- 






1 t 



1 t 




tuldui t»- It-r Bntai in cullslictfiUluU witli Prol. 
).. I'. UukM and lit. R.S. Bond. 




Mo«*o and aluo tiie u-riier haw ohraincd vvt}' MLlisfaetorj' canlioijrapliie curves from 
the ohangw of uir prawun- within ihe tliamx. TtiMr inuy be obtsiiieil by pludoj; in oii« 
nwttril n oork pcrfotuUii by u gliua tube which U connectcil with tb<! n^conlinc krv'cr. The 
Hpc nrr rloKml and Thr olhrr ncMlril in rlot^cH) by pmMiir«. Or, ihv liihc iiiny be placed 
ill thu itiDUth 4111(1 IjoiIi iiiiBtnlH cIohiI by jtiUMure. Tkie glottJH inunt btr uptrn and the 
brculb hi^lil. Curvcn tlitui ublnincd rlowly nwmblc the oiiophuKc-Al (racing in normal 
individiJHl*, though the wnvcx u-rv f'tiiuller. 


Another verj* proniiHinp; niPthod of pxamination which hns not yet, 
bct'onn; gi-iicriil is tin- u.-t: iif ihv rU-ctricnl viirialioiis iliio to the heart can- 
traction tclcctrocardiagram a! Kinthovcn). 

Eintho\'vii plucm th« jiutiviil in a. cliajr with both hands or one h«iul luitl one font 
imnicrM!d in n jnr »f 0,9 per real, nodium chloride nolution. F^ieh jar U connected in thn 
circuit with h very ilphctit(< Fiiiihovrn (or Kdclmnnii] thrciid |[»lv3LiionidI«r (F'ig;. 55). 
The iTLuvi'itictitH of till! ^ulvnnDiiivI^r are riHrunlffd ['huloKiuphicully. At i-iich hi-urt con* 
triiclidn ft nrricii of dcctricnl ehanpai appi-nr (I'ipi. -IS «nd .W), in which the flrnt wave 
t' C')rtffl]>oiiilB to ihi" aiiriculur (alriiil), Iliu second Qlt and third SI' 1o tlie ventricular 
Hyiitfili.'. TtiJH meTliml. al lirnt sight the nitict dil&cull, is. when (he uppliaoccs are once set 
up, one of the niiiiplent of till llic craphic mpihnilii. I-^inthovcn ha* coiiner.Ird ihe I-cydcn 
phyBiul(>g;ical Uburatury witli l)w huspilul by nicariB uf tctephoiie wirM s[>ecially luid. and 
i* able to make hi> dingnoefS at a diiilancr nf a mile without ever seeing the patient. 

In hyiwrtrophy of the riitht ^-eninclc llie wave QU in much Inrncr than iitual au<l is 
en th(! luioe side of the bnae-linc iu> the aiiHeutar wave /'■ In casen of hyf>crtn>|)hy uf 
the le/t x-clilriclc the (JH vaw h inverted and it« altitude in also (treatpr than normal, 

iMnlhoveii uiid Kmus ond Nikolai have bIiowii that exInwyBtoteB aiid other irrvgolar- 
ItiM may l>c <lpciphercd by this mcthcid better than by meaim of the venoiu [iviW; And it 
'm probable that il will to & great measure supplant the luttvr as M means of dlagnoels. 

Vcxors PVMR. 

Engelnwnn, Tli, W.: Veher Uoo Ur»prunx det ItMsbfWcigtuigen, Areh. f. d. gn. I*hy»iol.. 

Bom, 189T, 1«v, 109. 
Morrow, W. S,: Uebor die FortpflaniiinKsjwschwindijtliPt de* Vcnenpiili^ Arch, f, d. (ttti. 

PhyiioL, Bonn. IIKH), Ixxix. 44'J, Tlie Rate of Propuication of tlw Vcuoun I*ulBe. 

Cai'iad. Rm. Sc., IWIO, \nii. 205. 
Friednucb, N.: Ueber den VciicnpiiU, T)eiit4ch. Arch. f. kiln. Med., Lel|»., 1865, i, 211. 
Marry, v.. J.; Ln circulaiiou ilu KUig a I'ftal physiolojeitpie ct dann lea lunludicfi, I'aria. I8S1. 
Hackeiiiie. J.: The Vtaioiw and Liver I'uIn-s. and the Arrhylhmic Conlraetion of ihe 

Canhuc Cavities. Jour, PHlh. ami Bacteriol., Fthnb. and Loud,, I8(l^tM, ii, pp. 84 

and 273. The Study of the I'uluc imd Mo\-eineutB of the Heart, London, HH):i. 
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Sc.. Fhik., KHM, cxxxii. 378. 
Bachman, (i,: The Interpretation of the Vcnoun I*ul»c. ibid., 190H, cxsxvj, n74. 
Hay, J.: Grapliic Metho<U in the Study of Ht^rt IKsease, Oxfoid and Lond., 1000, 
V. Jaquel: Ciirdiotiphyi;mogrupb, Ztschr. f. Viol., Muejicheii, IDOI. 
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l-'redcricq, L.: La nccoiule oudulDtion [Kwitivc (pnuni^ nndulalion iiyitoiiquc) <lu poul* 

veinoux phygioloKiipic ehn le elticii, Arch, intern, do Phyainl.. 1007. Ilit^lnriacli- 

kritiHChc lteitierkiiii)[cn ueber die vun kliniBcher Seiti' iieucrrtiiip iiiii>rknnnti.' Idenli- 

tAt dor Venen- und fKiiophaj(uspiiliibildcr mil den Vorknnimenlruckkur^'irn, ZentnUbl, 

t. Physiol,, r*ip«. II. Wi*n, 190S, xxV\, 2(17. 


Ho«Tow, W. S.: Varioiu Konru ol the S<^tive or Phj^oUigical Vcnoiu fulae, Brit. H. 

Jour., IjmA.. 190i>, it. 1.SU7. Tbc Wnoiu Pidw. iUd.. IM)7. i. T77. 
Knull, P.: Uvili4c«xur Lrlit« vontlvr BtulUMV«pU)gUi<le« V«nen, Ar«Li- [. d. gtx. Phjvial.. 

Bono, lti88, ixxii. 317. ^1. 
TheopolJ, P.: lun Britniff xiir lidtrc von d»r Ariiylhmia perpeuia, T)eiit«cU. Atrh. I. 

Mia. Hod., Uift.. I9WS. Uxui. 4U5. 
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frecieritiri. L.. I. c- 

Paner, W. T.: Htwimbw on tlic Killing of the Heart, Jour. Pii>-riot.. ('jun.. Ism. nil, S13. 
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et <l» Pulh, K^i.. Pur, 190e. viii. 454. 
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kina limp., Rail., ISUT. xviij, -265. 
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xhx, I2M. 
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[ Jjewall, H., utid Hiraclifclder, A. U.: t'npublinhnj invratiipitionii. 

Ptabodf, F. W.: fVnmiuil rommiuitcailon. 
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exxxvi, 32. 
ilcrinic, 11- f:\ IHf Vi>rwichiiunR dm Wncpulaea am uulierten Kilniitlioh dutrlutiHimlcn 

SftUKC'liettu'niii, Arrli. t, d, irh Physiol.. Bonn. 19(H. cvi. 1. 
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ii, 1380. 
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.Sc., Phila. aiui N Y'jrk, 1907. n ». ciixiv. 12. 
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Uinkowoki. O., Dir Ittxiiiirii'niiig dor IlertiwwejryniEeii am liiikfri Vurhof. Deuidc)!, me-l, 

Wochiiaehr.. lIKNt. xx&ii. 1244. Zur Deuttiiig von Hcmirrhythmien miltelst dm 

CHophiKealen KanlioKntmn. Ziitchr. I. ktin. Mnl.. Bor)., Iil07, Ixii, 371. 
SanlMitMrx, C: N'eue M<'t)K>k- dirr Itei^intrierun;; iter \'iirliuf«|iul«aliun vunn OcMpblgua 

aiH. IViiliclie mix), Wclituwhr., Ij-ipz. and Brrl.. 1907. xxxiii. ^4. 
Younit, C. 1., and llrwlrtt. A. W.: The N'onna) Piilmliom within the (fyophagm, J. M. 

Reaearrh.. Burd.. 11(07. xvi, 427. 
Kinehfclder. A. (>,: <)ln<>rvnliaDi> mi n Ca^ of Palpilalion of thp llMrt, John* llnpldn 

ilauf. Bull.. B<>llinion>. 1!)06. zvSi. 'J9». 
Einlhoven. W : Lp ii^l^untiogrunmr. Anh. tntcmat. do Phywiol., IJeg*. IflOfi. ir, 1X2. 

Weilvm uclu-r da* Elt^klroka^dingF»Iltm, Arrh. (. d. gra. PhyHlol., Bonn, lOOV, cxxil, 

317. (Snp al*o cliapier on Atlt-iiitiuiui of Itliylhm.) 


The irrpg:iilaritie.'i in rhythm of the heart msy be divided first into 
thrc« clas.>"<;»: (1) arrhythmias, in whioh there la no discernible order 
lu tb« o«currenc(! of \n-&ia; (2) allorrhytbmius (altered rhythms), in 
which, though the rhythm is not rej^lar, yet the in«R<dar beats occur 
according to a rerlain regular system, ao that the arrangemeut of these 


beats in one section of the tracin); cnn bo prophpwed from o. knowledge of 
another: and (3) pararrhythmius (Wenckebach), in which two separate 
rhythms are ROtng ou in either the same chamber or in difTerent chatnber^ 
at the Hune time. 


il. Of extracardiac origin. 

I. Neurogenic, due to more or less rhythmic rcfiex stimuli pass- 
I ing through the vagi and acerlerators (toxic, rcftox from various 

I organs, respirat«r>' reflexes from lungs). 

I 0. AsiMicialvd with the phages of respiration. 

I b. Not associated with respiration — Mackeniie'ei youthful type. 

I II. Due to disturbances in the filling and i-inptying 
I of the boart from traction upon the heart and 

I gfcat vessels — dropping of beats without heart-block, pul- 

t 8U8 paratloxus and Ricgcl's pulse. 

£. Of intracardiae origin. 

I. Due to disturbance in tbc cooduetion of uormal 
I impulse a — dropping of l>eata. 

^H 1 . Auriculo- (ntrio-) vontneular block. 

W^ 2. Sino-auricular block. 

f 3, fnterventricular (?) block (heniisystol«) . 

I II. Distu rban ce of con t rae t ility — pulsus alternant, and 

failure to open the aortic valves. 
in. Occurrence of 'beats in reaponae to abnormal 
I Klimuli or increase. d irritability. 

1. K5rtras}'stoIe.t. in which irregular beat is brought on by a single abnormal 

a. Ventricular. 
^^K b. .Auricular. 
^^B ^' Auriculo- (atrio-) ventricular. 

2. Permanently irregular heart. 

3. Paroxysmal tachycardia (auricular tibrillulion). 


Alteration in cardiac rhythm resulting from intermittent stimuli 
pawing down the cardiac nerviw con>tituti-s one of the most coiiiiuon forms 
of cardiac allorrh\thniiafl. As has been seen {Cliapter III.), altera- 
tions of the pulse-rnte may re suit from any stiiiiu- 
lation of any afferent nervo, from skin, mueclDS, mucous 
membrane, and vittcera. or from stimuli ari^ng in the vagal or accelerator 
centres in the medulla. 

Am ttcul Hunt ami Hooker have sbowii, the i«flex Htiuiulutioii may eauw- a Ktuwiag 
of the piilw-mf« thronali ni.imiilnt.inn of the rnipw CMitrc, or, under »lbftr cJrcunwUuiec- 
anil eapwiulty w)i«n <ir a diff^rvnl inleuHJt.v, it may caiiH an aeceloratiuii uf the piilw» 
rarp. Hxml ha* nhoivn that ihis iiccelcralion ia Uup cliii-Ry to inommlDty pnaution of the 
tonic utimuli in the viuctix- hui Hooker provM ihnt ihrrp in also a Hiimiilatinn of the 
Bfcelenitor*. KiicTi BlTMvnl or wiiwir}^ HtiinuU inuy urise in the akin and nuircles, but 
MpKlally ill (lie viwcm nn<i the iTrDiw and iniK»iiE mcnibmnca. 





ft. c, -va iv<^ 4 t^-^**, 

;■ ■ ri I i L ( 




s 1 

1 ^^ >-■ 


1^ : ocvv c - 

- «?^ 


VMirmit'i. I.B 




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- 1 
r- - - 




■ 1 
1 1 


> ^ ^ ^ 

t v^ ^- 


K|y. (10. — IKwnuD NprftwiiiiiiK vtriDiu Ij-f" "t imtultt pul»»- The licaTy whlw ■m>«« inili- 
^U Uw Mm of oriDn i' <)>■ iliirtiirliwm ii( rhrlHiii. Tti* hnvr wliila lintv intlieilc iIif rounc of lbs 
n* I II *1 «r<l(A« trnpnlwi, ltK^/\ rv^piniiji-pn: A I' ft. «(irirt«: A~V ir A VB utiririilnvnaripulAr buC' 
•11(4 VgS'T. iMiUtHc; Cjlff, MKtiij puW: I'^.V. vanoiu pulat: .SIS, lunun rrcinn of ll>* hmrt; SVC. 
I VC. aapvior wdJ tnttrfoi vma tsvr. rviMclivdy. 

Reflex Alloirhj'thmiag FrancoU-Franck and Koblnm-k and Roi-')it 

hnve been abli^ to prnduoo siieh nn un-hjthmia by sliiimlnlinK tbo mucous 
tnrmbran*^ o( tbc duiuiI M-|>tum at a point juel opposite the middk- lurbiiiitle 
bone, and Stadler and Hirseh bave done no by stimulating the walls of 
tin' ittoinuvh and iiitesttiies. TIiltc \s iiorninll}' a reflex slowing uf the heart 




during swallowing, and similar periodic slowiug of the rate from sUmulation» 
of the vagus may account for mniij- of the disturbances of rhythm in air- 
swallowont. Moreover, Einthoven has shown, by rpcordiiig the electrical 
variations in the peripheral stump of the divided vagus, that, with each 
iiii>pin>lioEi, alTerent stimuli are paiiBing up the vagus, and these may evoke 
reflex responses when the entire nervous system is abiiormally sensitive. 

Occurrence. — Neurogenic arrhythmias are psrtiL-ularly vomnion in 
children and iu young persons, and hence are designated by Mackenzie 
as the "youthful type," but thi.'< is only because the cardiac, vaso- 
motor, and respiratorj- centres are in more labile equilibrium in them than 
in normal adults. However, whenever the nervou.'* system bi-r«nies more 
irritable. — from the occurrence of visceral reflexes, emotions, or toxic 
influeuces (bacterial toxins, alcohol, tobacco, coffee, etc.), — stimuli (lik« 
those passing u[> the vagus) which arc noriiially subminimn) become 
cfTwtive. Hence allorrhytbmias of this tj'i)e arise in nervous individuals 
and in the so-called funetiunul cardiac diseases or cardiac neuroses (Part IV, 
Chapter III). Since the afferent stimuli in the vagus an* continually act- 
ing, it is quite naturiil that they should athi tliein.ielvi-s to any other afferent 



tri%o tip (n^p -Imp I i*Mp 

i'uul'-i- — Rfxpimr.kfy nrrliyttinii.-i, LAfli-r llnMi^-iT ■ 

stimuli which may also be acting, and that the alterations of rhythm will 
then be associated with respiration; and, since the nature of rvllex 
responses varies with shgbt variations in the intensity of the stimulus, 
it is not surprising that there Is in some cases a series of slow beats 
associated with inspiration and a series of rapid beats in expiration (Fig, 
M), while in othei-s the slowing occurs during expiration and the rapid 
beats arc during inspiration. This latter type is often spoken of ns normal, 
but in perfectly normal individuals the rate may be absolutely regular. 

Reissner has shown that the irregularity is .sometimes of psychic 
origin; or, in other words, that the stimulus exciting the cardiac nervx-a 
may descend from the cerebral corlox instead of ascending by the uaiuil 
paths of afferent stimuli. This psychogenic arrhythmia is not extremely 
uncommon. Indrt-d, the writ-er, whose pulse has been regular at all other 
timi-s, experienced such an irregularity upon one occasion of inlen.-*e anxiety 
lasting for several minutes. The pulse became regular as soon as the 
anxiety jia-ssed off; and has remained so for five years, in spite of a severe 
tonsillitis and tonsillectomy. 

,\» Reyfisch has shown, similar neurogenic allorrhythmias occur in 
meningitis and in eontUtions with increased intracranial ten- 
sion and, as Ryster has shown, in association with Cheyne-Stokes breath- 
ing. Mackcunie has also shown that there are many other cases in which 
neurogenic iiTegularity is not associated nitb the phases of respiration. Id 


f^i ft wiB it may bo either periodir or entirely intermittent. It is most important 
that the vxucl inudo of origin of such stimuli and its chjiracti'mtieii shoulti 
be carefully Btudiect, since Ihis arrhythmia muat he <lif fcrenli- 
ati^d frum tho.-<c uf myocardial origin. In thp»e C!u>cs, though 
the relation of the allorrhythmia lo respiration may l»e timed by palpation 
and ins(M-rlion, » cawful vonous tmriiig should be ma<lc lest iin extra- 
nystolic irregularity be dmgno§cd when it doed not actually exist. 

Characteristics of Reflex Allorrhylhrnlas. — The striking feature of 
these neurogenic disturbances ol rhythm is that they are often charac- 
tieriwd by instability of rhythm, by the oceurrencf! of rhythmic 
changes In rate rath^'r than by the interpolation of beats which dilTer from 
the others in character. The heats usually occur in short groups, the first 
Ix-at of the slower grou)i being the longest, the rate of the more rapid scries 
^DwinK >^ progressive increase. The last beat of the rapid series, with 
the vagal pau.w following it. may he mi.-<takeii for an extrastyslole ; but. on 
examining the few beats preceding, it will be seen that this beat was not 
premature and not due lo an abnormal sliniuhio. More<iver. Ihe t>i'Hi» 
are usually of full and almost equal strength, thereby differing from 
the feeble beats of cxtraB>'Btotes; and they do not oeeur, as do the latter, 
abnormally early in the cardiac eyrie. It is an irregularity in rliyllim rather 
than an irregularity in force, though a certain degree of the latter may be 
prvtteht Ihrough the action of the va(ni« on the heitil. 

The rhythm usually becomes regular within lialf an hour after the 
hypodermic administration of atropine. .(KM).) to .001 Gm. (j-f^ to ^ gt.). 
This rule is not invariable. 

When long paiises alternate with short series of rapid bealK, the fore« 
of the first large iK'st may be slightly below that of the smaller beats, as 
.ihown by tracings with the Erianger apparatus at or near the maximal 
pn.'ssure. With eMnisystoIes th« systolic pre-ssurc of the smaller beats is 
usually less than that of the regular (largo) beat. In both eases, however. 
tbi.-" depend.-* ujion too many factors (time at which ttie extrasystoie occurs^ 
amount of systolic output, amount of peripheral resistance, factors causing 
the fxlrasystole. etc.) tJi be n-ganh-d ».■* absolute criterion for iUugno.4ts. 

II. Req^raiory (Pulsus paradoxus and RicKcl's Pulse). — As will be 
seen in the chapti-rs on adherent i>ericanliuiH (page SOG) and enterop- 
tosis. traction upon the aorta during re.'<pirat.ion may prevent the heart 
from emptying itself and thus cause the* dropping of a l>cat in the arteries. 
Or, on tlie other hantl, traction ut>on the gn-ut veins may produce the aaine 
effect by preventing the heart from filling. When there arc adhesions in 
the jtost^-rior media-ilinum or when the diaphragm is low, thi.s dropping 
occurs during inspiration {put>fus paradoxus, Kussmaul). whereas when 
tiiere are adhesions between the heart and the anterior chest wall it may 
occur in expiration (Riegel). 


^^^ III. Allorrltvthmlas due lo Failure to Conduct Impulses j^neraled 
M Normally— Heart-block.' — Of this there are several tvpes, (1) ,\uriculo- 




ventricular Heart-block. — Tho more usual, or at least bottcr known, 
typo of blocking thu impuU'^ in at tho fturifiilovfntriculur junrliuii. In 
thU ty))!- no chiinKC occurs id thr originHtiuii of tlic canliac impulse or in 
the conlraction of tlut uuricles (atria), but the eondurtivily of iht iinpuli*e 
to th(> ventricle by the bundle of Win m iiDpnired. Such impairment may be 
(t) functional, from overetimulation of the vagus, of nhirh frequent 

ASEC. ; 



" ^1'" lumuimmnx n u a u s iDit/ii 

if r f ' ^ A , ' 

[l.Vi.L" HM.n fy ... ..— j^yjj .,_, 


* • ' ' X^J'^-y} 


/Aa^/VV\/v_-/\ — ^_Y^-r4 

rir wijHC o/w i-*irf^ t 

Fu, AS,- 

-%~«ItDiu tndngi in hwrl-blook. PHrtikl hntrl-bliwk (3: ) rhjrthm) durios prwnir* on Um 
v*cu*. in a COM of AilBm».SU>lMa dlfaut. 

examples art; seen in ever)- laboratory experiment. Clinically this may be 
Boen also in thi- cases of diRitalta poisoninK and poBtfcbiile bradycardia, 
(•Tipecially after pneumonia and inllui'nxa, occa»ioiiHlly aUii in ciwest in which 
there is a tumor pressing upon tho vagus. (.6) Organic, from interrup- 
tion of the bundle of Hii^, In this ease the block may be increased by giving 
atropine or anything else that quickens the heart, or it may not be affected. 

' ol Adami-itiuksi dl 

(c) There may be a eomliinittion of the two effects (v, Tabora, 
(libson, Thayer), the eomlucUvily of the injured Purkinjc fibres of the bundle 
being still further diminished by the action of the vagus upon thom, and 
this effeet outweighing the favorable uetion in blowing the auricular rhythm. 
The block may be partial or complete, depending upon whether 
the vent rich's Mtill follow the lead of the auricles or initiate their own rhythm. 
Thus, in the partial block the ventricles may respond to only every second, 
third, or fourth, or even only every sixteenth contraction, or may .sometime* 


Diid lo every 9(-oon<J. soiiiHirnvs (o fwiy fourth heal, etc. On the other 
Jmnd, tliey may fail to contract at all over a conaidprabfc pcriotl (stoppage) 
(UiririK whii'h syncope (Adams-Slokei* Myndromc), epile|itifi)rm siMturt«, 
or death may set in (Erlanger), or, after a stoppsge of greater or leas dura- 
tion, they iniiy bt'|<iii to beat «l a rhythm of iheir own. brarinf; nn n-lalion 
at all to the rhylhm of the aurieleH (eoiuplete block). Tills constitute* th« 
permanent bradycardia of Adama-Slokes dii«oa»c. 

(2) Si no-auric id iir Block. — 8ino>iiuricular Wock moy aI^'■o occur, the 
cardiiu^ inipulw b<'inK Rciipraled as usual at the mouths of the great veins 
and coronarv stitu^ In the re^i'iii hriiiiolopiiirt with the aiquh venosua of th« 
frog, bill may fail to be communieiitcd to the auricles. 

Kritli ami t^JiAnhcrg ttaw ahown tlutt thin could iicorcc4>' be the result of a locotiud 
I leuiHi. anrl wiuulil llicrcforo (irpmil upon the ililTpiendn in Ihr pmpcrlii>ii nml irritobilJtjr 
! a( iiurieiilut uiid vriiom iDusciiIiitiirt lulhi-r tliun oriMiiii; tilui'k. Tlio prcwnce of such 
rblucke i« luuiiiiiifiil hy Auxtwt llolTtnBQii in fianixytmat tachjranilu. in wLkh iIiitp is 

a ■udikui iloutiliiij: or even ciuiulrupltnjg; of Ihv [lulvo-nitc durinx the ntlnrlu, anil hy 
jHeDlfll in <lijci'i»''!' powoning. KjcfwriiniMi tally Ihcj* have bwii jiroiliicwi by Erluiijccr 
iftml Bbwkiuiui on llic pxciwii mnmin:Llinn hrnrt, but both llirwhfr'Uii^r and Lystcr ami 

the (ottaet otmeniTH tuiltd ii> <iu ik> in the hturt in itCii. GlbHOD Msumm tlie t'XiMicncc of 

a BimilNr block in a rjuar of .\ituiu>'Stokm diMMUN:, nliicli lie citca. along wilh the block 

>l the nuriciilavenlrtcubr junction. 



Fid. 4M. — OcaManal mtmmic* of mptx ImpnlK durlnt LoifiMilaa dmuLitiiic ioWtVBitnDiiUi liMrt-UocL 

(3) Int«.'r\x'nlTicuUr Block (Hcmlnyrtdlc).— v, Leyden in 1868 reported 
a case of bi)ieniinat pulse in which ho aasumod that one v^mtricle whs ooo- 
tructiiig without the other. 

This CMC ami other caM8 reported by Ihe older wrilets, anj wlJcb mm undoubteclly 
due to rxirwiyiitoliv. am really not ounelunivi?; but rBceall)- ciihib have bMn r«por(«il by 
Kraua and Nikolsi. unit by Ilxwlrlt nml SehmoU, in which the elHclrocwrdiogniRi and 
vpDitus traciiigB have tuniiiilie'l Minie evi<leim- (liul the ri(iht ventriflc luii) thr left vtin- 
trielc may harr bi-en cotitniclinfc nltcmutnly and not ^nchmnniMly. For the pK»eat. 
one itt jurlifieJ ii) an utlllwl? of inmlertitr Hccplicinin upon iliif point uatti iilunJute proof 
hiw bcrn broiiKhl. Pnifpsnor BurkiT, I)r. HoiuJ. jind the writtr lui»-c pejicaleilly eiH thfoitgh 
llie left branch of thi- Din buniitn without injiiriiift the rixht bnuich, Ntr uBynobmiiiEiii 
of the VMittklm oceurri"!. Kxl rasyntolee j)rtKlui*<i in eitlier ventricle wrere coni!i>rtC<l 
to tbc other aitlmiil deJuy. It do™ not. thrrrforf . K*iti probnblr ihut a pMlch of eiulo- 
eanlili* or mifM-urilitiM, Hiich »» AitchnIT nnil Tawiini oceationnlly found iiivarlini; a idrqite 
brsnch of the Hin liurulliv wuuUl be able to blix'k tlir iiiipuliK' to one r«ntrieJe and tlie^r^j 
Ipctvitfit itc controcliftn, Morcovrr. it i« (mwiblp th™i. like v. I.ffydBn'a, Hewletfn InmngM 
tamy t>ert>ut uf a diffvn'nt Hiid im<re conventional explanation. 

IV. Diminution in Contractile Power— Pulsus altcraans.— When the 

contructile power nf the heart diminisliPB, or, more frw|uent]y, when i\us 
rate IB increased to the paint thai the heart ban .-wimi- dilTiculty in carrj-- 
ing out efT<rctua) contractions, it is found that the alternate cont ructions 



are of different Bite, sqidc larger, eomr Kraallcr, ^ving rise to the condition 
known as ]>iilsijs ftltern»iitt or «ltrriiHtiii^ pulsi-. This id cspi'cially t'omniun 
in the tachycardias aHHociated with some weakness of ihe heart muacle, 

and esprciftlly with paroxynmul tjichyeardia: but wherever it occurs it is an 
cxpresi^on of dii^pioportioii between ihi- rale and con t.raeti lily of ihp heart 
(or. in KiigciiniLnn'ci Icrniiiiology, between the clironolropic and ino- 
tropic influences). 

K«jjeri menially this can !» rvailily shown liy throwing induclion ■hockx into Ihn 
tieun u1 u ruti- which il can barely follow. A ptibiui ullomanii invannhly m>nli» (Itlnch- 
fcldcr, I(crinK). Alrer u ivvi itprmiiU or niinuiM llie lipart lius kuiuM lie full contractilily 
an<l llie ullpniulins churaelpr (lira|>|wnni, only lo rcnpix-jkr whrn il bc){ina In weaken. 
The ■nmc phc^nnnirnon in atun iv<en in attacks of paroi^'rnal iiichycanlia (Pin. (^)- Piil- 
81W nUeriianM i" alwi prowiil in otiiiie ctum of luigiiiu (Ha'toris (Mackeiiiic). Il then ioili- 
oalea tluil tlic licarl i« in a wrakrniv) coniiition, 

V. Dropping o( DcBt owlnjc lo loo low CiMiuactllliy.'-lf iha auricle bt^ iitimulat«d 
direclly M a raie nlill more rupid. i) can no loni^r (ollow every nmsjiP slimulun. but occn- 
nonally »tir beat, i* i1r>|>|>ihI out, jim :ii \4 ibe fnw in a [lurtial hrarl-hlork. alihoiish ihe 

nitiiitilua is livini; u|i|i1i«il ilirpcltv to tlw auricle. 
which inlrrmiU ii httic tncirf nipiilly, slwl it fol- 
luwvonly iJiemaiexiiniith. If the irricuMliiyof 
tlio auririp lie no* siiilifcnly iiicre-siK^rJ. il» by 
pouring warm ti«ll loluiion oivr il, it will ■ui!- 
d^iily rmiKiiiil with ucuulrucliuD luMch iiul^ail 
of In allemnlc diniuli, or it may rcKptmi) occa- 
sionally to nil und ocraMiomilly tn otily ali«ntatn 
(timtiii, tciving un ullorrliyllimia 1;1 4-3-|. 
ThiiA we may have nllorThylhinian ■imiilalinf; 
pnrlial Iii^urt<bli>ck8 0ti throne hiuid.anilexln- 
*v«lol« on the other, due merely to pMwml 
deorvaae in the irrilahihiy of ihe rnliir miia- 
culalure without any r<|ieciul iliHturbiuiCo in 
c<indiirli*"ity: .infl ju»t wich inotrojiliic and 
bathiuolti^lihic variiiiirins may be p«.pnn*iblr 
for many of Ihe iKvcuIleil veiio-atirieulur lii'ilrl- 
blurkH. Hiich a* hnvp bren dwcribt^i by Ilewlel I 
unit Wcnckcbacl). 


Irregulnrilios may be due to the 
origination of abnormal cardiae im- 
puL»e« or to abnormal responsie to 
fltlmiili (extra»y»tolc»). The sitnpleict 
form of this is seen in che occurrence 
of single abnormal bcata. Kxperiraentally it has been shown (Marey) 
that when a single electrical or mcehanical stimulus is applied to the 
heart al any time except the refractory period, the latter re^poutU 

abnonRil ilimuU, (Aluv Maiwy.l Ki««trie 
thuck (JiroVD iDta It at (lie in»lant markad by 
thanirliiii th* baa* lin* and liy Iba dultaU line. 




almost immiMlial^Iy with a contraction (extrasyHtole, Engelmsnn; 
premature Mystole, Macki-nKic, Cuifhny. and Slallhows). 

Venlriailar Extrasystoles.— If xhe extra aiimulus be applied to the 
ventrirlo, th<- latter nrttponds with a prcmnturc coiitrnctioit, then umally 
but not Bin-ax's miwiett the next impulM from the auriclo and puusei) for u 

e«d(d by Ml a ■«*•). Ilinccit ihv biBaainiu (ncuUr tytcok+ntrwyatale -t- pamw) "*^-* ^'^-^ 

whili', until the ."toooml inipuK^ from Ihi-aiiriric rcaoliritit. \\\- Iiavf. there- 
font, ft iiurmal eonlrartion, a premature eontraction, and the inubeetiuent 
pnuae (which togothcr may be termed a biceminuH), laiitinfi; as lonf: as 
two regular eonirartionM. The bifiieminus may be ^tpoken of as a"full 
bi^c minus" when it lasta through two full car iliac 
cyeles. and a ".shortened hi gem i n ux" when the duration 
of regular *y«tolc -f ex t rasy st ole -i- subttequent pause 
■ a less than two cardiac cycle*. 

Auricular Extrasystotes. — When, however, the extra stimulus is applied 
to the great veinn nr the auricle, the bigemiiiUH ln.'it.-^ U-fX than two cardiac 
eycle« if the i^limului^ follow:? clowly upon the repulnr contraction, and 
exactly equal to two cycles if it is applied late (Hirschfeliler and Kysler). 
If the Hiimului! i:" ap]>iicd early, the auriculo ventricular (atrioventricular) 
conduction time {a-c) interval is alowed. Later in the cycle it is unchanged. 

Jl'O I 



Pill, fla— Tnti^mci Jroiit rhp Jiimijlitr T*in niid linrttiAl tirlfry nf n pittirtiil milh Ifiifaiimtt] puliir 'iii« 
[M thm N^nlar iKvutncir* of i*n •iiricuUr Htn^^-Mnlfa iB, S) iilfrtnn<\i naulu (TMnlc. The o *ar« 
I vbvbI tofm of Uip i^«noUB pul» *rt the miu* for th« regular And tho «unrular «x^nf>i>1o]». 

The two forms of extrasystolra occur clinically and may be differ- 
enliatcd by the anatvflis of the venous puke; the ext rajiystolca of auricular 
(atrial) origin ofu-n ^ve rir« to tthurtened bigemini, while ven> 
tricular ex t rasy stoles alwuvx cause full bigcmini. In the 
tracinRs of auricular extraa>'stoIes one can ace the auricular wave before 
the ventricular even in the e\trarfyj«t«ic; the vcntricuhir showing a single 
large wave due to ventricular systole, sometimes with the notch due to 
iht* contraction of the auricle from reversed conduction of the impuL 



OccaKioniiltv' vrntrieulAr ex trasystoles can be distio- 
fEuiahcd on inspection by the 1»rg€ flapping "single" 
pulaalion in the jugular vein which accompamc^ them, in 

co&traijl en the double venous pulae of the 
normal beats and the auricular cxtni- 
Ryntoles (Hirschfeider). 



A further advance in the clinicul Ktudy of 
oxirwiyKloW i> Hun in [he clinicnl UM of tbc clec- 
Irvcaniiofcrani tiy EdiiltiovraaiMJhiH|>u|)ilB.andiniHv 
rwcnllj- hy Kmus and Nikolni. lIcrtnK. ""d Lcwifc 
Elinthovpii citllfHl aitc-nlinn to ihn pnsctiee of 
ccrluia vi^ry jMwuliiirljr (oniinl olcctivcurdiaK'Unh 
ul>uuiicd (mm irt«f[ulnrly acting ticndit. Krau* ami 
Nikolai wir uble lo reproduce (lirse alitinrtiiit] waves 
bv iwodudng tKtnM\itolia iu dopi: auil rmiDd Ihnt 
•xlrtuiyatolw aruinx in the riickt and luft i«Mr- 

elw retfiectii'el}' produced eurvts whicli nrrv llie iiivem' of one uiiollicr (PlR- fiS). 

Kalm in UeriiiK'" lutroratory hu) hnrn nl>|p lo confirm tlta>r liiidinni in ^rjiI pari- 

However, h» ea\l» olWMition to the fact thai ihey do not hold atwnlnlrly, and nhowii Ibat 

■liiiiuti upplied lo noiutihoHiii; jKiinUi in right anit left reiilriclen. near Iho ajiex, miiy rlicil 

clcclrnninlioKTain* nhich •lilTiir only nlightly from ixip citinchirr. 

I'lo. Ml.^DlaarBinmaUf rtprodunliHi 
ot tlia clceuveaidincranl obulnal in ifae 
ilua ■> iha r«>ult e4 (alra*y>K>lca •iibus 
in th« nfht and Ufl v«nUicl«*- lAft«r 
XniH and Kiknlal.) 

Fw- Tt>, — Klr*elf^K"*fJ"i(ra.Tii nf a t>>riintt with niifjiat *i*tii]*i>h, Blujwiiiit riilniJi)«UiL<^. wliirk 

Dr. C. (*. Bon'l. Pufiwi W off (nim ihr njhl hand nn'i MX l«M l^twrine n( rur%-» *• in Vig. ;•, 
f It T f«fir<Hml nomkal wava*: EXTUASVSt antfwyvloW- 

Stimutl which Cause Extras-stoles.— The question as to the nature of 
the stimulus which nWvs rise to Pxtra*y»toleB in man in of the greatert 
praclieal iniportanw, for many writers (espcrially Fr. Muller) arc of the 
belief that they never oceur uulesii the heart muttele in di^essed. On the 
other hand, Maekensie, whoae obeervatJona have been extended over a 
period of fifteen years, regards them as of no speeiid signifieance either in 
prognosis or in influencing the palient'a manner of life. He menttomt hav> 
ing advised one of hia patients to continue playinj! footbull in spite of his 
ex trasystoles. imd adds that the extrasystoles diaappeaR'd! 

Experiiiieiiliil|>- ii hiu bwii shown by KiioU. Matey. Reriii)t> ^nd utlien tlmt vontrie- 
ulur eitrnnysuil™ muy bt- prvrivicpil whp.ii«vc?r riilu«f the left vrntriple or the right ia p(t- 
wnt(<<l froni emptying ilarll (>.r-. by rlnnipinfi I.he uoria or the piilmonury »ncry). In 
mau tli^y are ttlao most cumnion in cuodilioru in irliich there is a IuieIi bluod'pnmuiv aiid 
the heart J* jual beginning to foil (chronic nepliritin. myncarditiii, aortic iniufliicipncyi, 
and probably falls to diacharKe a ■iifTiFinil amount of it» coni4>ntfi. This pmbably acta a» 
n •liiauliu fur a Recond extnu>ystole. tin lb frvqueiilly teen (puUuB iriiEviniiiU")- V'etitricuhir 
extranyslolrs ar«! tnoal eominon in hcaria wliotc rate is iilow and hptien which diachargp 
u lurKe amouttl of bloo>l. They arc particulnrly conimoo at the citd of tlie flr&l liiird ot 


(lionlole wlicn llip rillinc of ihc vcntride in nenrintc complfTlioii. Tlii; ventricular filim are 
■trctchcd morn or Icm> by Itii; influx, ami in poiiditioa* of iiicreaHeil irrtiitbility Iho i*tn>tcii- 
inK of (Iw librea may act a" ■> ■limtilu* and kivr rue to (he »trua7st«la>. 

Kmilur eondilioTui nre ubscrvvKl with rrferenc? to ihi^ auricle. [)t. ramnmn. in the 
tarilfr'ti IsJxiratpry, ohanrvM an inxtniiiw of perouiiH.-uI bigeiiiLuttl pitloe in a iloK due lo 
the prawDR! Ufa bubble of a>r in ih* lixht niiriclc. The uir had Dntcred 







Fm. T1. — VoIuiD* vurr* nl ihn vwitridiai. *lu>wiii|| (ha thliUliaii oliich tullowBd 111* (nliBncr 
tilood inlo llin antlli, />JJ., •lllaUtlciD. 

froni a hypodemiii' Hyriii^> duriiiK nii iiitnivrnous iiijectinu, \\ 1il>d the bubble was nttu>- 
■agod oul of the auricle (he bifieniiniil |>u)>c dimippraiml, U srrni* not impiDbublu llia( 
iniUttl ihroRilu may play a similar rOle, tliuiieh it i» ccrltiiii tlial thin iN not nlwayn theeaie. 
Auricular eiitniiiyttwkii niay al»i> \te proiliiecti «• xix-rinientiilly by cauniiiK a alenu- 
%ii> at lh«- nuncnlovrntrieiilar oriflem (Hituchfeliter), Clinically Ihcy occur quite com- 
tiioDly in niilml disrasr uiid inost (rti|Uenlly bcf^n at tlir^ time of llie c wavu, the very 
iiwUUtt in the eyclr at nhich the auricle i* moHl dintcnilfMl ll'iic- IVS). NevurthelcM, it rouat 
be codImmh) that much rfmaiiia lo be learned refciiMini: ihe nutura of the eliniubw or 
atimuli. nnd (hv ueliiol (unctioiwl xignificniiei? of extnui)-sl(>lni. 

PalpitatiOfl wilh Extrasystolcs. — Estrafiystolea are very frequpQtIy 
' U)9ocialo(i climrally with ennimc liyiH-ni^t ht-ttin in \\u- form of [>nlpit&tion, 
K) that many clitiiriniiH crroiu-ouniy regRrd all irrppilaritit-s with piilpitu- 
lion as exirasyetolic. However, il is possiltle that ihia hypersonsibilily 
about tti« heart may huvo »omc i-au8a1 relation, sint-c IIornunK hfti« .shown 
that extrasystoles in the tlog are most readily pmtluccd by stiniulating in 
the vicinity of the eardtac nerves — aiiricuh>(ntri<>)venlrini1ar and inter- 
ventricular grooves — and that they cannot be produced after cocuiniiing 
the epicardiuiii- True extrasystoles cannot lie produced ex pi- n mentally by 
atimulatjon of nervex (HofTmann. [leriiig). and though it La occaiaonally 
claimed that they occur in gostro-lntcstinal diseases the exact relation is 
not clear. It is certain that they ar« oftvn brought on by constipation 
and Hutulencc in certain persons, but whether there is a myocardial lesion 
already present in lbe.*e ea.Hea is a still open qucj^tlon. 

[Magnoels of Extrasystoles.— In some cases it is very difficult to dia- 
[tinguish between the neuronenic irregularities nnd the auricular cxtra- 
dIc8. Dehio has called attention to the fact that the former disappear 
under the a<lniinisiration of atropine, while the latter rrmnJn unaJtcn^d. 
Nevcrtliclcas one cannot always bo c<Ttuin that the dose of atropine, even 
if it has given rise to symptoms, has been large enough to produce the effect. 



All »xiunpl« of ihis type waa prvsMit in a paliriit ii«*u by ihc wrilcr iwvftnil 
■(CO, in whom pnlpitation onii ■rrhythmin hai) Itrm pifocnt (or »e%'i>tiil y^Atv. the palimt 
heiafc conscioii« iiot only of l1ip nccciirn-tii> liiii also uf ihtr size at i-t-ery bi-nl, uiul iiuli(!int; 
npeciiUly a groui> of one iiir)i;<! Iwal witli two amall onn* foUownl hy a pnuw (piilstw Irijtwn- 
inu»). The iracing laaiie whiln the pntirnt wad in ihp hoitpital s)ioweil lliut tliene utre 
(tue <o a single beiil luDuHml by Iwo sinullvr anil vurticr uiim uiid thi'n by a puunc, iill the; 
.bratH beinjt precwird by un auricular coiiirneiion t<i wnvr). This irrejtulariry whb niiich 
mure marked viienevpr Iho palienl wax conM(i|>at«<l. bin [I alsu pcniHtnl after 0.5 mg. 
(ih KT.) atropine, wliich govL- tin- patient murknl niinploiiiii Imt cauiwd no rbiinjtr 
in rat'. In mirb » cam it in vrry iliffidilt lo date whether nx* have to ilt^ul with auricular 
exIraisytitolM or with a very rHpid piilw internipleiJ by variutioiin lti cliual«l<? l,>'(iutMiil 
lyjic). Thr incfTcctivnnoa uf atropine und the uxtrcinc irrrgularily arit n4[nin«t the«r 
view. }Iowi>\vr, tlie dinKncois of rxinwysiolf^ can tMually be made by meaiiH of tbe 
electnKardiuKnun - 

In the routine physical examination extrasVHtolea may often be dtafc- 
noseti on HUetfiiltntioii \>y ihi> abrupt change from n rhythm 1-2 — 1-2 

-- 1 - 2, etc.. to 1 "2-^-4 1-2. etc. AccompanyinR this thpre may 

be seen an early wave in ihe jugular pulse. In the ease of nuriculHr oxlni- 
cyKtoles the pulNittioii <hn-t mil (litT<T from the tlouble pulse of the rcpular 
beat, but with vcntiieuiar extrasystoli^a there is a single wave, lurge, 
(-oitapitruuu.s. anil fliipping. 

Ineffectual ContrAdions. — When the extrasystole occurs early in <lia- 
stoie. the hciirt rimy not hiive reeowred from th<* effi-cl. of t1h> last systole 
sufficiently to generate a forcible conlraclion. The aortic valves are not 
opened. The aortic spconil of the extraaystole disappcnr.t mid the sounds 

ehangc from 1-2-3-4 I ~'2. etc., to 1-2-3 -1-2, etc. 

Hy beating lime to the regular beats it is sometimes po^iblc to note that 
the total rhythm is undianged by occasional ventricular extrasystolea. 
Surh extra-tysloles correspond to impulses on the apex and jugular tracings 
but not on the carotid. 

The variationa in the force of the cxtrasystolea or in the heats of the 
absoIut<>ly irrcgultir pulse arc great. Occasionally. espctia.lly when the 
extrasysloles occur early in the cardiac cycle and there is a hiph ijeriphcral 
resistance, th»^ intracariliac priv-isunt may not rt-ach (hi- aortic pressure nnd 
the aortic valves arc not opened. The Hystole has been incFfoctual (P'rus- 
tranc coiitrnetionen, HnchMUs and (iuincke). The eomiK-nsatory pause 
After these may be so long and the circulstiou may be so poor that actual 
syncoite (tiinulaling the .\daraH-Stokes syndrome IW. H. James) may lake 
place in the intcrviil between the n-giilnr lieats. On the other huml. a* 
great deal of cardiac energj' haB been expended without openinfi the cardiac 
valves and without proptrlling any blood. This increases the cnrdiuc fatigue. 

Bigeminal ond Trigeminal Pulses due to Extrasystolcs.— Very common 
fornix of rxtriL-iyNtolic irn-]M;utjirity are those in which the extra.-'yslolcs 
reeur after each regular beat; thus we may find every beat followed by a 
xingle extrasysiolc and compensator}' pause, so that the pulse beats occur 
in pairs separated by pauses (pulsux bigcmiuus), or there may be two 
extrasysioles following regularly after each regular systole (pulsus trigem- 
inus), as in Fig. 68. Thew^ may be of either the Hiirlculnr nr the ventricular 
type, dependent upon the site of the origin of the irregularity or of the 
so-ealled aurieuh)(«trio)vcntricuiar type refeiTcd to below. As stilted 
above, it is sometimes difTieult to ditTcrcntiute the auricular extrasystolic 



groiipii from tbfi youthful typi> of arrhythmia, but this may usuftUy bo 
ai-<.-on)|jUi<h(-(l by Uw uso of a sufHi'iciitly large dow of Btropiiic, 

As Hcring has shown, ventricular i-xtrasysiotes fre^ivicntly (lii=Appear 
under atropint- or any other influence by which the pul«<>-rBU* is accelcraled, 


*Tvpi in thu itur]Kijli3v«o^cu- 

Ho that the normal stimuli fall in at about the periodB at whitvh the abnormal 
niimuli would have fallen. The form of the venous pulse in venlrieuhu- 
e\tru]>y»loles J:*, however, charactcrietie. 

Flo. 73. — Varialiuui >u obiuJucliou time ia-ii iu a cue u( milml alcooiU. 

Auriculo(Alrio) ventricular Extrasystolea.— Tt i>< nl.-so claimed by Hir- 
ing ami Hihl. M:irk(n/ie anil Wenckebach, Lohmann. Kchmoll. Mackenzie 
and Morrow, and others that extrajfVNtoli'* niuy nri!<e in the Purkinje celts 
of the conduction system, and that such extras y stoles are 
ehnraeterized by a shortening in the conduction time 
(a-c interval on the venous pulse). Extrasyfitolos with shortened conduc- 
lion time are not e.vtremely rare, and it is pos^ble rhnt ihi.i e\jilitniition 
may be correct, but it is not founded upon any direct experimental proof. 

lleriiic, who orii^iriuliHl itii- dovlrine, ubwrvtti bucIi t^xlrar-.yntultrFi oceiirrii^g ipoc- 
tancoiwly in niien. but (li<l not e\t»i it up hy nuy ex penmen Is. (itUikpU han nhnnTi in frnci 
lliut if lh« ttMiiir at itic aiiriciiInvrritTiriiUr jiiiic-lioii via* TniirhtKl with n probv a wHub uf 
cxtrusyclolni sel in in bulli aiii^lta iiiiiJ vciilnck-. l»luiiaiiu ulsu iituprvcil (hcni per- 
Hiittuif; after the lissiip in ibr virinilr al the His Inindle hnd bfrn utiiiiiilaicl. In a laler 
ini-mtigatton ii|>on lht> eKciocii bean LolmiHnn poixoiml ilic iVKiiin of ihu veoie cava- by 
lumnn uf culluii Mmk«l in fornwlin. lit.- iben sninL-tiinui aav ■rutm-iystoloi net in «pon' 
luiieMiwIy. The nurirlrM mul vmtriv'ln) bimiplimn cnniracli^ Mmiiltnii(iouiily. bohic- 
limta tlirrv vvre vcntriciilur FXtnuyRlolen. 

nirocb(el(k>r hu* ivfK-Dte<lly produenl exlni«yil€))eii mth ■hnrfcnnl ctindiictlon Umo 
by fanuUr utimiilalinn of llic uiiriculnr appriuiix. The »iipmnince of mich exIriuysloUa 
itft«r fanidiiHt lull . in fxcitnlili^ lifarlii. in tlie iciVTrtiilii tvlwetrn piiroxyami of tnohyrArdia 
in man. etc., iirrtini lo corrr*|ionil oilh n "inlr of grrntly hraghteiunl (■icllabilily. Whelhpr 
llic uctual Kiiiiiiili UTin- in the cell" of tho Hiniw rcKinn ot in itit^e of thi- conduction i>yi>lpni 
i* atill unccrliiin. It is not iiiipmbable thul there aiay be nn incrca»nl irrilahillty o( all 
Ihe primitive cnrdine tiMiiir (Hiniw .ind ctuidiiclinn i>y«tnn), nnd itial in llie Biotu (tiis muiii- 
fivt* itM-lf by the Kencntion of Hbni'>miul stimuli, wblle iu 1b« cunduction vyntcin il i* 
nhoim by iiicn-.unl upcwl of wmduclion. 

I'pon the flinical side there is little positive evidence. Peeuliar cxtra- 
B>-Hlo]es often occur between attacks of paroxysmal tachycardia, but occa- 
tdonally alxo in eawi( with simple valvidar lesions. Keith has found patchea 


of fihrouR myorardttii* in the vicinity of Uie Bin Imndlp in casc-i which had 
shown these extrasystoles. and thinks thai ihey irritKtctl the ci'lU in the 
vicinity, Imt such spars are very common, and elsewhere in the heart are 
not knuwu to act m trritativo Ivsioiis. Morvovor, the writ«r has never been 

Fio^ 74. — Tnfiiiji hliowiriK »Jj«nJuti' irrriiiilar with »i*k i[ic-fTrt*tijaI ayttiilih (/. /, /} whloh ilo not 

able to produce them by pressure upon the hundle with an F-rltingcr cltiinp, 
injection of mercury into the left braneh of the bundle, ete. So that la 
spite of the interest in the Mubjeet it must be almittinl that the occur- 
rence of extrumystok'n with fihortenod conduction time cannot Ix- as yet 
reganied as absolute proof of a, letuon near the His bundle. 



Fm. TS. — OiMEntm •hoMnc (lie tUintiuni at tliythni wliidi niay rmiMt ■ puUiu UsKninn*. 

tiiclicat* Ui« inoldcnff* uf ■tiiuuli vn. 

T!n» nrrow^ 

Various T>pcs of Allorrhylhmia which may Result in a BijEcmlnal Ihilsc. 
— It l)e borne in mind that ihe bigeminal pulse is not pathopnomonie 
of any single disturbance of function, hut iiiny occur in any of the following 
conditions (Fi([. 7.^1 : (.1) recunuiR ventricular cxtrasyatoles; (2) recurring 


Huricutar oxtr(ujyEto]i>H; (3) recurring nuriculoventricular extrasyatolea; (4) 
recurriRR flight auriouloveiitriculAr heart-blook, th« ventrieln fHiliit); w foltonr 
every third liCHt: (.')) recurring si ao-a uric ulur block (?), tbc auricle fuiling to 
re8]K>Q(l to every third impultw; (6) recurring vngal prolongation of every 
alternate diaiitolp. Similar conditions hold for the tri)^niinal puli^ic except 
that two «.\tru--<y»lolc.-4 ur irgtilHr tjcula are intcrpolntt-d Itofore the pautto. 
It is evident that thcife conditions muHt be carefully difTercntiated 
from oiu! another by niean^ of the venous tracing or electrocardiogram and 
atropine test^ bcfoit utt^^'mptK tu remedy them ahould be begun. 


In Bome of the ftllorrhylhmias separate rhythms may be noticed in the 
different chamborn, either conducted to one another and interfering peri- 
odically, or not conducted (heart-block). Wenckebach, who fin*t called 
attention to this, hu* proposed the name parnrrhythmia for thun; 
forms. The simplest example of this would he the bi);emini. Another 
example would hy -feen if, without low of conductivity, ^ipontaneous con- 
tra<rlion8 would occur in the ventrielea as the usual slow rate, and these 
go on wmultaneously with the regular healfi following the auricles, though 
with occasional pauses due to interference. Cushny has shonii ihts to 
occur in dtgilnli!( poiKoninj;. and it i^ not improbable that it may explain 
many otherwise undeeipherablr arrhythmias, though little work has boen 
dom- along these lines up to the present. 


\cxl to the neurogenic allorrhythmias the most common form of irreg- 
ular hciirl artioii i.* the peniiaiieul irn-gulnrily (ili.^ordcrly rhythm, Macken- 
xie; piibuc irregularis f»crpetuus. Ileiini:: arrhythmia perpelua. (lerhardt). 



Pm. to. — AtsotuW pmniinanl irncuUritx mitk a v«n pnMrvad in ■ cnx ul mitnl hUduhii. 

This reprosentjt, ax MiickenEie has shown, the common t>'pe of chronic 
arrhythmia seen in old c&seit of myocarditis and of valvular lcsiom<. An the 
ittsult of chronic st-nsis there ix a permanently high x^nous pressure wtuch 
brings about dilatation and paralysis of the auricles. The a wave i.s .ilisi'nl 
from the venou.-* (racing (Miiekenrie) (Fig, 76), from tho (esophageal tracing 
(Hewlett), and the corresponding wave has disappeared from the Hoctro- 
cardiogram (Hering). Tliert^ i.-* probably « perpetual or a transitory paralysis 
of the auricles (atria). As Horing's ©lectn)cardiogram3 show, the arrhylh- 

'IV utm pnperual irrcgulariry is inaccurate, aince It i* mniHimn tnumtoir. 



mia )i due partly to cxtrjutysloljw, which arc shon-n by iheir charafiteriatio 
curs-ea. and partly to periodic (respiratory) idt^rations in the regular beats. 
The MU- al which ihv rardinc iinpiiLHc ori>(inaleH in ihia irregularity 
is a matter of some dispute. Mackenzie believes, without further proof, 
thiit Ihc Mi(> of automaticity i^ Khiftt^d from the Mnuii rofrion of the auriele 
(atrium) to the cells of the Ills bundle ("nodal rhythm"), but it hnn nol 
lietn shown that, just beeatiae the auricular contraction and the corre- 
sponding negative wave arc abiwnt, the e^irdiuc itnpulw i.t not arising in 
the region of the sinus^ Accordini; to Mackeiuie, the auricle and ventricle 
are beating simuttancoUKly in »ueb cawa. Cushny (Heart, vol. i) has 
shoft-n that such simultaneous contraction* actually occur in experimental 
aconite poiituning. On the other hand, v. Fiey hfts shown that the 
auricles become paralysed at about 2U mm, Hg pressure, and observations 
by Dr. HooWr, a» ufll Ai< by Mr, C- C. Cod}', indicate that in eaaeii with 
permanent arrhythmia the venous pressure often approaches this level. 

Fm. IT.— Prrpomnlly itnsulat ihi1»b wiili abHiivt iJ u "«vr. 

Ksdasevvsky, under Dehio's direction, was the first to call atteatiou 
to the occurrence of fibrous changes in the auricles under these condition.^ 
but the exnt-l n-lations were idiuwii by Schnnbcrp, who studied careful 
serial sections of the entire veno-auricular region in five cases that bad 
been studied clinically by (ierhardt during life. .SchCinlierR eonlirin.-< Rnda- 
sevrsky and fuuU definilo patches uf infiltration about the veno-auHcuJar 
bonier. On the other hand. (i. Midler has reported a case in which the 
entire musculature uf the auricles had disappeared and the rhythm had 
ntmained repilar. 

Clinically, one sometimes sees an acute onset of absolute arrhytlimia, 
with paralysis of the auricles. es|}ccinlly in the acute heart failure of mitral 
stenottis. This state niay last otily for a day or so and disappear under 
treatment: on the other hand, it may last for weeks, perhaps for months, 
and then disappear. The longer it persists the greater is the probability 
of serious change.4 and the lcs« that of rccnvrn-. On Ihe other hand, the 
presence of an absolute and apparently permanent arrhythmia with auricu- 
lar paralysis is perfectly compatible with a fair degree of vigor. 

Thix is ohovii by B mc<licitl Miidr-nl nnw nnilrr flic wrilor'i rare, who hits had an img-j 
ular |iu1m of tkiti l.vpe for Iwo yran, itiirinm hIiicIi uiity occtifioniil auricuIiiT wav«a hav* 
tuwn obtaituible upon hU vi-ootui piitv. utid lliete rfuriiig bin period* of KmitcKl vigor. H« 
)iM hiui fJixhl Bhortnpm of hrcalh on i-xerlion-biii no mlanciTnciil of Ihe b^irl, iiiurniun. or 
ulJier si|;iis of oncaiiic licflrt •liscaac. Hih uirliytliiiiiii ibil nol <bwippFiLr uoder .ODOT.I Uiri. 
(A (tr.) Btropitic nubciiloiit-oiuily. Tlic clof Irocanliojcmin doe* not rtvcnl any rxt rnHyi>l»lrrs. 
Ills Iroiible dncn not <lAlr fmm any acute inrectiuiin <bMtnjtc nor fmm any oventrutii oihrr 
than (lie loag hours of work in a ho))|iils1. The na1un> of the lAiiun luid it< ■ixnilimncQ 
In CiUH likp (bin an >tiil myilorioMii, but it it iwsablu that in mcli oumi iherv luuy be a 
patch of inyocardilis id the mou* irgioo of the auricle Ukc those abown by Sclidabcfg. 


Permanent arrhythmia with peraUtpnee of the auricular conlra<:tion 
(ft wave upon the vonnui* [lulsel is met with c>r<!aaionslly in mitrul discuae, 
especially in mitral Hteuoaii>; aiid rvprvaseiits oae form of the 8t>-calied 






(Afur HwuiK. DtutrA. Arr/.. f. JtUn. V*d. xav.) S. CKUwyiUiU; B. T. •iMcUtsI warw. Tlir f 
UnrlFnlatl oBvii u ■■■Hnii. 

"mitraJixetl piiLte." lit nmh cat^e:* it may at firdt seem ah^ottitdy impai- 
sible to itnulyxp the arryhlhmiH. but from tinic tn time ik'linttp ^oiips 
nt syst<ilp« may be (liftoerni?il. .Sometimes these proup« are produced by 
the occurrence of varying numbers of auriculur cxtrasysititlc*, wjmctiniuf 
by I be occurrence of a few l>eatsiii which there t8doublinf;of the pulse-rate 
and shortening of the coriduclion time, ju»l as i" seen in paroxy^'mal 
tachycardia. Since HerinR has demonstrated the extrasystnlic oriftin 
of the nlisolutc arrhythmia with auricular paralysis (Mackenzie's "nudal 
rhythm"), and since llirechfelder haa produced the latter in experimental 
mitral »teni".'(i» by briniiing about extreme stiii^ia in the left auricle, it 
seems not impossible that the question of auricular paralysLi may Iw one 
of the ilcftni* ralher ihiiii of the chiiracter of the disturbance. 

The prognoi'tic importance of a permanent arrhythmia with auriculfti- 
paralyslii dependct, like all other canliar condilionM, chiefly upon its effect 
upon cnrdi»e function. 


The mechanical effect of any arrhythmia is to slow the circu- 
Sion . as nuiy Ix- ea.-'ily wK-n from the volume curve of the heart during 
a period of irregularily. 
This slowing in ilitclf tends 
to bring on cyanosis, in- 
crea«i- the (!(), in ihe blood, 
and. as Cumcruu has shown, 
to diminish the tone of the 
heart muitcle in this way. 
On the other hand, the long 
pause--* caus)" an incn-asi-of 
pressure in the veins, and 
the influx of venous blood under a relatively increased pressure acting 
upon cardiac muscle, whose tone is diminUhH, lends to overdtstend the 
hciirt (as set'n in ]~ig. 7«t). The overditfteution, by increasing the diameter 

CAR aim 


Fra. TO. — Krfn-t of Arrhyllimid im IliB drvuUliuft. blixfit- 
prruur*. ami t'cifimui u1 1h« mlrirlw. Tntrim fivni m df^lit 
lii'iirl amriulblHl jiTf^ulfifly with inilortjon fibmkA. f, f, /. 
ITi^ffHto&l t>'ii1<i1t«; DiL, .tiUlalioii. I'P<Uo^f« oq TolumA 
curve w pimu t ouillaw fioni tlie i-silridsa. 


of the v«ntrit!uliir <rhiiinber, increnaes the hydrostatic pritssurc upon it« 
whUs and causes it to work at u disadvantagp. Thus is cstabliiUicd the 
viniouH circle of iho irregular heart: 

OwritlliiiK oT Iwart I 

I 1 

Slowinfc of *ireulalion^lrrcit«larity 

The eflect i» tncMt nnrked in the nuriclM, where tooe dumgea nbow ihenuielt-M in mnrt- 
Riurkfc) defend limn in the vrnlriclcs. niid ihc diminution in ihrir toniciiy hiixlonn iheir 
panJysis. Wbf^ii tlio aiiriclfw niv parulyxeil, llic |i;enesiB v( f iricionl stimuli bvcuniMi more 
rfifikiilt, it ill hnrrfpr to oRCvbrnlv Ihtr pulse liurinR exevtite. i-tc. mid conwqui-ntly it 
twcotiiee easier for CO, [o awiinulaiP in ihr blond in the infpibr r.hiui in the fVfiiiiar hoarl, 
and the bntrt in thin tundilion in per He |M!nDiuii>Dt]y nvakeiieiL 

Effect of DlKitalis in Absolute Arrhythmia,— The good effect of difri- 
tftli.* in ihi.s coiiiUlidn lii-N not in iifffilinK t.hi' liiythmicity but piirticuiarly 
in restoring tone and force of the heart -be at, thus re- 
versing the vifioua circle. The pulse I)econiea more regular, sometimes 
entirely regular. When the rhythmieity is destroyed by permanent paraly- 
flis of the fturioles it never returns, but the general cardiac condition may 
be benefited by inercase in lone and .tlroniith. On the other hand, when 
the muscIe-fibrcB are in too bad condition, they are oversenfiitivo to digitalis 
and a sinuU domrr cuust-^ them to pM» not into the first but into the second 
or third stage of digitalis poisoning. 


Another group of allorrhythniias which may be classed with the extra- 
aystole.i is that in which there la more or less paroxysmal increase in pulae- 
rote, frequently amounting to exact doubling of the rate, 
suddenly taking place and suddenly subsiding. 

Thi* condition U «ecn in pnroxyamul (luhycnrdia (IIofTmiuui) aaii in pnmxynmnl 
imgularily (('luKny and Ivlninnd*), and in thn l:klTPr mndilinn bna hrfn ithnwn ((■ tic 
iiMOCialcd wilti iibrillutton of ihr uuriclfa, Ex[ivriiiieri[ally il ctui bu brutiiilil on by ntimii- 
Isting tlic niiriclm nilh u xtroiiK fnmdic curifjit. tlic nuriclpx then going into very rapid 
tiiofc OP lens fibrillary conimcliong, the ventriele* tolluwinK hi. a fairly re^Iar 
mte wlijch is alinDal exactly double the prvvjuus rule, tliis rhylliin penuslinj; for ncveml 
minule« .after the fnradiiiHtiDn hn» t>cpn utoppcd and thirn nuddenly halving. !>iirin|{ ita 
euNlinuutiei! t( may or niuy nut be stopped by maxima] tilimuleilion of the vajcus, just ua 
is thp cuw clinieuliy in purox%iinuil luchyeurdin. but w«mB lo yield at oneu ii) stmphan- 
I.I1U8 inl rnwnoiisiy. The nntiim of thin Midden <loub!inf( in peeiiliar. I|. a'.na oecun in 
Ihe venlrielc iiiHin fanuliKint! the ventricular iniiMie dirveily, and siuiitur exiict duubtliiK 
and exact halving of rate have been (ibaei><ed in the frog by tlngelnuuin and in the 
Riamroal by Tr^ndelenberg. iSee Part IV, Cbnpter I.) 


For gcDcml diacundona of nJl^ntiuna of earxliiio rhythm the remler may «ooault: 
Wdtelwbach, K. v.: Die Arhythmic ala Aitiulfuck bivtimmicr Ftuictinnwlflrangren dcH 

Hcr«eru, Ltipi., IIMXt. Leu irr^ularilfe du ccpur, Arch, den maliid. du ou-ur., Pni., 

lOOS, i. IS.V 
Maekcnxie. J.: Tlie Study of the Pidw and Hovcmenta of the IlMtrl, l4>nd., liWf Ne»- 

Melbcxtn of Studviniic AfTecliuni of the Heart. Brit. M. J., Lcoid., ISOfi, i, 519, A$7, 

702. 7i9, 812. DiwawM of the Ucart. Loud., 190S. 


UinMlifelder, A. D.: Gmplilo MelboUe in the Sluily of Cardiac DiacaaM, Aid, imu. H. 

8c., I'hiln., 1900, cxxxii, 3TS. Keeeiit Sludii» upon tlic (.trvululioo luid tfacir Im- 

purliuic^ lo ihi- Pr«flice of Mrdicinc, Jwir Am, M. Awric., C'hicnKo, liHJS, li, 173. 
Hewlett, A. W.: Some Cduuhou t^Mtbae Airhytliiiiiiui, liitvniut. Uiii., PhU., 1907. I7Ui 

•or., tr, 47- 
(jerhnnh. D.: Di« l'ni«f!eliafiietKl(oilen <Im UrrMohlaces, CryetiD d. Innere Med., Berl., 

I9US. ii. 4 IS. 
Duck, tk!0.^ Rocvnt Ailvancm in the Stiuly of tlntrt Diaraw, WUcon»in M. J.. Aii^., 1007. 
B«r<l, I-.: D™ liici-m lj"pm il'iirhyttimit- cunliaquo iibuervpH I'O cliiii<iue, Sum, mtd., I'u., 

HuRuuuin, A.: U^ber di«i kliiiiaehc BedeucunK dcr Hrntarhylhiiiic. Dciiiitcli, rtivil, Wehn- 

Rctu-., Lcipa., 1W)G, xxxii. 1IJS2. Neuere Fort«chritt« iii rfer l>iu4-Dc>Hiik dcr ilcn- 

kraiikhcitrii. Dniiisrh mcd. WclinHhr,, l.ripx., 1008. xxxiv, l<t. 
Hunt, ft.: Uiivci and Keflex Acoeicmtiun tif Ihc Muimtialian flfitrt, Aiii: J. PhyMiol.. 

fiott., 1S90, ii, S9i. 
Houker. D. R,; May Reflex Cardiac Accclcralkin Occur Indcpinidmily of the Cardio- 

inliiliilufj- Cunlre ? ibid., 1SI07. xix, 417. 
Miick«niic, ^.■. Tlir Study of tiii? PiiUc and MavcmcTiT* of the Heart, txmd., IW3. 
PraD{uiii-Fninck, (.'li. A,: Cviilributloii Jt I'l^iiide oxperinipnliUe d«« tifvruiei) t»flexeB 

d'oriKiiic ;uOiii!(!, Arch, da phyHul. de rlionitne. Pur., ISSlI, .1 ht,, i, aSi. Conlri- 

butlun a I'Atiide dc I'inncn'nl.ioii viwmlilatai rim dc lit mutjUMUM!, ibid,, IMW, i. 
Koblnnck and Rueder, H.: Expvriiiientelle LIiil«niuc)ii.ine«ii lur ivEJeklurincli^ii Hcn- 

Arhylhrnip, Arch. f. d. ((«, I'hjiiol.. Bonn, 190S, exxv. 377. 
Hlodlcr, t., :iiid Hinwh, C: Mrt«ori«Diiu iind KrcUbuT, Mittli. a. d. UivnEp^), d, Med. 

u. Chir. Jma. 1900, xv, 449. 
RsyftMli: Klinischo und (^xpt^rimcntcllc Grfbhruitftcn uebcr RciKURKOD ilni l(Rnv«4pw, 

Bcri. klin, Wcluisclir., VMj. 1468. 
Rewmet.O.: I'rbrr unnrgvlmiiaaige HeraUltiglteit nuf iKychiachcr nrunillogc, Zljichr. I. 

klin. M»d.. Dorl,. [904. liii, -IIH. 
ESnthorm, W., Fluhd, A., uiid Itiitlaenl, I>. J. T. A.: On Vagua Cummta Exunined witb 

llie Slrinc (jalvanomotcr, (Jiiart. Joiir. ICxpcr. PliymoJ., Lord.. I9US, i. 24% 
Eyvler, J. A. E.; Cliiiicid aiid ExperiTiittiilul Oboervatlotui Upon t.'bt^>iie-St<ike> Re«|»m- 

tMiD, Jour, tlxper, M,, Sw Vork mid Uuie.iatpf, 1906, riii. 5fi5, 
KuMUiiaul. A,: L'eher Hrbwietifco .MrdlsAlinn-prricurdilia und paradpxon Pub, Berl. kliu. 

Wehn«hr,. 1873. x. 43:!. 443. 401. 
RieRd, F.: l^nhcr cxtrnpcricardi.-Uc Verwaeluiunj^, ibid., IS77, xir, 6S7. 
Kcitii, A., and Fluck, and SchOnbcrx: IHoe Cbapi«r I. 

Henlntt, A. W.: UigiUU* Heart-block. J. Am. M. Awoc.. Chicaft<>> IB07, xlviu, 47. 
Eriaogcr, J,, and Itlai^kmiui, J. It.: A Rludy of ilic lt<ilali\-n Ithythmicily niiil ronduo* 

liirily in V;kriotui KuKions of (he Auricles of Ibe MaiiiiuabBii Heart, Aia. J. Phyidul., 

Rnst,, 1907, six, 125.~ 
HoCfmann. Aue.: See chapter on I^woxjtnial Tacliyeardia, 
HirachfeJder, A. D.. ond Eyntcr, J. A. E.: ExtntayBlulea in the Mammuliaii Huirt, Am. J. 

Phyni^., Ro>t., 1907, xviii, 222. 
Knu>, Fr. and Nikolai: L'obor dna Elcklrokardlci^miiiai uiiter noruiaJeu uud patho* 

Intcisclieii VMlifilraiiHen, Berl kiin. Wophiinchr., 1907. 705, 811. 
Kalin. R. EI.' t'otx-r dnx Klcktrokaniinjcramm kilnntllch niii^n'li'Sler Ilf^mwhl^'e Zentralbl. 

f. Iliysiol,. Leigii, and Vienna. IDO!), xtiii. 444, 
nowlclt, A. W.: Ucart-block in tbe Ventricular Wa'U. Areh. Int. itrd., ChicAK", 190^ 

ii, 139. 
Ba/ker, L, F., Hirechfeldcr. A, D,. an<l Band. 4J, M.: Eltecls of Cultine tbtr Branch of thd 

Left Kin Bundlperanjtlo Ibe I j-'fl Ventricle, Tnuia.ABioc. .Vni, Wivs., Phila., UMW. Abo 

Barker. UF,.Bi.iniin<chfHdcf,,\, D.: Arch. Inl, Med .Chicaco,' 1909. iv, 193, 
Aachofl, L.. and Tau-ara, S, ; Sw rbapler on .Acute H.\iK'urdili)'. 
nirtchfoldcT. A. 1),: (ttiwrvniiuiui upoa Paroxyamal Tnchycnnlia. Johns llopkiiia Iloap. 

Bull.. Rait,, IlHKi, x^^i, XX:. 
Hrrinx, H. E.: UeUrr Hi^nallenians. Muenchcn. med. WoehMchr., 190S, Iv, 1417. 
Mackeltiie, J.: Sro rhaplnr on .Angina Pectoris 
Wenckebach, K. F.; Beilriiip^ tur Kennttiitti der incnuchUcbcn Ucntxtigkett, Ar^ f, 

Phyiiol.. 1900: 1907, i. 



QigeJnuuin: U«I>»r die Leitung <ler B«u-cgun)i:sreiiic im Henru. Arvli. f. ij. gm. Phj-uol., 

Bonn. I8B4, Ivi, MB. Uebcr die Urnptung der HmlicWRRiiiigrn, ibiil., Ixv. 
Cuahny, A. R., aiuI Muilhcw«, 8, ,\,\ On tliu EffMrU uf ElM:lrica]i*liiniiluliou ot ihe Mum- 

DiuliaD Hi?url. Jour. I'iiyiiol.. Canilj-, 1S97, x*i, 2M. 
HirerWclilpr, A. 1).: Iiutpoclkiii of ihc Jugular V*iji: iw Value and its Limilalionii ill 

Kuuvliuntd DiugDCMis. Juur. Am, M. Aibuc., ChiciUEii. 1907. xlviii, 110^. 
I«wiii, T.: i^inKl'' nnd Succiiwivc lixtmsyslolp*, l.,inn>i. I^njiil,, IlKKt, i. 
Mutler, Fr.: NvrvoiiB AlTi-cliuiw ul [li« H»>urt, Arcli. Iiil. M«ii., (.'lucaKu. 190S, i, ). 
Mncki^nxir, J.: DiitonMs of Ihc Iti^iri, Lciml., l!Kt4. 

Knult. I'll.: L'ehor div VrTueniier\tngfn dew D^niiichlagM bei refiectorinchcr Errvguiiic des 
%iii>oniuti>riiichi;ii St-rvetuj-BU-nia. somip boi .Slngcrung dc* iiilracardiuleri Ihucks 
(iberliuiJpl, SiTiiiiiK»brr. <l. k. Akiul.d. Wiuu-nM-h., WJen, .\hih. Ill, I.S72. Iiv Ixvj, !!>.'■. 
Murcy: I.u cirauliiliuii dii nuiiij; a I'^tut ))li}siul(iKi<|>i<^ I'l duim W iimladiiw, l*ur.. IHSI. 
llerinK. II. t..: Ziir pxpcritiiciitdlcii .VimlynF <lcs unrr-^lmtia»grn Itcruichlo^a. Areh. f. 
d. (cm, I'liyiiiul.. Bonn, I'.XM, Uxxii, L~ol)«'r coiiliiiiiR'rIiclit' IlenliiKftiLiiiii^. l)^iiUch.| 
Arcli. [. kliti. M«l., L(.-i|a., liHM, Ixxix. I7S. Ergcbiiisa.- cxiH-Tirociitdlpr uiid Idiit- 
iwlw-r irtiwrmicliiinicfii uribrr tien \'orhofvciiraipiils bi-i tlxlrnnyslolpii, ZliKhr. f. 
exptrt. i'alli- >i. Tbenip., Bcrl,. 1905, i. 2B; also hia pujnlH. 
Rjhl, J.: Exprrimriilrllp Aiui1>>r dnt Vcnrnpuluv bcl drii diiich Lxiraiyvlolen ivrur< 

■acLlvn L'iin>Kclmflwi|;ki-il<'ii dea Sltu^lliier herxcDH. ibid.. 1903. i. 13. 
I^, O.: rpbtT ila» Vcrhnllcn cira Vpn^npubcs i)« ifcn durrh Exlni*>-slolcii rcmruclittn 

Utin>»elmilM»i(tki-ilfii <l«i nirniirhlicheii Ilerxefi*. Ihid,, I'JOJJ, i, 56, 
HinchMdLT, A. D.: Tlie Volume Cun'U ot the V«hiitrii'le« in Kxperiuieiilul Milral ^ilviiosis 
and iU Rc-l.ttion to I'h)-)iicnl Kigiu. Joliiw llnpkiru- Ilrwp. Bull.. Bolt.. IDOS. xix, 319. 
Hukeiutie. J.: The Eictnui}Male. Qimrt, J. M.. Oxfor<!, lUOS, i, -tSI, 
Qertuktdl, D.: Bcilni^ xur Ijelire vmi ilftx Exlmsyslolen. Dcutiieli. Arch. f. kliu. Ued., 

Leipi., I0t}5, Ixxxil, 50». 
KofTmnnn, AufC-: Arli.vlhiiiie d« UeneUa, I>euli>ch. nied. Wcbiuchr.. Leipi.. 1906, XXXti, 
168^. li^'iwr die ICntalliiins der Extmivstolen irrvgularitui. Hucnehrn. mod. 
U>hi»chr., 1907, iiii. 11W7. 
I>ehi<). K.: Elnniuo den Atroplni niif arhythmiicbc HrrxtAi^keii, l)etit<«h. Arch. f. kUn. 

Mrd., U-ipx.. ISM, lli, 97. 
HeriiiK, n, K.: Kxpnriinenipllc l.'iiier»ucbuiigcii iicbcr HerxunregrlinllHigkcltcii nn Aff«!D, 

ZlBtlir. f ex|*r Pnlh ii. Thcrap , Borl,. IIXW, il, Mfl. 
lIprinR, H. K.. and Hihl, J.: Uclwr ulriuwtilnkiilare ExtniBj-iIule'n, ibid.. 1906, it, 510. 
GuBkell, W. II.: The I'mfHTliw nf C^rdinc Mmcle, tichi(cr'« Text-book of ITiyniolofty, 

l,«nd.. 1900, ii. 
Lobnwinti. .\.: '/.ur Autoniutie der BrUckenfiuiem dw Hentens. .^rcli. f, ['brsiol., Lctp*., 
HUM. 4.'tl; an<l Siijiplhil., 'Mli. Tphrr 'let Funklioii der Urllckenfnwm an Stelle 
ilcr gnnieD Veneii die l-'illiruii^ der Henlalijcknt beiiii Silu^tienf «u iibemehnieii, 
Arth. i. d. goi. Pli>-*iol , noun. I90S. cxxiii. I12S. 
MnckeDzie, J.: liipeptioii i>f the Rhythm of the Heart by the Vfrntriclm, Bril. M. J., Lmh)., 
1904, 1, 5m .\biiomiiil Inception of the Cardiac Rliytliiu. Quaxt. J. M.. Oxford, 
1907. i. 3<l, 
Maf-kcnxlr. J., niid Wenckebach, K, F. . Ueber an der A(rii>veiitrlkiilargr«nte uiiit^l^le 

Systolen Iwim Men.irhen. Atvh, t. Physio!,. Ijei|u,. 190.^. 
Schinkll. E.: P&roxyMmnl TMliycardia. Am. J. M. Sc.. Philn. and X. York, 1007, exxxir, 

Miwkfintle, R., and Morrftw. VV. S.: Catvliiu? Atrhytlunia due to Extmnt-slolen Originating 

in tlie Bundle of Mis, Vm. .1 M Sc„ 1'hiU. .in.i X. York, liHft, ox.vxv, .V(l. 
Cushny, A. R.: Bur cliupler on the Aetion ul HruCii, 
Iloriuic. II- E.: L'elwr <i'K hAii6|[e Kimihi nation von Kanimervencupulii mit PuUiu irtVK> 

uiaria iierpcluuii. Deutorli. nie<!, Wchnnrlir. l.etpii., I9<W, '.'13- 
Gerhurdl. I),: .Irhythniin perpcttia lics ViH*. Deutscli. mod. Wclin«clir., Leipz,, 1907, 

xxxii), 'UR. 
Hewlett, A. W.: Oii the lntcr|>retntioii of the Paritiw Venous Pubw, J. M. ReneAreh, 
1907-8, x^li. 1 19. dinicnl Ohwn'ntiana nn Aliaolutely Irrcgulitr HEarta, J. Am. H. 
Ajw,, rhieago, 1908. 1!, 655. 
llieopold, J.: Rin DritRtK etir Lchrc von der Arhytbmin perpelun. Deulscli. Arrb. f. klfn. 
Med., Leip«., 1907, xc, 77. 


Hering, H. E.: Daa EUektrocardiogramin des PuIbub irregularis perpetuus, ibid., 1908, 

itciv, 205. 
Radasewsky: See chapter on Chronic Myocarditis. Ueber die Muskelkrankungea der 

VOrbofe dcH Heraens, Ztachr. f. klin. Med., Berl., xzvii. 
Schanberg, S.: L'eber Veraendcrungen im Sinusgebiete des Herzene bei chronischer Ar- 

rhythmie, Frankf. Ztwhr. f. Path., 1908, ii, 153. 
HUller, G.: UngewOhnliche Dilatation des Herzena und Ausfall der Vorbofsfunktion, 

Ztschr. f. klin. Med. Berl., Ivi, S20. 
Quincke, and Hochhaus, J.; Ueber frustrane Heracontractionen, Deutsch. Arch. f. klin. 

Med., Leipz., 1894, liii, 414. 
James, W.: Clinical Study of Some Arrhythmiafl of the Heart, Am. Jour. M. S«., Hiilft. 

and N. York, IOCS, cxxxvi, 469. 
Hirschfelder, A. D.: Contributions to the Study of Auricular Fibrillation, Paroxyemal 

Tachycardia, and the ao-cdied Auriculo(Atrio) ventricular EstrasyHtoleH, Johns 

Hopkins Hoap. Bull., Bait.. 1908, xix, 322. 
Hoffmann, A.: Neue Beobachtungen ueber Herzjagen, Deutsch. Arch. f. klin. Med., 1903, 

Ixxviii, 39. 
Cvtshny, A. R., and Edmunds, C. W.: ParoKyamal Irregularity of the Heart and Auricular 

Fibrillation, Am. Jour. H. Sc,, Phila.. 1907, cxxxiii, 66; and Studies in Pathology, 

Qua tercentenary Public., Aberdeen Univ, 
Engelmann, 1. c. 
Trendelenberg, W.: Unte ranch ungen ueber das Verhalten dee Hensmuskels bei rhythin- 

iscber elektrischer Reizung, Arch. f. Physiol.. Leipz., 1903, 271. 


The discovery of the X-rays by KVint^u in 1SM5 introduced a new 
era in cardiac diagnosis. Hy this means we can now actually »e« ibe heart, 
obacrvc itH outlines with accuracy, and note the changes of po^utiou and 
of contour with different phases of respiration, and even to a certain extent 
the changes from 8y8toIc to diustok*. All these data, when obtained with 
proper precautions, are absolutely accurate, and have greatly supplemented 
the observfttioDs made by percusition.' 


Most of the facts desired in the study of the circnlatorj* system with 
the X'ray may be gained by means of inspection nith the fluoroscope, 
a screen of bunum plittinucyunide ur calcium tungstate which is rendered 
luminous wherever the X-rays strike it. 

A tube of low vacuum ("soft tube") should be used, one 
which shows the bones of the hand black without re- 
vealing their internnl structure, and the tissues of the haod a 
fairly dark gray. The patient's chest wall should be at least 50 cm. from 
the screen. Kecentty the uHual dintance has been increased to 2 M. ((>} 
ft.}, at which Uic rays are almost parallel. 

Ii U Boiuuiiiuea b«st (o liit«tpow a luwl acraen, with adjusuble opening, between ilw 
pstinit nnd Ihc tube in order to cut o? nil the raya except thoae cmanBtins ftam a ■mall 
part uf tlin tuilicnthodr, thr'rDb)-fin;iirin{[ ihr Kif-otr^t pOMJbl* definition of rociw. Todcod, 
InimL'ltuuQD fuuiiiJ lEivutdsl lieliiiitioti nlii-ii (lie upciiing io tbe lead acreen was cioly I cm. 
Oflen a tniid cylinder (Alben-Sehncnbcrg) in vcn- unlufactor}-. It in aUo inipartant ()i>t 
iia large ol)j«cU be plac«tl near tlie ralliode. a» rayti etrlbing Ilieae nnuy abto genenla 
Mooodary rayn which aRiTt the flnonncopc or phoiogrnphie plate and thiu blur the outliii 
o( the orijrintil imace (Waller). Tor securing nharp jnugcea il if (■rvferftble lo keep 
number of tubni with vueiia of difTereiil (l(^;;^t.■).■s wliicli may be intercliauKed, rather than 
ehanicn the vacuum in oiu^h ttibr. C^hiuiEinR the Inlti^r nborUti* the life of the tube by 
healJTiK the platinum lancet and caiuint; the latter uliimaUly lo become bent, to that th* 
my» are not reflected ilnifoniily (rum its nurfuce. 

The X-ray image is s true shadow formed by the cutting off of ray* 
and not by their refraction, and the shadow is magnified in proportion as 
tbe object u nearer to the tube or farther from the fluoroscopic screen. 

■ Baamlnat ions with l)ieX-ny r«qu{r«B very «peciBl techoif.for wtiieh the BtU(}ent 
is advincd to tonsuk the »peciu! IfKl-bouks uiion Ihc unhji-ct. lappeinlly: 

AlttenKSMiciPiilwrR: Die Ritntornlechnik. Ifamburit, 19(Xi. 

Gooht, U.: Ihuidbuch der Rftni^ilehre tiun Gebreuehe fflr Mediciner. 3te Aufl» 
SlUttKnrt, l!KKt. 

Williams, F. II.; The Rfrntirfn Rayi? in Medieine and Surjiery. New york, 1903. 

Beek. V.: Ront)ieii-ray Itiairnouis and Therapy. 

Kaaeabian: Kontgcn Rays nod I-llectro-Thpntpcmiea, PhiU., 1909. 



In fiuoroscopic <;zRmination it is rimi important for the uWrver Ui utciulom tiia 
eyes U> the darkneM before luruiti); uq tbe cumul. It iti « wlUpmvcd phywolo^cul fuct 
that tbc longer the H>joura in dnrkncM the Kra)t«r the <lrlicury of viiriuii, IIpiir« thi? oxunU 
ncr*f vidon is unproved by clotduK or bliodfoldini; hiM oyoi or by RciiiK into it dork room 
•ome t«o or fifl«eu rninul«* beforc tlie |]ul4<!ni; uiitt itic exiuniiiiii^ room slioiitcl bo lixht4>(I 
only enough to penmt the pnlient to undrem and stiuunie the [iroptr potudmi. Tli« exaiiii- 
ner may alao ke«p Ids Iwod uiider a dark liood or we»r lieavily Kinokcd )tluiM« during thia 
lime Bu oa to iic«tu(ora hi* eye* to the darknew. 

In looking over tho umiut of light aiid !<l\u<lowi< cHch region should be 
i^iudied carefully and in detail, the size and shapi- of th« shadow, the clcw^ 
n(.«H of the outline, anti the diMribution of areits of half shadows as well as 
of full shadows. Not of least importance urc the Ho-cutliKl puhnoiiary 
fiRures, the half-tone shadowa of pulmonarj' veHflelei, of bronchial glands, 
nnd of j'trnnd.'' of adhesions.' Not only the full shndowii but cwpeciftily 
tb«8e half shadowa should be examined with care, for an interpretation 
not a}ip&rcnt at first may booomc elear »/tcr a few minutes' observation. 

RAdiagraphen am. monoi-er, in llie hnhil of looking at the Buoroiicc>|>e tbmngh half- 
«l<Mpd eym in order Co intensify (lie contrast. This may be fiirlher ini«Daili«d by the use 
of durk gliUBM- The writer has uisa found il very uiefu! to look iit the sliafioir or skiagraph 
throiiiih a l>iconcavc lena which nt oner vhnrpniui tho coDtoilr» lubi intrnniricH the contrula. 

Often an area may \>v indefinite during r|uiet breath- 
ing or expiration and become quite definite on forced 
deep inopiration. or it may liecoitie no by dimpj)' turning 
the pnlient ao that the rays pass through his body in 
a different direction. These nvA ^timilar pi-ei-nulions, like a care- 
ful physical e\aminHtion, reveal tli< 
unsuspect«l, and distinguish the 
skilled cxainincr from the unskilled. 

The Car(lia<; Shadow. —The heart 
abadow thrown upon a screen nt the 
front of tbc ehost is sliown in Fig. 81. 
It will be noted that the outline of 
tbc slindow closely resembles the 
area of relative dulncss on pcrcus- 
sioD, except that the former e\tcnd.t 
upward over the manubrium stemi. 
where it is due to iho presence of 
the latt*'r and of the great vesBtds 
and not of the heart. Inthc second 
left tniersjjftce the .ihadow 
of the pulmonary artery is seen, and in the second right 
thai of ihe aorta. Oceaaionally asmall prominence is soon tothuk-ft 
of the >tenium arising at tbc arch of the aorta. Thia is iwtmetimt-ti mistaken 
for an aneuriom. but if the patient be turned a little it will be sw^n to be 
due to the rurvinc of the aortii (HolKkiiecbt). 

Oblique Illuminations. — Much can be h-anted by turning the patient 
aliout and cxaniining bim in several plant's, as watt first performetl 
by v, C'ricgem and Holxkiiccht {1. c.), and later by Itivder, wbusu£gesl<-<l the 

V. Zhuuiihh Biid Ki*<lFr.< Tube bftiinil ihcclinn 
ptiilt III fmnl. 

■ See ehaptcff on Adlwrent PeiiNudiuai. 



following cardinal directions (Fig. 81): (I) cioreovcntral ; (2) vcntrodoreal ; 
(3) sagittal from right; (4) Bagittal from loft; (5) from right posterior to 
left anterior; (0) from left posterior to right anterior; (7) from Mt «nt4.'rior 
to right |)08tcrior; ($) from ri^ht anterior to left pousterior. 

Fio, SI.-~X-ny iluulOWl b dtBrnnt bim of (lif body. (MottifidI Irom Unlikml.t.) Tli« 
tmffn aIiiv Utf tUt9cU<m at fll* n i tO Bti«m uuL |>uHiiorj of titv tutt« rifriai>[Hm(liTi4 in tlip •hivtnv. 
AO, kon*: fA. piilmnnmy uMrr: tA. Mt, •iitirlr^ RA. nght sunrlf: /.!'. Mi intXncie; HI', rlflit 
vuljic]*- In S tb*rc it m melBj ■ounil ip the ovophik^t. 

By the examination in these planes every part of the heart can be 
Viroughl into view, even the left auriele, which escapes observation in almost 
all other mt'thods of examination but appoars i|uile olcurly when the tube 
iis placed at the back or behind the right scapula. The oblique and trana- 
exADiinations should never be omitted. 



The shadow of the heart and vfssoU upon the somen or plate is 
always largier ihau the objecta theRiselve8. In order to obviate this 

whon nieaHurinK out the heart F. 
Moritz devified au instruiiient kiiuwQ 
aa the orthodiagraph (Fig. 82J. 

-A simple (arm at «rthoil»cnph. 
lAtMr UillDI.) 

FrupSa. — DiMi^m ■howing th# uh* nf the ortbi^ 
4iBCraph. 1. Hnf tvioon; 'i. •Monil pndlioo; t". 

In ihc orthixliaffrapli the fluomwcnt wireftn an<i X-r»y iiibn tar. tim.1 iipcm wwh arm 
oF B lantc (.'-nhuiiFil (nitiif.- in such n wny that thi; patient iiik>' Htaiid or lie belw««D the 
two nnm of tiic t' nnd ihr my» thun 
pa«8 Ihroueh hi§ body lo (lie screen. 
Al the iKjiiil upon tiip ■erwn which is 
euwtly oppodtc to the contrr af the 
oBtioatbode or turjtet of the tube, a 
miall bole i* picrcni. nnd a nktn pencil 
1« flxod Jn pUcT hen- mo llml the ititenf 
tbia ifWl can be Ina^kt^d upini the body 
of the patient. The whole IZ-shniini 
frame bearirw the tulio niul fluoroncufxi 
i* morable in two directiona by iiny 
one of a variety of n>echanisms, so that 
the jvr|iviidit'iiliu' ray uiui be brought 
Opporalc any ilt*irnl point. A cerien of 
pointa oofreepondiDK U> the oiHct coii' 
tour can ttiu» be muiked off, uad wht-u 
th«W an joined n-ith linni ibe oxact 
OUllioe of the heart in reprr- 
■ anted . An «bown by Flic. K3, tin 
famUiee a means of delemumnj; tin. 
Kixe of Ibe heart or any msan Willi 
abMtutc OMnirncy. 

The outlines and mobility of the heart thus obtained are disnusaod 
on page 97. 

It is also (lowiihle with the fluorosropc to watch the individual con- 
truftiuns of the heart and to note the ehaagea in size due to »yalolc and 

(■■r !■ ■ ■ liPHAnfTl: JU/.. mxltln* t" Iffl hwnlH; 

L. ul>U<|U>> lui^n.iudiaal: Q, Iruuvom: DUmonb 'miti- 
fata r<«nti:iuitrr». 



diastole, but this ii very difficult and t-an rarely be done with Raiisfariory 
•pcuracy. On tht? iillicr hand, ihe contraption.-* of tht- iiuricU-s cnn be nwn 
with consid'Tablf ttofinilrni-ss, and disHociatioii of rhythm, h earl- 
block, cttn oftc-n be diajfiiuMod in lliin wav by sim- 
ple inspL'ction (Kmus, (iibaun). 


For obtaining permanent photoRraphs n "medium soft" lubo (Moiitx 
scale W 6 B W 5) is usod in coniR-cliun with a Wchncll electrolytic inter- 
rupter and ,111 induction coil with proper self-inductinn yieliling ii -11) lo (SO 
cm. spiirk. Thi^- patient is hdd upon ii lubk- with the tube sibove or below 
him, as is moAt suitable to the purpose of the examination. In order to 
absolutely immobilize him it is well to .support the Hhoulder^ upon sand 
bags, lie miiy aUo be examined Htan<ling by immobilizing the 8h(jiildei'^ 
to prevent blurring of the picture. Maftnifieation of the shadow may be 
obviated by placing the lube at a distance of 2 M. Skiagraphs of the chest 
made with very short exposures have proved particularly valuable, since 
ihey give greater definition (Rieder). 


RAntKcn, Vi. K.: A Ni-n- Form or liodialiou. Science, N. York nnil l^ticiuitcr, ItiOO, N*. S. 

ill, 7'^ unii 72^1, 
Harkl^r, tk-o. K.: The Koritiprii Huyii. Kli-mojn by R6DtK«ii.Slukm, tuid Thuniiiion, N. V, 

and Lonil.. INMt. 
MichrlM>n, A. A.: Theory of llie X-niys, Am. Jimr Si- . IS96. -llh spr . i, 312. 
Kowlunil, tl.: Xnlm nl UbH^rvntioiu on (be ItAnlKcii itayi, ibid., lS!)(i, llli unr., i, 317. 
For lielaiU nvanliiu; llie twcondarii' ra>i. *ce: 
W^ilU-T, B,: I'h.VHikulincli li^chniiiche Miltciluiigcii, Furltichr. a. <l. Gtib. d. Rai)l|[eiuitmb> 

Icn. lliuiib,. IfHK), i, »■•- 
Paulhnlx^r : I'vber vi»v durali 8ekiini.l:)n<lra)iliiiie iHxIiiiKte Encheliiuiiij: niif Ki>nlp!u> 

platlrn, ibid.. 1<KIH. vi, 9.1. 
UoUkiiwbl, Ij , Dip ri'jnlKiilojtisrlie Di.ijfnomik Her tCrkmnkiinmn dpr BnuKeliifceu-eltlp, 

tlnrob.. 1001, l>iu rudiulu^^lie Verhullrri <ler iiortiiiilfii Briiiiluorta. WinL kliii. 

Wchnwlir., 1000. 
Cotton, W.: Suitie PrinciiileH ami FHltitcie» of X-ray li>t«rprelitlioTi. Practitioner, Lotid-, 

1!HN>, Kxtrs -No on X-myj.. 100. 
V. Cricut-ni: BrK^hnixHe dcr rnleraiichiiiift deji ntenaehlichen llrntenx nu'tteUl fluoKwcli^ 

riiden Schinnw. Vf'rhuiidl. •!. Kdiik- f innvro Mei).. Wintbudi'ii, 1890, .>ivi,30^'. 
Rieder. 11.; Din fnlrraiifihunit drr Bni«tor(;iuie in vvtiicbiHieiu-ii Uurohleuclituiipiml- 

luDf;K[i. Fort«ctir. a d. Geb d. RonttcniiMmhlr'n, Ilnnib., 1002 at. vi, ll.'i. 
Moritx. F.: t.'cber die Bcalimiiiimi; tier wuhn-ii GrOme vuii tit^iuitAiideii itiitli!lii dca 

ROnt^nvi^rfahwiiH. Milnehpn. nitid. Wchnnchr.. 1900. ulrii, .'.09, 902. I'elier Prtlio- 

diugmpliiflche [j'nlerMielmiLKvii urn Ilerxonx, ibid., lIMyj, xlix, 1. UHier Ti(ifenbcrtl- 

itiinoiDKi'ti mitti'l* dm ()riboi!iw;ni|ibi'ii iiiul dprMi VcrkUnungen bei drr Orthoilia- 

graphid dm Ht^nwriH lU crmitloln, Fortuclir. a. d. Ocl>. <l. Ronlfteiwtmhlen, tlamb., 

1904, \-ii, IR9, 
Levy-Dora : .Sohiitxninnxarefteln RCRen RODtRcniiirahliMi tiiid ibiv Dcuirunic, Deutuche 

mod. WcbiiM-hr , Bvrl uiid Uipi . ItMKt. xxii, 021. 
For niimermJB form* of ortliadingnplui of Morili and Albtra->Schoeiiber|; (I. c.), but what 

■MtuiH Ut the oHt'Pr lo lie liie moct eon^-cnieiit and nraple form i« the npparalua 

dmcribed by; 
GlUet: Fin OrthorAnticenofcnpb eiiifaclier KoiMructiun, Furtiicbr. a. d. Geb. d. HAntfp.>n- 

atmlileii. Haiiib., 1900, X, 114. 



For the examination of the heart cf. also 

Horitt, F.: Einige Bemcrkungen zur Frage der perkutorischen Daratellung der geeamm- 

t«n Vorderflfiche dea Henetu, Deutsch. Airh. f, klin. Med., Leipz., 1006, Ixxxvii. 

Dietlen, H.: Ueber GrOese und Lage des normalen Heriena und ihre Abhangigkeit von 

phyaiologischen BedinguHgen, ibid,, 1906, IsjcK^-iii, ,5,1. 
Levy, H.: Ueber AbkUraung der Expositionszeit bei Aufnahnien mil ROntgenstrahlen, 

Fortschr. a. d. Geb. d. R5Dtgenstrahlen. Hamb.. 1S97. i. 75. 
Rieder, H., and Rosenthal, J.: Ueber Moment- Rdtitgenaufii ah men, Fortuchr. a. d. Geb. 

d. Rdntgenstrablen, Homb., 1900, iii, 100. 
Rieder, H,: Neue Ausblicke auf die weitere Entwicklung der ROntgendiagnoetik, HUn- 

cben. med. Wchnachr., 190S, Iv, 381. 



While it is impossible to enter into a treatise upon physical exami- 
nation, a few [)oint9 which are of »]>(!oial importance in cardiac ca«e!( may 
be ditwussed. 

General Appearance. — The Reneral appearance of the patient, exprea- 
tiou and oulor, »rr uf great importance. The position which tic naturally 
aasumes in bed, the presence or absence of dyspncea and orlhopnoea, the 
general degree »( nervousnew or dulncw are all to be note*). 

The typical appearance of the cardiac patient (cardiac facies) ia 
characterised by an anxioua expresMon, bright eyes with moint, glistening 
conjunctiva', checks full rather than xunken us in the abdominal facicB, 
and &a a rule a tinge of cyanosis about the tips. 

There are two main tj-pr*: (I) ihc mitral (or mitrotricutpid) fa (lion, wittrJ 
rosy, flushed cheeks, dilated c-HpilUrieR, and cyanoeU (most commonly wen in mitTalj 
.•tejuwU]; and (2) tlie uurtii- fucieii, witli pale, ufleu Balluw, nilher niDken chorks, j 
briitht «yni, moint oonjunctivic, and >liglit cyanown of lips and fingcn. To thcAC mitcht bt ' 
added (3) the i>iibicteric faciei of broken compeiiMttion, with pallor, itublcteric cciojunoUvie, 
and cyanutiiB uf Ilie lips. 

Naxophar^nx. -1'hc tonaiU and ptwlcrior nsaopharynx ahould always be carefully 
exaniiiieil. Tlie funiier are llio chief portals of entrj' for the germs of rheumatutm. while 
adcnoiiln and nlTcetionii of the nasal icptum may nf tlirmarlves induce 
canliac arrhytliinia, mud may also ho an im[}ort»nt contribullnji factor iu iliu atlticka uF 
utlunu in urjrjiiic lieart disi.'ow. 

OphlhnlcniXKupIc t^xamjnallon. — The cyc-ground* iihould aln-ay« l>c examined when 
arteriosclerosis (paxe 300) or eoiigeiitlal heart diaeaMe (pa^ 438) is suspected. 

Neck. — In ttie nock eyix-ciai attention -should l»e direcu-d to the visible 
throbbing of the carotids, the fulness of the neck, and the size and coo^st- 
ency of the thyroid gland (page ■'>s5), the pretence of thnllet and munnurvJ 
over vessels or thyroid, or a tracheal tug (page 53^). The jugular pulsation 
is discussed in full in Part 1, Chapter IV, page 49. 

Chest.— Tlie form of the chest is of eoniddeniblc importance, not only 
aa regards kyphosis, but particularly as to its fulness or flatness (see 
I'art HI, Chiiptcr HI). In recoitling this, tlie width of the costal angle 
should Ijc noted, but tlie general obliquity of the riba in quiet 
expiration should be designated by noting the vertebral 8pinv8 
which arc on the same level with the at e rno xi pb oid 
articulation {normally at the level of the eighth thoracic spine) 
(page 5yS). It should be noted whether ttie chest In quiet brt-atliiiig ap- 
proaches more nearly to the portion of expiration, liat cheat, or to that 
of iiuipiration. Pulsations, bulgings, ttcaving, or retractions of the ribs or 
interspaces, as well as the presence of abnormal shocks and thrills, should 
of course be noted. 

Abdomen. — In the abdomen the import'ant features to be noted arej 
presence or abwnce of ascites, enlargement of liver (systcniio 


stjuib), piil(<ntion of the liver, systolic impiilsfi (tricuspid insuffi- 
ciency), i^sloUc retraction (diluted or hypcrtrophied right ventricle), the 
nature and the time of epigastric puliation (systolic elevation beinf; trans- 
mitted from the ubdominal iiorta. syatolic relraetion indicating dilitt 
hypcrtrophied right ventricle). A palpable spleen of eanliac origin' 
points bo infarction, septic or thrombotic. When aneurism or arterio- 
sclerosis is suspecU'd the t-oursc of the abdominal aorla should 
be mapped out by deep palpation with both hands, one above each rade of 
the aortii and that veiwel between litem (page 550). 

The genitalia should of course always be examined for signs of gonot^ 
rha-a and luei<, — urethral smeurs for the former and a Wasserniann 
reaction for the latter being made whenever possible. 

Extrcmjilcs. — Upon the extremities the presence of oedema and 
arthritis, acrocyunosiif or pallor, and the size, couinstvncy, and 
uniformity of the brachial, radial, femoral, popliteal, and dorsulis pedis 
arteries arc the chirf points of importance. 


Mechanics of the Cardiac Impulse. — The apex itaelf, as shown by 
Ludwig and Dogiel, does not move appreciably up or down during systoleji 
and, as lie^^te has demonstrated, the transverse diameter of the heart' 
shorten.'^ more than the longittidinal. 

The chief niovemenlx which lead to the production of the apex 
impulse are due more to the systolic crcetion of the heart upon the greal 
veoDcLs than to its diiniuutiou in taxv. 

If one watchf* the cxpond bcttrt of n dog. 
eal, w nbbit, it is Keen to ex«cule two movc- 
mcnta in ij-atolc: (I) the gtriieml roDlractioii 
afl«ctin)[ cliif^y tlin tnnnvrrvr dinmctnr of the 
heart, aiiil (2) ii iwinliti); uboul of the 
■ pcx froiu l«ft to riftht nnd forwurdn. 
litle lonlon of (he apex is the nsiiltant of th« 
MvenU linua of Inwtioa exi-rled by tlw museu- 
lature of th« rijcUt and Irft vcntrict« upon tlie 
twMi of the Huriit atid puimonnrf ari«ry, nnd 
modilied by the pivoiuig of tht? hvurt U4;aiiuil 
tLn TtTt«bnl rohunii nii<l by the shifting of itn 
centre of gTkvily oa'InK to variation iit lt« 
)i(|iu(l oonlrni. The tendency uf this inovv- 

mnnt iw to push iht^ upox of the Mt vcntriein ngtumt the chcwl wnll, while the left 
wall of (h« 1 1- ft vent rifle and the right (tintoriur) wnll of the 
right ventricle move inn-urds lowsrd tdi" septum. WhcMVcr In 
man tlinw walls an in cootoet witli thr cheat wnll Ihioc inward moviMntints nlv« rise to 
retmclion of the lii(«npac(s ubote them. The surface of the lhi[i-H'ulle<l richt rcntricU 
ntorcorer b oelually piillL>d inwards during syvlole. no Ihnt there may nctnally be itn 
indeatalion of ilx iiurf.i<« which itill further conlributrfi to the systolic retraction. 

Pfx>truslons and Retractions. — A variety of protrusions and retractions 
of the intcntpaces may be wen to occur with each cardiac contractioQ. 

Graphic reconla uf tlie iinpulst.- \i^vv Imvix taken by menm of the [lolygnphs 
doMfibed ahov«, the raceivinK fniuinl bcinf; plao^ onr Llie area of pubittion exactly 
M for a iugitlnr ot carotid tracing. Traeines can be mnde ettfaer with a nibbor- 

Fiu,NV, — U',v<<inr-D(ji vt the iipArt tDkdJUC 
to Iht prolfUrtoiu kU'l rtlrtcliou dilrin« »>>■ 
tolv. Furcaw shviVD by ihd sTrows. 



«Ovend sprintc trnnlxiur like that u*ni for Ihe carolid, or with uii open fuiuict : 
llie fomier siertiin! pns»ure upon iJii> upex, tlie Uiltcr incTO!)" nx-ordinK tlin roui- 
prcmion or rkrefoiClian oT the air :d (hu (iinnrJ due to t.lif: iin[iuli««, 

Tlio writnillflolindx that ariirinnliiniule rmm ti hoFI rubtwr atrlhcwcopn tip nlopiwrcrl 
lightly aith u juTforiili-d nibhpr Mopper i>enptrBleil b.v 
^ I a kIiw* I'lHn hikI hcjiriniE » ^u^Jbl■^ lip, is vitv luitis* 
f factory (Fig. Sti). 

The movements seen may hfi (livitiod ftjt: 
(1} Lifting of the entire precorttium. 
wliicVi results, cspceially in ttat-chraled individ- 
uals or in those with v<M-y large heurts, from 
T.he .tyHlolic vrcclion of the heart as a whole as 
it pivots against the venehrni coluniii behind 
and pushca ngain.-<l the chest wall in front. 
This is usually seen in hearts which from any cau!* what«'v«r «re 
beating heavily, though It is moat marked over large henrls. 

(2) The normal type of apex beat ronaists of a large protniHioo 
synchronous with and la-iting throughout the duration of ventricular systole 
(Fig. .SS, I. i-d), usually prtH-eded liy u small pn-syst nlie wavelet (o-sl, due 



Km. 80. — Uublwr funnri fct **r- 


cd cd cd ct! 

»TM l.KFT 


Fio. ST. — A, tncing fnnTn llic mpri impul*r ftnci <Aroric] urttry: r. liln* of «flrotid v»««^ rf, limp 
of dierolic notch. lTp|t^ |^d« k^v^ llis ume In { ht. B, oattttoffrain nbumul uwr ■ nurruAl Ap^K. 
C anil l>, ranliotmn over iIib Imirlh liEl intanpaoe D cm. from cixuJ msipn (irttnlir nitnurlinu t. Imm 
Ui> Hm* mdlt-liliul u B. 

to systole of the atiiiclea. The large ventricular wave is followed by « fall 
in early diastole, coincident with the fall in intraventricular pressure. 
kiXvx thix fall there is sometimes a small upstroko of the lever (paa.<iivc 
protniaion nf the apex by the inrushing blood) which may terminate in n 
small protodiastolic wavelet (p). This protodia-Holic wavelet correeponda 



to ihe shoulder upon tlw cardial- iik-tliyifnio^ram at the pnd of voiitriculiir 
filling (imp? !»). iiml is paniciUaily marked in ciiai'S in wliith u third licart 
Bound ran be heard (Thuycr). 

Id nwt-s with hypertrophy of the left ventricle the protrusion is 
usually very forciMo snd henviiij; throuKhoiil .tyMoU'^iiorne-like prolni- 
Mon, choc en domt.- (Itard). 

Occasionally, however, espeeially when ihere is some hypertrophy 
of the right ventricle, the systolic protrusion may not last throughout 
^■Bntricular tyi'tiiic, hvit may Ik- represented by only a momentary protni- 
Jon, fglloweil hy a. retraction during urKUy^tolc (Fig. S8. III). Such u 
beat, which ri-uUy represents the algebraic sum of the systolic protrusion 
over the left ventricle and the systolic retraelion over tho right, niny \w 

■I apr.\ bt4l <lM^ivjnjr ■^'■■tv 'ylnVn' vlnation . 1 1 1. '^ M i . . ,"' <>f Lmpiii-*^ ■Ikuw-in^ an riovftiitan 

futloved liy u (vlnolJoo .lurtng thv p«rii^l of ^jMiolr. l\ . t^y^uiiic Tf motion. Apn lvnn«j by iti* 
fighi rmtoeis. V. ■■JlixnJ" type o( »|»» boil rfiuwinf ptuiruiuaii .luring owlculai •yilula siitl 

t^-nned « "mixed" type of apex beat. In other mixed types 
there may bi> protru!<ion during nurlculnr syntole (presystolic protnieion) 
followed by retraction durint; systole of the ventricle tsystolie retrav- 
lion). The rmhl ventricle plays the hiding r.'de in the production of 
8Ueh an inipul»e. 

(3) Syntolii- retrBei;on!< over the entire right ven- 
l riclc [third, fourth, fifth left interHpaces between the parasternal 
line and sternal marfiin) when Ihin rhanibi-r U hy pe rl ro p h ie d or 
contracting xtrungly, somrtinu-i' iilsu in second left inii-r^pace 
(Maekenitie). Oecasioimlly. esjierially in eases of mitral stenosis, the 
prewnw of a jtystolie ri'traettnn of the inter)>paccs over the nght ventrick* 
and a tiyatolic protrusion over the apex pveti the cardiac impulse the 
wavy a])i«'»rnhce of a peristalKis. In n-ality, however, the two move- 
ments an- synchronous. It is not a peristalsis but a nec-saw movement. 



(4) Syi<tolir impulse in the second right intPDipAce in aortic 

(5) Sy:<1olirimptib»einthe second left intorspsco (pulmonic area) in 
pulmonary insufficii-iicy or vigorous rontractionoftlieviRht v<rnlricl<'. 

^6) Svrttolir rctractiiin at 

Fio. m, — Arm- ni iiulj-ntion uicl rrlnrtiiin, • , 
ptotmnion. ■ . ifHBoiion, I'Alt. nm>in! urirty, Jl!<:. 
juitulj*' vem; CEI'ft, iPvhxUf v»n^ AtK norUk^ fA, pul' 
nnuiniT lulxrT: KV, riiihl >«ilriilp. AI'IIIK Atiu wllli 
hich diKphniKRi-. AP. niin: UV.TRJ.fS. l.v«-puUa- 
lion in trlfUinii'i iniuflirnmi-y: IJV. IIYF. RV. Vir*t- 
rMmfUon with hypcrtropliT of riflil i-diuicl*. 

I he a pox ill iulhcn.'iit peri- 
cardium or when tho apex is 
fonm-d by an hypcnrophicd 
riRht ventricle. 

(7) 8 y .■» t o I i c r c t r » c - 
tioHH in thn inierapaces 
Ijcyond tho a|K>x (li-ft axilla) duo 
to nt'gativc prrssure ovi-r IhoiM! 
arpim of lung produced by con- 
trnftion of a very liirge heart or 
to pleuropericardial adhe&ionti. 

(8) Rctrartion of the 
xipiioid proeesH or ribs 
(mill traction of coKtoporicnrilial 
adhesions during systolo 
(Broadbenl'H Hign). 

(9) Systolic impulses 
in various abnormal xites 
due to aneurisms, tumors, or 
tortuous sclerotic arteries. 


Palpation of the prcrordium and thorax i.< undertaken with a view 
to determine, (1) the forte of the apex impulse; (2) the pi-esonee and force 
of any diftu-w heave; (3) the intensity of the shock accompanying the 
heart sounds; (4) the presence ami dLstri- 
bulion of "thrills"; (5) the presenee. dis- 
tribution, and charaelcr of other puUationH. 

Thrills. — CorriKHd (1S37* and, later. Marcy 
showed that thrilbi m.iy b<- iriiiiaicd by prodiicinft » 
cvrulricliun in ii rubber liibn nl.tnchrcl In a «alcr 
faucet. Il will be mvii tlial ibis ruiUHn Ibe Rlreuni lo 
awtumcA co>lucrriw(omi,f[>vin)( ri*n locddjps. tntntK, 
•ail DuduB bclon' llit'cixwtriclion. Tliwe U'lxl topnxliiceKone8orcoiintricIioiiiui<l(Ulataliao 
in the tube itudf and thui net il tiil'> vibruliuiin uliich atv piUpabk nii thrilbi luid audible »» 
muriiiure. Above llie contitriclion tlirrr nrr no cddir*, hrncc nrithor l-hrilU iior luumium. 

The thrill i.* bi\Ht tran.'tmittcd in the direction of thi? «lri-ani protiiieing 
it. It disappear* when the cunBlriclluu becomes too great or the pressure 
falls too low, and increases with the force of the stream (blood-pres»ure). 

Fill. 00.— EJWit. producina iIuiIIb •> 
>^uw line* of lorrtt. Tit* Urf c iirn>w khII- 


It is of the greatest importaiuru to determine the exact outline of the 
heart. As has been seen, this is done most accurately by means of the 
orthodiagraph (p»(pr S.i), but under ordinary clinical conditions this is 
not available and the cardiac area is outlined by percussion. 



In (letermmin): tht^ area of rardiatr ilulnftM it U important to map out, 
(1) iht* nn-ii of vardiur duliirss, or, more accurately, the relative cardiac 
dulnvHs; (2) the area of absolute dulnees or cardiac flatneaei. 

Fm. Dl,— OoU> 



In mivppiii^ out the area of rclativp cardiar dulncss it is important 
to begin percu^ion im far away from Iho hrart &it poiu^ibk-, and ttiOD to 
appmiu-h the heart, marking the poiiitx nt which thr very Erst change of 
note can he recognized an the heart ia approached. In thi.i way one ohtains 
an ahitoluiely n-»on»iu note as loiijc »-■« the ple»wiiiieter finger is over lung 
lix»ue. and a sharp contrast to this an soon as one percuasca over the borders 
of thp heart; whercatt, if one won* to bt-gin ]>ercu«sion over the heart and 
percui» outward there would be a gradual change of note, 
heeoming more and more ri'sonant. until it finally fadt-d 
into the perfect nvronanL-e over the lung. 

Choke nf Mcihod.t. — In oittUiung (lie canlbo om one has iho 
cliOiiM of !V%i.-fiil riiclhuibi: 

(I) Dirrf I la tnimntiikt<> [irrciiMion by ta)>|>i»K the chrat wall 
directly with the flriKor-tifis of vue liaiul. 

<2) Heavy jiidircct or RiHliatr pcrcuHioD. 

(3) M « d i II m • 1 1 e h I [wreiiwion. 

<4) Liicliltsl uudil-k tn'rcuHsiuii ( t h r u ■ h o I (I percunrion of 
Ewald, (toliliwhcider, ('iiiwhinaDn aiul riclitnyvrr). 

(5) Psl|)alory percumioii (Ebsiciii) by Dot« loo low to be 
heanl at all. 

<6) f I >i o |> « re u 9 B i u n ((JolilKchpitl^rl (Fik, 91]. (listAl 
phalanx irf tlie plewriiiitier finjfpr hclci |)prpiMidiculiif to ilie cbt-rt wull. 

(T) Inal ninir ril nt |>crr<iM'i')n u-ilh a mrclianlral [>U*riinctrr, the blow beioc 
Mmck bjf *ilher llif finder or u Imniiiter, 

In Meleeling the method of percus^on tt should be borne in mind that, 
though botlies near the cheat wall on either side of the line of percussion 
Ktruke may lend tu damp the vibration of the lung an<l impair (he RrK>> 
nance of the note, this tendency is greater for heavj- pcreUBsion and loud 
jfraonanee thiin wiili light Mtrokes which m-i miiy .-tmall area." of lung in 
'vibration. Moreover, it is a well-known law of sense-perception that the 
softer the initial smind tho eiutier it in lo detect variations in it. Indeed, 
df la Camp goes so far as to rrrummend light direct pereu>>»ion through n 
single layer of blanket laid upon the chesi a.'* the most accurate method 
of outlining tin- cimliac duhieiw. 

MoritE. Dietleii, de la Camp, (Soldscheidor, Curschmann and Schlayer, 
and ft nuinl)er of other writers have compnn-d outUneK made by the various 
methods of [jercussion in hundreds of cases with those obtainc<l by the 
orthodiagraph, while Simon haw marked out hi."* outlines by percussion 
upon (lie intact cadaver with pin.* and then t«'stod hi» accuracy upon 
opening up the thorax. All these observers arc unanimous in 
advocating very light percussion for outlininn: the left border 
of tlw! heart, but Moritx prefers a rather heavy palpatorj- percuxsios 
for the right border. 

Moreover, the sensations which percussion imparts to the finger are 
ore delicutely graded for a hghl stroke than for a heavy one. wnee the 



prfSKure of a heavy blow somewhai dulls the wimibilitj- of the finger-lips, 
and in this wuy iili<o a light ^rokc is more sKtisfactorj'. The oft-cnado 
eluim that s light stroke doeti not potictrate deep enough for mapping out 
the right !>onicr of the hemrt, though seeming pliiusiWe, is not wiiminted by 
experienee. On the ronlrarj-. the writer haa observed thai thoise elinieianWi 
who rarely make otit M all the uri-a of eardine dulness which lien to the] 
right of ihc midline were usually thoAc who used lieavy percutuion. 

At-oidabic EiTOn in Perc«i»don. — Tlic cxnct method uwd is ii iiinltiM- n( individual 
)>rrfrn-n(y a-mi prHCtiw, The MMtilial* tor all rnmin imv; (I) a lo«ae urisl. loutd}- hdd 
riutter-joiitlo. anil ■ iliott nharp blow uith imniriluiU' elunlie rrcoil:' (2) Rmi pm»iir«< of 
the plBvinirlcr 6n^r nxninitl lhi> rliwl wnll. especially In the inipre[iae(*>- In ihe writ««'« 
exjienence the iinfiurluiil point is iiot llu? aielhixJ iihrI but the rarf in iliaenmiiiaiinii the 
linit iitiuhl diflrnrnoet in nolo nnd ncntation. Thi^ (errors of |iorr>i)uion m fn<>|iipnl lunoii^ 
■ttidnnio and even exi>er)cnM<l |>h,vi(ieiaru aiv far inuti- freiiLiently d ii r to in- 
ability to delcei differFncen in note Ihan tu liinbility lo elicit 
lliem. Tbia inability to (krinci iJinht dilTen>iiee* v»» d<ii- in iixxt <-a>ieK lo u pmoiv 

ceivefJ iKitiun lui to tin- inteiwity of trhiiniK^ 
ohljiiruihlr. The olBrriiY'i iinuHlly ex|>wled a 
Kitiatri'dian^eand permitted liiieur to ncglocl 
the leawr. ■Ithoush once hi* nttMilJon wi 
called he wn" iierf^rily sWe to det«et it. 

Special Methods of PercMXlon.— Tho 
metlioil of i^hciier varim lomfwhal with tlie 
ptirpOM-. For unliiiury purgKuv* vpr>' light i 
Hiiwl percunnion i» qiiili? aatiiifactory, or ordi- ' 
nary thre*bhold pt-rriwiioii with barely audi- 
ble note, Whi.Tr jiceiirncy ii import nn I, 
OK ill detennininif the nmhiliiy o( (he h(-art 
or tif the Imiie borrltrv, Uoldaclieiifer'n or> 
t bopercuxiion or J. O. tlirwhfdderV 
orlliopiesiii meter In iireffnibli-. 

(ioldiH'bei<ler Iwlievwl llmt orthopemw- 
Hion waM xn driirnf 'hal didnp.8> waa K'^'^il 
only by lioilimi iHrecMv in llie itxis nl lite 
plrmi metier phnliuiK :in<l iti thin way ihr 
plane of an obUque surfaue eonld litr ilet(HM«il but exiierieiiiv nhnnf that this la niivly 
pdMiblt!. It iiuc<«ed)i much moir (miuently whtn tht- ortliopltwini^ler (t'i<t- K?) in 
iihmI; ho thai a mNcinanl note may be obiaine'l when the diaft i« pointed parillrl to th* 
iHTiirt Biirfaoe: u iliitl iiolc wlii-n it in (Kiiiilcd lunurr! (lie lu'ur'. 

Unavoidablv Errors in Percussion Outlincs.^Iii outlining the heart 
by penrnssion the right nnii left bor<leis prejient different problems. The 
right border is situated deeply and recedra at onee from the ehesl wall, so 
that it reprenents the Brat point at whieh {lulness eould be obtained. The 
left border in iniperficial nnd convex «nii ihe eoiivexity aometime^ follows 
the curve of the libs in the left axilla. Accordingly it may h:tp)H-ti-that in 
round narrow rhe^ts or in persons with large hearta the left ventricle may 
almoat fill the left half of the thorax. The curve of tbn ribs (vUows thv wsU 

Flo. OS. — PamuBlon Iritli th> iinhaplivu- 
iBsUr. A J.O, HitwihWiJrr"ii nnhnplpximriri 
add III taotit vf apt>fif«t^op, &.SuppCH«l ljn«of 
IrananlaBOii of tlir {nmiisian iiopuiia Irum (lis 
orlhnplauimtUr. A£A\ HaunantfHimikpiunnot^- 

' 8oiiie pentons are powwwod of n loooe wrirt at onw. i>then< ae^iiire it iwily after 
Uian practice, for the latter the writer rewimmends ihct following escrriw practised two 
tu five minutes dully: Il»ld Ibe irriiil lu lixitrly a« pomible, then vibrate ilie forearm wrv 
rapidly lo and fro from llir cIImw until the bund nbaken uLiout like a ilail upon Ibe tooM 
wri«t too fajil for the eye lu follow i[fl inuveirivnl«. Tho improt-cmcnt in pereuwion fol- 
lowing this exercise Is >'«ry xratifyins. 



of the left ventricle anil the latter may rpmiuti near the chest wall throu^- 
out Ihc axilla. The ouU^r bonier of iliilticsK iiiHy thus Ix- oi)1ain<!J not over 
the apex but over the posterior wall of the left ventricle. In pcrxonx 
with iiHrruw eh est 8 or much 
enlarged hearts the area of 
dulnts* (Fig. «3. P P) ex- 
tends arouod the heart and 
not merely aero as the trana- 

verae diamt'ter [O O) . The 

triin»v(Tse diameter (O O) corre- 
sponds ncfuruiely to thi! point niappt-d 
out with the orthodiagraph. Acconl- 
, ingly there may be a <U«crepanoy of 
Bevcr&l centimetres Ik-Iwich the pcreus- 
Mion and orthodiagraph estimations of 
the distance fixim the midline to cbc 
left bordflr. In broad Hat cheats where, 
beyond the apex, the left ventricle recwies 
from the cheet wall, this discrepancy does not occur; and the findini^K by 
porcusiuon and by X-ray coincide eliisdy. In a very large jR-rics of 
cawa Moritx found his percussion (light percussion for the right border, 
ihrctfholil perciisiuon for the left) to be correct for the right bonier in 
86 per cent,, for the left in 70 |kt cent. 

Kio, 03,— IHwUBBi lo thoK rlir mum oI 
uiuvoidAlj]« ant 111 percuia^Qn ul tht nkniLLu 
oullin^- F '" F, vutlina un pirrrmvian; 


In mapping out the aiva of canliac dulness the position of the apex ia 
givvn, denignalin;! the level of rib or interspace during quiet riv<pi ration, and 

llie number of centimetres to 
the left of the midline (Figs. M 
and 9t) (MI.). The level of 
upper border at the left sternal 
margin i« given ttn<i also the 
tli^tance to the right of the 
midline (.MR) in the fourth 
right interspace. The acuteneas 
or ohiusenesd of the angle 
formed Iwtween the hepatic and 
the cardiac dulness (cardio- 
hcpalie angle, angle of Bbstetn) 
is also noted. In addition to 
this Moritz and Dietlen call 
attention to the importance of 
recording the two citagonat di- 
ameters of the heart (longitu- 
dinal, L, from apex to the 
aortic angle of the dulneas, and 1ran)>verse, Q, from the eardiohepatic 
anrfe to the upper left border, as shown in Fig. M). Normal figures for 
thitd- conjugated weonting lo Dietlen are; 

Fro. IH.^Anmi ol awdlu •lulnM »«(! flalntM In • 
nmn Ike tnn*> lM«v)r lin> rrpmwnli nrdimr 0iltti>». 













Cm. Cis. 


















Dulncss Jti Children. — In chiiilr^n tlie burl :■ proponionnlcly iarf^t snd lin more 
tmrntvorwly tlian in ailiill*. The s^yirx in UKiialty in thn fntirtti iiiii>n>pHCP lal*™] (rcim the 
iiipple. Willi hiu Bbou-ii ihnt tlie cunliar nhs'luw i[i cliiMmi cxlvrids cKoclly twire aa 
far to the Wt iw to ihi? riahc of the miiHini! <MI. : MIt 2 : 1). 

Chanices in the Relative Dulness. — The rcktivc proportions of the 
various conjugRtcri untk-rgo quite lypioal diungi-M in various lorms of heart 

fluieaMe. In weAkoniiiR of the riRht 
hfan, in iricuwiiid iiisiifricicncy. and 
tricuspid stenosis the conjuRate MR is 
inrreaM-d (dulnos.'* inrn-iutfti tu the 
right); in hypertrophy of the left ven- 
tricle and in mitral insufficieney, dulneim 
iiierctwc!" to the left (MR incrfascd), 
while in the latter comlition as well aAi 
in mitral stenosis the obltijuc transverse ' 
diameter (Q) is inercased. In aortic 
iliw.-a«c there is letijcthemng of the 
loiig axis (I.). 

C.\n[>IAL' Fl.*txe»«, 

Flo. U.— Outliu outliDH in a duM o( 
nin* ywn. 

Tilt; area of alwoUitv dulneju or 

cardiac fiatnesa represent* the portion 

of the heart which ia not covered by 

lung (Figs. >M and Hi). It forms a 

triangle extending from tlu' fourth rib above lo within 2-3 cm. of the 

apex, or even just to the latter in the fifth Jeft interspace. 

It is best mapped out by very light percussion, begiuniiig over in the 
fifth left interspace at the left j<ti-riial marj^in. percussing lati^rnlward 
and upward, passing from the absolute (laine»s to the area of impaired 
lesonance instead of in the oppo4tc direction). 

Variations In the Arva of Flatness. — In the primitive mammals (dog. 
cat, rabbit) the liearl doc« not. lie in eloge apportion to the chest wall, but 
U nlung rather loosely between the folds of the media.-'tinuin anrl rom- 
pletelj' covered by lung. There is no area of flatness. This same condition 
Li met with in many otherwlne normal perjion.*, i-rtpecially in the long flat- 
chested, and in ihose who have extremely movable hearts or general mo- 
bility of all the viscera (visceroptosia, enteroptoaifl, page 59S), 

Entire absence of cardiac flatnc.^a is also found tn the exact J 
opposite type of chest, in tho barrel-chesl patients with emphysema, in^J 



whom th(> exa^eratod oflortfl at tiutpiration hiivo caused lh« lung^i to be 
mickcil ia gradually bctwocii the heart and the chest w»ll- 

Oii the other hand, the area of i-ardiae flatii<-t)H ih often 
cnlurged in permiiis with Hat, rhachitlc, or tubi-ri'uloiui chcxtn. In 
hypertrophy of the right 
ventricle* the area of flatiiei» 
18 enlarged and the right border 
bccomvs ohli(]iie, exteiidinR 
downward to the right margin 
of the sternum, often interrupted 
by step-like protrusion.* (Kroe- 
nig). In pericardial elTujiion it 
extends well into the fifth riRht 

Changes in Size of the 
Heart.— A.I ;*e<'n in the inve»ti- 
liHlions upon cEirdiiie volume, 
the siiec of the heart, and heiue 
the area of enrdiac dulnera, is 
wibjeet to a physlolopeal in- 
erease wlten tiw heart is slow 
and df-rlieaae in niw when it is 
rapid (Henderson, «>f page 9). 
Ttiix decrease in raze is espeeially 
noticeable in cert»ui eiuies with 
rapid heart:*, like paroxysmal 
taehyeanUa when tlieiw i.* no 
lieurt failure nor vasodilation 
(UofTmaiui, Dietleu). An in- 
<Ti>a8e in size may be asHoeiated 
with a jtlow pulw («* page 9 
and Fig. 12). hypertrophy of 
the heart, or with a patholojpcal 
dUatation. Th« phywiologieal 
4;nn<lition should first be con- 
sidered before a.SKuming the 

Changes in Position of the 
Heart. — (I) Ui»on changes in 
poslure. Xunnally changes 
■n p<i«ture ar« accompanied by 
eonsidemble changes in the 
pottitinn of the hean. The apex may move 'S-'t cm. when the pntient 
tum^ from one side l^ the other, always moving towards the side which 
is lower. On standing a similar but less marked change occurs. Morits, 
and. later, Oietk-ii hiive shown that tlic area of the oiirdiac shadow is from 
ten to thiny gx^r c<cnt. smaller on standing than on lying down. The latter 
observer confinns Krlanger and Hooker in stating that the pu!si--pn-sMure, 
and hence the systolic output of the %'cntricles, diniiuishes correspondingly. 

FiA,OA. — Dinsnun* iUtultmtxnd Ui^ ino\KnertU of 
Ihn iHinn»1 htmn on fhano* ol |H>t<ur« tfmm >M« tr. *i<|« 
i^K iin't In ih* vmioUB phvr* nf refptrbiiuii (til- Hulul 
IjUck litiK. fiorn\Al onfihnF oulUitr ui quid IjraBUiitiR; 

nfhr •iiIt: hmkxn hut* it-^. ranimc oUTJihv vitli pAbmt 
lyiDE nn Wt n-\^: HXI' 'bortconiAt 4li»J^ar}« uuiEia* tn 
^Ttpiniton: /.V>7' (vtrtirot thAd'iiC^ «nitu <mtliti« in 
iiiipirqlLuii. Tha luux'HOwU *kown in lhm« Afum 
r«pf#n«ii tliA iipp«>r limit* of nonnK^ mob'htT-. 



The diminished filling of the heart iit due al«io to the fnct that the proetiure 
iiiider whit'h itic blood ent«rs it in diafitolo (venouit prwwun.') is lower upon 
Btandinu than upon iyiiiK down. 

In wtiiif people extreme mobility (6 ,S cm.) of the »pcx i." found {wan- 
dering heart) — a condition often asaociatod with cardiac neurasthenia 
and palpitation, and even paroxysmal tarliyiuirdia. Chan)^s in po«ition 
of the diaphragm, upon expirntion, inspiration, or inteslinai nntulenee, also 
KiTect the position of the heart, especially upon standing; xo that in 
expiration or (liitulem^e the apex is pushed up and tiie heart 
lies more tranjivcrMcly, while in inspiration the apex falls and 
the heart lies more nearly in the long axis of the body (Fig. fl6). As can 
be readily shown with Hcinh-rson's cardioineter, the former postion inter- 
feres with the cardiac filling and hinders the circulation, while the latter 
podition facUitates both. The amount of change of position of the apex 
is normally about 1-2 cm, 

CHaractbr and timb or tue ueaiit socnds. 

The beat of the heart is ftcroinpanio<l by two definite sounds oniinarily 
likened to the syllables "lub-dub" or "tff ta," the firat sound accompany- 
ing eytttole, the seeoud occurring jutit at the beginning of diastole. 

Qraphic Rccordiu — The iriact period of ihe cardiac cycle to whicli ihey cormiponi) 
wMi Ttinl iiJvi:Hii(;ui(!ii by Uonders (IK.W), who mnrketl the onNrt »f the Miunds by tapping 
ii|iona reoeivinKiaintioiir thcinHt^nt he hctinJ soiini) uckI ivronlini: thiif signul upuunilnini 
while iriniiiltuiipou»l)' ri!crinliii^ ibi- (^unliuKritiD. TliU mutlnxl van siibiini:| developed by 
Marliiiii and hai: fiiniwhrd uimr JntrrcsliiiK info nun lion, hut cvon in tvR;iilar pulemi ihi^ nsulta 
aiv very fictile unJ the uielliixl caiinut be ui>«il u( ull wlieti the pulae-r>to i* Jrnigular. 



FM. PT.— OMplii« ncqnU at th* hMtt uumli, IKLuiltiMi ol Piul. Kiatbovm.) KMh rttrtiMl divUm 

During the pnxt Hftecn ynur* iwvcral mcthcHli; of rroordin); thp heart imiindH jc^plu' 
Q&lly have been tlevived (Eintliuven and tieluk. Huerthie, Hotuwiiuiki). Eiutlioven, 
Flohil, ancl Diiltoiml plnce u riiim>p!Kine over the hiiin, «)nnr*i Ihc micrDphone with the 
thread (talviinomcli'r, Hni) pliotOKwph tlio iin>v(-iiieiil« fl tin- Inlicr. 

U, I'' r 11 II k utliu-lim tlie lube of u iitclliuiM.'<i)ie la a luiobour over wUicli tberc is 
Htrftchctl a di'lirnttt condnni niciithranc Ivarinji a »msd\ minor. A benm of li^tit i" thrown 
upon thin mirror. :iiid it« iiiuyenitnUi, wiiicideiit with the souati waves in the Hlvthuacupe, 
afc mrordod pbotogniphic-nily. 

A still nion.' delicate method Ib that of Weiss and Joachim, fnelead of 
tJip n>ndnm mRRibmni! uurd hy KraBk. these invesiliftntom rcgisler the vibratjoui of n soap 
bubble liliii blown over their tweiiina lanibour. To prevent Immtinji this is kept, in a 
moiiil chanilier »f Rloni. Tlie ^'ibmliolu aie iiiaKnllied by means of a small /. of eIubs cap- 
illary which reftiA ii)>oii iho film. Thi< moveninita of tlie shadow cniit by thei end of thr L 
are rvcordml phottHtrsphically. Weiw and Joachim's rasiilt« arc at least as Kood an those 



of Eiiithovcn. Tbrir raconii n.n> Kimilar and quite as ilelicaw, and aidA miich to our knowl- 
edge ol heart »niin(ls. Moreui«r. (liey urv abtu ucttulty U> ayntbelixe and reproduce tlwae 
MUnda by Iruiuti'iring tlidr nin-rs to itnc utripa which atr. raialAd upon n (Iruni ■nil set 
H Biilc in moiinn. Th« \-ibmlion gives riae to houikU wliEoli they atate Imve b«ien idsntifled 
by olh^r cliniriuiiH »itli tboie of the ciutM recordi-d. 

t^vprxl nicthixlii of rr«onlini; (hi> heart noiinds by vlbrittioiM ofn k'" ffninr 
(Marbc, Ron/) hnve iieva uiily iDO'li-niti.''ly BUtxKsiful, luid tliougb niiiiple am nut tut 
utisraciory iw the photogmpliic mclhiKU. 

Clinica] DiaKnun for Heart Sounds, — In many t«xt-books the heart 
Bounds are reprei<eiilcd grnpliically in various ways, but it iwcm* to the 
writer that the best in to indicate the occurrence of the sounds directly 
upon a Dimple diagram which indioatxis (hr relation to the auricular and 
ventricular voiitraetions, as shown in Fig. 98-' 


Fib. Wl.~TK>«Tuii fnr rniTWWOlinB the hnri wunila in dinlMit nnu*. XJpjta rum NpNwnU 
Ihc «v«nu of th« cmnliiU! oycJr. xhr- unall fturtfruiof contraction foUowM by iJl« ^Afrrr ^rriTrtculu- ojm- 
imeUun. Lower lioa ntmacuu liiBlicart wunils. True li^ri luunat am leummiB! hy •oUilly uliiiliiJ 
btoekji. vhoav hnsbt iiuliftttia th«r intansty mnd whoH brfladth indical** llintr durmtimir 


Firri Sound. — Harv-cy states that "when then- is the delivery of a 
quantity of blouil from ihi? voina to the arteries, a pulse tiikcs phvcc which 
can be beard within the chcjit." Lacnnoc (1819) was the first to describe 
the chnnirU'r of thr »ound». He rcjtardcd the first ttound as due lo ventric- 
ular systole, though he thought the secoHd to be duo to the contraction 
of the iiimcle. In 1830, C. J. B. Williams and a committee of the British 
Medical Association inve»tJfi;uted thi^ heart »ounds exjteri men tally. He 
believed that the first sound was largely of muscular ori- 
gin, like the contraction wiund of skeletal muncles, beeause it rouhi be 
heard upon the cxcist-d heart even when the auriculoventricular valves 
were held open with the fingers, but the second sound could not he. hoard 
unless the aortie or pulmonic valves cloiwd. This view V3ni substantiated 
by Ludwigand Dogiel; but Sibson and Broadbent found that in the exposed 
heart of the suw the firitt sound l>ogins with a sori of rumble, which disap- 
pears when the blood flow is shut off by tying the vcnro cava?. This 
rumble they aacribe to the movement of the auriculo- 
ventricular valves. 

Graphic records of the heart sounda by Binthoven, Flohil. and Battaerd 
have shown that the first sound in man bepns at the beginning of ven- 
tricular svntole and lasia .07 to .10 aee. It \a loudest »l its very 
b«Kinning, is decrcsccndu in character, and is almost 
completed before the aortic valves open, — i.e., Iwfore the 
heart has begun to pump blood into the aorta. The first sound is followed 

*Thu« in CMWS of mitnl *i«nori> (mv ptge 348) Ifao 6nt Bound may be «faoK and 
(appinc in rhttracier. ilMoiich tracinic* ohnw ibo lynuilc lo be oT (liimljon no Iras thsii that 
met wiih lii Ibo nbecnoc of (apping cbuacli^r (Hirschfcldcf ). 

too\sfjs of the heart and aouta. 

by the Mhort pause, which usually lasts .15 t« .25 sec. and whk-li in thon 
followed by the Mcond »ound. Einthoven's results have been confirmed 
in mun by ihe reconU of WeiAt mid Jonchnii, Hcs-t «tid Frunk, iis wt-ll as 
by Prof. Barker. Dr. Bond, and the writer. In the dog, K. H. Kahn has 
shown lh»t ihe duration of the first .sound w exactly coinddent with tin- 
period during wliirh the- intrnvontricular pressure is rising, whilp the dura- 
tion of the .Hhorl pause U exactly coincident with the .\V!<tolic plstvuu. 

Sahli and othvr clinical obscr^t-rs boliove that the first HOund at the 
aortic uea beginf) later than that at the apex and in due to liw ru!«h of 
blood from the ventricle into the aortii. but graphic records ^eem to indicate 
that the ftounils in the two areas are aynchn^tnous, and begin before Ihi- 
aortic valves open. 

However, the first sound heard on listening in the suprasternal notch 
IB often split; and it is possible that the latter [mrtioii of this sound Is due 
to just such a forcible distention of the aorta. 

The valvular element of the sound ia probably brought about when 
the vidves are thrown into tension by the veiilriculur !>ystoIe. The normal 
valves give no sound at all when they open spontaneously.' There is no 
evidence io indicate that the norntal sound is brought about to any extttnt 
by eddy currents as are thrill.-^ or murmun^, nor does systole of the auricles 
produce any portion of the normal firat sound (Einthoven). 

lless and Frank beUe%'G that the movement of the heart within the 
chest »n<i ix-rlittpw against the chest wall (systolic erection) inuy be an 
important factor in the production of the 6rat sound. This might explain 
why the heart sounds are orciwionally iiinu<libSe in eniphyscrnatows jror- 
eons in whom the organ is separated from the chest wall by a layer of lung. 
On the other hand, this factor is .'ihown to piny only a minor rflle by the 
fact that the first sound may be heard in its normal intensity in the exposed 
and even the suspended dog's heart. 

Second Sound.— The second sound has lieen shown by C. J. B. Winiaiiis 
and the liriiish Cunirni^ion to accompany the cloHure of the uorlic and 
pulmonary valves, to be modified when these valves are injured, and to dis- 
appear when they ai-e held against the vessel wall. It last* abonj .OH second. 
It is loudest nlien the blooil-prt>s8ure is high, when the valveti are thicker 
and more rigid than normally, or when the vessel walls are more elastic 
than usual, the intensity varying at different times of Ufe and under patho- 
logical conditions. 


MonAural Stethoscope. —The monaural stethoscope, introduced by 
].aenncc, is a simple wooden tube surmounted by a flat disk acting as an 
ear-pieec and resoruitor. The tube is press(-d against the chest and the «itr 
laid upon the disk, so that the observer receiver at once the sound and the 
thrill in the wood transmitted directly. Obviomdy this method aceentunte.s 
the notes of low pitch which are nearest lu the cjs^-ntial tone of the 
iosimment (and constitute most of the normal aoundB), as well as thone 

' Both tlie valvM and (ho cardiac wall* are at that lime oxtTMUly lax and Ifae val- 
vular opcmtig ut KlrnuBt e(|uat lo tlie diainet«r ttt tlic vcntricubr cliunb«r. 




of rclftlivf loudncsi*, which cause it to vibrate mpphauically. Hdice it 
ifl particulnrly adaplcd lu iIm- detection of prcsyjiiolie »iid other rum- 
l>tin)c itiurniurti, and is the method used sltnoat cxt^luNively outside of the 
I'tuted Staleit. 

Binaural Stethoscope. — In the United States the binaural stethoscope 
is in more <;eneral use. This euuHHtis e»!N.*Mtiully of a Htuall I1ecei^'inR lieil 
whieh is placed upon the chest wall, and from whieh two tubes feail off to 
smiull rubber ear-pieces which fit tightly into the external auditory meatua. 
The nio»t iittpnrUtit ei<i<entials in these three fonnx an>, (1) n bv^ll conipuwd 
of various niaterialH^ivorj', wood, celluloid, or hard rubber^ provided with 
» ^uflieieiitly Iht^k air spare at the tip (Knieraon): ("ij ear-jiiecei* perfectly 
fitting the ear of the individual. It is sufe to »uy that more errors of auscul- 
tation reffuh from poorly fitting ear-pipces than from real inefficiency on 
itie part of the listener. (3) In stetliu- 
scopes in which the enr-pieces nre held 
in the ears by n spring this should not 
exert cxeeftsive pressure lest it produce 
sounds within the ear from llie preHsure 
on the dnim. 

There are three main forms of binau- 
nd stethusc-opt;: (I) those with ri^d r>u.w.-ctiw« vtiMtbuHapc uiu. 
tubes (Cifinnctt's), [2} tbo>BC with soft 

rubber tulx-H, (3) tho-w with soft nibber tubes, flat bells, and a small elastic 
disk of metal or celluloid to act ns a resonator (Bowles), Of these three 
funiis it may be said that the rigid tulws certainly convey the ooiinds fiome- 
whai bi^iier, bui iJiis is often more iRan compensated for by the better 
6Uing of the ear-pieces in stethoscopes ^ith soft rubber t ube». In Htvth- 
06eo])es with disks certain sound waves, and particularly those of high pitch 
(soft Mowing murmurs), are accentuated, while Other sounds may Ik* Rela- 
tively suppressed. Moreover, any movement of skin or hair ox-er the disk 
may give rise to a sound simulating a friction, and this source of error 
mu.-<t be carefully excluded. Iltur should be moistened, and a sniall boll 
shouhl be uned with perfect upproximatiun (o the skin throughout its 

AKeralion of Sounds by Pressure.— Emerson has shown that many 
murmurs, eM)iectidly presystolic and snapping sounds, are diminished or 
obliterated by pressure n*ith the stethoscope, while certain utlicrv are inten- 
sified by prej*sure, and that I his is dependent upon the pitch of the sound 
and not upon the site of its production. It is tlierefort^ important for the 
observer to listen carefully, fii-st with the Ughtest possible pressure upon 
the stethoKCOi>e aii<l then with grudunlly increasing pivwunf. He should 
do this consciously and as a matter of routine, rather than allow such 
sounds to escape hint or .ilumble upon ihem by accident. 

Moreover, since the monaural and binaural stethoscopes each inteoiufy 
different sounds, both should be used in any important or dubioua caae 
before the examinnlion is conchided. 

Graphic Methods. — ,\h stated above, the most accurate and reliable 
information which hus thus far been ut)tiiine<I is ihnt obtained by means 
of the recording microphone. I'nfortunately, however, all the methods 



thus fur devised have been loo cumtwrsoiue for the be<laid<> or even for 
niutiiie hospital use. They are of value only in exceptional raaea for re- 
search, but there i» no douht thnt, the future of gt-ientific uuscultutiun lies 
in this field. 


The various rardiuc aound.t nre bcsi heard over eertain definite locations 
corresponding more or less to the structures in which they arise, hut par- 
ticularly to the coupjte of the blood current ami to llwir moih* of origin 
(Hg. 100). Thiw the sounds produced in the left ventricle are best heani 
at the upex; tho«rc produced at the aortic orifice, though produced behind 
the Hterniim. are heard just to the right of it in the necoud interspace: the 
pulmonary noundn are t'arrie<l to the second left interspace at the sternal mar- 
gin; while the sounds from the right ventricle ure heard over the entire body 
of the st.emum, over the greater part of t he area of absolute dulness. and over 
the bnse of the enaiforni cartilage. Abiturnial M>unil9, murniunt, etc.. Have, 

however, a different diatribution 
which will be dt!*cu.**e<l laU*r. 

Normally the first sound at 
the apex and ever>'where else 
l>elow the third rib is louder 
than the second sound. It is 
aliio of loHj^er duration than th<! 
latter (.08 second as compared 
to .05). Over the aortic and 
pulmonic nrca.i it becomes some- 
what fainter, begins a trifle later, 
and irt of lon^T duration than 
overtheapex. The second sound 
ie then louder than the lirttt. 

The [tecond sound at the 
second left interspace (pulmonic 
second) is u^ally louder than that over the second right (aortic *econd) up 
to the age of '25 to 30, when the latter beconie?i the louder (Cabot).' This 
varie-B greatly in different individuals. Merc chanji^a in blood -prciHu re are 
not suflicient to Account for «ll these conditions, since the pressure in the pul- 
monar>' arter>- is never more than half that in the aorta, but proximity to 
the sternum, greater elasticity of the walls, etc.. cond>ine to bring about 
the relative loudnes.s of the second pulmonic sound, and therefot* any 
further increase in pressure in either artery alters the relation of the two 
sounds lo each other, increased pulmonarj- pressurr increasing the pul- 
monic second, increu»e-d general blood-prct<sure increasing the second 
aortic, etc. The progrcMive thickening of the aortic aifmilunar valves 
after the age of 30 alao contributes to the intensity of the sound. 

Other ate* for AuKullalion.— Boy-Tcimivr han alw rpcomnw^ded su«ciill«([an in dw 
aupr»«l<'tnal n n I c h , pmnnt! >l"- hnll «f the HlrtliOHPu(>e lu fur down bchiiut tlic 
manubriun) as poMlbl*. In tbw way he ttottM ihnt ine ran lii^ur uorlie diulolic mumiim 

FlQ. 100,— Tli« "Vklvulsr ■: 

' Diwrtly avFt ihe expoatd aorta the aound in louder than over the expcaeii iMihno- 
nnry artery. (Thaj'cr.) 



Fii 10l.~Th*pniiB9it«iofihah«ut*MiaiblHMivalTMt»ebsMinll. A. Coutwofil**™™! 
wavM niliin ibn hMrt. B. Piopc^Uon «f Um hart MHud* M Uia tnil ot Iti* N«iiul inMnvun. 
C Pnipaatiinn of Uis Miunila ■[ Uit Uvd Of llw boith mod fihh inUnpMa. 


not othorwiM! niidiliip. lie tbinkn that heualaobetti>riiI>ip to dJitinKuiiih lhocliiiriiou<ro( 
nortic Hyatolic iiTiiriiiuw. The nirthml iiiw imvpf (lairied ji:etiera) hbujco, uiid Oie wril*r is 
unuble to linil in it Bny at tfif Bili'u[ilii|i;ra <^Uiiiic<l by buy-lViuiii^r. The cliict value of 
*iipntiil<>rnnl aiuciiltalion \r found in jivriKitiii wIiohd hcarl Koimdn arv frctilc or innii<lihli> 
over llie prMonliuiii. Il niu«I hn Iwnicin mind, howcvpr. thai the iiulnil iiiurmurt arc nut 
wi'll (TBn*mitt4.'d to ttiin rcijiuii, and tliul (he first huiiikI tii-uni Iht-re i» ftequciilly rtdupii- 
e>l«<d ornfilil. 

Aiiuthpr form of Htii)cu.)<&iion not tn ffMimi3 u«e is ilie auaoultulioQ 
through the utoniHch-lulx?. iiilmducrd hi For n tmcinf; from the Irft nuriclc. 
Thi* iiielhnd.riivl ii»cd by A- lIotTmjtnn in tS!}2. bimlicpn revived by GorharU. but, thoiitch 
it ini|;hl throw ootiii- 1ii:lil i.i))U[i thi* iiututi! of an occuniunul iiiitnd miinnur, it is in j^rrnerul 
diflieiilt and iifry inconiiTiiienl to entry out; luid in ninny tamu nt |pa*ti the miinniini nm 
no belter hi-atii than over the clifwt wall. Nei-erlhelew wlii-n.- it ix inipurtant to know 
whetlict n mumtui is couducicd bitck into the left nuriclc, n puuiivc finding by this would 
bd concbuive. 


Ordinarily th<- diastolic pauKC botwtH>n sournla is ton^r than the sys- 
tolic period, and ihc. inl^rvai between the seeoitd sound of one cycle and 
the first KOiiml of the next iif longer than tlie interval between the first 
and second sounds of the same cydc. Uowever, when the heart-rat« is 
wry rupitl, th« diastolics ])«UHe may bei-omv shortened to nbout ttic annus 
interval as that between the first and second sounds (long pauae^ 
short pause) , so that tlu-i'ound.t Murt-ecd oiiv another ul uniform intcr- 

■j I 

Pia. 103.— (Irsphic rtPCuUi of Ilia fatal lioarl hiudiI*. i.VfUt Waiu aiul Juarlrim.} 

vals like the tiekiiig; of n clock. This rhylbm is heard normally over the 
fetal heart and hence has been termed embryocardia or fi-tal rhythm. Il 
»lso occurs in adults when ihe rale is very rapiil (120 ami over), and hence 
under conditions in which I he hcjtrt is untler an abnormal strain (see paicc 
227), as in fevers with hi^h temiMfralure, acute heart faihitv, and nt^ute 
overwork of a chronically diseased heart, also iVi eases of paroxysmal tachy- 
cardia and allied conditions. It« abK)lut« significance is simply that of the 
rapiil hvart-rato to which it cormtponds. 



Reduplicated Sounds. — Occasionally one or the other of the two normal 
heart sounds is repla<'ed by two clear sounds, or, in other words, there i." » 
n.Hlupncwtii)U. This nHluplli-atiun may occupy the place of either the first 
or the second sound, and, as already noted by fjkoda, it may seem to be 











, i 

1 1 


1 1 




kiu uiu 

M ii M fe 

Ltir. fAjfci 


H 1 

FUB (Hlfi tl> 1 

due to, (1) splitting of the normal sounds into two distinct portiona, or 
(2) prcsinire of an accessory- sounil beidtifs the normnl souiiil, ln'iiig in ihc 
latit^r cftiM' presystolic (Ijcforp tho first soiin<l) , protodiaiitoiic 
(shortly ufU'r the ai'conc] Hound) , or m e if o d t ii ^ t o I i c (in mid 'diastole). 
The relation of (troups 1 and 2 to one another and to the cardiac cycle is 
shown in Fig. 10.'t. 

V<iLU)u or Vkntmiiu 

MnjT Vttm KocNn 
flri.lT Steaxivii Soi^xn 
PMtTODiAirrouc CuLOt 
Fm. ICO. — INkcmm IlluiUmuac Ilia >pli( inuDiiii uiil oallop rhytlmia Mul Ihrir iihunMir aquivulHiUu 

An lo ihc caiisntiim of Ihewo alxiofiiial eounciH, little rjpfinite Ih known. A ^nwt <]eal 
of tlie iiiilefmti''n<«ti ohich [vniientra llir cnornitmn Utrr.iliiri! u[>on the subject in dtip lo 
Ihr (oilurc of llip writorn lo ilistinjtiiinh clearly brtw««'ii ilic diffireni fi»nn« with nhieh 
llie>' arc ilrjilintc- Thp prwj'nlolic iiikI pnitoilinitlolir funiu un: gruufiwl iiii'.kT one licod 
rvgsnllesH wf their nrlaliium lo iin'chnbiiini or <iliolti(ty ; it « mainly due to the wrilnfn ot the 
Frrnch *rhool iuuIm Ihc Icsulrivlup of I'otiiiii iIlhI Itio <)iff<<reti tint ion hnx ri>iirii<^il even it« 
pnisnit Ela^uf <l«vel(i[iiTi(Mit. L. iiard, of (ifiict-a, hiu rcecndy gjvca un exci^llcriit uiialyniN 
of tlie miUject froiD' this staii'l-Fiainl, 

AecotdintE to Bard, the two iiiaiii groupi of MHWsitury •otuidn urv: 

(1) Tlw pnwyvUtlio gitllop itHluplickiioD (lH-t;i-t:(l) or ti U tut, to wMch the Ixnn 

I t 
ItaHop rhythni chnuld l>n liniilH, motfl conunuiily inol lit iw^iliritiCM wttli cardiac hypti^ 
Uofiliy and in 'illiir lieavily Ix-iiiint; licarla. 

(2) Tlie protnUuiilolic luiund tft tA ta (I<>l'-<ti't>-<ln>, C-ailrd l>v tinuillniid bniil ilo 

J t 
rappel. — "uminil of recall" or "itraxlulie eelio/'^fre'irii'ntly heani at (W «|>w( In loit.ral 
■rtcnnin. BanI lliinki lliat tlie ulinvc-inimtiaiin] ucceiHorT wmiidn nre to lie nnganlvd lut 
merely the rxaiocrniiion of vilirniioiM normally prcucni but normally inaudlhlr. 

SfHit Sounds. — The sounds (tlat-tiit; tiit-tati) arc charnctcrizird by the 

absoluU^ siiiiilarily and short intt^rval hetween the two portions, and may 
be due citlu^r to i>lt{;ht iisynchroiiism of the two ventricles (C. J. B. Williama, 
IS30. Skoda, Cibson. 1874) or slight separation of two pans of the ven- 
tricular sound, which ore of dilTcR'iit origin but onlinarily fusttd, 

A« Im» been Mon, (he YVtiirioulnr aound coDtaino txiih a valvular (auriculovetitric- 
uter) and a muxruliu' cl«'int'iit. nnd jwrhapa alao an element due lo tlio ulretchias of the 
walh of the aurlH. Bnnl lliiiikv lluil variation in either the mui^iikr or th^ valvular 
|,«lMnent might give ri>e lo tlieir Kcpnralioii into two sound*. Tlic <|tiMttou nf uByiichnMiiica 
Iho two vvnlrirlfH which ariitrA in chia connection in onn which wiu> looft without an 
cxp«riiui-nial liaau. tiu[ IIjc rvcriil obnrt'iition^ of Stiuweii, Krau8 utid Xlkolal, and II^w* 
lelt indicali- the pcmibilily that it iiiuy occur clinicnlly. Sliwaco, in t'rederieq'n liibor>> 
lory, ha* rvconied uiynchronotiH contractions of the two ventrirlm when thi> latt«r n«te 
fMoveritiK fiom vajpin inhibition, and nlso with \-enlricular fxlrasyatolcB producvd during 
pMiock o( vagiM inhibition, Tlie wrtl4'r luu on one occniiion heard it dplit Ural aoiini) in an 
in which tlw cuntractiunii of both ^'cnirlclei were being n«ord«d vith inyocaidio- 



ftnplu. The i-vulnriilar conlru^lionit uere sliK^'ly aflynctironoiift. In a DuinbiTuf utlirr 
infctancm in which no *plit first sound could be bcnnt tlie canlmetionn were BbiiohiC4-Jy 
eynchronoiiH. IlDwcnr, no eonclusioiM atv juatifiod from nn iiiol$tie<) olMcrvaiion. 

Th« splitting of the first sound is best heard over thi> biiw and body 
of tlio heart, ill Pontrasl lo thi- wrwMOry Huuiid» which are best heard at 
the apex (see bolow), jV» to the splittin); of the second sound, this hkvwiiw 
may be du<* to shght asynchronUm of th<r two vcritricl*-*. or to tfie fact tha^ 
even without this the sctniluuar valves may not close at exactly the sal 
iuiftAnt, It in oflen possible, by passing the slethoscojx? along the second' 
tight and left interRpaecs. lo deU'rniine which second sound laRs l)ehin<). 

It inuKt be added, however, that, as Bard himself states, no accurati* 
knowledge of cither the split founds or the accessory sounds can be f;ained 
iintii they are reRisterod graphically by cardiophonographie methods along 
with simultnntroua venous, arterial, or cardiographic tracings, so that their 


"^■- ■ ■ %v,.. - — 

il, SECOSn^ 


PRE. I SyST. A 3 B 

Tvt, IM. — Gnphlf rrroril ot • ■plii piilmonio •ni-oT><l Hiiinil. (Aflcr W«« &nr( Jnaohlin.t fRK . 
pMMjrMBlto ranlile; SVST,, pyiUiLie murmur; I. tirnii hmrt .-ujurij. 'J A, B, Iwo paru iri ipiit tcfonrt Mmupi 
(JM me. kpKH). 

exact relation to the cardiac cycle may be determined, So rapid is the 
sequence of the sounds that in an individual ease the differentiation between 
jiplit and accessory sounds is often ditTicult. 

Rtilupllcailon of the I-'irst Sound from Portcariliai Adhesioni. — Rudupliolioii of tlw 
fint Kiund UnlHo hi^unl inn miinbcr of ccucn in whicii uUl pcncnnhul luid plciint adhcnionn 
are toiiml al HiiTii|H-y (Sewftlll. whii^h may be cwily iindrritiooil in tcivc an ahnormnl xound 
in lyHtnli-. Jiial liow corniuuiily lliis Kroti)) uc'cuni huB nut Ixwii Uel^riiiluei) HtallHlicslly, 
biiMuidor thrwcciDditioiuil np«lnot signify niiydialurbuticc of function. 

Prcs)'stolic Oaliop Rhythm. — Aa regards the accessory sounds, tb« 
great majority of writer.'< take thft view sug)i:e!tted by Kxt^hiujuet in 1S73 
and Johnson in 1S70 that the first sound of gallop rhythm (pn^systohc 
sound] is due to the vi^orou.-* systole of the auriclfr, a view which is further 
BUpported by the studies of Kriege and Schmall (1891), Friedrich MCillcr 
(1906), G. C. Robinson (I90S), and others. According to Miiller, Marey 
believed that the extra .wund was produciMl by the auricle sending blood into 
a defectively emptied ventricle, a view which has been revived by Sewall. 
Moreover, the writer has been able to show on the excised heart that when 
the veutncl«s are dist(<ndcd under a sli^cht positive prei^sure the auriculo- 
ventricular valves may open along only a small extent of their line of clos- 
ure. This gives rLte to a slight functional stenoaia at the point where they 
actually open, a fact which may account for tlie audible auricular con- 
traction. Miiller coniudera that the extra tone may be dependent upon a 



Ifty in the time between the aiiriniilar and ventricular eontmrtion, po»- 

"^ably due to lowered conductivity in the atriovpntricular bundle of IlLi, 

and when the two roiilrantionii are abnonimlly neparulcd two sounds 

instead of one are produced. Tracings, however, do not usually show 

delayed conduction. 

All ibest wnieni base tLeir view* upon tlie fael ihat Uie aouiid sppwini to bu |)n^- 
•ystolie in time axul Uuil in man)' coms n wrll-ninrkml aiiriciilnr Wiim may hn M>pn u[K>n 
(lie Ciirili<4rnim »l a conwpondinic point of iIiocitIp, It must lici uiidixl iltui tliix isulso 
teen in miuiy taeni in wliich lliere is ni> gallop rtiytlun, and lluit it m-irm* to he di-firniirnt ' 
morr ui>on the proniincncn of the apex iinpubo In ihr int?ni[>nrr farilitntini; tlit' reccinl 
tluin it (Jom upon t)ie o\iHt«ncc nf the Bounil, l{oive%-er. this wave is ufleii ijiiitt.- u.i |i(t>iD> 
tn«iit in the euri-m (pntloiiiiuitulic sound) in which nu pniKvulolic wiund vriut hrnnl an in 
. tliote U>ed to ilttutrntc the nuilup rhythm it>r]f. Ttie ptixif w tiwrfSuiv irLiulIiciiMit. but 
that dotiK not nwon tliul the iLi-ory is nwe»srily wronK. It i> not iit oil iinpmhnbk that 
tlw fombli- roiilniclinn of an ovrrlniidinn aiiriclr lony kivp an siidihlc HOund jvml oa ll 
do«i whi-n fomitK Liluud tliroiiiEh a iiarn>u«d orifico (prVHytitolic nimble), but tliis )uis not 
■yet bwn provpil and will r«|iiirp careful invpi-ii^ntion with thr cardiophnnnitraph, Ttip 
pombility of Eiinctional mitral slenoaii likr thnxr mcntionpil on pagn :i7t mtwl nlitn bo borrir 
in tttini). 

Another explanation for llio phrnomrnon in that tho M>und occun tiiirinir thr vrn- 
iKoulsr ii)ni(ule. aa sucjpMl^d by H- Chuvivoait. who thoiiKht ll dii«i to the li-nsiuii ul llit- 
aiinculovrntricular vhIvm. Hi* api'i Imcinipi. howi-vt-r. arc not cai«fuLly timud and might 
(|uit« Ml well t>i>' ln|pr|>mtnl sm ctidnnco of the auriciilnr loiiiid. 

The tiuQirrutin iwiewii of tlie lil^raiure. >iucli an thow ot Obraiitow. Pftwiiuki. Robin- 
aon, *1h>i) no further light ii)ion tlie subject. 

Clinically, the prc:<yr'li.dic gi\llu|> rhytlini ijt usunlly met with in eases 
with rapid hypprirophied hearts which are untler a slight oventtrain, as in 
the clwwicftl group of chionic nephritis, chronic cardiac disease, aneurium, 
easeit with arteriosclerosis, exophthalmic f^oitr«, mitral stenosis, and ac^ute 
fevers. OceH»ionu]ly it i.t heard in normal individunlit (Krchl). It necmi) 
in most cases to accompany slight 
overwork of the heart, but its me- 
chanical and pliysiologtcal itigniflrnni-e 
i.-* jttil! not rlear. 

Protodiastolic Gallop Rhythm. 
Third Heart Sound. — Tlie role of the 
protodia-siolic wound (bruit <le rup|)el. 
<li&»loli(- echo) seems to be more 
definitely c » t a b I i » h e <l. Though 
already heard by Bouillaud in 1835, 
in mitral i*teniwiM, its occurrence was emphasised by Durostez (1874) and by 
Sanmm (ISSl). who u-rm it the "oiK*niug snap" of the mitral valve, indi- 
eating that it was brought about by the opening of the atiffencil valve. 
Baric (1803) and Thayer (IHOO) called attention to its occurrence in normal 
individuals. In IW7 the writer observed thiii sound in a normal Individual 
with H itlow and vigoroiw heart, whose venous pulse showed a peculiar extra 
wave (Fig. 108. k) which follows the inflow of l)lood into the ventricle 
(as indicated by the normal i' wave, Fig. 103, page 108). 

Tbc writer niro culled iittenCioTi to the fact thiit thiw wave bore a cloite relation t« the 
end ot tli«i rapiil tlllinK of the htinrt (or diiutole proper) upofi tlie volume curve at Llie veo- 
tridts. and that livmlfroon had clainicd that nt thi* time the niiCnd vaii-t» and lh«eupiil 
vere clo«ed by Iho ida«tjc recoil of tlie heirt wulLt. That thin actutll}' lakn placa aoA b 

¥ui, lOA. ^"Oraphici r#conI of th* thinl bmri 
mund. <Kiniln«B ol Pral. Rial hovim . ) 



dependent upon a hlich vmous iiresBurv «ui b» hIioimi oh the dead hmtrt hj- pniirinx water 
intu ifav veatridea from a beaker oflnr the niirielc* hnvi? bivii cut olF iii tlie maimer devtaeil 

tit * > 'J* 

followlns ih« A wav*. scnnonnlly loanii tiiouth prrlupt ui BfUbicl. 

by nntimeortini (l!^^]. K ibo w*at«r in poured frDin jiwl uliove the vnlvm thi^y tncrrly 
floni "ut n liltb towiini th(^ miikiln of the orificis if fmm the hi>iKh[ of nhniil 10 cm. ihcy 
lluat intoupponilion; if fmin '>»rin. nfioii-d they nrr left lifihlly cIobwI when tfie flow ceases. 
Tliuxc DbMrr\'iili(mi hiivF b(fn coiilimicd receiilly liy t*. Liuii iii FruiitoiB-l''nuick'« Inborn- 
lory. Ilirtctifelilpr nUo •iij[([«itPil that lhi« cloi>- 
iirc of the vnlvi^* iiiuj' be xiiiklen mid vigurcius 
enough ti> cuiiiw a M)iiri<l.' Thi? relulion <if Uiin 
sDimd lo ihU potiion of dinololo i3t«in>Hl <|iiil« 
liclinilc by rniiipntixon wllh a K^apKlc rvcord iif 
I lib MHiiiii iriuiie Hi about tlie nnie dut« by 
ICintliovcii (Fig. lO.M, which shown it to orrur 
0.13 KOond after the wcond wund. Thi» ex- 
planutioii has alsu bit'ii supported by A. O. 
(iibnon nnd J'mfpiuor Thayer. Thn tmciofpi of 
RobiiMuii. wiio wiu iii%'eKtii:»iinK the Mibjeri 
front a dilTrrefit iluiid-iioint. have also kIiuwii 
the constant ptwitmcc of the h wave ii|xiii the 
venoiu tfttdnjw occfunpanyinn Ibix »^>iind. R<il>- 
iiisoii aiid Thayer hn-W almi aIiuwh ibat it ncconi- 
juiniea a waiflct p upon the cardi(i|[nim in early 
ditMiole (Fill, ^M. i, peffft 91). probably diie lo 
tlie filling of tlie veiilriclw. llicy find tliis wave 
upon ihi! ranlinfcnun in altno^t idl enMs of pm- 
tcMlLaBtulic jullup rliylhm. and n^ifUFd it Ha ehar- 
neteridic of the lut ler. Thayer hna demoiuitnitfd 
I bat il cjtnnot Ix- an artefacl.Miice it in 0(1 en 
both viflblL' aad pu I p a bl o . iiii<l hpiice 
pan often be (auiid by the ordinary mnijile 
iiielhodftof phy»lcal cxaminalioa. Sriine venoiia 
Iraciiim mode (ram aiiiiiiala by Kj'Aler. aloiif; 
with the volume curves of the heart, chow Ibat 
the rise at the fool of ihe h uax'e ixfiirK !ii iho 
.^ccordiiiR lo IheBC exphuinliuui the iwiiueiice of 
event* would be hh fullowv: Tlll^ rn<l of dinMloli> Ih marked by lbrB«cond hriart noumland by 
the fall in the enrdioj^mm- The tricuapid aiid niitrul valves o|icn almost iiiBtunlanmutily. but 
n period of alwHii i^ij nw^ond in rr(|Uirpfl before the fall of pressure !■ iratutniiliHl to the jueii- 
lar von audtliuprewuni bf^iiwUi fall (i'-jioollAf«e). The innuh of blood into the vwitriclaa 

' The naeumplion of mieh a dlspplng t^jwlher of ilip aiiriciilovpnirieiilar val^-mi at the 
end of ventricular filling i* not at oil inooinpalible with ibe fiicl that aMiiuIl net^'ralion (I 3 
inni.) may reappear belmen them in the Uilcr pari of itiustcile. wbea tUe accumuUliuu of 
bloodiiilbeaiirielt»ha»becwiie»ufficient 10 jiwiforw the cu»p« apart (page 371). 


end of tb« rapid riJaAlolic filUn;: (Thnyi^r) 


rapidly distenda the latter until they reach their full diat^ntion.atwhich the inflow ceases and 
thecuBpBof both mitral and tricuspid valves slap together (closing slap in diastole). 
The end of this inflow may be accompanied by a slight recoil or similar movement of the 
ventricle, giving rise to the small wave and shock noted at this moment. The intensity 
of this recoil is probably dependent to a great extent upon the elasticity (elastic tissue) 
of the ventricular walls; hence its absence in old penions. Whether the feeble 
third heart sound is due to the slapping together of the valves 
or is due to eome other cause cannot be stated with certainty. After the period of 
diastasis (slower inflow) has set in, the blood begins to accumulate in the veins, which 
are distended at first rapidly and lal«r in diastole more gradually.' The angle made by 
these two portions of the venous curve forms the h wave. The foot of the p wave com- 
mences at the end of the period of rapid ventricular filling and corresponds to the crest 
of the protodiastolic wave upon the cardiogram. 

A priori, according to this explanation a protodiastolic sound should 
be heard in slow hearts because in them the ventricular walls are distended 
to their full extent early in diastole; in cases of aortic insufficiency because 
of the high intraventricular pressure which tends to slap the cusps of the 
valves together early in diastole; in mitral stenosis owing to the peculiar 
events in the filling of the ventricle (vide page 9), and perhaps in cases 
in which there is a large amount of residual blood in the ventricle (dilata- 
tion) which tends to diminish and shorten the period of inflow. These 
represent the chief conditions in which it is actually heard. Thayer 
states that it can be heard at the apex in about 30 per 
cent, of normal individuals lying upon the left side. 

By decades its frequency was as follows; First decade heard in 58.9 
per cent.; second decade 84.4 per cent.; third decade 50.9 per cent.; fourth 
decade 42.3 per cent.; fifth decade 14 per cent.; sixth decade and after 0. 
It seems to occur in practically every condition, especially in cases with 
slow hearts, and seems to bear no definite relation to cardiac wealcness. 



As has been seen above (page 92), when a narrowing occurs in the 
lumen of an clastic-walled tube through which liquid is flowing, eddies are 
fonned which set the walls of the tube into vibration and give rise to a pal- 
pable thrill. Accompanying the thrill a blowing sound known as a "mur- 
mur" may be heard over the tube; which, like the thrill, is heard much 
better below the obstruction than above it, and is transmitted in the direc- 
tion of the flow. The character of a murmur depends upon the width of 
the orifice at which it is produced, upon the nature of the walls of the 
orifice, upon the velocity and tension under which the fluid passes through 
it, and upon the direction in which the flow occurs. 

In this imv a valvular orifice may be compared to the larynx 
with its vocal curds. When the cords are lax and wide apart, the air moving over them in 
even forci^d respirutiun j^ivca no sound; when Ihc cords are approximated a little but still 
held looBcly, it gives a whifl]>ercd "ch" sound, ami when they are held very tense true 
vocal sound is heard. Similarly, no sounil can l>e heard over the excised heart when the 
fluid reBiirgilnteslhroUEhanol'Hulutcly patent mitral orifice (Fig. 108): if one of the chords 
tendine.i- lie alretcheil and the regurgitation takes [ilace Ihrough a small slit whose walls 

' It is not impnibahle that, though the cuHfis arc in apposition along the greater part 
of their line of closure, Ihey are separated at a few points during diastasis. 



nre IWbb)' (rcUtirp iiuulTicIc'iicy. l^, lOft). * «oft low hlowinx mnrniiir nill Iw hnttf! {lh« 
KmiUlcT thi* oriflcG Uie hiftlu^r inlcbeti anil niotv dtitincr the inuniiiir) : wltitu if oomi^ more 
or Inm liiinJ irregular body, fikr »ileili(wl vri[rl!ilion, in idtiiatnl at tlif oririrr, ilii* acts mure 
or law a* a mHHWtor, increosw t)iv auund, uiid tiui,v even git-v il u rowring or a Kiiienkitii! 
tmiulcal) obaractM.' 

Fn. 108. — l<hnllantylwtir««i iKndueti'lnuf'oTi-i'fniKulckndUiapniitiwiiuuuf miirmun. (KimbiMa 
•f iheJ An.M, Aaw.) A. B. <X vof«J otpfilt; 1(. B, f, »unrulov™tnculiir >iili-«»; <l. II. I, ■aitlrkort pul- 
nouli^ vain*. A <h[cn uetai, D. (). uuiJl lcaL> projucinc liiih-piielinl munniin: D nom note). E. 11. 
1iiT|»r l(*ltft pmdiiriiii I»*'pi1cn«d murauirvi C. F, I. vpry Ikripv Ifalc^ pnxtuoknc aoinunnurv- 

OccHsionally murmurs Ihtorw »<> loud «.■< to be heard Eeveral feet awity 
from the chest or even across the room. Surh raurmiirs are umnlly systolic 
in time and are often due to culciGed vogelation!<, arterial plaques, or aortJc 
or mitral utenosiR. As in the larynx, th* rhnnicter of the sound protlui-cd 
at a valvular orifice is due not only to the WKe and shape of the orifice, but 
aUm to the ten»ene.ts of lh« walls and velocity of blood flow throufch it, and 
hence is largely dependent upon the height of the blood-prewMure. AH 
these factors, both tlie widening of the leak and the decreased force of the 
beat, explain the fact that ae the licnrt weakens under the inlluence of the 
leaion the murmur may acutally disappear. 


Miirmiini nuiy lie rtiiinhly ilividpd into the follonintc clamnr (1) Direct mur- 
muni bvsl tRuianiitt«ii iii thu <Lroc(ii>Ti iif (hv blixnl tluu', u from ■traaini or calclfled 
plaquM; (2) RcKurgitant aiuimun) due toa Saw in the direcUon oppunite U> the 

' Miitiiral nr nqu^skins munniirn arc ■nmctimm due to llie ptvwiici^ of Icnm mod- 
cmlor hruida strvtcliiii); ■(■»>» )hf veiilrieulsr ca^'ity and rmounding like lianjo vtriiigs, 
allhoiiKh iwiiiiUy lh»o band* ilo not cniisr murmiin at all. 

Very IrvfjUi-ntiy tliey arisv iii diliiled ri^ht i-eiilriclM In aaiociation with funcliotial 
tricufpail lUiil jvrhuiB functionui ptilnioDory ituufjicii-nciiv. Thry arv uaually «y«tolic, 
bui HotDPtimca iliontolic in tim*'. llicy tif. oftrii CArdiopulmoiuuy. 



usual blood now (ss ill mitral and aoriie ineiiflicioncic*); (3) Tii-^iitiUfm "inactiSiwo'" 
munniin which dccut in both ijhIdIc and (Uuatulc in congenital heart Imioiui (4) num- 
bllDg mumtutv. 

Of lhi>s«! I, 2, imd 3 niv more or Irss Mowinj; or ronring in charnrtor; 
while the rumbling murmurs are ck-void of thia churai-tcr. and are rumblinf- 
or echoing, more like a serieK of heart sounds which vary in intenaty (mitral 
^«iio:(i!>, Flint murmur) than like murmurs due to the paacung of a stream 
through an ori6ce. ' 

Broclcbnnk dftiniii thnt thnw mar bn pnxliiecd upon n moild by tuMuiii of a Rinisni 
flowinK through a coftical \-u\vt rmm apex la the baM uf Oiv cone. The mechaEuam ot (lir 
produclion a[ luch murmiini la slill very obicurc, bu<1 furthi-r nnearehei are netcmay 
before natiarnclory eliicjilalian can b« ipvpn. 

"accidental," "BMiaC," AND *' CARDIOPCLMOSARY" HlTRHrRS. 

Murmurs over the heart without the presence of valvular lesiona are 
so common that autopsy eviiteaee led Lacnnec to the erroneous belief that 
murmurs (bruit:^ dv souHlct) were of no diagnostic importancv whatever. 

Such murmurs are designated by various t«rmB: "Haemic," on 
the a!<»umption that they uie always due to aniemia, hydnemin. or other 
changes iji the quality of the blood; "Functional" or "inorganic," 
I)ecau9e ihey are not a.s.-<nriHted with organic Ie»on; "Car<liopuImo- 
nary" or "cardiorespirator)%" on the assumption that they arise in the 
lung above the heart and not in the heart itself; and "Accidental," i*incc 
tbcy are not associated with any diaccmibic alteration in form or function. 
Tliese terms are not mutually excluaivc; but, since tbo U-rni "functional" 
haa been used to designate conditions in which there is actual leakage 
owing to muscular weakncau, aud Hince "inorganic" should include both 
"functional" and "accidental," the term "aecidentar' appears to be 
Ibe one most generally useful. Thus, one murmur may be said to be an 
accidental murmur of h^mic origin, while in another ca»o the accidental 
murmur may be of caniiopulmonary origin. 

Occurrence of Accidental Murmur*. — Potain, who hait made the moflt extensivci lnvet»> 
tigalionii upon the rnibj eel. found such mumiura inoiie-eichtli of all the putk-nla m-n in lu« 
bcMpital MTiicc. It wiw prrwni In alnioxt all hi> cnnrMi of itniciiow'ii dinrauv (pxi>|>)itl)alniic 
piilrv). In chluftnls Ihe fr»|ue[icy waa 50 per cent.; in rheumatism, meaelea. aiMlwarlet 
tercr, 20-25 per wnt.; in typhoid, Ift percent.; in pulmonary alTMtionii. 5-10 per cent. 
Thwc muriniini irerc conimon in suhjecl* in lhi> fimt thnv. docadps of life, rrjichinR maxi- 
muiii (nyjuoncy at tlie sjlimi from 20 to 30, and ^nulually deon-iisdl in fre<(Ui?ncy alter Ihu 
ngeofSO. For ilcscription of the munnura I^tnin divided the ptvocinliuiti into tlic fol- 
lowinK ftijnong; I. Abotil the ap«« <apical «one); 2. .Mjovp the a[iex (suprs-apicall; 3. 
LalrruJ Irum the apex (para-upieal); 4. In froDtof Uie tnfundihviiuin luid eonus urteKiMiin 
of lh« pulmonary artery [prt^infundibulnr) ; 5. A »onc lirtirKMi the prr-infimdiliular 
r^on and the apt-x (left prevent ricular); 6. An are» behind IheHtf-mnm (i>t«rnal region); 
7. A rosion behind the xiphutd (xiphoid rvci(>n>, Tiie rnuminni an mo»l tomnion in the 
tviDon lyinjt betwena Iho pulmonary arva and the apex fPotain's left vnilricular r(vBioii), 
— tbi( is, in the re^on above the H^bt ventricle and Ibe intftrvciitriculiir wptuin. 

Cbtiracter of Accidental Murmurs. — These murmurs usually 
are soft and blowing, and often seem rather .tupcr- 
ficial. They vary greatly when the patient changes 
bis position. Sontetimea they are bc«t heard when the patient is 



l>-ing dowu and Jiminiah or dUftppcar ctiitiroly when he staade or site 
up; sometimes they appear ouly when the patieiil'H pnxition i» vertical 
and dieapjicur im his lying rlown. Thi-y aluo vsin,' with the phases of 

Time of Accidental Murmurs. — A.* regards their occurrence in the 
rardiac eycle, aecidental nmrmurs are moat commonly ej-HtoIie in lime, 
though oiriisioiially <!tat<tolii<. Potain raiUt atlention to the fact that mur- 
murs nmy occupy either the whole of sjstole (holoAvat olie) or only 
a portion of it. The latter may oceur only at ihe very beginning of i<>-0tole 
(protosyetolie) , »o that they acoompany or replace the first heart 
mund. Or, ihcy may be heard in mitUystoIc ( mcaosy » t ol i c ), in 
which case they follow the Tirst .sound hut are separated from the second 
eouml by thd short pause, which is then aomewhat shorter than uKual. 
Or, they may occur nl the \ery end <if fiystolo (Iclesystoltc) and 
end, without interruption, in the second sound. Aeconlitig to Potain, 
the murmurit of mitral and tricuspid insufficiency 
are heard throughout the entire duration of sy.ttole, 
a view which is coiirirmed by the graphic records of Einthoven and Weis« 
and Joachim. The accidental murmurs, however, are con- 
fin od tu only a portion of HyHtole. Potato believes 
that, as a rule, they are entirely mesoay. italic; white 
Weiiw and .Iiinchim, from both auscultatory and graphic evidence (Fig. 
J 10), believe that they also accompany and modify the first sound though 
iHcy do not replace it; in other wonls, that they occupy both the prolo- 
sy.ttolic and the ineaosyHtolic portions of the systole. 

Sahli states tliat accidental murmurs never occupy the very end of 
systole (telesystolic, Potain; prediastolic), but Potain has ahown that 
though such murmurs are raiv they occur occawonally. 

Accidental diastolic murmurs are also rather common, and may occur 
cither in the aortic R-giun, Itchind the st^^mum, or along the upper left 
border of cardiac dulness. Occasionally they are heard at the apex. They 
are usually ^hort Hupcrficial puff.") following a well-marked second sound 
and lastini: during only a short portion of early diastole. 

Olflercnilal Dlagnoili of Accitlcnlal Murmurs. — Polaia sim the following parntu in 
which oilier uiuriuure iJi(ri>r fnjni the ciiniiiiptilmon.ary, 

1. Pulmoniiry Sltiiosiii : louj, rougli liolooifHtolic miiniiur, [iiusiinuin in 
Moond led tnlentpacc, tRiimniitli^il tnwurci left claviclr: nlwnyii acc^impnnicd by n thrill. 
Th« accidental Diuniitir is sufl, ufltfU riiCHUHysUiUc, ijovoid of (hrlll. 

2. Pulmonnry I n«uf f iciciicy : diAilolic murmur muxiniuiii tu M-'coml Irft 
intentpuce: fiulniunie ('«>con<l itQtinil nlment or diminished. ThRiuridentaldifMlolir mitrmiire 
very nrely have their niuxiTnuni in lln- Becuiid Ml ititen>|wice. 

3. Aortic Stpnoni*; rouKh hnlonjTiUilio murmur, miixirnum in aocoiid ripht 
inlcnipDCP, |>ni[iu^t(<d tvwanJ rijcht clavlrli; accon))^!)!^! l>y thrtji. The hcarl in hy]>ci^ 
trophicil, The accidental or cardiopulmonary murmur in ihis n-gioii is oiorv superficisl, 
■oft, and cliauieM on clinnsc of pnution. 

t. Anaomia : mummr v^ty simllur lo that of aortic steniMiii, but the thrill is low 
marked and ihn heart in mmll or iIUuImJ mitier limn hyiwrtroptii^l. 

5. Aortic InBilfficifncy: miinniir eoimnenei'i" cxnctly at ihe bfvinninK of 
the Noconi) loiuid an<i ulmotii eniirvly filU dinsiulc; whcrcajK ilie canliopulmonary diantuLic 
niumiur follonn Ihciwcoiid loimd. often lifter ii short inliTveniiif; pauie (i-r .the murmur is 
niwodiuslolic). Both aortic and lu^cidental murmt-iro am nf side distribution, rmhracing 
the rntire precordium, and varying ttrvatly with clmnitp of jwsilion. 



6. Patent Septum of the Venlriel«a: holoHj^stolic tnumiur loudwt git 
the thin) Mt inlerxputw: mufch, lUwitj-i nceompftRted by n thVill; whcfnw tlic noeidnntal 
and caniinpiilmotiiir>' miirm^int niv iioT- 

T. Mitral 1 II a u [ r i i> i « II c y : iiiiimiur holmyitulk. tmually rulfarr rough, maxi- 
miim nt Ibr iippx. Tbn cardioiiulmonary murmur may liavr its mnximiiiii Iwo or tlirva 
<vii timet res lateralnards from lheHpl^x; and ihi* is usually amociatcd with a By«U)lic retiKe- 
tioii ni tlip Bpex. 

a. Trieiinpiil InBuffirionry: niiimiiii mRxiniiim over slemiini anil xJidioid 
ptooCM. Ttiere is an increased iif«ii of llai(i«t« (liyiMrtrupliy ul >-?[iihplni). Tliis inurruur 
b aUa incraupd by k-uiiiiii; f&fwnnJii »o an to Ihrow Ihp tieiirt n^ ttiprhoit wnll. 

Nature and Catisalioii of Accldenlal Murmurs.— The incxs mvQtioucd 
fthove appiy to a large number of esses in which murniurs have been heaird 
during life, but in which no bftkit and no lesions uf the hcnrt were dcuion- 
xtrable at autopsy. 

A InrjCF vnricty at fnctnm havn bwn mentionrd tncxplnln this« accidental murmiin: 

HtBOilc Murtnurc— Rniiillnud v.-nt. tlip first, lo call atipntion to tlie faM thai mur- 
iDUrn ui-rr iiiorF rc:iilily proilucfd in ttic li-ss viscuui bluod of 
annrmin than und«'r nnrmal ci> iidit t«ni< ; a fact which wiui niliMniiicnlly 
verified by folinhcini; biii Roiiillaiid himMtU rcAlited ihaT. though anH>niiamlKliti;i«'<- rise lo 
■omc of iht- nccidniliil iiiunnum. tllt^^e imrv itiuiiy cusm in nliich it cuuld iiul be a factor. 
Tho Wood roimtii nmdc in Inlc-r dccadea hove? rnlifrly mjlutiiiiliiilixl noiiiUniid'* connerva- 
tiuii. However, nimif^roiui oluwrwra (roni Boiiillaiul'F lime lo tbc present have a<lhered 
to the "hwinic" oripu •>( ihe sooideotul munnuni. SuMi goes so far aH la (liit« that 
tlicy may in ri^nlity be only vonnUH hum* Iranamltlcd lo the 
V e n t r I e I e », ihoiiKh he does not explain why ihey should Iw sjfiloljc in time. Even 
though tluHexpliinaliuii lh inmletjualr. i( in ccrtmn that in ciuus of cravi.- oiioi^niu aucti lnui»- 
mitt^ii miirmiirs cio iirisc Thi-y ure hcanl \Trj- lotidlr over the aona and wmnd right 
inlernpacc, bill art loud, rouiih. and EUpvrficiul, quit* different from the gcntic blow of tlie 
UMiol arridr-ntid miirmum. 

Functlonil ln*urriclcncy o( llw Aurlculov«iitrtctilar Vali'U. espoeialiy of the mtlnil, 
wiM ■iii>|)UH'd by Nutiiiyii lo be the cliiL-f cawe of tlic neciiieiital niumiur in thD pulmonary 
area. Naunyn believ«i that lliii miimiiir wna tramnnill/'d fpriin l.lic left niiricle ilircclJy lo 
ilie pulmonary artery and Ihence to Ihe client wall In the ;>itlniunary arvu. However, in 
iheae cnacH Iht- inumiur niay not be lieurd ul ull in tluise arvun in which the definilo milral 
and inciwpid murroum are hp»l heard. Fiinclionnl in*iifficiwiey of the irieiitpid valve 
has also been atitumed. bia this in reiidrrcd improbable by the tact Ihut tliestMiiiinnuraliave 
a very different diatributiun from thuM.- of the (liciLipid and art mtrly licnrd over the 
xiphoiil proenia. In doKB the writer ha* found aerideiilal miimiiin very common: but. 
In contrast lo the inunmirM In tricuspid or mitral iiisutliciency. IhtRe accidental 
murmura cannot be heard over the right or left auricle. In man 
alM> they are riol hnani over llie retcion of the right niiricle, evpn viheu the patient i» madn 
lo lean (urWHrd uml Ihe uallis uf thnt chHiiilHT are thus prensird o^iinst the eliest wall 

Functional Slcnosi.-i ut the Pulnwoary Artery and Intundlhufum hni. l>pen luuumed by 
Luethje in oriler lo exphiin (lie proiliirtion of cyntulic munnuni in Ihe pulmonary area. 
It is true tliat the iiuhtiunary artery iiiukm a sliarp bend junt lieliind the KL-cond left iiiler- 
spacv: and aliut, a* ItomheffC nn<l other* have shown, that often the ace.idrntal murmur in 
inepfascil by preMUre with the »l«thoaco|ie. Aicainst tliis view art' the softness of the 
murmur, the absence uf u thrill, and the fact that it ia nut truiuimitled toward the left 
■boulder, liut is well heard over [he rif[ht ventricle. Moreover, in dnjcii the accidental rnu^ 
inur may persii^t in jiraciicall.v every {losilion in which llie heurt itiay Ih> held. 

EMy Currents ulthin the Ventricles.— Hilton l-'ajtce ha« called attention to the fact 
that eddy cuireTiti may !iii*e within the ventricles, as the blood passes hot ween the papillary 
niusclM and the 1rul>ecula- cumeu!: Lhut thne may strike u^inst the biiscs of the papillary 
muaclea awl the chordir trndlneje, net them into vibmlion while they are tense rfurin){ 
■yatole, and thus sive rise to a >i%'Blolic niurtnur, Altlioujch Fafige himself believed that 
this irould "I'ply oidy lo u dilated heart, it aeetii.i aUo applicable to a >niall heart, ninoe 
durioK ayiitole Ihe apcrtum lirlween the w.ilU and the papillary miiacka are Mnallcr anil 
(nor* altt like, nowcivr, the explanation lacks eoDfimiatioa. 




Biinilttr to thi« view ia the old-lime amumption timt aocldental blowing as wdl ■■ 
niiwiral mtirmuni uulicat«il tlic iirratmcv or n mo^lenitur band acram tlLC chamber of lli» 
riHbt vciilricle, I>ii1 ilii« i» not liomr mil by aiicopty rxfuMirnci". 

Cardiapulnionary Pactors. — Lwiiiiec in ISJO u'rul«: " In itirtaiit jH^monii the plc^imt 
and l.ho unt^rinr bonlcrs of the liiiifp pxteiid in troiil of llic licurt •nit eovrr it alnioct rntinrly. 
If uiH- exuiiiiiiCB aiirti a [Hereon whpn hia br»rt is bcalintE nioro forci- 
bly thiiti M 1 II II 1 , I li e iliuBtule of t h u h^arl. cuni prcmiiag theae 
portion* of ihi! Iiidki and forcinx t)ip air out nf them, nJtrri) Iho 
breatli Buunds In Hiicb n vay r.hai il imilnt^'n a hlowinic miinniir or thc< »oiiiid of wood fil^ 
But wrilh n litlitr hIuII it becuniiai auay to distiuguisli thin wiiju'I frurn u conlioc murmur. 
Il ia more oupcrf icin) ; one hear* tbc norinnl hi^art notinds bn> 
low it: and It dl«ap|>rnr* altno«t entirely wb«n ibe patl«nl la 
mndfi to hold bin bredtli for ti t*w inomenlB."' 

PhyaioloKlcnl rx[irnmi>nl« have Inrtic out Iju-tincc'i claim that the lung movm tn and 
frowilht-aclifnriliuccyelefRiiitinoii, Voit, vandprHnil, Landoitt, MHlwr), but have demon- 
■imtnl ihnl the iiiosl luddeu iiiovenitnl of the air acpoiiipaiiiea llie ntrvfiu^tiua of the air 

within tlir lung durinff iiyi>Iiilc. rathpr 

r-'^^^^^^^^^^m than it« extmsinn diirinn <lju«lole. 
^^^^^^^^^^^1 Tbe riinlii>pulitti>iiur>' inurniuts 

^^^^^^^^^H fomw'd llie stibjpct of an pxhatulitv 
^^^^^^1 «lit(Iy fmm tSCi/i In 18!)4 liy I'uluin, 
^^^^1 niuny of wbine dutu liuvi' been Ritfii 
^^H abovr. t'oluinconlmlliHl ilir- finding)! 
^— jJtL ^^M by aiiBcultalion wiih carefully niad« 

' t JrX ^^^ ciinlioKramn mid (^xperiiutrulul iludiea 

I *■ '!!^' , , and found that; 

^^M I . The carri id pulmonary' murmurs 

^^H aiv louilvvl and iiiuit friv^iifnl in 
^^1 tliciSL- ri'iHonA (iiifumlibtiluni nnd vicin- 
I ^^M jiy of ihe pulmonary artcr^'l where 
I ^^1 llip inovpuu'til of the licurt i> grriitcsl. 

I ^^M 2, TKry ncnir In i(i|{ii>ns 

1 ^^M and in iibnKcn of the car- 

^^^^^^^^ I ^^M diar cyi-Ie al wbic b Ihe ear>> 

^^^^I^B^K ' ^^1 diofrrum nhoii'ii 

of llie inierKjiace (urMu of 
nc^tirc jinsBuri! wilb nuddcn cxpnn- 
Hlon of tbr limit). , 

Henw, ihp syntolic mnminr is mom common over the iufiindibuhiiii and right ^*cii- 
tricle, uver uliich lliere is UKUully u Hynlolic retnieiion {aec pugf 91 urid Fig. SO). 

If the ntraction (fall in IhccanlloRmni) occuni in tljR middle of nyMole, the murmur 
is found to be mc80»^Rl«lic: if at the cnil i>f Hyxrnle, the murmur is tcleeyaluhc; if tlir fall i» 
in diaalote. the munnur is iliiinliihir. Indeed I'utaiii encoiiiilvrcd spverul cunrs In which 
thp fnrm of Ihc canliojcmm chunjci'd ii[h>ii alteration of Ihi^ po«ilii>n of the piil.icnt; and 
«om*pondini; lo the perioil of Kn^tesl retraction the murmur over the arvu cliangiid from 
tneM^TKtulic tu diastoUe, 

Thui i> a nitpridnic oonfirmnlion of the theory of cardiopulmonary mumiurt. Tliere 
«an indeed be no iloubl that cardiutiulinunary niurniuns arc friHguenl, and that Ilwy fomi 
n very cotuddcnible prupurlion of '■accidental" inumuini. Bmidci Ihc blowinK miirmura 
rcfcrfrd to above, il i^ probable thai ninny of ihp iKWJilled "niusicnl" or "siiiiedk- 
iag"uurinurB arc of curdiopulmuuaryoriipu, and Are rvally piping rftlea produced by tlw 

Kill. 10(1. — IMmtribuliun of lh» •«nil»iiTiii rniiiiiiur. 

' ' (liei <)ueli]ue0 nujetii, las pl^Tea CI Icb bordn aiit^rieun dM puiimom !R> prolongent 
nu-dernni du cti-ur irl Ic rtrouvrcnt pnoHpic cntii^irmrni. Si I'on cxjjorp un pnrril nijat 
all moiueitt oil il ftproiive den batWrnente du copiir un t*" 'nentifiue*. la diaxt'^le du cti-ur 
cuuipriiniiut cm portions ilu pouitioii rl en exprininnl I'uir. alti>re Ic bruit dc In n-vpiration 
de ninni^iv ik cr i|U'il iinitc plo* ou moini bi«n celm d'un aoulBrt clonni' par Ir ci'iir lui- 
mf-mc: il e»t plu« ■■uj)e'rticiKl ; on cntend an dewouti le bruit nalurvl du cTiir; ft en rccom- 
mandunt su moludc de reie'iiir jvndaiil i)Uel<iiie(i instantd aa rwpiratiou. il diniinue bonu- 
coup ou ccjup jimiqui-' entit^rpmcut." 



to-ftnd-Fruiiiovpmnil inlbtr luiig(ltiTini;ci(lwrptinBe<if tliecanliuccircle. Other rile* of 
cariliopulmoHar.v origin nioredowly rraomWiug thc«iiiKironjiui<l crepitant rtia 
of respiration ttrvulmi v«Ty roinnion iJoiijt I hi- injirjt'i' of tJiplcft lunii. Mnrcri\Tr. ihnbnatb 
•uiuiiU thiMiiwlvtrA un- fn.t|Uclilty rtioUifii-il by llii^ {'anliur iiiurt'irrentii. piiiijE rise lu the im>- 
mllril rnti-wherl lypc n( liintt: in which inapimtioii ii> iiilrrruptrd by a srriM 
(•f Nniult clielu u)i<l puiiireH cuiii^idcni mill and due la the effecl« o( cartliac conIr»ciionii 
upon thr uir in the lungx. The cogwheel lype of brealhuifc i" uflcn uncucialed v,-il>k sliiclil 
rhaneee in ihe overlyinx hiiiK&nd is ihut oftrn a pirmonitary njtii of ptilinonary liilH-rriilcHuE. 

Differentiation between Cardiopulmonary and other Accidental Mur- 
miire. — Hiiwcvcr, in nj/Hi- of i\v fit-niiPiicy of i?ardio|iiilinoimry njurmurs, 
it is probable that Potain erred in iiscribiiig nil nccidciitHl or non-vulvular 
niuniiurH to tliis origin. In th« Tirtiil plucr, many Kuch uiuniiurs are audible 
over Ihp area of cardiar nutiii>:<i« n-vt^rnl <:pnttnietrc» from the lung bonlcra, 
when breath sounds which are of equal loudness over the lung cannot be 



Flo. J 10. — llT»iiliir timinl •■( tii •rndrnliil iimnimr. (A (let W»i>i »rut Joarliun.l 

heani «l all ai the»«' Kites*. Spcondiy, tlti- inurniiin< fan !«• well h<^aril dirocUy 
ovi-r tho expoiwd doRit' hearts when the lung has been entirely re1ract«d. 
and when valvular iu.Miflicii'iuieK ami i*lcniiw!< fan Im- alisolutcly excliidwl. 
For the present, therefore, it must l>e admitted thai iheit; are still 
many uncenninties in the difTerc^ntJation l>etwei^n <-ardiopu)monar>' and 
ritlier aecidental murmurs. The diagnosis of the former muiit 
be eonfineil to raurraiirfl of diatinctly xupcrficia) 
quality which arc heard loudeist over the lung bor- 
ders and are abHeni or murh diminished over the area 
of eariiiar flat n ess, and which vary with change of poMtion. 
The diagDOHiH may be considered an rendered probable if the area over 
whidi I he iiiiiniiiir is hcanl moves toward the ^tcnmin in Insifirution and 
Bway from it in expiration. correapondinK to the movement of tlie marginal 
trip of lung. If the reverse is the caj* iiiid tbo area of intensity extends 
lateralward in expiration and recedes toward the st«mum in inspiration, 
the murmur in more !il<ely to ari.'<c within the heart. 

iHlluitoat a( th« Heart SouniK — A rvtiiarkably aecunite ilwlhud fur iinilatinK iIk 
btart MHUidn, mlu|iliciitiuii>. luid rough or blowing mumiura bun been ui«<l for the piuit 
ihtMynni by thr wriirr'H rollciixup, Dr. ('yi:irlf« W. learned. Thi« iArarnrd out by plnrin|[ 
the palm of tlw alioervirr'B hiind lightly over Ills car. and (hen tuppitiic hjhiii ibp •rlliuir 
with (hfi lin;!er lipi of Iho other hiunl. Thf blow inmit be struck aiili lotw rinfipr-joiiit*. 
]l« f<HV« ran he variinl lo Hitit riiri.ilioriH in the lotiilnetn of the nounit. Diil) and 
.dJHlaiil •oiiiiib nny hr iniitatfi.1 by lighl blou's (if llie lin^ror by nuMnj; the palm of Ibe 
nd from tlir ear, cnappinit noiniiU by prruinj; ih« hand lightly ii|H>n the Mr and 
Kecutiitfi a *hnr[i stroke. Blowing niunniirg ot« repmdiiced by a senile Mlroking of the 



elbow. Dr. Henry L«» Smith Iiob iniKli&ed thin procedure liy RtrikiDg tbo blown iiincl\y 
upon the back of the hanii, inolcnd of the cihow, a. niethod by which iihnrprr and more 
Bnappinic ftoilniis cun be |>nxiiicei1 llo Im able toxive a very accurutt reproi.liicliorior tti« 
pmyslulie ruinblr ujiri Jiiuppiag dm sound of inilral Kii^iioaiii by bringing nil Ihp four ftngcm 
down ii|Kin the kniickli* or ntelarnrpnln In a* mpid NiircD^ion an pmwililr. a maniruvre 
uiiivh ia bt.1t cxccut^Hl by u quick proiiiitioli fam the elbuw. The blun- struck «ith the 
index firiKtr (i>>pinK tint unund) thDuld be (nn^cwhal louder thnii Ihi^ n^l. 

Wiliile ihetie incthuds art excellent fdr dernontitrHtiiuc t<i one student at a time, they 
Gwuiot lie usrd for dnnonit rutin); tii a wtiult.- group limtilluiieoualy. Kor Ibia puqioae the 
wKtitr hiiR naorted It) the iwmewhnt eriidef method of exnriilinic Ihn luimr taps ntid utrokea 
upon the lop uf a derby or even a Hoft fell hat. Tills iiiiitatiuii is nut <|iiite no aeciimte, 
and the snupiiinK und rumbling quuJily arc nut repmdiieed. but nerertlirlHs it euiibW 
the inxtniclor to [loiiit oiil the Kihent features to all and to illiiHtrnte tiiejr main vnrialionn 
anil rvlaiicoM to the cvcnii ol the cnnlisc eyele. 


V01UM[ OF 


Vtu. 1 1 1 .^ t>iiitfrmiii Hbnwijif th«r«latiaii of the mora ««nmoo iilmpl* mHrmiin lo orwU or iho 
Ganliae rytlt. ^oltil bitck b*rp rntlitfait iht hwrt ttnnd*. Vrritnil jArvhtl ItoH rtflclitnc ft ihv L4uin 
indicMla b1u<viu( ut tuuili iDunour, Wivy vaiticaJ lias DOl ikicIlihk (u tlis Iwh imlirsui a lunihlo. 

Tlif extict method for tlie reproiiuction of each sound or iiiurmur can tliiin l)p indi- 
cated (lehemalieiilly by (!eMiit,nnIing tbc finger to he iwed (t~ index. M — middle, U = rin); 
finger. L — little Gtiger) und (he iiceent uf the suund'. Time iiiten'als may be ihonii by 
daohm, and mpid succntsiun of ihu split souudu by hmckcling tJic cortc* ponding leliers. 
Mnriiiiin>Kre in.lieated by Hlroke. 

Thus; r — l^.Noniial llmt sound at the apex; I — I'-N'omuil fir»t found at anria; 
Blroke !' — Mitml nmrniur; I — (L'Mi = Split second Hound; (IM — I)— Split first »oui)d; 
(I-M'— !) — PreB>*tolie Kftllop; I — I'-M - I'rotoiiiatitolie ^lop; I (ilmke T — Metiueyatolic 
mumiut; LltMI' — I — PreoyBtolic umramr; I — Btn>ke = nittBtolic btuwinj; niumiur rvphie- 
inff wcond Hound; 1— t itruke- Dioatolie niumiur foUouing the *econd Hound; I.RHI' 
atroke 1 — Prwystolle «y»tolic murmur of niitraJ alcnoHs; Gentle t<vand-(ro rubbing of 
akin - IVrieiiflinl frietion. 

Rclntloni of the Simple Murmum to Hvcnti of the Cardiac Cycle. — Tlie relatiotut of 
the sutijik- eu^llac murmurs to tlic euntniel ioiia of the eardiiie ehajiibvn:, a^ welt bb tu the 
filling and wnplying of the vmlrieltti. i.» shown in Fig- HI. The mcehnni*m of their 
pmdueiion will lie diHeuwird in drtail in connection with the valvular lexionx to which 
they eorrvspond. It will l>e wen, lionever. lliut the mitral Bystolie munnur iM-giiin 
eoineirlenlly with the first heart Hound before the blood flown into thn norta, and that 
h enntlnuei) lhraU)[hout HVatolc: that the aartie syvtolic murmur followii the Bntt Kound 
niul ia loudent in midHyxtole; that the aortie diastolic inumiur is luudent in early diiwtale. 
nlirn the filling of tlie heart ami tbe regurgilutiun am mo«t mjiifl: and that the pnsnyn- 
lolic nmible iit pemtueed by the inruali of blcxxl into the vcntriclM during a\iricular systole. 





Prvyitolio ■ 


HvooyHUitie or td 
oaystolio (piwti' 




RumbliTift, occvion- 

Blowing or roaring. 
Eat«n into or re- 

iiLiuna iLfl veil tu 
E>t1owB fint bound. 
Uaiform or d 

Blfiwiof or rouing: 
faUotot first Aound; 
h&B A crHoaido 
character in mid- 
Aystote Bsd d«ereB- 
oendo in Late sys- 

Similar in cb«rvel«r 
to aortic lyBtoLio 

Bofi blowinie, uni- 
form or aeore»- 

BkiwiDg . 

Rumble . 



ftat-ta; trat^t; tr 

abuah-dub; jije-dub 
«Bb-dub; laf-tam 

liuncb-dub; taf-dub 

lujBch-dub: taf-dub; 


liipff-dub; taf-Ul; 




lub-dub-tra. . 


Apex only, lower 
precordiuiD be- 
tween parasteraal 
line and fltemum 

OvflT body of hp»rt 
Bt apeji and to ax- 
illa, often at bftok. 
Over lower ater- 
mim Hnd neigh bor- 
ing precordium 

Loudent over 2d 

right J ntvnpaw : 
thrill aljHJ in vee- 
eel» of neck. Not 
■oloud atapeix. 

2d left interspace 

and to left of ater- 
num (thrill). Btae- 
where ovor cheat 

Over a tire preeord - 
jump ftp, 2d and 
3d Left mter^paoe. 
Varying with 
change of poeitjou. 
Not transmitted 
beyond apex 

At 2d rib near ater- 
nai margin: loud- 
BBt over alemum 
at level of 3d left 
interspace and ia 
the latter ua^T the 
atemal margin 

At Zd left inter- 
■pacff and ri|(ht 
atemal margin ' 
alao to right of 

At 2d left intprapaee 
and ■temal EoargiD 

At apex only . 

CliDlcal ooodition. 

Mitral Btenoua ; tri-* 
cuflpid atenosJK. 

HitnO in sufficiency; 

triouapid inaum- 

Bcieroflia of aorta; 
aortic fltcnuHs; ccm- 
genitaJ heart leaion. 

Pulmonary at<noaiA, 
crmgenital heart W 
iion, aneuriim. 

Functional, aoeidoit- 
al, or anvmio mur- 
mur. Anemic fever; 
DBuravtbeoia etc. - 
eometimefl organ- 
ic (T). 

Aortie inniffideney* 

Pulmonary insuffid- 


With no other marked 
Ki^n of valvular iu- 

flumcjency. Abnor- 
Tual murmur (Potaiu, 
Graham. Steele), 

Mitral Ktcnoai"; aome 
(aaee with pericard' 
laL vdhasioiiB, etc. 

iTb«M phonetic equivalents most cloeely imitate the cardiac »UDd* when the catAonanta are 

proLonged as much na poesible. 



Presystolic < Flint 
murtuur), ayBtal- 
ie, and diaetoLic 


Presystolic rumble; 
ayatolic blow; di- 
astoLic bluw 







Blow loudest at 2d 
ter-ipacea; at apex 
And out in axilLa- 
Rumble over apex 

Clinical oouditioQ. 

Vegetation at aortic 
valvflp aortic insuf- 
ficiency. Sometimea^ 
but not nHnsnarily. 
mitral insufficiency, 
occasionally also 
mitral ntenofliii. 








Clioica] condition^ 

ftyntr^Jc and di- 

Systolic and dimu uf-tA0h; liuh-du?h: 2^1 right uid Left ip' Acirtic mHufliciency 

tolic blow 


lernpace. titernuin, 
Itfl HteiTiAl mar- 
l^n. trvnnm}(te'L to 

with mortitirt; Aorlic 




Loudest at left J^ter-- Pulmonary iit«noKi<i 

ual- margiii; thrill and insufficjeacy; 

mBximuin to first open ductiu nrt^no- 

ond Recoad left ^u^; other eormeni- 

inlempaee (aL heart teaiun*. 

Irrefularlyinboth Soft, nupernciaLH fllunh^du^h; sluah- Over the entjre pre- Frbriaous pericardii is. 

tystole and di- 


Accompaninbothi Pleuroperieardial 
heart sounds and 
both b rea t h' 

Crepitant; ^^mall e^i 
plonive rAles 

cordium. espvcisU 
Jy over the area of 
abndulfi dulne»; 
increased by pru- 
sure With Btelho- 

Over reladve cardi- Pleuropericarditis- 

ac duihPiiB QJiLy;' 
scratch "imultane-, 
ous with respira- 
tioD B4 well a-« 
cardiac cycle. In- 
creased by pree- 
sure with «tetho- 

O^'w relative cardi- Emphysema. Inter- 
ac dulneec only i siiiial eniphys«diiap 


Arterial. — Besides the murmurs transmitted from the heart, murmurs 
also occasionally arise in the arteries themselves. A systolic murmur and 
an audible first sound (pistol-shot tone) may be produced by pressure with 
the stethoscope over the arteries, but without exerting a definite pressure 
it may often be found accompanying the dilatation of markedly pulsating 
arteries, as in aortic insufficiency and with dicrotic pulses^ etc. The eddies 
arising in an aneurism usually give rise to a rough or blowing systolic 
murmur which may be transmitted for a considerable distance along the 
arteries. In aortic insufficiency a double murmur (sytolic and <liastolic) 
may be heard over the arteries (Duroziez). 

Venous. — A sound is heard over the jugular vein, especiall}' over the 
jugular bulb just above the clavicle, in cases of marked aniemia, chlorosis, 
etc. (Camac). The murmur is humming or roaring in character and 
occurs during both systole and diastole {humming-top murmur, *' bruit 
du diable," etc.). Weiss and Joachim have registered the sound and have 
shown that it never ceases. As shown by Cohnheim the anaemic blood 
flows more rapidly than does normal blood, probably owing to its lower 
viscosity; and both these factors facilitate the production of a murmur. 
However, it has not yet been shown that the murmur is loudest at 
those periods of the cardiac cycle during which the flow in the veins is. 
most rapid. 



It is evident from what has gone before, as well as from the consensus 
of medical practice, that auscultation furnishes a most important means 
of diagnosis of cardiac lesions. It is equally evident that each abnormal 
sound may tie associated with any one of several clinical conditions, which 
must be still further differentiated from one another, not only by the mur- 
mur but by its distribution, transmission, and variations, but particularly 
by the other methods of physical examination, graphic methods, and 
X-ray examination. The e-\aminer should not content himself with a 
simple designation of the lesion, but should become fully conversant 
with the disturbance of function in all parts of the circulatory system, 
and with its remote secondary effects. 

Physical Diagnosis. 

Herz, M.: Herzmuskel iiiBiiffizieni durch relative Enge dee Thorax oppressio cordis, Ver- 

bandl. d. Kong. f. inn. Med., Wiesbaden, 1908, xxv, 292. 
Selling, T.: Untersuchungen des Perkiiseianschalles, Deutacb. Arch, f. klin. Med., Leipi., 

1907, xc, IM. 
Holler, Fr.: Studies in Percuaaion, paper read before the Johns Hopkina Hoepital Medical 

Society, Mar. 21, 1907. 
De la Camp. O,: Zur Methodik der Herzgrdssenbeatimmung, Verhandl. d. Kong. f. ionere 

Med., Wiesbaden, 1904, xx\, 208. 
CuTHchmann, H., and Bchlayer: Ueber GotdBcheider's Methode der Herzperkussion, 

Deutsch. med. Wchnachr., Leipz., 1905, xxxi, 1996. 
Ebatein, W.; Zur Lehre von der Herzperkussion, Bert. klin. Wchnachr., 1878. 
Horitz, F.: Einige Bemerkungen zur Frage der perkutorischer Daratellung dea geeamten 

VorderflSche dea Heraens, Deulach. Arch. f. klin. Med., Leipz., 1906, Ixxxvii, 276. 
Dietlen, H,: Ueber die Groese und I^e des normalen Herzens und ihre Abhftngigkeit voii 

phyisiulo^Bchen Bedingungen, Deutsch, Arch, f, klin. Med., Leipz., 190S, Ixxxviii, 55. 

Die Perkuaaion der wahren Herzgrenzen, ibid., 1906, Uxxviii, 286. 
Simon, A.: Die Scliwellenperkussion des Herzens an der Leiche, ibid., 1906, Ixxxviii, 246. 
Hoftmann. A.: Die paroxysmaje Tachycardie. 
Dietlen, H.: Orthodiagraphische Beobachtungen ueber Veroenderungen der HerzgrQsae 

bei Infektionakrankheiten, exeudative Perikarditis und paroxysmale Tachykardie, 

MOnchen, med. Wchnachr., 1908, Iv, 2077. 
Williams, F. H.: Rontgen Rays in Medicine and Surgery. 
Veith, A.: Ueber orthodiagraphiache Untersuchungen bei Kindem im schulpflichtigen 

Alter, Jahrb, f, Kinderh., Berl., 1908. Ixviii, 205. 
Dondere: Quoted from L. Hill, Schafer's Text-book of Physiology, Edinb. and Lond., 

1900, ii. 

Martius: Graphische Untersuch<iiigen ueber die Herzbewegung, Ztschr. f. klin. Med., 

Berl., 1888, xiii, 1)27, 453, 5.t8. 
Einthoven, W., and Geluk, M. A. J.; Regiatrieruiig der HerztOne, Areh. f. d. gee. Physiol., 

Bonn, 1894. Ivii, 617. 
Huerthle, K.: Ueber die mechanische Regiatrining der HerzUtne, ibid., 1895, Ix, 263. 
Holowinski, A,: Phyaikalische Unteraiichung der HerztOne, Ztschr. f. klin. Med., Bert., 

1901, xlii. 186. 

Einthoven, W, Flohii, A., and Battaerd, P. J. T, A,: Registrirung der menachlichen 

Herztflne, Arch. f. d. gea. Phyaiol., Bonn, 1907, cxvii, 461. 
Marbe. K.: Registrierung der Herzt6ne mittelat ruasender Flammen, Arch. f. d. ges. 

Physiol., Bonn, 1907, cxx, 205. 
Rooa, E.: Ueber die objective Aufzeichnung der Schallctscheinungen des Hersens, Ver- 

handl. d. Kong, f. innere Med., Wiesbaden, 1908, xxv, 643. 



Frank, O.. and Ilnw, (>.; t'cbcr ilnn (*<tnJi(igmtnni uml licn mtcn llcnUtn., Vcrhandl. iJ. 

Koii);. (. iiiii«T« Meri,, Wipsbsuilcn, IW)S, xiv, fflj. 
Weiw. O.: D» I'lionuakop. Miilii, nuTunr. .\reli.. Berl. uml Vifona. I90S, i. 137. 
Wcisg, O., ami Jowchim, (!.: Kp^iKlricruiift iinil Itrjkroiliilttinn ilcr mpnitohUclien ilvmoae 

und llvngrmiiBulie. Arab, f. d. pv. Physiol,, buna. 1908. cxxiii, 3tl. 
Hew: Knuirhung dcr Hcnit'ine. Dcutacbt^ incd. Wctmichr,. Ijnpa., lOOK, xxxiv, Iftlt. 
Kalin, It. H, : Weiterv HeilrAiro ziir iCcTintniw (1h Elekltoeardjo^ruinniifti, Arob. f. <i. gea. 

rhyabl,. Bonii. 1909. ciiU. »ll. 
Sithli, 11.: l«lirhiicih ilcr Idiniwbpu UntcniuchutiffiRiRthcHltrn. 
Harvey. Will.: [)o moiti cordis, 

Williams, C- J. H-r Itcp. Brit. A«oc. Adv. Se.. UmkI., IS,16, p. 269. 
LiidwiK. C., and DoaiH,.\ S,: Tier. d. k. nftch*. GrwIlM'b. nuilfa. nal. Cl„ Leipt., 1868, 

xx. 89. 
BibMB and Hroodbent: In .SJfaKOii'i MiKlical Anatomy, ISOO, p. 89. 
Emerson, C. P.: Thr Kftupt of i'lTwum of the Stclhoecopo on Intntthuncic Sounds, Bull. 

Joliiu Hupkiiui Hoop., Baltimore, 1908. xix, 49. 
Colxtt, R. C: l*hyiiieftl DingnonK. 
Bo/'TpEsslar; L'aunoultatJon r^troatentale dtuM Im tiialadiM CArdio-ttortiquea, UnracQlM 

idAL. 1892, xxix. 303: Rev. de itiW.. Par.. 1S92, xii. IBS. 
HofTm.'knn, ,V: U*l>pr oraophngcali^ Aiwkiillation, Onlndbl. (. kiln. Med., Loipc., 1802, 

xiii, 1017, 
Gcrturts, H.: Zur FragedesRicthoitkopii, DcuUeh. Arch. f. klin. Med., Lripi., 1007, xc, 001. 
Bard, L.: Du bniil do galop do 1' hypertrophic du cpur gauche, fietii, iiiW,. Puris, 1006, 

szvi, 229. Also Lie lu ttiultiplicil^ utiomiaie den bruits du cwur. ibid., 1908, xxviii, 'd. 
Kricfp^ Olid Schmull: Ucbcv den Galopprbythmiw dc* Ihnaa, '/.ttcht. f. klin. Med., B«rUn, 

MOUer, v.: I'ebor (iHlopprhytiutiUH dea HtM^rns. M(liiclii.-n mtd. Wt^hnschr., lOOA, Uii, 7M. 
Muvy, !£. J.: l4i(^rciilntiondu»iiiRikr'tnt physioIiiKiquc rt d.'uiaWmnladicx, Par., I8?)l. 
Sewall, n.: OntL Common Form or Reduplication of the First Sotiridof the llL-arl, Contrlb, 

Ijd. Med. (Vuu^hiui), Aud Arbor. 1003, 20; ftlitv, A Cuniniun Moditicution of tlic Firxt 

SoiiDd of the Normal Hcnit Simiilntinx that heard with Mitral SWDoaiei, Aiu. J, M. 

Sc.. 1000. czxxviti. 
RobinwMi, (J. C: Gallop Rhythm of the? Ilnart, Am. .1. M. Sci., Phila,, 1008. cXKXv, 070, 
Chauveau, 11.: tJtude canlioicrjphiquc Hur la m^anixmo du bruii de jraluji, Tbosis, P&ri«, 

Pawiiwld, J.: Dtc Kntotithunjc und kliniachc Bedcutung iln Galopprhvthmua den Horvoru, 

Zlai-hr, f. klin, Med,, B«H,. IWI7, Ixiv. TO. 
UuruKti'4 and Suusoin: (Juuted from Bard. 
HiriMlifrldnr, A. D.: Some Vimntionn in the Form of the Venou* PuW, Bull. Johlw Hop* 

kino IlrMp.. 1907. xviii, '265, 
Hnthoviin, W.; Ein dritti-r lU-raton. .\rch. f, d. );«. Pliyniol.. Buuo, 1907. cxx, 31. 
GilMon, A. G.: Upon a, llithcrlo KmlMFribrd Wave in the Vrnoun Piibw, I.anocI, Lond,, 

1007. ii, 1380, 
Thiiycf, W. 8,: On the Eurly DiiuXolic Hunrt Sound (Hit- So-chIIhI Tiurd Ilrarl Sound), 

Bout- M. and 8. J., 1908, dviii. 71.1; Further Obnenation* on thn Third Heart Sound, 

Arrh. Int. Med.. Uliittmo, 1009, iv. 207. 
PotMn: 1.8 (Unique mtfdioalp ilc la ChnriK^. Ihir.. !S94. 
Laennec, Bouitlaud, Tlillon Fhuec: i|ii(iti>d from Polnin. 
Luethje: qtiolod from Briigncli und Scliitletiheliu, Lehrliucb KliniHcher Unl«niucliuiitei- 

melhoilcn. Brrl., KIOS.' 
Buieeon, Voii, vsii der Ileiil, quotrd from Melim-r.R. J.; On the N'aiurr of Cardio-pn^u* 

niulic Hovcinenls, Am. J. I'liyi«iol., Bosl.. IISUO, i, 117. Also, Saiidem. G,: CUr^opul- 

monaiy Murmiim, Edinh. M. J., 1807. N. S.. i, fi22. 
Sloigel, A,: The Signincancc of Systolic UurmurM over the At«x and ItaM of tlie Heart, 

Clftvp|un<l J. H., !K08, iil. 191; and FuHhuy, P. M.: A Ciuw of (.'ardiupuliuiHiury Mur- 
mur llhiiimlinx the Impiirtancp of iHffrrrniiaiion, ibid., ISOI, vi, 236. 
PuUiain. J, J.: The Clinical .V«»oriation)i and >Si£nilicanco oi the C-ardiopulmoriary Murmur, 

Tr. Am. Am. IliyB., Phila.. 1903. xviii. 167, 

PART 11. 



It has long been known that heart failure may arise from simple over- 
strain of the heart without the intervention of any actual cardiac symptoms. 
This condition usually remains acute and ends in rapid recovery, but it 
may also become chronic and reduce the patient to lasting invalidism. In 
its worst form such a purely functional weakening of the heart may result 
in death. 

This conception was first introduced by Stokes in 1854, and was con- 
firmed later by studies of Clifford Allbutt, A. R, B. Myers, and Peacock in 
England, and da Costa in America. Their articles were collected, trans- 
lated into German, and published, along with an excellent monograph 
upon the subject, by Johannes Seitz, of Ziirich, in 1875, bringing them to 
the cognizance of the German writers. In I8S6 v. Leyden added important 
contributions. In 1S98 the matter was subjected to clinical experiment 
by Theodor Schott, whose conclusions have been disputed by a host of 
later and more careful observers. 

The most interesting, extensive, and complete of all these papers are 
those of da Costa, based upon several hundred cases occurring among 
Union soldiers of the Civil War. It is impossible to do justice to these 
studies in a brief abstract. His presentation is so complete and so nearly 
a model of clinical study for its time that the reader ia urged to consult 
the original publication. 


A very typical case of da Costa's series ia illustrated by the following 

Case I. — Irritable heart, chiefly from hard service; recovery. 
— Wm. Henry H., private flSth Pennsylvania Vol., admitted into the Turner's Lane Hospital 
Id Philadelphia, November 2, 1863, having juat returned from a furlough. He enlisted in 
August, 1862, at the time in good health, though he had suffered occasionally from rheu- 
matisin. He did a great deal of hard duty with his regiment. Some time before the battle 
of Fredericksburg, he had an attack ofdiarrhoeai after the battle, he was seized with 
lancinating pains in the cardiac region, so intense that he was 
obliged to throw himself down upon the ground, with palpitation. 
These symptoms frequently returned while on the march, were attended with dimness of 
vision and giddiness, and obliged him often to fall out from his company and ride in the 
ambulance. Yet he remained with his regiment until J u 1 y 4, 1S63, when he was wounded 
at the battle of Gettysburg. The wound healed in about one month; but the cardiac 
symptoms became wor^e, and violent palpitations ensued upon the slightest exertion, 
sometimes also whilst in bed, obliging him to rise. There was soreness in the cardiac 



niciu[i. itnd a conatoiit dull puiii. The initiiLbr wnji f xl<'ii<leil, nIIkIiIIv Jerky. 1)6. Mml of 
irrrgiilnr rhyllim. kiiiic hc«la follovinx one iinolliur iii npid aiico-vNioo; ibi- fimt nound wiw 
fmble, llie wwitnl <.-*ry disliiicl. Thf iiimi did not, look KJek. Hitiithl 5 (pm 7 inchu; 
DintAurrd ^1 iiichis Hn>uii<l tlip clicst one inch liclo<i ttio nipple; tie did not oniuki!; cbewnt 
tobncc" in modi^rntinn. 

Tl;c^ fuiiwfiil did Dot iinpruvt undiT aconite: but under difci talis Ike iiapulm became 
qtii«l ntiil TS. aiKJ on Mnrcb 2^1. Iiiiving prnxiuusly iluiii; duly as o r d » r 1 y. bv wax di-taileil 
on iiulioe duty, and lilt treatmt-nt slopped. Tlic heart cantiiiuinK w act rneularly, 
he rcttimed to hi* regiment May '.i. ISlM. 

Anothvr case, quoted from v. Leyilcn, illu»trates tlic various plinwy 
of the uialuily very well. 

Cask It.— Car! Timm, butcher, s^iod 3(1. Family hiHior}' □cgaii^'e. Syphilia ten yean 
befon^, <iiii(M(Cifnl for Bcvoml yenn. Olherniiw oln'uy* hfialthy. I'erformcd military Mtrvire 
for a years wilboiil any irtmhlr. In Ihir faUoC IS^ltl l>P(?anie a butcher in lhoChurit<^ lIuBpitul 
where Ite bud tu lift ami ctiup sides of b««( weighing 200 lbs. Tlio 
fimt aymptonin n])]K.-iirKl middcnly on tbi- oTlcnKioii of Dn-nulicr 'M>, l!«>l). durinjc an 
ordinary dny's work, when he fflt n Krver*- pri-Ki tire in tlie |'it of tlie sloiuscb, 
prcveiilinK liini (torn taking ii deep breath and cuuniiig hiui to nlop in his work. At thi* 
timrv lie noticnl pnlpltntion »nd irrpgulnrlty of ibr, ht^an. For nevpral dajv 
afli-r ibid 111- did no ht-Hvy wurk and then Felt sell. When he tried In do heavy 
UfiiaK again the aamc pitin and a<? tiHU t ion o( pressure reiurnpd, and 
thouxb h« continued hiis work hr no* oompclli-d to Mop for breath from linn- lo llin*. On 
Feb. IT, IKSl, the pain bevuiue very iiiteriBt anil he enlered the liuspilid on l''el), 21. 

I'hiftiad Kiaminntiim. — Patient is a very vfell-buill young man, well nuwrlrd, well 
nouidiihw] but nut fat. t'oniiilexion florid but healthy lookintc Nu dyspnoea of 
eyanoBi*. Moderate oedema of lower Mtreitiilies. I'niient compliiinii only 
of palpitnlion of the lirart. The pulHc i* Mrikinnly irregular so that it 18 im- 
pcaHitile l<i ouunt. Tlie ndiul urteries an* tiniall. bluud-prvnurv apparently low. The 
cardiac impnltr ia intenae, rihrslory. and very irregular. Apex impulur ■<■ in 
5lb left iiilerspace 2 cm. beyond mammillary 1 1 a e , a'ell marked, read- 
ily ]iiili>able. Cnrdiuc tlidniss Ijcfsiiiii above at 3d rib, exteiidinR below lo 6Lh rib. and 
Nachinx just in the rixhl of \hv Htemiim. Horl wiiindo arr freblr anil unequal hut 
clear. Lunpi clear. IJver and spleen are not ciUaifed. Uriuc SDU c«., sp, %t. 1023, no 

Ordered real tn bed. icr>haft avvr heart, inf union of diniralii rvory 

lioun. Within a lew days ByrnptoitiN and a'donia had xubHideil, but the 

l^rwipilar heart action perainted. By March 20 he waa well eiiiiueh to be diwrhanretl. witJi 

the (oIlowiitjE note' Ajiex 1k>hI IV.'i cm. lo left of innm miliary line: Gnl unmid at apex 

loud and ringing, aeuund sound diataiit but clean pulw imgular; examination othemiae 


This repreaentji the first stape of his illness, in which iht- following 
features are noteworthy: 1. .\ very strong and perfectly healthy young 
man suRcrei from beait failure as the immediate result of overstrain. The 
firet attack came on suddenly white at work and passed off ijoon. but attacks 
recurred whenever the patient did heavy work, and he wan compelled to 
enl#r the hospital. 2. Physical findings: heart dilated especially in the 
Ionf!;itU(linal axis, weak apex lieat (dilatation of left ventricle), ftreat cardiac 
irregularity. 3. Relatively rapid improvement after rest in bed and digi- 
talis. -1. The heart then returned to almost normal Bize. but the irregu- 
larity in rhythm peraiated. 

Second Stage,— Patient returned to hia old work in "pilr of n-amin^, 
and u'itliin Iwo inontlu oedema of the U-kb had again sel Iti and he was ooiifiued lo 
be<l for nif[ht wt-ek* more. KeluniiiiK lo work axain. he could perform only 
very I i (t h I labor, and very «oon relumed once more lo the hospital for seven week*, 
with still mure marked usieiua. Once mon; thoe diiturbancea diaappeared after rtst and 



ilipUlis. I>i)( t.licn-afirr tlic ■li^htftit work caiucil pnliiilnljou and the fFftin); ae iIioukIi 
then wKrv U lielil cord iilxiiit the rhoi- llr mIno Mt pain in the region uf the 
U\-rr. At thi* jxiinC licr re-vatcml ihc tioBpitul. Pulne mo. biiiuII, irnviiW. VaiFc fliuhcd, 
tiu cyiuio^iv. Expmwiini iin|>nsiiKl. Skin riumial; ipilrmn [>f feet and lefus. (laii^roiio of 
hig toe »f Tifihl fool. It0i^pi^lli<»l a luflc rjpkl.ilyBpnti'annly on p\iirciw, but while walk- 
iliK h^ iiflfii <tUips to canrh hia bfvulh, Orciiaionully lii; luiB attncks ot d.VdpnfJtA liwtJDK 
idtoul 10 niiiiu(i>i. U'KiriTiiiie with ik f<^plii ^ of pr»«iiir in the rrKicui of the hi'urt. He 
then fnci* lU Ibmigb hul liquiil vmn poiiriue from tlie liearl upwurd* lo c:ich dilo iif 
lh« Dock. 

Pkyttoit S'giu. — Apex beat tn aih loft IntofRpneo in nnttrior oxtllkry 
iitic, iKjift luwl cmuly coniprrMpd. Il«irt thpn-fom niucb piilurgeJ. soiiiidx clear ani) falriy 
louil, acli'tii itiurkeiily JrrvKular. [>iv«r vnliirnv) anil lenihtr. 

Onk-R'il nwl ill Iwil, (UgilnliB. iimrpliiiie ui nifht. Pulii^ni hecuini' miirb lici.tcr 
vithiii tmrnty-fdiir hoitn. jniW ihrn iW pnr tniiiuM. The iiltJiDki uf ilysjmu.-u idinoHl 
ilimtppeiiri'il. I'rine I3(XI, r\>, gr,, Wiilun mx diiyn nil cnidiiie ■ym|jioiiiB liad ili«- 
nppcan^l. Murch 11: I'ulw &2. t'pola wi'll, [lu paiii. A|>ex lieiil in Dth left inief*pa<« 
X rn<. tiryiiitd ni.'unmillnry lino, nwHicRilrly fnKvfuI. Ilmrt Minidii clear but uregubir. 
Ue still oFciuioiuiUy Ii»b feeling of prt^iute in chwl. 

Features of secoiKl stage: 1. Dilatation of livarl much 
more marked than before. 2. Ver>- rapid ami very irregular 
heart anion. 3. Definite nitark.s of jmin in heart and feeling of pressure 
(aOKin<)i<l in eharaotflr) . with rndiating pains in Hhuulder ami ami. 4. Swell- 
ing yf Jivi'i' Ifiiilurc of right lii'iirl). 5. Ketiini lo almo-il normal untler 
Ireatmeut, diminution in size of left ventricle. 6. Intcrfurrcnt nfTcetioiis: 
small infaret of lung, preiwure gangrene of great toe, recovered from. 

Thin) S4ai!e. — RetuiniHil lu i]i<> li(W|iiial in July. ISHj (two yctuii Int^r). lie h:u born 
kbJF to do srry Utile *inii- la»l ndmiuion. Sow murb emaciated, (ace thin, op- 
pear* depr«KH><l. t'lieck* anil li[B< -liKhily eviinoilc, Kwpiralion djupnoiic ami 
HtCrtuioiiii. So ortliopnicu Moderate u-dema of sjiiim. 

C^irdise impiilM' hn-ii in .^tli tn >th left inlcrnpacRs, npex l>r«l. felt in ith in lUciUary 
line, futcible. Ilmirt rate abiiiii I'.fi. irrtKul^r. Cunliuv dulnew) 19 cm. from left »temal 
Durfpn. (,1'pprr liiuit of canliac duliion an lii-'fon! begin* ul 3il rib.) Livur rvndily p«l- 
paJ>lc. Sniinds loiid. mure or liv« nlinrt hill nn niiinniir. Did not n-ninin in hoHpital. hat 
on October 4, 1S'4.>. nag bruiiiehl in aetun in cul1u|)w. Mark(>il cynnmiii, exiteoiilini cold, 
tedemn of Ickh up to kiimi. linirt a* befotT', (ouiicIh niill ruW l.M). I.ivcr a Iianda 
braadtb below ontal iii»rxiii. Onh-rei| diKitaliB, alxu I' Fiiil<ciiUine<~>ii>ily, Ic* uiiU 
eOKiue. .\t iiiidciifihl colUpir ini>iv marked, very nmrkini dynpiiieu mid cyanoBis; tlirvw 
himu-U lo and fro, uroaiifHl loudly. I'ulur nut [lalpahle, ncit. re \-iv«d by caniplior or rlher 
injection, Al 'i t.u. beeuiiie quiet ; nlertofuini breulliiiii; net in ul 3 A.M.; ■lied (juielly at 
3.IS A. tL 

Autoftti/.—WiuktiA cedetna of Ucs. Botli lungs NliKhtly retracted, slightly adherent 
over apint*, IVricuidiutii disleudeil. little fluid. Heart markedly cnlnrtied (nuire 
than twice Ibe mxt nf pBiii-iit'i fiiil i.Ripcriitlly in thr Innjiitiidinul axi*. I.rf I vni t ri- 
e|i> more dilaled than rlfibt. Dintatice frutti iriMTtioii of pulmonary artery 
to apex i:t em., to riKht border of lieart 10 eiu. L«nt;lh of left vfnlricle la cm. Utile 
epicanliol fni. Valves ii<)nnid, aortic valvcji clow iwrfccily. Pniiillnry miiiteliTS well devot* 
op(»l, iKinie ImtieciiU' t1alletie>.l ami utidurKuin^' libiuiu ehan|.-ee. A libnniB ('"'ch in Man 
on Ibe interior nurfnee of llie left \'Piitricli'. KndocanUum othervfiw' debcnt*. sfaowing 
•oniB yeltow nrriui nt fatty <lcKcncraiion of the endocanhiiiit and papillary riurcIih. Cut 
RUrfacn nf heart tnuiete slium cluiidy owelltni;. Left auricle markedly di- 
lated. Kiitfat vetitricle apptam pole with lipoid nf yeDow. Lungs, (r<leiDa of bnimi. 
Liver, Riarkcdly etilar^l; deRnile nutin«^ liver. Kidnvya, lafjte.dark red, hatdor 
than luinnal. 

Micmicopie exaniinalion thowa cxt«n«ive faity dtvcrieralion of miwclC'-fibm. but 
only in the imter la>rrv. No in 1 erni i I i al changes, no chanKea in blood-^iwiela 
or iiefrea of the heart. Here and then: Ibr inleniiiial •Imnda of connectiro Uaaiia 
'.^ipearvd tfaidiw than Dormol but aitbnut ocUular infiltration. 



In da ('oeta's 200 soldiers, wpU-mnrkerl fever preceded the ovcrslrain 
in 17 |>or «nil.; diurrha-ji (nniong which thcrt- iiiny h«v«- (jccn iiiiiny niild 
c&nee of typhoid fever) ;i0.5 j>cr ceiii. ; hard field service. piirlieiilHrly exces- 
flive marching, 3S.*» jht n-iit. ; woundu, injuricn, rheitmiitlHiii, sturvy, ordi- 
nuiy duties of soldier life, ami doubtful cases 18 per cent. Contrary to the 
belief of many obHervcni, tolmcm did not seetn to be an ctinloj^cid fuctur 
in his scrips. 

.\llbult jKivea the following olinlo^ciU factors of cardiac ovcnttrain: 
gii'nmasltoi, rowing. Alpiiic climbing, long-distance running, intense fits 
of ajiKcr or cmoiion. sexual excess^-H. Overstrain U very frequent among 
inincm, incud workers, carricni of heavy burdens. blKcksmtths, moulders. 
Morton Fringe calls attention to the development of cardiac dilatation 
under M^vcre invntJil slniin, as in a civil service examination, .\na-niia and 
chloroms (Henschen), apparently mild ilinesses, intestinal disturbances, 
acut« alcoholism, and febrile diseases (Dicllcn) are al.-*o frequent causes. 
Sexual excess is an important factor, especially in men; but it.-* effects 
arc usually mure marked in hearts already weakened from other diseases 
or from valvular lesions than in perfectly healthy hearts. 

Myers, Allbutt, and Schott have shown that tight belts, uniforms, 
and corects displace the heart upward, embarrass its action, and predispose 
to overstrain. Indeed Myers found that cavalry .noldiers with tight belts 
Buffered more from lung rides than infantry from marching the same di&- 


The chief symptoms are dulness, excitability, nervousness, loss of 
sleep, loss of appetite, restlesttness, huEsing in the ears, vertigo, muscie 
volitantcs, palpitation of the heart, usually very severe and often asso- 
ciated with a feeling of pressure or constriction over the chest. This may 
be very dislrc-^sfing, but does not, as u rule, chubc the patient to remain 
absolutely still nor give him the fear of sudden death, though da Coata 
mentions cases in which the precordial distress was great enough to cause 
sohlicrs to fall to the ground in the mitbit of battle. 

Fain over the preconliuni and the left shoulder, occasionally down 
the arm, increased on inspiration and on coughing. 

Dull headache, distiness, especially on bending over, sleep- 
lessness, indigestion, tympanites, and diarrhea are common. 

The patient ofu>n wears ;in anxious exp[\>ssion and there arc usually 
pallor ami more or less cyanosis. I'ulse ia usually small, feeble, rapid, and 
often irregular. The cnr<liac impulse may !«■ hnivlyornot at all visible, 
but on percussion the area of relative cardiac dulness is usually found to be 
enlarged ("n.-fideraldy to the left both downward and upward, and often also 
to the right as well. This corresponds to the dilatation of the left ventricle 
andof both auricles {t.e., diameters MR and ML, Fig. S.i, are much increased). 

On the oilin tiaiul Kal*piuit«tn lias tJiowii (hul in jtui Ihnv case* the impulae 
nisy he exceptionally ■troiig aod impart a benving to iliu wbol* 
olieMl, even tfaoii|[h the hnnrt bo tnuch •tilated, fsiliac, and lievdid 
of the ■lightcut Intcc of byp«rtmi>ti}'. A ByaiolU' lelractiun ia unuiilly ttxa over the greater 



|iart. cif thn prcconliiim of tbfl«« a\'prworkinjE; Iteurts (F^;- 89). curmponding ta the con- 

Irtictiuu (if llu.- riuhl viMiIrirle ([Hi^ fil). Occwriontilly in riipii) and irmiiliir hearte lia» 
appraranw i« anmrvp-hnt piWKlinjt anil ha» led BOnip tliiiitfiiuui li> dieluU aot« o! "delirium 
cunlis" w/)iere tills cmiililioiL vion nut prvscMil Dt iilL' 

Tht; nrcit uf rolalivc cardinc lUilneoH la miirh ptiliirgcd (Fig, 
112), eepecially to ibo left, both downwunlv, fonvapoiiiliiip; to the dilata- 
tion of the vpntricle, ami upwarils. romespotidins to the aiiriplo. In nutm 
se%'ere ca«c», esppcially with marked ry«tio:ti^, iliv duliic:sM is enlarged 
al»o to tho ri^ht from dilatation of the right auricle. Occaiuanally thiii 
diUtdtioH may have paswd of! befoix> th« patient baa been .■<(.>i>ii by lh« 
phyidcian and only the other 
symptoms and signs [K-rsist, but 
it U safe to assume that it ha.4 
been prr!!*ent M an earlier stage 
of the disease. 

The heart sounds may 
be either very distant and feeble 
or very short and sharp, eorre- 
Hponding to the two ty[»s of 
eardiac ini|)uise. They are usu- 
ally tin accompanied by mur- 
murs, but in an irregular heart 
may be of uneven inienaiiy. 
The seeoiid pulmonic i.* usually 
the loudest sound heard. The 
clearness of the first sound is 
often altered by a reduplication, 
especially in rapid heart,H, or by 

the presence of a soft blowing systolic murmur, which i.'i usu-iUy loudest 
over the pulmonic or tncuspid area, but occasionally iiIno hciird to the 
anterior a:<illu. These sounds do imt always but may sometimes corre- 
spond to the presence of functional insulTiciericy of the milral valve 
(vide page 323), tu other ru,!V to tinu'mia. It is. however. e.\treme!y 
difficult or sometimes imimssible to decide alK^olutely whether such an 
insufficiency is present. 

The pulse is usually rH|>id, ran^ng from SI) to 160 per minute, 
small, and weak, in many csiws irregular in both force and rhythm. In 
less severe cases there are only occasional extrasystoles (Schotl); in tho 
more advanced then* is an absolutely irregular rhythm which persisus 
even after the rate slows. There is often persistent tachycanlin without 
dyspmpa, lasting for even weeks or iiionlhs. 

Clinical Course. — Id some cases, however, all the signs and .'tymptonis 
of overstrain may W present without any irregularity whatever, but often 
associated with a rapid and regular pul."*!!. OccaMonalty the pulse may bo 
regular only while it is rapid, but becomes irii'gular as the rate diminUhes. 
In many ^ases no murmurs or other signs of valvular insufficiency are 


'i, — <^nIijiiTiitil&p«M tn V. I^>ilnr]'> mud ut>'Mi U19 
ihn* lUpvoiHv* ulminaiiiii* (1,11.111). 

■Th«t«nn delirium cordis b iwed ratlier iniMlnildy to dmixnalc coiulitioni 
vaiylni; belwevn »trvniF irregularity with tii«liyriLnliu aiid lru« fibrillation of the heart. 
The omrt of tlic luller U, however, not eoniiiiileot with Ibc cxintcncc a( liXe, 



unco«nt«rp<l. while in Rtill oihorn « relnlivc or functional insufficiency of 
the mitral or tricuspid valve ro^uits from the cfirdiaf dilatation, with iioiik? 
cmbsrruiwniiMit of the heart n-jiulting ihorcfrmn in addition to tht original 
failure. SyetuUc (fuuclJonul) murmurH are heard in these hraw. and the 
st»ia» is Klill further inrreaae<l by Ihe reRiii-gitatioii of blood. The UHloma 
becomes oxtrenw.', hydrothorax may set in. and death soon results. As in 
the cftsc of diL (!osta's patient under disenmion, iho progress niiiy be stayed 
somewhat by occasional Ireatinent and mjit. If the latter is sufficient and 
the disenw not too far advanced, the patient'n life may be saved. 

The li vcr, as i» Ciisc 11, enlarjjes when the eondition becomes severe 
and tricuspid insufficiency haji set in. Its e<lKe is then Kmooth ami varie.s 
in consi»teai'y from l>eing rounded and mo .sufi as to be palpable only 
with the side of the index finger to almost board-like hardness. Ii ia 
ulways smooth. Id aeverc cuses jaundice may be present and Ihe liver may 

The abdomen is often distended with gas, a factor which runtrib- 
ute« largely to the CMrdtnc diitconifort by pushing up the diaphragm. In 
the later staj^s of heart failure ascites may be present. 

The go n i I A U a iihow cedema only in the later dtagcn of the disease. 

The lower extremities are oft^rn tcdematous. the swellinf; first mani- 
festing itself about anklf." and Hhins. 

The urine during the jx-riod of heart, fiiiluix- is usually «ntnt,^iess 
thanUOUc.c. (^0 ounces) for ^4 hours, -owing to diminished rapidity of btuod 
flow. It i.s then of high specific gravity ( 1020 and over), and often contaiiut 
albumin and cjixls. In extrenie stasis nuinenius epithelini, coarsely and 
finely granular, and hyaline casts are seen in every field of the microscope. 

Blood. The blood picture may vary from a moderate anifniia to 
a real polycythemia, dependent upon the condition of the patient before 
the over-exertion. 

The sputum may l»e scanty and nmcovis. or profuse, frothy, wid 
albuminous, de{x>n<leut u|K)n the relative strength of the right and left 
ventricles. In rare eases hu-mopty»is resulu during the exertion from 
engorgement of the pulmonary capillaries. 

Transitory Cardiac Dilatation. — A particularly instnietive scries of 
eases t<tudied with modern methods are those reported by Mornung (IBOS). 
Among 1100 cases which he watched with ihe .\-niy during the pa.*! seven 
years he has met with a number who usually showed perfectly normal 
hearts but were snlijcct to ucut*' ilihitation aftttr overstrain. This was 
ptirtii'ularly frequent in [jersons who had uscil alcohol to excess, in those 
who hnd ri-cently suffeivd from infectious di.-H^aHC.-i, and in ana^mii- indi- 
viduals. The attacks of dilatation an- brought on by fright, 
high altitudes, excitement, over-exertion, etc Sexual ex- 
citement might be added to this list. Honiung returns to the old view of 
Seiti, .\llbutt, and v, Ix'y<ien, that cardiac overstrain with acute 
dilatation i.« much more common than might be supposed 
from the work of Morili: and hii> pupils. 

For a long period, however, he may be expectei) to be more subject 
to other attacks than before, although by care he may remain free from 
(hem. .lust how long this susceptibiUly may last varies with each case. 



but <1h Costa haft shown iir that aft«r rarofuUy HparinR the patient from all 
severe offort forwpcks or pvt-n niontht^. he may jiniuri perform evon such 
severe elTorts il!« arc entailed on cavalry i'harti;e4 and funiid iiiitrelie» without 
injury and may lead a life of perfect health. 

The other side of the picture is tihonn by v. Leytlen's case. This man 
returned to work in spiw of the diapomfort The latter became worse, and 
after bearing it for three months he entered ihe hospilal with a heart already 
dilated and permanently irr«gvdar, and with well-marked a>dema of the 
UmbB. Definite heart failure hod liet in. From thts he recovered under 
reflt and treatment with diititalis. His heart resumed almost normal «ixe, 
hia cedema disappeared. The circulation once more returned to idmost 
normal, but one permanent injury had been done for which the treatment 
wiuf of no avail. The lieart action had Ixicome irregular and remained ho. 

The commencement of jwrmanent ab-wlute irregularity in rate (pulmis 
irregularis perpetuus) (sec I'art I. Chapter IV) at this fitage is a ver)' com- 
mon occnrrpnce in ovei'strained hearts, and se^ms to Ix? one of the moKt 
important faetore in itct^^rmining the subsequent course of the ilisease (see 
page 123). When the irregularity i>ersists it aiUls ils own mechanical ellecls 
on the cireulation to thonc already present and increases the overstrain. 

When a life of strenuous mu.-4cutar work is continued by such a patient 
tile result is inevitable. Strain follows strain, and the condition brought 
about by the first fnihiip is cxsggi?r»te<l with each ducccssive day's work. 
The attacks of pain and pressure in the thorax (anginoid attacks) increase 
in severity and frequency. The heart dilates more and Vx'comes corre- 
spondingly weaker. Blood stagnates in the veins, first in the more depend- 
ent portions, raUHing (udeiiia of the ankles, shin.*, thigh.-*, gvnitatin. then 
enlargement of the liver and ascites from stasis in the portal system, finally 
UHlema of the face ftn<l arms. The heart dilates still nion>: the mitral and 
tricuspid orifices no longer close. After each attack he is less vigorous 
than Itefore, and greater care must be taken to avoi<l exertion. For the 
ninnun! laborer sucli a life may be at once impossible and intolerable, but 
the litK'Taleur. the scholar, the scientist, and the man of affairs may be 
savetl for years to a life of tguiet but none the letta useful activity in spite of 
a conaderable degree of cardiac break-down. 


The diagnoeiii of primary overstrain of the heart is not alwa)*!! simple. 
It is always a question not of whether the heart ha.* been overstrained but 
of whether this weakening is priinar}'. and whether the heart was perfectly 
healthy before the effort was made. If the heart, muscle, or valves were 
in any way discanvd before tlie effort , the overstrain may be coiLsidercd as 
serotidarj' to that lesion. .Accordingly the diagnotus rests upon the pre- 
vious history, upon the nature, ilurntioo, and sequela- of previous infec- 
tious di.'aeaaes, ui>on the degree of arteriosclerosis, and upon the general 
health of the patient before the un.-<et of the ti-ouble. 

I.aLent myocarditis, fatty degeneration, and arterioseleroMs are par- 
ticularly difficult to exclude. ,\ mild graile of myocarditis nuiy have given 
no symptom whatever in daily life, but become nppiirent when exercise 
w violent. A mild grade of arteriosclerosis is practically univer^ among 


persons past middle age, but if considerable efforts had been made without 
symptoms of cardiac insufficiency these may be disregarded. When symp- 
toms of heart failure occur suddenly in a robust individual during or after 
some intense muscular or nervous effort, acute cardiac dilatation and over- 
strain may usually be diagnosed with certainty, but, like hysteria among 
the nervous diseases, it should be arrived at only after a process of careful 


Stokw, W.: Diseases of the Heart and Aorta, Dublin, 1S54. 

Allbutt, T. Qiffnrd: The Effect ot Overwork and Strain on the Heart and Great Blood- 
VMsels, St. George's Hoop. Rep. (Lend.), 1870, v, 23. 

Da CoBta, J. M.: On the Irritable Heart; a Clinical Study ot a Form of Functional Cardiac 
Disorder and ita Consequencea, Am. J, M. Sci., Phila., 1871, bd, 17. Medical Diagnoeis, 
Phila., 1864. Also, Observations upon Heart Diseases in Soldiers, etc., Hem. U. S. 
Sanitary Commission, Washington, 1867, ch. x, p. 36. 

Uaclean, W. C.: On the Diseases of the Heart in the British Army and the Remedy, Brit. 
M. J., Lond., 1867, i, 161. 

Hyers, A.-R. B.: Etiology and Prevalence of Diseases of the Heart among Soldiers, London, 

Peacock, T. B.: Lectures on Diseases of the Heart, Med. Times and Gat., Lond., 1S73, 
ii, 1, 57, 113, 169. 221, 319, 349. On Some of the Causes and Effects of Valvular Dis- 
eases ot the Heart, Lond., 1865. 

Selti, Job.: Die Ueberanstrengung des Herzens. Berl., 1875. (A monograph by the author 
containing translations of the articles of Allbutt. da Costa, and Myers.) 

V. Leyden, E.: Ueber die Her£krankbeit«n in Folge von Ueberanstrengung, Ztschr. f. 
klin. Hed., Berl., 1886, n, 105. 

Schott, Th.; Zur acuten Ueberanstrengung des Heraens und deren Behandlung, Wies- 
baden, 1898. 

Homung: Beitrfige lur Prage der acuten Herzerweiterung, Berl. klin. Wchnschr., 190S, 
ilv, 1769. 

Henschen, S. E.: Ueber die Herzdilatation bei Chlorosc und Annmie, Mitth. a. d. med. 
Klin, zu Upeala, 1398, p, 27. 

Katienstein, J.: Dilatation und Hypertrophic des Herzens, MUnchen, 1903. 




It ia evident from the foregoing examples that muscular efforts which 
lead to cardiac overstrain are in themselves merely the exaggeration of 
ordinary exetcises. To understand these effects it is necessary first to 
understand those of ordinary exercise, 

McCurdy has classified exercises as — 

1. EzeraiaeB of Epeed, Uke nmning, cheet weight exercises, etc., in which 
the mdividual movements require little efFort, but the main effort lies in the rapidity with 
which they are repeated. 

2. Exercises of endurance,a8in iong-diatance running, prolonged walk' 
ing, forced marchee, etc., in which the movements are neither diSicuIt nor especially 
rapid and the element of strain sets in only with the onset of fatigue. 

3. Exercises of strain, as lifting heavy objects, wrestling, etc. 

Exercises of Speed.— The cases of cardiac overstrain reported by All- 
butt and da Costa represent overstrain from exercises of endurance; those 
by V. Leyden and Miinzingcr represent exercises of strain. 

Masing, Erlanger and Hooker, Dawson and Eyster, and Gordon 
have investigated the effect of exercises of speed such as rapid weight- 
lifting, running, etc., upon man. The three last named have found that 
in individuals in training, whose circulation is least affected, mild exercise 
causes either no change or else a fall of blood-pressure. Tang! and 
Zuntz also found this in horses and a similar period, though of short 
duration, in dogs running on a tread-mill. 

In all muscular work an increased amount of COj is given off from the 
muscles and acta as a hormone ' which sets into play the following physio- 
logical mechanisms: 

1. Vasodilation in the muscles, diverting four or five times as much blood through 
this channel {Chauveau and Kaufmann). 

2. .Acceleration of the heart, at first through diminution in the vagus action, and in 
the later stages of prolonged severe exercise chiefly through stimulation of the accelerators 
(Hering, BoH'en). 

3. Vasoconstriction, especially in the splanchnic vessels, which tends to counteract 
the effect of the vasodilatation in the muscles. 

4. Stimulation of the augmentor fibres, and perhaps also of the heart muscle, directly, 
causing an increased force of contraction (higher maximal pressure) and an increased 
xystolic output (higher pulne-pr^ssure). Stimulation of the augmentor Rbres also, as a 
nile, causes increased cardiac tonicity. 

' Hormone, a snbcitance generated in one part of the body which circulates in the 
blood, reaches and sets into activity another organ, thus playing the rAle of a "chemical 
messenger." (CE. Starling, E. H.: On the Chemical Correlation of the Functions of the 
Body, Lancet, Lond., 1905, ii, 391, 423, 601, .579.) 

9 139 



The heftrl of the trained athlete Is habituully throwing out 
an amount of blood suited, not to the needs of the moment, but to the 
needs of ihfc periods of cxprcijtt' to which hf has iiei'ustotiifd himstdf. The 
fty.^lolir output is above normal when ihe exercise (and henee the increased 
production of CO,) ia slight. The heart is thus able to take can.' of the 
excess CO, production in cxcrci^ without increasint; itei output; and hence 
the vasodilatation in the muHcIes is the only factor inRuencing the blood- 
ppfssuiv. Whvn ihe owrcisc becomes severe the other mechanisms begin to 
play a r(>Ie. 

In normal but not trained young men Masing found 
that ui>on lifting und lowering a weight with the feet the blood-prca- 
0ure (maximiil) and ))ulse-rate rose at once to a con- 
Biant heighi, where they remained until the exercise 
ceased. They then fell almost immediately to the ori^nal level. The 


FlO- 113. — Altefiljoiii. ol Uood-pMMUro ilur to tMitiii httjiiminighl wiigliliwilh thi"/r»t. ( AfWr Jtauug. 
OeutMehrt ArrA. /. ktiik- MM., vol, Ixilv,) A, Noifiikl jquDf (nan^ ly Ma^j m^vd <VH, 

writer hius found that the minimal pressure riaea also, but lesa than the 
maximal, the pulse-pressure being increased. In middle-aged persons 
MiL-<ing found that the presinirc rose higher, and on cessation of the exercise 
rcquirt'ti sfversil minutes to reach the original lcv<'l; while in very old persons 
the rise was still greater and neither pressure nor rate returned to normal 
for a consjdcmblc period. The response ia proportional to the effort. 

When exercise is continued in normal young persons and 
the organism readapts itself to the effort (the "second wind'' selling in), 
blood-pressure and pulse-presicure again fall to a fairly constant level 
(Daw.ion and Hjitfield). This probably explains why the heart-rate of 
well-traiaed Munilhon racers is sometimes slow at the finish. In animal 
oxpcriiiients it finds its analogy in the improved cardiac action obt>er\x-d 
as a result of clamping the thorueic aorta, and represents the responiie of 
the heart to a strain which is noi exces.sive. 

The weaker the individual or ihe more severe the 
exernise the more prominent become factors 2, 3, and 
4, the greater the rise of bloo d-p resBure and the 
greater the pulse-rate. The slowness^ at which condilion.'t return 
to normal is more or less proportional to the exertion and the fatigue. 

It is also true that for n given amount of exercite performed in a given 
time the amount of CO, formed is least when it i-s done with leust effort 
by trained individuals and increases when the effort becomes marked. 



Zuotx and Schuraburg have cihon'n upon 0«rnisD «>ltliors thai u certain 
Hhori march uwd up only o54.S calorics of enerRV when the eubjects were 
fresb, but required KJS.S calories when ihoy w«r(' fniigucd. This is prob- 
»biy due to the fad thai with the increase in effort accessory muscles arc 
calletl mlo ptay, many of which contract and give off CO, without mate- 
rially improving the execution of the exerciw;. 

Fmi. II*. — Eflecl o( "nlkliMi on ■ level on 
liftUnil friih bodlir bmkAi cciiiipviuiwlicin. (Aftvr 
, Cktmt aod Snicr. Ant, J. U. St.. «uuv.) 

Fib. II^.^Edcct of prtilEiniol ueKiiE upon 
Uir blood-pctHUrt of mm in T«ridii> <l>ar>A> nl 
muHUlAr ttrcncth- Th« uro** tnrtio«i« ihe point 
•t Hlticli lymplunin at nhxiiliuii 'ri in. COM- 
PE.VSATSD. niinp*n«iHl l>Nin Imiiisn^ FAIL- 
/.V(r. br«l»D KdnpcDHUoa vtilt heart fbjtun. 

dxcrcises of Endurance. — The point at which an exercise of speed 
becomes converted into an exercise of endurance is more or less relative 
and depends chiefly upon tbc; condition and the training of the individual. 
The moBt typical exercises of endurance, the forced march, the long-dia- 
tance runs (Marathon rai-es), anri long-<ii.'<lanre bicycle r«ce«, have been 
carefully studied by Zunix and Schuinburjt, Blake and l-arrnboe, Dietlvn 
and Moritz. and R. T. Abercrombie, In these exercises the least changes 
occur in the best>traine<I individua!.-< in whom the amount of effort put 
forth is least or least prolonged. 

The pu1w-ral« a( the nicMi who flnixhrd in the Marathon nice* nt Boston Hhowed nur- 
primtit;))' Utile iiicrMM. ttw Kt«ut«et riiw <iuiiii^ the ntce uf 1900 Ueiii); (n>in TK before to 
144 utu-r; }iiil tlir! avenue nU« uflrr ihc rncc wnii \Wi (Illakc and LdttuImv). Hirrc wiui 
lrvi|U('iiil>' u ■[loib'nite icrviJo u! irrvKiilnrii.v. 7,wiit unil ScliunibiirK found »iinilnr rtlocit. 
Thp l>looil.inniiiufi- iiftiT ilie race wim unuullv finiii<l to be it trifle lower tlmii before tbe 
■tart. IhiHiKl) il vnrinl icmilly in ililTcrml imlividiialii. .1. Itanuh h^ii mccnlly t^t»inod 
■itniUr rcBults wttb I lie Ertaacer u|>|ur»tiu u|>on jnoilier eel of trained Uatathoa ncen. 
Th0 nftliodia«ntph iihi>i>-ed dllnlntinii of ilie lienrt jii uU liii ciuvh. CJuitO diffemil an.' 
tbe nstillA in 1f>nK-<UMjinc« rnrm run )iy .'unntcur*. Dr. R. T. AUrrcromhJC! hiu recently 
iuade • Careful atudy uf (lie conditiMi of eoQiMtantH in a [weiity-niile road ruM' before 
and Immcdinlcty itftrr the rtcr. B^'fom tbc mcc tbc at-rrimn l>liH>d-|irrjHum< wilb lb« 
Erianser ^ifMnitijn were: miutiinn) rJO-130. minimal 7i-Mi; pulscr-rate SO. Immediately 
afWr the ruec the puLv- wmi in almonl every iiulance too ftcbk' to be coulit«d. aa irtre 
ulau the heart gBoiiiuU; and ndttirr lhi!<« nor Ihr blooil-iimuiiirc coiild tw witidaettmly 
rutinuiiL-d until oue-lult hwir alter the tiainli, «lien tbe puls^^mte wna uttiidly ahoiil 1'JO 
prr iuiliut«, Ifac inaximal presure about 7a-100 mnul^. Tlie lieart sounds were still 



rapid nnd foelJp. Nrv«nhel(«« all of tliMO men felt qulle ««ll, and nviv able tA enjoy a 
cntd piling iinmwiiawl}' niter tlie PKaiiiitiatiuii. \^'iIlliD on hour aUrr llie fiiiiiiti lhi*y 
iren nil fwliDg quite ac(ir«. The tilooil-jirrsKiin' wn* Ufnially loiiad lo be luyivt than lie- 
fnra the ■lan, but thU vnrir<l erfHtly in iiuUxidiud ciums. 

N'ot aL tlie ^^^uTt!l of triidurancH (cats are «> mQil iw th»c. DuriD^ the tunateUT 
athldlic conUMtM in thi: I'niird .States the pact five yntrnt there haw hewn nevetn] comv of 

ferman«nt lifiurt fuilutt- fuMon'inKl iliroolly upon uveriitrsin in 
onK-diilnncc runii. Aniiula CobIo'» m-Tin*. the pcrBonn wlinw licaria wcrr injun-ii 
irrrc iiHUnlly boyii under twenty nho wen; poorly li»ined anil wlio»e heart* tss-k not fltletl 
for l)ie attain put n|>u]i iheiti. 

Aa rcKnrdi the (neiaboliiiin durinft (ucb «xerci>c Ztinit and Schtimburt;. and ako A. 
l/iotvy and 1,, Ztinii. foiitid that liolh tiie amoiiint of CO, K'ven ofl |»r minute and the 
rv«|nrat(in' (|tiutieiit K-i'rc mnrki'dly jesncfied <CU, fulling fruni 803.^1 c.c. to T4'<-0 c,c. per 
iniiiiili!; rwpirrttory ([unlient fnllinft fmm li.S5.^ to O.TSO) nt the end of the exertion. thi»i|th 
the O, lueil n-as iinehuiiuni. Thin ia due to fiinnulion of iiit«niiv<lj«te onidalicai prcHl- 
ucl*. snruiiliiclie acid, ,)-iixybutyric acid. etc.. tla- pri-uure ot whose nulls may aild to 
the fstiyie Morvnver, the lowenvd output of ('O, indiejiIeH a InwCO, eonfnt of the blood 
(acapnia), and. tui HciiderBoii haa nhowii, thiiH in turn cauMa dilatation of the veins and 
cau>*e5 I he blood to irradually leave the nrleri™. at agnate in the venous renorvoir (tee 
page SI), anil thus diminish the rapidity of the Itlooil How. 

Correspond ing to the variations in rapidity of blood flow, the uriae 
is incrcaitetj in amount dui'inK mild exercise, decreaaed durinR severe exer- 
cise. After boat raeeii and itfter tin- Manithon nici':* il often contain; 

iiibumin, casts, and even traces of 
blood, probably aa e. result of !ttasi« 
or high prc»!<ure in the renal wins 
and capillariei). 

ExeiVtw of Strain.— The effect of 
esercUcii of strain, lifting, etc, ii< totally 
difTerent. McCurdy. Bruck, and others 
have shown that these exercises cause 
a far greater rise of blood-pirasurp than 
do the exercises of speed; and. on the 
other hand, the pul.-«c-rat* iloejt not riw 
rapidly but is at Tirat either slowed or 
unchangetl. The rise in blood-pn:ssuiB 
is RTeater in arlerioscleroties, old [wr- 
.■«oii.-<, and ^veak iudividnalK fur the 
same amoimt of work than in well- 
tlevelopcd normal individunls. In per- 
sons already suffeiing from broken 
coinpen.sation. on the other hntxl, the 
heart absolutely fails to respond with 
increased effort., and may be so givally 
weakened by tho strain that the blood- 
presaupe may fall. 
All the factors which are calletl into play by the hormone action of CO, 
in cxerciaeM of spceil and of endurance art.- also acting in exereiws of strain: 
but, since the latter are usually intermittent or of short duration, their 
effects are at first ovewliadowed by others which are more iit(erti«. 

In carrying out any exercise involving muscular 
strain the individual in vol iiti tartly closes his glottis 

FlQ- 11C- — Mitu at htuod-pvt^ttirP dU'iHC 
VaJhIva'* ax|i«riukBiit umi ciunnc tuor^JM-- 
Noniinl indlviiiiul- ISfh^miiiic, *'tft ttrtjuk.) 
ARTKBtO.-iCIXH. run* of Uoo-l-prtMuro lo 
nuin Willi KritfioHJcnxii p«tf«rniiu| tlw lune 



un«] executes aa attempt at forced oxpirnliun. The 
result of ihis U n treiiwndoiiii iiicroaHp in intrathoracic pret^ure. uhieh 
hindei^ llw uutllow of booU from the righl vt-iilrirle as well ii» the inflow 
into the right auricle, 

Thn result ol llinm two faclom it ililatnt.ioii of the riahl v-mtritile nniJ *tn«a ill tlw 
f>)'Hl«mk velnt. whlfli in ullll (iinln'r nJionii l>y Iho e>'uiKwiB of lh*t faice aii'l liiBtrnlion of the 
iium Itiul iiccompiiiiy utl i>iicb exercises fved in trninnl sllileles. TIu* vvnotis elstuti ia 
fiirthrr incrv:>«nl hy Ihc iiuiiil(<n ta|iii>«xiiiK out of l>Ii>m( from llic latge roowM of ■kclctal 
hiiiwIfi, uflii«li aiv )>i'ing forcibly euntiacwtl HimutiaueoiuJ)'. a» well us from tJie vcfwcis 
of Ilic Kf'lancliniE ari'a. 

The hiith iirowiiiv uiihiu tljelunjiBHliiiHiUlm tlwaMwory endinssof tlin vngus. which 
ill luni rrllexl}' Bi.ittiiilnlu Ibe motor niiclriiK of the vmeiih and tlw voKauutor ci^iitrv in Ihc 
mpHiiltn luul ciiiise l>oili Hli>«in); of the |iijlie nnd riw of hlo<id<p(rMiucc The t^nmil mult 
It Ihc uiiiii^, htit kw% murkvii when the VulsuUn oxpvrimriit only (forrc<l expiration urilh 
^ultU cUieetl) in ciurit^ii out, ami dcpoml* very Inrsely upon this fnctor. 


Plmlnulion In Size in Healthy Hearts. — Kxninitittd with thf \-ray 
the RiiricW are seen to tlilate greatly, but ih« t'entrirles do not, lus n rule, 
dhow any (lilulAiiriii u'liHtfv<-r. Thitt figftiii is a qiuMMon of tonus, and here 
also the Intt<^r fjiclor seems to determine whether diliitalion slinll «>! in 
or not. .Vll exerciwo-'i wiwn HufTicii-ntlY wvere lead 1o ihlatntion of hearts 
whom myocardium has euffereil iojur^*, especially during the cour« of 

rm. 1 1'.— ^lffnl-»«^of^■t»e tlravjiiB vhuviiix ^^tiaUoub in uta at Lfir Lfltrl t)i 4 l(ntK.<lJ'l'*0^ 
bi^vrlc nitrrr, »« llao rt>ui1 uf » vtrrlrmx rdM; rtviifi*trvirUil trtJtn tint onhixUjkJtmpKic tiMlmt, A- KfJot* 
ihA law, B. Inimnilijiiply fthvr ihp tmrr, thonrin^ tUr cirai (hminutinn in iiiae of the bcorl- tX Fnur 
*ink> latrr. lAller Monli «iil Incllrii: MiinfAm mat. ItYAnKAr,. 1008. It.} 

infectious diseawe (da Costu. Zuntx and SchumburK, <lc la Camp, Moriti 
ami IMellen) or during ilie fir^l few w«ek.-< following them. On tlw other 
hand, Schott has claimed to have seen cardiac dilatation in healthy wreatlers 
and bicycle ridera ait a rei^iik of nhort wre.->llinf; boulN. Thtx fiiet h»N Ik-vii 
diiiputetl by a number of obwrvcrs who have carefully controlled the more 
or less suhjecrive findings of ])ercuHftioi] by oullioing the heart with ihe 

Tlie foiIo"~inK cxefdw* have bwH Ktii<lieil: bicycle riiUne. hy MeiKlclsolm. Alhu, 
B^yer. ScliielTcr. Tlietlea niid Uorilx; iiiarolung. 1>y ZuiiU and Scimmhtirg, Alhu mid 
L'asjniri. BuldefH, flrichelhcim and Metittrr; foolhnJI plnyiiiff, tiy I'. I'irk :iiiil tn' Seliz: 
Kkj runiiiui:. by IIcn«clieTi: wtvelline, by I^r^'-Dom. Seli^. Mnidl uiid Svlig: ■winiioitiic. 
by RioilKNik, Scii)c and Beck. 

The results of thette obM-rvations quit* uniformly confirm those of 
lie hi Camp in showing Unit excrci.-^-, even to the point of exliaui^tion and 



fainting, docs not bring about cardinc dilatation in otiicrvrijtc healthy men. 
In mo.ii cases the X-ray and orthodiagraph show an actual diminution in 
the volumvof ihvhcurl' (see Fig. 117). Dp laCainpul.4« found that healthy 
doga could run upon » tr«ad-niill until they drop|)ed from exhaustion with- 
out cnur'iiiK dilatation of the heart; whereas the hearts of ilogs whieh had 
been poisoned with pho»phoru:< and wideh were in a state of miUl fatty 
dffgencriiiion dilated greatly from the same exercise. 

Dilatation and Myocardial Injury. — On the other hand, Homung, 
who has watched th« coun* of 1100 eft»c» of weak hcsrt with the X-ray, 
Maw.'* that in such [>ersons acute dilatations (demonstrahle with the ortho- 
diagraph) are very common na tlie result of slight dverstmin. It may 
require comparatively little strain to bring this about. For exampk. he 
cite« the caw of a woman with a weak lieart who acquired a dilatation by 
taking a abort cut instead of a gradual ascent while climbing a hill (Oertel's 
Terrwnkur). The dilatation Ia.iu*<l for neveral days and gradually passed 
off. Persona whose hearts are in ibis labile equilibrium are liable to have 
repeJ>t<>d attack!*, But the <rardiae rondition ran'ly stands still, Ii grad- 
ually becomes either better or worse, according to the treatment and the 
mode of life of the patient. 

Thoracic and .Abdominal Constriction as a Factor In Cardiac Ovef> 
strain. — A high diaphragm due to tight belts or corsets is one of the most 
important factors whirh predi.spose to cardiac overstrain. This was already 
shown by A. R. B. Mverjn in lStt7. Mjx-rjt obiw.Tved that certain cavalrj* 
regiments in the Indian Army were particularly subject to cardiac over- 
strain and to chronic cardiac disea^-, even more !H» tlian the infantry regi- 
ments which were doing more arduous work under the same condilion.7i of 
climate and diet. He noticed that the uniforms of this cavalrj- regiment 
were verj- tightly belted and had tight cuirasses compressing the chert. 
Upon experimentation he found that the men in this regiment, when not 
wearing their uniforms, were quite rw strong as (hose of other regimenta 
in the service. He also found that the same men were able to withstand 
much greater exertion in the .Kanie uniforms if only the b<du were worn 
looser. This has been shown with somewhat greater exactness by Th. 
Scfaott. Schott demonstrated with the orthodiagraph that wrestlers could 
withstand much gir-nter exertion before the onset of acute dilatation or of 
cardiac symptoms if they wore no Ix'lts than if they were tightly l»elted. 
This is, of course, not «iirpri«ng, and is simply another way of demonstrat- 
ing the every-day experience of most healthy women that they can do 
more work without a corset or with a loose one than when wearing one 
that is tightly laced. 

The reason for this is twofold. The bell interferes with the respira- 
tory movtiments of the abdomen and diaphragm, and hence dimini^hcH the 
rhythmic alternation of positive and negative pressure;*, of force-pump and 
suction-pump action, in one of the largest of the vascular ri'-iervoirs, thus 

' The syncope (cervbnti niin>min i undrr ihrsc conditiana in proluhly duo to the ntacUjr 
apponle cotidtiiuD, iliiuiuiBbeil curilia.c filliiiji und henc« d i in i d J * h o d 
cardiac om [>u( ; artcnal nnipmin clue to mpid pulsp-rnte iii n bmrt u-Hmo loakil)' 
it incnaaeii. (Thiit cotidition i» fully disciUMKl in ilm cliapum on Paroxyunal Tachycurdia 
and Hiaeellaneoua Heart Discoam.) 



diminimhiiig the rftpiciity of blood-flow. Moreover iho visccrn arc puttlicd 
back and the diaphragm is pushed upward by the belt, and this causes the 
heart to AHflume a more triin.4verHC portion, in which kinking uf tho great 
veins, the aorta, and the puluionnry arten,' sets in. and both the filling and 
the emptying of the heart ar« impeded. This raechaniHin is rcaflUy domon- 
ittraled upon the exposed heart of the living animaL A comparatively 
BliRht upward or do«-nward displaoement of the heart from its natural posi- 
tion may cause tremendous fall in blood-pressure and interference with 
the work of the heart. 


The diminution in the «i4.' of tho heart which was found ko uniformly 
by the above-mentioned observers seems to be due, in part, to diminished 
(illinK of the ventrirleit when the heart 'i» rapid, but chiefly to the fact that 
the cardiac tonicity was increased by the strain.' This clinical ohw;rvn- 
tion has its nnalo^e in experimentation on animals. (>. Frank has shown 
thai, other thin^ being equal, a moderate increase in intraventricular 
pressure acts as a etimulua and cauaes an increase in the force of the next 
beat. If the pressure u raised further it reaches aa optimum; but if it 

Flo. lis. — IlfTivr i<r iiiiiiL .11 iht Jo(t'> lipkri vhn** loiiirily k> gooit- Voluma curve (I'OJ^.I 

Mail bluod-pRBvur* rurvt ',B- F- * of nri KcijumL whu»* Tintrt t> \i\ coivl wmliljuti. DtBnnOlui; ^orBCi« 
■nrta elAinMii at th« mamctit inilimurj hy thp ■rcixr, ]^lrpiitvialBr>- dilaBalion follnwvd hy > iliiiiiiiul'ou 
In no. Ill* hsurl boMinas fnuUvr ibnii briorc Ihe (lampini. TaoUiljr U llHrwwt (1* -t 1. Bloul- 
prcHuna mkilnud •nd niiaiiiul ij* ■!••( iDcnawcd. 

becomes too high the force of contraction becomes much weaker than if 
there were no load at all. There is a similar effect upon cardiac tonicity. 
Hirschfelder hf<s shown that if the thoracic aorta of the dog is damped the 
ventricles at first dilate rapidly and the systolic output diminiahes. If the 
heart is in good coiidilion the systoles 8O0n begin to increwie, the excess 
of blood is pumped out of the ventricular cavities in systole, and on th« 
other hand, in spite of the high prei<«iure in the veins, le.'ta hlood enters the 
ventrieW than before. 

*It Is powdblr ibnt oekpnia (page 31) amy play a r6lc under titeme cwuUtiotUk 



The amount of blood which enters the ventricles depeitcU upon two 
fftctom: 1. As Hriwcll and Donnhlson hiive 8hown for the «xci»ed hoart, 
and Uoy and Adami for the dog's heart in ailu. it i» more or loss propor- 
lional to the venoiiii or iiil rii-«urifuliir pre.Hsurp. 2. Hoy and Adiiini, 
liirschfclder, Cameron, and others huve nhown thut it is al»o dependent 
upon the cardiac tonicity, beiuK greater tvhen tonicity is low (dilatation) 
and least when tonicity is high. It is therefore ovidonl thai u heart whose 
tonicity is high will withstand a comparatively high venous pressure with- 
out dilatinfc, wheiras when the torneity is low il readily overfills. 

Several factors contribute toward diminishing the strength of an over- 
KUfid heart; 1. With the increase of the cubical eontenlK and th9 internal 
surface of the ventricles the mechanical work necessarv to exert a nonnml 


B. p. 


t'lu^ 11(t.— Vfiltimn riirrv uf a <^n< trhiiu* rxfiiiui umjtrity ii Ui^- v'laii^piuit ihn uuiLn i> (ulIuiAr.i 
by pennanflil diUf lion unil only b *hfEht mimitn (iiTy fr»cr«»»p m blood -pff^'iif*, 'Hn* •ir»tnl"' nvlpiiT 
il diminiibad. obIuk Io iuubilliy ut Un- biwrt tu force Uii iuukL i^uatA of bloul ngkiDtt the iniiaaMd 

pressure is increased (Uoy and Adami). 2, In ilic diluted bcart tlic blond 
Qow through the coronary arteriea And hence the nutrition of the cardiac 
walla ia diminished (Hyde). Moreover tlw dilatation of the ventricles may 
or may not he permanent, dependent upon the tonus of the heart muscle 
(llirschfeldcr, Cameron). If the latter is low the dilatation Remains and 
increnflen, whereas if it is high the increased pressure acts as a stimulus. 
It is usually n bigh venous pressure which keeps the heart dilated and a 
low tonicity which permita it to remain so. 

Since the venous pres,Min» is certainly highest in the exercises of strain. 
It is not surprising that permanent heart trouble arising in previously 
healthy persons as a result of primary cardiac overstrain is particularly 
common among |x.'n«ons (butchers, porters, stevedores, etc.) who lift the 
heaviest wvights. 


The response of the heart to a muscular exertion which just fatigues 
may be of three grades: 1. The heart becomes smaller or the cardiac 
outlines are unchanged — tonicity high (normal hearts). 2, There is a. 
Iransitorj" dilatation (after acute infections and in hearts with myocardial 
or some other cardiac distOrbance). 3. The overelrain leads to pi-rnia- 
ncnl injury of the heart, often with permanent arrh>thmia (chronic car- 



diac overstrain, inyocardinl cliangi-e). These three conditions find their 
Rnnlo^ucH in the effectH of clamping the thoracic aoria upon the volume 
of the ventricle.t (FiiB:. 110). 

.\s has been seen in the caaca quoted above, the repetiiioii of the strain 
it* (luite as importniit a factor in heart failure as is the overstrain i|j*eU, 
Even a heart with extremely low ionieity will, in moHt easee. recover and 
gradually return to nonnal volmne after the slrain has been removed, but 
iliiriti^ (lie jteriud when it i» »lil] dihited it is much more tniHceptible to a 
further overstrain. On the other hand, after a sufficient period of rest it 
rt^gains il.i former volume and still later its former tonicity, and once more 
reaches its original strcnglh. That this is probably the case in roan aUo is 
e^hon'n by the fact that Poyiiton did not regard an oecR:^onaI overotrain 

3, aUNhtly vtf^pruhl h«Arl laith ^imlniihfij loniciiy; 3l vrry wtk 1i«»rl vrlth Inll'■^ iliTninLf<h«il lonioiijr. 

aa of any epeelal significant in bovj', provide<l it were followed by a period 
of sufficient reat. lloreover. Meylan has found that the li^'es of oarsmen 
upon the [Iar\'ard Ijoat-creWH were somewhat longer than the average for 
nornml individuals, in spite of the fact that albuminuria and other signs 
of cardiac overi«lraiii are quite comniun just after such races. Indeed 
not a single case uf cardiac ih.iea--<e develo[>ed anions ihe 152 oarsmen 
of hilt jieries, which comprised membprs of the inU-rcollcgiat<> crews from 
1S52 to 1.S92. There wati only one case in which eidargement of the heart 
wftjt noted and one case of irregularity, but neither uf these inconvenienced 
the patient. 

These contrast to cases like that of v. I^yden. had rested 
aufliciiently between the periods of strain, and the second strains bad not 
been imposed upon their hearts until long afler their stren^h and tonicity 
had returned lo normal. In v. leyden's caw; and otlier cases of jK-nnaiR-nl 




heart failure, the heart was still dilated at the time of renett-wl strain. This 
condition seems to determine the border-Uoe between heart failure and 

The border-line conditions may therefore be i^ummarizcd as followai 
Klatation of the heart during or after exerritie repre^ienta a pathological, 
though not a ver>' infrequent, condition in whirh the heart ha.s overstepped 
il.* liiniiN. .The condition uaually recedes and leaves no tracen unleiut the 
heart in again overstrained while still in a (liliiloil oiin<lilion. 

Aa regards the anatomical changes induced by the condition of over- 
train, Roy and .\dami have shown that, when the dog"« heart bcgini; to 
fail after clamping the aorta, starts occurs in the coronary' veins and th« 
heart muscle becomes ^edematous. This <cdema is especially innrkcd in 
the regions wliich arc richcM in connective tissue, the auricles and the 
auriculo ventricular valves, They behove that when the strain is eoii- 
linued the aidema is replaced hy infiltration, the infiltration by connective 
tissue, and that fibrous myocarditis resultj^t. Indeed, a fibrous myocarditis 
(cardiosclerows) is a common autopsy finding in cases of Inng-contiiiued 
cardiac overstrain in which there hiv been no severe infectious disease to 
account for the lesion. On the other hand. Pcarco and F'leiaher and Locb 
have found exactly the stages mentioned by Roy and .Adami in animaU in 
the various stages of adrenalin myocaniitis (see page 2"il)). 


As long as the heart is able to maintain a certain velocity of blood 
_^,. Atoudiout the cinruSntion, the latter may be said to be comjjensatol ; 
mAwfadLtne blood stagnates to such a degree as to give rise H> the signa 
and sj'uiptoms of stasis, coinpensaiinn may lie sniil to l>e broken. 

There are two forms of broken compensation. When the blood stag- 
nates in the systemic veins from failure of ihe right side of the heart, the 
condition may be termed b [■ o k e n systemic compensation; 
when stasia occurs in the lungs because the left side of tlie heart is not 
acting as strongly as the right., broken pulmonary compensation 
results. Kach of these two forms bring* with it a characteri.nic group of 
sj-mptoms: The broken systemic circnlalion (usually designated simply as 
" broken compensation ") manifests itself in the signs and symptoms which 
are .icen in tricuspid insufficiency — breathlessness. cyaiioi't!", a-dema. begin- 
ning in the feet and legs, enlargement of the liver, and systolic pnbation 
of the liver and veins, etc. Broken pulmonary compen.saiion is accom- 
panied by the signs and .symptoms of an acute .■«e%'ere mitral insufficiency — 
intense reapiraton,' disturbance, dyspnisa. cough, occasionally pulmonarj' 
hemorrhage, and ihe spitlum containing the characteristic cells of pas-iive 
congestion (llerzfchlcrjiellcn). 

Broken Syslemic Compcnsalioo. — From the physiological stand-point, 
the cardinal features of broken systemic compensation are dilatation and 
weakening of the right ventricle, dilatation and paralysis of the right 
auricle, increase n CO, and decrease in O, in the venous blood, functional 
insufficiency of the tricuspid valve, rise in venous pressure (often to aa 
high as 20 mm. Hg) (Fig. 121, Ul). The signs arc cyanoMs, engorgement 
and systolic pulsation of tbe veins, enlargement of the hver, tcdema of the 



foot and leRs. and eometimeit venous stui^m in thv modullft, vasoconstriction, 
Wgh l)loo(l-|trcs*une, nml liyspncea of n«'iiiillar>" oriKin. 

Broken Pulmonao' Compensation.— Tin- clmriictcri»lic8 of broken pul- 
monary eoiii{>eiisHtion nm dilatation and weakeninf; of the left ventricle, 
<lilatation and usually puralyw* of tlic k-fl iiuncU-. rise of piv.-wure and 
tstoitis in the pulmonary voins. ensorRenient of the pulmonar}' ciipilhirii^ii, 
and "erection" of the lung tiswut- (v. Riisrh) (Fig. 121. IV), Welch ha» 
«hown that when the stasia is very intense, pulmonary ccdenia sets lu. 
V. Basch and his pupils huvo applied ihis idea to the milder pulmon- 
ary manifpslaiions and have r^howD that a modt-nitc crcetion of the lung 
tissup bring!? im raniiiic dynpno-a and leatis to bronchitis and cough. Ilia 
pupil. Kauders, has shown that the position of Ihf diaphntgm is affected 
n-flcxly by the amount of blood in the lungs, rongestion causing tb« 
diaphragm to descend, depletion i-uwting it to aiicend. It is thus usually 
)wer than nonnal in mitral lesions, higher in pulmonary aud tricuspid. 











iPt^ fi t'*t^l f ^*t^l| i^^f<>^ 

Pio, 131 >— Diacnim lOiovinB rhmitn in ih« tiiviilAtiiMi. I. ndrniMl; 11. hrok«t Dulmoniuy roni - 
V«nmil*o; III. brolHn iyi(«nii> «ampciukiMni; |V. boUi eomptiuBilDDi tail: iuwk ia luns> aail vrLo*. 
AO, pMMure In llio aona, /M. 

V. Basoh also believed that the congestion of tlie lung» causes (he elastic- 
ity of the lungs to diminish and to become so rigid as actually to diminish 
the respiratory expansion, but the experim<^nl,*of D. Gerhardi have thrown 
doubl upon this phase of his conclusions. As regards the changes of pre»- 
sun? and the distribution of the blood, however, v. Baseh's conclusions 
have Ix^n confirmed, not oidy by Gerhardt in tJermany but by W. tl. 
MacCallum and McClure in America. 

In badly weakened hearts bolh forms of broken comj>ensation may 
be present, sometimes features of one, sometimes of the other, predomi- 

Functional Valvular Insuffkiency in Broken Compensation. — Although 
it has not been absolutely proved, it scemj« almost certain that the occur- 
rence uf broken eompenHatton from acutt- dilatation is accompamed by a 
functional insufficiency of the tricuspid or the mitraj orifice which may 
be of tran.-iilory duration. Indm-d <hi.-< functional insufficiency of the tri- 
cuspid valve in heart failure is much more common than organic lesion of 


ihc valv<\ ftod in loiig'Htan<ling cn«c» u KrcompunuHl by actusl stretch- 
ing of the triciispii! ori6ce (T. W. King, C. A. (Jibson. Mackenzie, Keith). 

T, W. King, ill l>i;(7, (kiiiomnratvd that such fuiicltoiiiil InKutricicncics 
occur at the tri»cupi»l valvci". and even that they were tlependeiil upon the 
tonicity of the vemricular fibrmt; since llip valves which hail bceti in- 
sufficient a ffW huuDt nflcr death held wat«r perfectly after rigor moitis 
hiul sei in (((iioicd in fidl im page 3fl6). These ohsfrvation.-* have ix-en 
confirmed and cxteniled by 0, A. Gibson. Fnin^-oijs-Franck. Mackenzie, 
Kriedreich, Harey. lUntchfolder, Keith. Hering demonstrate*! tlie same 
phenomenon for the miirai valve in rabbits, but found that in dogs tlw 
mitrul valve did not k-jik even after clamping the aorta. Stewart and the 
writer have been able to <lemonstrate Ihc occiirrenee of .inch an insuffi- 
ciency of the mitral valve when the aorta wa* clamped, in dogs whose 
aortic valves had been rendered insufficient. In man Morton Prince and 
Broadbent have nowd the presence of transitory mitral systolic murmurs 
(sometimes transmitted to the axilla) in men who were being i^ulijeeled 
to the htrairi of civil service examinatiom), and in ca,'»e,'< with similar sii:n» 
Minkowski lias obtained tracings frum the u^tophagus which have the form 
cha|-arteristic of mitral inauEGciency. 

in Ihe earlier stages of cardiac overstrain the dilatation of the auricles 
is a more or less passive phenomenon which exerts little inlluenee u|)on the 
circulatioti. but in the murt- severe .itaKCN it. may play a leiidiiiK riilc. 

Auricular Paralysis and Arrhythmia in Cardiac Overstrain. — Condi- 
lions which affeet tonicity and filling of the ventricles liavc a still greater 
effect upon the tonicity and filling of the auricles. It was demonstrated 
by Ludwig's pupda, Waller (1S7S) and v. Krey and Kreh! (1S90). that 
when the ventricles lit-gnn to fall, the auricles soon became overloaded 
with blood and ceased to contract entirely when the pressure reached 
I')-20 mm. Hg. As a nde this does not afTcot the cardiac rhythm, but 
llir^chfcldcr has «hown in dogs that when this ii; brought about by nar- 
rowing the mitral orifice, an ab.solute irregularity (disoiflerly rhythm) 
may scl in without any apparent contractions carried out by the auriclM. 

It MWiiia probttbli! ihiit, luiik'r tli«« rin'iiiruitaimw, llii- contructiuu Klinmll un^iiiale 
in thn aiiricin and an? imnmiiiUeil but an? not cirrinl out by llicjir cliainlirr*: jusl stf. 
Bicilcniiaim ha* itbiiwii Ihitt iiiiincln in wnicr rijior curi onEiiia"- iinil lr*nnriiit » ■tiiiiiiliis 
witlioiil itavlf coritracliniE. Miicki-rixic imil (itbi-rs bplivvi- that uiitlt^r lliiw^ I'ln-'uinslntins 
the stlniubis no li>nttrr tirittJnnl''* in tbi: liniiit jKirtioa of the nurirJc hut in (he Piirkuijir 
cells uf ibv His Uiimlle (»i TuwHrn'ii mxlal |ioirii. Knotenjiiiciki). and hvucv dtviicriuiea 
thia abcolijlc ine(!uluril,v as Dudul rliytlun. Tlii-y believe Ihul IIh- uuride .nml \*eiilrieli; 
arc COntrai'iinK oiniiiltnnpoiisly andrr tbrM- RirciimitiuicvH. f>ii<cc Rdzrr biw t^]u^rMl the 
buadlo ibrpctly itiUi (lie siniis n>|doii nnil belicfcs Ihiit (licrr Is no noilal point, this view 
aecnui open in qutstiuii. 

ArrliythmU.--H'hntrv-tr iiiny lie the origin of Ihc nrrhythinia it i» vrry oiinimon in 
savere It vent mills. This tiut iiirrvifiicnlly urioM In the r»time uf \'ulvulur Inioui an npll. aa 
Mackcnuc I191 pn>\'cd. The nuc cited on iinge-tAOsive* nii rxsnijilc of auch nii Irregulurity 
ariidnK dtirittx sueli un uttai^k and niiiMidiiiK n frw diiyu Utrr nfirr it«t nnd digitalis. FivH 
days Isler the rhythm licrauie rr^iil.-tr and lite aurielm wore cootnrtit); uiioe murv. When 
tlie ovcwtraiii is intin- [irutrueled Ibt- iitiricular cuntnctiun may ivninln abiirat for wrrk* 
and evea nionthii. and most fm|iiently. it it hiis |i<Tsi>.l«l for a mrwiiirralilc tenjtih of tiiTie, 
permandil chniiKcia "Cl in in ihp iniwculaliirF of the wniis region iKi-ilb. Schftnberj;). and 
regulurity Is never reptined. Tlie inline hus tieconie pennanently imtJiiUr ([luUii* irirKn- 
laria perpeluiu. arrliytbinia petpetua). As lias ber.a mxn un page Ti, tlio arrliythuiia 



itaelf ftlovv the blood K(mm and tlv ijumu^tl cmuliiioo of llie mnue pivwnto tli* bean 
froni Hinipmiuitinx for ilua hj- a Bronipr iiunilwr of contrncttoiui. Thi! velocily ol Ihu 
nmilalion i« lliiiHselMiniiliHl. Uitly acntum sniouiilotCO, (icr minillc can !><> Iiikrn tsrc 
of ami any exevttt Imntt* on ovcfstrain. 

Changes In Venous Pressure. — Changes in pressure in the systemic 
veins, whirh nhnw how wt-lt the light ventricle is pumping, often alTortl 
uii cxwilcnl iiuli'x of ihc brenk in syslt-mic hjih pen nation, nting from 
normal pressiire of *)-10 cm. Il,() lo a height of 20 or 2.*> cm. It usually 
r'u--* when the pativnt'.'« eondhiuti hcroniM wor» anil fttlU aa improvement 
eels in (Maoker and Kyster). 

Thft arterial prewure, on the other htmtl, U nfff^cted hy too many 
factors to i-how characteristic chnngcs. It may Ix- kept up until shortly 
^before death, hy asphyxia of the mednllary centres and reauiiant va»o- 
couHlriclor ami uugmciitor Mtiinulittion; or, on tlir utlier bund, when tbiit 
meehaniHiu is not brought into play, the arterial pressure may be low and 
the pube niuy bv ^niall and weak. 


There U another form of failure of the circulation which sometimes 
«!Curs an the n'suh of exertion, even in Iniined athletes. This form ia 
?conipuiiied by pallor, a small rapid pulse, iin<l ."Dnictimcf even by syiicoi>e. 
However, as Uietlen and MoritE have shown, it is not accompanied by a 
[^dilatation of the hviirt, liut, on llie contrary, lh« latter i.s smntler than 
Dnnally. It ia a failuR- of the real of the ctroulalion rather than of the 

It m'lsl Iw- ^Imilt^l tliul Mb condition Iiuk nnT allncMl niUcS Mlt^nliori, anil but 
link' CUD Iw Hiiil of liur mwlmniiimii iin-olvrd. Tlic (wiUor. mniiJl puUe. am! Hinnll heart, 
howcvnr, are fralnivM which art' ulw> eomition In Ilir: onnililion nf Hhiirk iind The carttiac 
nelirowH. In llitvw.- ci-imiilLunH, ihi- iiiifiotliLiil nivchuiiiral fticturs an.' Iht- uceuiiiiiluliou uf 
btuod in thr <tilaU?d atidniuinal vrinr . icii'init rine tn u Urn- vciiout jircuurv. Ihit dinuniabed 
lUlinji of thrv hi'ait, »n<t roti>>e<('ieiilly (lie diininiihpil niiiput iiiii> tlir aorta. Thvaymp- 
l«ii)^ ant Byni|)luniB of " arU-Hul uintDiiti." 

'Vbf tiiiiKal fiictnr in liriiiKinii iilmiil ibiii condllion niny hr dilntation of the veiiWv 
In ihi- rauw" of exercif* lhl« vi-im- »iiil MismliluiHlioii may rwiilt eitlipr rrflcily from <li»- 
lurbed ditcmtiun. or. pcrfiii|». a* Hcmlcwon lUKgrntu tor somewtml similar coiiditiutui. i1 may 
■•I ill nhrn Ihc m{>idiiy of l>mithii>K eicmsia thai npci'»tiary (a at^ratc^ the bliiod. «-efi lo 
tntrl the incmt.-tHl iip<mU of the IhhIv. t'liikr lUvae oniiitiono CD, leavm die hiiim. nad 
lienw also llic lilooil. ■ lillb loo nipidty. ocniiriin ffnull*. nii<i. a* its ftint c ITi-ct. bIIovtb llw 
veins tu dilatp ihv \mgt 31). The blood thi»- iil.iKnnrrst in the vointi. A* n rnallpx of fad, 
Kniiw. Zanit iind .Schiinibiii];. and alw>A. Loewy lisvu nIhjuii tliat a) thiH *laiK ol cxcteW 
iCXi, u sivi-n uff from llw luttn* ihiinbcfow. and Ihnfiwiiiratoryqiiotionl ('(>,iiili!«H:ocd. 
ey hfthpvc tluit oniilntion i* lew iil Ihjii BlHite and hence l*i« (.'O, in preMMil in Ihn blood. 
In other mdhIh, fnitii a totally iliffvrvnt iitiiii't-tiuiiii. and ycnrx Iwfun Elvodcnmn'ti experi- 
Blent. it (vn* nMidrrrd pcohalilc th.->l s xlnie of aca|>nin ia |>r»itnt at llu; itajci; of fatisiie 
intatMcitawot endunnee, and therefotv lliikl the niechanism nhirli lieobwrv«d tabeaclive 
in acaimia in liusely twponnble for this funn of circulatory failure. 


It iil evident from the facts discussed above that the motft important 
question in the functional study of heart failure ia to determine accurately the 
border-line between fatigue and o%-er»tniin, to di^itinguish between the nor- 
mal anti the pathological. Various tests have been devise<l for this purpose. 



1. Ponurol CbotisE in Pube-tatc — The riac in tbo pii]«f<rat« which oc- 
cun when the patient sinnd* siter iying dowD H of aosav iiufiurtuiw*'. UixWr 
noraud condiiitfiui the acccieraiUiD in nut mure than twenty beaU frr minulc. ibe. at-ernitB 
aoorlention for Dormal inctividmla being wircn- Ilow^iir, this depend* upon auny 
(notora. uoe of which is (lie length of tiioe dariDK which tli« patieat htm lain down, bin >late 
o( mental pxcitcmml or quiet, etc. The jwyehic element piny* a pankulariy important 
M«! in thii icAl. 

2. ContracliiMi of AiKasonJatfc HnKk*. — Il«rz \iaa iiilnMluciMl another pmcedutc, 
the irlf 'Checking or K(?t f-an I ugoniii lis tnt U'^lhalhRinmuaipiprnhr). He 
counu the pulee over a period Imiic cnoiijili tn »t*iire a reaMinahly oxitiliuil ral« pur [niiiute. 
Tlie patient ia then miule lu lil duwn uihI vcrv slowly Bex snd pxictid (he right forcann, 
piittinu. all the while, hi* fiill atlttntioa upon the mn\'cinrnl. but conlnKIinssimiiltaneouflly 
(he flexoir aixT ex tensor miuwIeM of the arm, and aticni|?tinK «■ aii(a^:onize lii« uwii iiiuve- 
ment with nil much force ua puaiiMe, Thia conTrrts the cscrcue Into a mild exemiw of 
■trein. tlen staler that in nomiAl IndtviiliiaU ihia caiiBTK no ch.tnge in pube-fat«, 
while in ibune with feehle lieurla (lie pulir-rate ia ■ 1 o w e '1 o-20 beats per luiiiule. IPer- 
haiM t!iii> i* due ti> the mom vigarotin cxptratoty effort which Dccompcuuiv this procedure 
in pernona with iliwaAei) lwan».) Cabot and Dnicc hnv» rvpeateil llers's ohfcrvaliniw, 
and lind lliut Ihey uiv correct in at leant a ciertain nuniticr of c«ms. but they are unwilling 
to inib»cril>c to hii ({cncnU rule. Tlic writer alui hiw found a number of perfisclly atrong 
and healthy iniliviiltiiilm viho zivc Here's jiaiholoffical reaction. 

3. KlK of fIlood<pTeuur« oa CotiUricOnt ih« Femoral Arl«riw. — M a r e y (tSSI) 
demoniitrntr'l thnt in noniinJ inilividiiulu the blood-preiiure roue when both 
Temoral and liolli brachial ar(cric« K'erc coniprMsed. Katienalein found that on com- 
preeaing both femoral urtcrie* aloue, in 

BI™«t-pr»"UfB Palw-rei* 

Normal indivldu&ls Rraw .'i-K') mm. . Fell. 

Con>pentBt«d cardiac Iniona Kuw 15-^0 uun I'nehanged or fell. 

fHight cardiac inauflicipncy t'nch.inKed Unchanged or roae. 

Very weak hearta Fell FsH. 

Uolcc And M^nde and othem liai'c repeated KnixenMein'a obMTVntinnn, and find (hat, 
though the«e results buht true in general, the inetliod in unreliable aa a (e«( and in bad 
caacB is tixi dangi^miw for uiie. 

4. RIk of Blood-prcMurc upon EurclM. — Another method, introduced by Orftupntir, 
of Naulieim. dependu u|>on the rine of blood- presiure which occura dur- 
ing exercice. Gnlupner found thnt. an MiuInK had nhown. mild rapid excrciae. such 
a* wnlkinx up and down slaini ra|iidly. etc. caused a n'w of blrKHl-pmunirr in norninl indi- 
viduals but a foil of preniurc in Iliooe with failing hcurln. Mis ubservationo have been 
repeated on a eoniiidcRible seriea of pntimi.a by Rnur (alio of Nauheim). Buur used the 
stationary bicycle a* a test, rturulatfnj! the effort by applyiniE a loaded brake lo the wheels. 
He found that in norma) individuiiU tliero wiu at lirit a ri.w of S-10 mm. (In and later a 
fall of .S-ll) mm,, while in intiiiRicient henrls thrtr was n fall of .^-30 mm. Ilg. 'I1ie liiuil 
of perfontiance of the latter waB 4S-300 III: of work, however, only a "raall fisction of that 
wlilch could be done by the normal individuals. Cubot and Bruce also have repealed and 
cuofirnuid Gniupiter'a olMWtrvnttnn, and believe that it will pn>ve of avistanoe as an aid ia 
functional dtaxnosls. 

That a close rolationiihip exists belwcen the increase in blood-pressure 
»nd the iiicri'iiHG in tonicity [stimulatioa of augmentor libn>)(), which re^iults 
from strain put upon the heart, iiiiiy be seen from the curves of Hirsch- 
felder and Cameron in the dog's hcurt (quoted on page 13.), and shown in 
Figs, lis and 11!)). It is probable that, in most cases, riw of prt-ssua* cor- 
respond.'* to inrroa.-'cd .-(ystoHr output nnd coneomitant increase in tonicity. 
Il muKt be realized, howe%"er, that in some cases the rise may V>e wcond- 
ar>- to stimulation of th<! vasoconstrictor centre from medullary status or 
asphyxia, but may rcprrsent an unfavorable condition. 


r SeiTrul objcvtioiu may be made to the value of thiit test: 

1. G, A. (lonlon in (i. A. Glb«on> t-limc and nlno I*rofmK>r Dnwiion, in eaUnboration 
with Prnfrunr E)-it(^r sad uJsu u-illi Mr. l{«lGel(l, h&vc shown tliat Ihe bloud-prtHsuni 
ill Imtneil ai.hlrict fnils liuring tnild exereiae exactly a» it doca iii tiiokvii 
cumpeuBUttixi ; u1m> tliut it Talla when the "sooood wind" la acqtiirod and while tlie 

I ptraon's funetianal power is incrviuiiig railier thua decreasiiig. 

2. As Alrfady iihom by MmiinK, the Ktvnlntt riic» ol blood-praaaur* 
occur in i)i<l and f«eble pnraom. whom ihe eufercise briu^ oeiir to ihe border-line of cantiM 

3. In persona in whom ilie full in Vilooil-[>re«eure occurs as a result of the test exercise, 
the genemi »ynipl»nui. rt«pirnt(iry ilintnaa. cyiuii»iii, etc., to auy aotliioc oS the dimiiiiiJicd 

r-dccre&xe in ihe »icp of the piil«e, tachjcanlin an<l .irrhyihmta miultiDE, Arc more than eiif- 
licienl «vi(lriice that the patient's ntreiigtli hiu been Dvcrtuxed. 

4. Thew Eimplrr clinical niAnifoitntioiM am more dclicuic iiulicca and mn lew ambig- 
UOUB BJ^us than are llie Q^ianKM in l>loo>l-pn>Mure. 

Tlie rccont itudien of Scholl. cic iu Ciimp. v. ("riegcni, Homuiig, Moriti and hia pupiU, 
taken in conjiinelinn with the phyiiinloKicnl cxperimrnl* of 
Prank. Hirsehfelder . and Cameron, indicate that the only true 
numerical criterion of cardiac efficiency in whether a xiveo 
• train csiiiie« it lo diminiih in iiiie(increaae in tonicity— atiiDu- 
lation) or to dilute (decrease in tonicity — overet rain). 

I Functional studies upon the bordeMand betwcvn functjonal suffict- 
ency and cardiac failure aro of ihe moat fundatnenlal importance, and all 
the f»ct« uddcd to our kiiowlcdgi" of the .'*iil)ject are of the grviilesl value 
in adding to our understaniliuj; of the subject. 

Observation versus Estimation. — However, it mu»t be admitted that, 
in order to be decisive, all these tests usually have to be pushed to a point 
at which the apiwarance, sensation.'*, ami signs of th*; patient arc in thcin- 
Dclves perfectly characteristic of cardiac insufficiency, and at which, for 

Ldiagnoetie purpoma, a little cominiiii-sen.-<e observation in at leaat as unam- 
biguous a» obwrvation with elaborate apparatus. This tlocs not meaii 
that exercise tenia are unimportant. On the contraiy, they are of the 
gn>atct^l value; and no change in the patient's mode uf hviiig during con- 
valescence or during after life should be undertaken without them. But their 

[importance depeniU more upon the care with which the physician watches 
the general appearance and condition of the patient . the rapidity with which 
he recovers from the exercitte, hi.* general condition, and whether nervoua- 
oes-f, irritability, cough, or insomnia have set in during the twenty-four 

' hours following it, than in the numerical change.t which occur at the moment 
of exercise. The symptoms to be looked for as evidence of overwork are 
diflcuii«ed in more detail in the instructions for giving Schott exercises (page 
105), These arc subtler mnnifei^itations remilting from imaller changes 
than may be detected by even the most refined observations by mechan- 
ical method.-), and which are le** easily masked by ainliignities. Moreover, 
it must be rculixcd thut any one form of exercise furnishes data which 
may depend as much upon the condition of the skeletal muscles as upon 
the heart. The blacksmith with a diseased heart may be able to do more 
work than the book-keeper with neurasthenia, and yet umler the conditions 
in which he livcti, even if not under the ."ttviigth tcjit arranged for the average 
man. the bhtcksmith's heart may bo failing. 

Relation of Pumrtional Test (o Mode of Life.— In diagnosis, prognosis, 
and therapy, the testing of functional insufficiency is a matter of Hociolog>" 


as well as phy»olo)0'- The iuportant question is not what the 
patient can du in a gy mii n-tium, but whnt he enn ilo and 
what he can not do in cvery-day life. Each roan must be lit 
for hi» own mod« of life or muat be made to rhan^ il. His curdiae jxtwer 
ni\ifli be studied with a-ference to that mode of life rather than with ref- 
fn-tK-c lo a rigid scheme. 

Probably the most thorough syittem of routine functional testing ever 
iostitutod v.'iut thai roitorted to by J . M. da Costa during ihe Civil War before 
he permitted his eoiivalescvnt^ from cardiac uvcnlrain (o irtum to active 
duty with their regiments. He subjected them first to light camp duties, 
then to guiird duty, then to provo:>c duty. »nd Inter iniulc tlicin run frequent 
races comparable to charges upon a battlefield — each test commensurate 
with the mode of life which the patient was about to live. Step by «tcp 
he ascertained the endurance of his patients without overstraining them, 
and thusi obtained a series of |xrrnianent cures which stands as a worthy 
monument to one of the moat cun-iul and brilliant of American clinicians. 

PAtHOLuaicAL PBTSioioav or Cakmac OR[\. 

ticCurtly. J. H.; (IITcci of Maximal MiiMrultir LITort on Blood-premiirc, Am. J. Pliysiid., 

Biwl . IIHII, V. ttS. 
Muaiii)!. K. : L'L-ber Oiui V««halicn cin Bluttlruclui dot iungm und dw bcjihrlcn ^uchnti 

bci MmJtrkrhi^ii.. IVitlM-li. AkIi. f. klin. Med., Lcjpz., 19U1, Isxiv, SSa. 
ErlunK^r. J., uiui lf<xikvr, I>, It.. \ii). p, 3a. 

DuwDun, 1'. M.. and ByiiCvr. J. .\. E.: t'npublialuHl olHien'utiuiiH. 
(.iordnn. (i. A.; Olwprvatianii nn thr ICIToct ai I'roInnKcd nnd Sevi^rp F^icertian ou the Blood- 

praHurv in HMllhy Atli1«tv«. Bdinb. M. J., VJOi. xxii. .^. S.. ^'(. 
Tangi, V.. and Zuotx. N,: I'cbcr die KiiiH-itkiui]{ drr Miwkdiitbdt niif den Bluldniclf. 

Arch. r. d. KM. Physinl., Bonn. ISKtS, Ixx, M4. 
Kuufiruitin. M.: Kvchtn-hm i-K|H>riiiiFii taint sur lu circulation duu lea musclo* «n acUvil^ 

phj-«iol<))(iiiui;. .\frh, ill- I'lijTiiol., Par., 1903. 5 *cr. iv. 278, 
ChAiivi>ati, A., nnil KAiirmann, M.: Coinpt. rend. Acad, (Im 8c,, Par., 1SS6, Nov. 29, and 

May te. 25. Juin- 20, 1SK7. 
lining. II. E.: t'cbcr die Brairbunitvn <Ier oxtnicnrdinlRn IlrRnprvcn aiir SleiKenine der 

lUrxtchla^iilil Iwi MushellhftliKlwii, Arch. f. d. ^k Phjfiul., Buiiii. ISUS. U. 429. 
BuvLTii. W. P.: T}ie I'lilw-Rtte •■ Uodifiiil by Miucular Work. CUintrili. Sc. ilcd,, dndicstrd 

Ui V. <:. Vauichan. Ann Arbor, 1901. 
DawMR and lletrield: Unpublished ob«er\'aiion. 

ZunU and SchutnberR: .Studicn xu (Hntr PhjndoloRie ifm Slnrehr*. Berl,, 1901. 
Hough, Th.: On ihd Physiiiloicii^nl RfTcctia nf Mo'lcrnle Muwilar Activity and of Stmia, 

Science. luncaHler. liKiU, N. t^. xxJx, 4S4. 
Blake, J. B.. and I^rmhrp. K. C. iViuinell. D. It-Tilcnton. W., ICmpnton, W. R. P.,SlroD£, 

L. W., and t^onnllv. J. M.: Obwrvalions upon LonfE-diNlance RunncTB, Bott. M. and 

8. J,. 1903. (-xlviii. ig.V 
-Abcrefombic, It. T.: Prnmnal rotnmunieatioa. 
Pivtlrn, II., and Moriii, F-; I'ctwr das VlHiallen deb Herteru nacli iHiu^UMmdKU und 

aunt nriif^endem Itudfubn-n. Uunctii-n. mptl. Wchiuchr,, lOQt. Iv. tSO. 
fjoewy. A.: Die WirktiiiK rtmiidcnclRr Muikrlnriiril auf den mpiratorificben GanUm- 

weclisel. Areh. f, d. bc*- Phy>iiol„ Bonn. xlix. W5. 
Ztmti. L.: [.'ntera<icbuap-[| ucber den (iiunvclucl und GneTfcieinuuita do Rndfnhrers, 

Ik-ri,, 1S!>9. 
Bruek. E.: I'l-lier den Bluldnick bei ptOCtliciien ilarkeii .Aiulrennungen unil bcjm Val* 

■ulra'Mlicii Vi-miich iit-bul Bt-rnrrkuniien uebpr flic hitrlit^ rintrriirHirn VrnwrdBtun* 

gea dcr lIent)tri>Bp. IMilfch. .\rch. f. klin, Med., Leipi,, I',IIT7, sc. 171, 


De la Carop, O.: Experimentelle Studien ueber die acut« Herzdilatation, Zlachr. f. Idin. 
Med., Berl., 1004, U, 1. 

Epkbct of Bictcle Ridikg on the Hkart. 

MendelsohD, A. A., Albu, Beyer: Quoted from Moritz and Dietlen and Kienbock, Selig, 

and Beck. 
Moriti, F.: Ueber Herzdilatation, MUnchen. med. Wchnechr.. 1905, Iti, 681. 
Moritz, F.: Zur Frage der akuten Dilatation des Herzens durch Ueberanstrengung, MOn- 

chen. med. Wehnschr., 1908, Iv, 1331. 
Schieffer: Ueber Hera verfirocsBe rung iofolge Radfahrena, Deut«ch. Arch. f. klin. Med., 

Leipz., 1907, Ixitxii, 604. 
Dietlen, H., and Moritz, V.: Verhalten dca Herzens nach langdauemdem Rodfahren, 

Mtinchen. med. Wehnschr., 1908, Iv, 489. 

March I NO. 

Zuntz and Schumberg, I.e.; Albu and Caspari, Balders; Heichelheim and Metzger: Quoted 
from Kienbock, Selig, and Beck. 

Football Playing. 
Pick, F., Schig: Quoted from Kienbock, Selig, and Beck; also Gordon. 


Gordon, G. A.: ObtiervaUoDn on the EFTecta of Prolonged and Severe Exertion, Edinb. 
M. J., 1907, X. S. Mil. 

Ski Running. 
Henschen: Quoted from Kienbock, Selig, and Beck. 


Schott, Th.: Acute Overstraining of the Heart, J. Am. M. Assoc., Chicago, 1907, xlviii, 

Levy Dom, Selig, Mendl and Selig: Quoted from Kienbock, Selig, and Beck. 


Kienbock, Selig, and Beck: Untersuchungen an Schnimmem, Miinchen. med. Wehnschr., 
1907, liv, 1427. 

Frank, O.: Die Dynamik des HeramuskelB, Ztschr. f. Bio!., Mtinchen., 1895, xxxii, 370. 

Howell, W. H., and Donaldson, F.: Experiments on the Heart of the Dog with Reference 
to the Maximum Volume of Blood sent out by the Left Ventricle in a Single Beat and 
the Influence of Variations in Venous Pressure, Arterial Pressure, and Pulse-rate upon 
the Work done by the Heart, Phil. Tr. Roy, Soc., Lond., 18S4, Pt. i, 139. 

Roy, C. S., and Adami, J. G.: The Failure of the Heart from Overstrain, Brit. M. J., Lond., 
IS8S, ii, 1321. Contributions to the Physiology and Pathology of the Mammalian 
Heart, Phil. Tr. Roy. Soc., Lond., 1892, cbuxiii, 199. 

HirschFelder, A. D.: Recent Studies on the Circulation and their Importance to the Prac- 
tice of Medicine, J. Am. M. Am., Chicago, 1908, Ii, 473. 

Cameron, P. D.: Physiological and Pharmacologic^ Studies upon Tonicity of the Mam- 
malian Heart, Thesis, Edinburgh, 1908. 

Hyde. I.: The Effect of Distention of the Ventricle on the Blood Flow through the Walls 
of the Heart, Am. J. Physiol., Best., 1898, i, 215. 

Meylan, G. L.: Harvard University Oarsmen, Harvard Grad. Mag., 1904, xii, 362, 543. 

Welch, W. H.: Zur Pathologic dee Lungeniidems, Virohow's Arch. f. path. Anat., Berl., 
1878, Ixxii, 37.^. 

Sahli, H.: Zur Pathologic dea Lungenoedems, Ztechr. f. klin. Med., Bed., 188S, xiii, 4S2. 
Zur Pathologic und Therapie dea Lungenoedems, Arch. f. exper. Path. u. Pharmakol., 
Leipz.. 1885, xix, 433, 

Klinisch-ex penmen telle Untersuchungen bus dem Laboratorium von S. v. Basch, Berl., 
1891, vol. i; 1892, vol. ii; 1896, vol. iii. Vol. i. Groaamann, M.: Das Muacarin- 



LuuK«iio(Kleiin. p. ' (nbo Zuclir, (. klin. MeO.. Ui^., 1SS7, xU, AAO}. V. Baack, S.: 
Utbor cine Function dea Cniiillnnlruck* in <icii l.iinicnialveokn. p. 49; fnlholcijQO 
der tardiolm Dyipnoe, p. 53. UnNttDk&nti. M.: Expenini-uidk- L'nlcniucliiin^ii zur 
I^chre voin actiwn aligcnicincii Liinseriuciiuni, p. NO ^alw Ziwlir, f. klin. Mod., 
«vi). Itettrlhcim, K.. wJ Kauder*. F.: Expcrinienielle I'lilemucliungm titber die 
kiliiHtlicli ^rxoiiKl'^ UilraliuiulBcii-nx luiil ihreu ELiiHuiw niif Krriolnur uiid Lunge, 
p. 144. V. Hoacli. t>.: Urlicf I.iintccnM'hwDlhinR iind l.iiiiifciinturrlieil. p. 171; Zur 
L«hrt' von ilrr cinliakn iJyjipnDC, p. IS.*(; Uebcr Lungwischwi-llmig bci drr r-!ir<lia!cii 
Dynpnoe ilva M<^iibcIicii, p. li(8. Kamkni, K.; (Jcbcr ^nim Ex|>eriineiilf lur li-hre 
von ilp( I'nnliiilpii Dj'Bpnoe. p. 211. Vol. u. Zfriier, Tli. J.: VAn-t cicn Einfiii** der 
DiimitiiliH uiif <iie RMpir.ilion, p. 19. (iroiuaiuiiin. M.: Kctirr Slniiiinmrli^/iieiwuiie in 
den Lutigfii, p. 30, Kunifdd. S.: Experinienc^llcr BeilrUK itir Ltfim vum Vrium- 
dnick im VMrnt d*» linkeii Hi-rarnB, p. I2l(. Vol. iii. Uctgctin, <^: ExporimpnI#Ito 
UutvniudmniKn ueber die Wiikiing dcr Dourhn, p. 1. Zertier, Th, J,: Klinisrb- 
CKperimciiii-Uc Untertuobungen ueber die turdiult- l)vB|)n(ie. p. 77. Btida}', K.: 
U^ber die UvrxfallunK wtbrmd dcs Lcbetig unci nach ilrm Toilr. p. 100. \S'[nklcr, F.: 
Experinwiitetle Studivn ueber die Funklionelln MiiraliiMulTicieiit, Ztschr. f, klin. M«d., 
BmI., 1809. xxsvli, 456. 

GerlianJt. D,: Ucbor die Compcnmiion von Milmlfehtcro, Areb. t. <!xp«r. Path. u. Phar- 
inalwl.. Uip>., 1001, xlv. 186, 

MacGkllutn, W. C, and McClurc. K. D.: On the Mi-chiuiicBl EtTvcU of Uilrnl i^trnmin and 
InaiilHciency, Tnin«. Am. Am. Phyii., Ptiila., \9W, xxi, &; iukI John* Hopkiiu Hoap, 
Bull. 1006. ivu. 

Ilf^rinji, II. B.: Zur pxprrimcntcllc AnnlyM <l«« uorcgdmfUBigcn PuIrm, Arch. f. d. gM. 
Pliytiul . Bunii. IMM), Ixxxii. I. 

Miokowiikj, ().: Zur L>FUlung der Hrrurli,vlhmieu niitlelKV dui usopli^eukn Knrdio- 
KrHjnme, Zlimhr. f. klin. Mnl.. Ilcrl.. 1906. Ixil. 

Prince, M.. Physiulouical Dilaiuifun and ih^ Mitral 8phlnct«r &« Faciorv in FVuieCio«i&l 
*nd Organic Uinlurbiuicn of tlie Ueut, Am. J. M. Sc., Philn.. 1901. cud, 18S. 

Broadbvnt. (luutcd fruiu Prince. 

Wftllcr; Uin Spannunfi in den Vcir!i6fen dcs Heraenn wabrend diT Koizung dc» ]lak> 
inarkt«, Arch. f. Physiol., I^ipz.. ISTS, A25. 

V. Frey. M., and Krvtil. I..: riilerH>icliur]Kt.'ii uclifr den I"iil«, Ibid,. ISOO. p. 31. 

Biedemuinn, W,: EIrcif(ifihys)<)l<)gy, trunsl. by V. .\. \\'flby, Loud., 1S9H. 

Kniiis, Fr.; Die Ermfidunjt al» Maw dor Constitution, Bibtiothw;. Mrd. C'mwI. Ahlli. D., 
18fl7, Hoft 3. 

Stfiphrnn: Rlooil-prMwiurp and Pulnc-rntr a* Iriflurnci-d by Different PUiiliona of tilt 
Body, J, Am. M, Awoo., niieajBio, imM. xllii, U.'.j. 

Hera. M.: Eine Funklioimprilfuug den Kniukpii Htraeiui, Deutacli ined, Wchiwchr,. 
l.cipi., iwn, xxxi, 2in, 

Cabol. R, C, and Brucy, R. B,: TTie Enlimalion of the Funclional Phwer of the Cardio- 
viuculitr Apparatus, Am. J. M. Sc.. Philn- and N, York, 1907. exxxiv. 491, 

Marry, P.. J,: Iji cirrulniion dii ksinc n IVtnl phyiiolojiique ct dnii* )» m.'dadin. Parin, 1S8I. 

KalM-finl^in: L'eber vine npue Funkliuus prilfunif d» Ilcirt'iiH, Deuloche nied. W«bniichr., 
l.«ipi. and Btrl., 190.'i. xxxi, m$. 

Ilokr. B. and Mendp, J.; I'elter die Kaltrnairinnrho MHhodn xur PnifunK dcr fitn- 
kratf. Berl. klin, Wt-hnsclir,, 1907, xliv. 304. 

Ijevy: I'ptipr Kraflnir-iuiunK des llprtciw, Zlnchr. f. klin. Mtd., Barl., 1906, Is. 74. 

Prllner, B., and Rildinuer, (',: Bi>itra« sur FiinktinneprQfune dm IknwnH, B«rl. klin. 
tt"chn«hr„ 1907, xliv, 417. 47i;. 

fiwupni-r; Die Memimg dcr ITirxkrafl, Hunehr'n, lOO.'i. 

Baut, Fr. : Zur BeiitimniurLii: der LeiHluriKsflihExkeiT des |£e>unden iind kranken HcrBCiu 
durdi Huikelurbeit, Vcrhaiidl. d. Kung. f. inn. Med.. Wiewb.. 1904. xxi. 620. 



The symptoms for which a patient suffering from cardiac disturbance 
presents himself to the physician are variable, and frequently seem so far 
removed from the site of disease as to mask their real origin and even to lead 
to mistakes in diagnosis. Accordingly, it is important to consider the 
symptoms early and the conditions giving rise to them, remembering that 
in general they are due to (1) slowing of the circulation and local aniemia 
or accumulation of CO,; (2) overfilling of the veins with blood; (3) disturb- 
ances in the nervous system, of circulatory origin. 

The following are the main symptoms associated with cardiac diseases: 
(1) shortness of breath; (2) cough; (3) swelling of the feet and legs; 
(4) urinary disturbances; (5) palpitation of the heart,, precordial pain, 
pain down the arms; (6) digestive disturbances, indigestion, vomiting, 
abdominal pain, jaundice; (7) general nervousness, occasionally transitory 
delusions and hallucinations, sometimes fainting spells. 

All these symptoms are liable to be increased after exercise, 
excitement, or worry, on account of the increased heart-rate and 
often increased blood-pressure that accompany them, and the conse- 
quent increase in the work of the heart. They are also much increased 
by damp and sultry weather when there is little air stirring. The patient's 
color is then usually pale, showing a vasoconstriction to which some of the 
embarrassment is probably ascribable. The symptoms usually improve 
when the weather becomes clear. 



Shortness of breath is usually the earliest and most common sign of 
cardiac failure and especially of failure of the left ventricle (broken com- 
pensation). The foundation for this doctrine was laid by the classical 
experiments of Welch under Cobnheim's direction. Welch demonstrated 
that in conditions in which the force of the left ventricle was impaired 
without impairment of the right, cedema and congestion of the lungs set in, 

V. Basch and his pupils, Grossman, Bettelheim, and Kauders, have 
shown ^ in a very careful series of investigations upon animals — that 
dyspnoea and the other respiratory disturbances of heart 
failure are due chiefly to. stasis in the pulmonary capil- 
laries and veins, and are associated with rise of pressure in the left 
auricle. Under these circumstances the elasticity of the lungs is probably 
diminished and the volume of lung tissue increases. The respiratory 
excursion decreases. These conditions disappear when the output of the 
left ventricle (and hence the suction-pump action of that chamber) in- 




creases tufficieatly to pump out the excess of blood from tbe lungs and 
remove tho stssU. Accordingly, an \i the common cllnicail experience. 
Bovcru ilyHpnnc-a b an early tugQ of mitral lesions, which readily comes 
and goes witb slight ovon<trajn8; while tn aortic dii<C9u<« it i» a «ign of a 
severe hreak in campcD«ation, and often indeed of a secondary mitral 

This group of symptoms — cough, dyspnoea, cardiac 
aHthma. pulmonary oedema, pulmonary hemorrhage — 
confltituto a group of symptoms characteristic of stasis 
in the pulmonary veins (broken pulmonary compensa- 
tion), just as cyanosi:*, enlargement of tbe liver, and 
ttflccnding oedema arc characteristic of failure of the 
right hvarl. In Wilkinson KiniLc'-* ".*af<'ly-v»lvc action of the right 
ventricle" failure of the latter substitutes a slate of broken svstemic com- 
pvns.ttiun fi>r oiii* of bn^ki-n piilnionar^' ronipniMition. 

Itubow has shown by r^pirumitric isvcj^tigations that in cardiac dyfi- 
pnu-a there in a tendency for the lungs to a.«sum(> the gr«at«^ possible vol- 
ume (diaphragm descends lower and lower) just us is the case io emphysema. 

Accordini; lo Knkun ihc aniuuiit <>f O, takra up hy Ihr Moot aod of CO, f^vm ufT per 
ininUT« i» practically unchnnti<HJ in cnr^liiw fniliirr. Thn comliiionii arv thi<n>(OTV praclicnilv 
■nnlugouiloZuiitiandSchiinibiirK'itOKtirriiii frit. ill uluvbiucnvBinclbt-'COiUi tl^iiupinHl 
air caiwcil poJypno!* And caust^l l)ii! total utnoutit of nir taken into the hiiitt* prr minute 
lo rJM treBi«n(loii«ly mtboilt iklicriiiK liic ninnxnl of ox>Kcn i»lu>ii up by ih? tilixxl. It 
b p«t>bal>li! tliuL ilaais in t1i« pulmonary capiUaricti stiiuulalva the vngus didiiiga in tbe 
tatae wny m dora i'O,. 

Orlhopntra.— One of the most striking features of cardiac dyspncea ia 
the fact that it Is increased in the reclining poe^lure and relieved by Mtting 
up (orthopnoea), although this position favors the accumulation of 
a:idcma in the lega, unil, as Krlanger and Hooker have shown, imp^-dcs tbe 
total velocity of (he circulation. For this fact there may be several expbt- 
nations, or, more accurately, there may be several factors invols'ed: 

1. Ak Htibow lu« iibowR, when tlic patient t« (iropppd up, hi# livi-r and <Usp(iragm 
deaceiid, and tKerp U thtw mt>n> air apiico avnilabie in the thoracic cuvil.v. 

2. Siiict' ilie tiMul up aiid fi^l down iHsilion Icnda to iiupujc the trtTim of venoiui 
tilood from the Invrr nxtrcmilica. trunk, niid nlxliimiin, it Thiin Ipndti to c<4U&liIl^ tlie octivi- 
li«or the rii;liti>iid left i'«nInclM, By Bluniiij: tlipiiitlow of blood into thelutigait rRiiblco 
the irmki^M'd left virntriele to doplelo the pulmoniiry cnpillnrir* nrnnt elTpctually than 
wuuld occur U more Wood wrm ihmwTi into l hein by llie n-liiiively utruiiscr right ventricle. 

3. In tbe bead <lp pcvilion tht- vviiu of tlir mpdiillo dniin marc rradily. Ihiw dimininh* 
tnjC vrnoiifl Rlami in the mecltilla and coniv<|iiifnlly »Im) iliniinlBliiiii: Mie dli-ct of dirvct CO, 
Blimulalion of tlw vaKUS and mfiiratory ccntrni. Thui etTivt of i\ik errri poration in ditntn- 
lahing Ihp volume of (■>. Ibe blood in) Iho bniin is mU known to hndn minieoDS, «ho »oii»e- 
tlaiM make nw) of it for penettaiiiis to othnrii'i*ie inwomrible placn. 

Cardiac dyspntea is partirularly marked during sleep, partly because 
the diminished sensitivenesa of the rrapiratory ponlrcs allows CO, to acou- 
ciulute (if only momentarily) with greater ease than during periods of wake- 
fulness, and partly because the musrrles of the lai^-nx relax, the Inj^-ngeal 
slit id narrowed, and air enters th« lungK willi mora tUfficulty, thus allow- 
ing a slight asphyxia to set in. 

Cardiac Aalhma.— Occa*ional!y the respiratoi^- dlstre^ takes the form 
of a definite paroxysmal dy.-spno^ or cardiac asthma. These paroxysms 



arc particularly common in aortic insufficiency or roronary «;tcroKis. They 
frec|iiently occur at llit- niumoiit o{ uwukoning; or, more accurately, the 
patKol is awakened by the need of air. C*>, having accumulaUx] during 
sleep, owing partly to the slower respiration, partly to tho ahove-mcn- 
lioncd n-lnxfttion of the laryngwil rouscloi-. This factor may also give ri»c 
to an acute failuri; of llie left voritricle from impairv'<t nirdiuc tonus which 
arises during the mild aoiphyxia that has preceded, Perhaps the dyspncca 
ia due partly to heart failure and partly to respirator}- failur(^. 

While the patient i^ awake, such attacks aro somcttmeH brought cm 
by the act of defecation. Thia is not surprii<ing. sunce defecation presents 
a typical Valsalva's exijcrimcnt, in which, as previously shown, a great 
strain is thrown upon the left ventricle, sometimes severe enough to pro- 
duce a functional niitrnl innufTiciency. 

Morphine and Strychnine in Cardiac Dyspntca.—Such attacks of car- 
diac lufthmn may he relievetl by morphine, but the continued use of 
morphine for this purpose often has a bad effect. Though it momenta- 
rily rcheves the di-ttress. it also diminishes the irritability of the respira- 
tory centre and thus allows still more CO, to collect in tho blood. The 
patient then requires still more morphine to quiet him, and a vicious 
eirclti is introduced : 

Ac«uiniiIntion of COi _ „ , . 

inU>«Im.e< - I'Oroxy.m of dy.pi>«. 

1 i 

DimiaUhed (niUbility ^ Momhn 
of impitatory centre *~ '^™P 

On the other hand, tho patient so quickly aequin» the morphine 
habit that frequently he brings on a paroxysm of dyspnoea voluntarily in 
order to get the drug, and docs himself considerable harm by this efTort. 

Under these conditions strychnine is the drug indicated by its pharma- 
cological action in stimulating the respiratory centre (as Eyster has shown). 
Wlicrc strychnine (.002 to .005 Om. = gr. ^ to gr. ,i,) or with atropine 
(.0005 Gm. to .001 Gm.- gr, yij to gr. ^) does not suffice, morphine may 
have to be given, but it is best to give some strychnine along with it. .After 
tho firxt dose it is frequently possible to obtain the quit^ting psj-chic effect 
by injections of distilled water or of strychnioe alone without giving rise 
to the morphine habit. 

Cardiac Aiihma frnm fiatai Dficiuc. — Annthdr form nf anthina with canJUc ii>'m|ilomii 
ha* iu oripD nol nilliln Itii- hturt but in tht [kjm. f'rHiii,'o''''^'nuicl( in 1389 was able to 
dcniontiimii:' Tli-i[ coiigli, laryngeal spajmi (folae croup), aclhma, unci a rnficx bronchitis 
ftriic rellexly fnxii Miimulntion of the naul tnucao. Ih wm ahl« to rvprotluoe lba*e pli^- 
noBwna id aniiDuIi by Atimuiulini: itiv iiiiiciua or llie wpluni. Thejr were BeeoRi|ianlod 
by acceleration of tlir bnnit and vosiCQiiatriclion. They dtil iiol appeitr when the lall«r 
Imd been uocuiniuui; or if Ilicy ha<l once net in, tlicy disappeared on cocuinJMitJoti. lie 
fannd that ihcw ctttvUt were much niunr j>n>iuiUD(i«l in iiniaiab with cxpcrimcnliJ aortic 
InKUlGcieiic.v ihnn in normal aninutU, iukI hn hrlirvm IhnI Kiirli CKaKecral«<il rvaputum to 
nenl mAcites aiv rt^ponslble for many uf the (wmxyMiuil rvspiralury dutuibnnccai in c:tr- 
diae pttli«nU mifTrriiif! from contiuo diipuw. ao<I rspnciaU]r (ram MfUc iMUflicienc]', It 
pottiiUo tliai ilicy maj' giw rim to sotuo uf the vuomotot vriaat. 

It is important to dilTet«n1<ate cardiac asthma from the bronchial form. 
Both may be accumpanied by broni-hitis and by the presenco of rfllos. 
Ill the cardiac form there is no impediment to either expiration or inspira- 



tion, and hence only a simple polypntpa is obsorved, while in bronchinl 
uthmu then; U sleiiiwis of tin- .sriuillur broiuriii with liimiiTiinfe to both 
expiration and inapiration, and hence a peculiar labored and wheezing 
bruatbing with prolongation of expiration which is quilv characteristic. 

C, M. Cooper (Tile Rpspinitory Rulici: A Preliiiiiiiiiry Xole, J. Am, M. Amo., Chir«Ko, 
ti)09, Ui, I IH2), suggests thr dilTrrenlial iliiigiicuiii in ilDiilitful num may M)it>etiiiie* 
be made by imtitig [lie ratio ^>«tuccn tlie |>erio(it duritig uhii'li the tin^ulh ran be brid in 
full imiunitioii and those in wlikli it nu^y Iw Iii>ld iu fuil expirnlion. In tiormn) indirjd- 
ual» tho bnmth may \» lifid in innpimtian fmm 40 la 70 atconds; in cxpirsUou (ivin 20 to 

!>., ratio on"!;; )■ In putieDtH »-itli canliac iimuffideiiry tbia ratio \» pre- 

■wved, tboufh the periods arp BhorHTncid ( t-,- I In bronrhial mirlimu, on llie otbcr 

band, the breath cao be held lunger in expinliou lluui in iiupiratiiui and tli» t»tiO 

U «wf«d (^). 

It M«ins probsbte that this ratio will pmvn of |trr>al vnlu<t in differvnlialinfc V- 
twten aatlimatic altitcliui due to tucMe failun.- ut tbe Ml vi-nirivk' and lliuoc wliicb anw! 
Id caw* of cardiac dincwic*, from reScMH of iiuul or viaueral origin. 

frmoNART < 

Occasionally tbe attack of cardiac failure ib very severe and is accom- 
panied by tedcma of the lunga. Tbe above-mentioned cxperimenta of 
Welch and Cohnheiro, and later of v. Basch and his pupils, have shown 
that thiB ia due to pulmonary )tLa»iii from acute failure of the left ventricle. 
It is moM, frequent in caees of mitral stenosis in which pulmonary statiis 
readily sets in, and ih the complication particularly to be feared during 
pregnancy and labor. 

Eiperimen tally, pulmonary (cdirma ii rviidily producnd liy ovorvlrainini; the left 
ventrinic thiuugli an overdotie of Mlrvnnlin (I.. I«cl>'). BwiiIcm conditioua of cardiac 
diaeaae i( i* iwcn*i(irmlly rncounU-fpil iJltr oppruiiiiiui in wliicli iidn-riolin lia* be*n until. 
MpMiully when in laixe iirnouni* or ii|>on ^urfncm from which il in rradlly atiMrboil, Oc- 
casionally. a» ill a coj* reopntly known lo the writer, nuiiden deuth result* from Ibis rause 
frum an operation olhcrwiw trivial. 

J. J. Miller uutl S. A MHiihewti have recently invegtiicat^ (be action of numerous 
|)OiiN>nw in prodiicinjt piibnonarj' UHiemn. iind lia\-e fuiind Ilml iii«:hiuiicnl fnclon in tlie 
eireiiliilion (failure of the left venirirlp) nrc llir imnii>diiitr' Panar of the pnhrioiiury uilenui 
nfti-r ndrp:ialin. iodiden, and iodine, but ilml acetic elher, uitrit oxide, mid tunntnnia CDUM 
il to ii[>iieBr w-ilboiit iuiy cviilenci' of din proportion bi-lwwn tile action of ibe two **n- 
Iricliu. Tliese Eitl3«tanc«8 apitarenlly art^ly hy injuring the vann i>( tbe (lulaioumy 
vewel" and by Incrrjuing the secrelion of the alveolar walln. cells, and pulmonary lymph. 

Signs of Pulmonary (Hdenui. — The onset of pulmonary oedema ia 
marked by pallor, cyanosis, cough, coarse moisl nilcs throughout the rhcet, 
and often by a frothy ((erou.i expectoration which may be very profuse. 
Friedrich Miiller has shown' that this v\pceturution contains couaiderable 

' Uavon Emcmon hae shown that this occiira only when Ibe chest is closed, not when 
tilt ehest i« oprnnl and urliliciul mpimtion aubstituted. and ihut it can often b« cured 
by artificial respiration with licllows ioflation. BH>rriiigc( retiortt good rrtt^ults from arliScial 
respiration in one pulienl. 

' 1'u demon"! rai<' ihn pmwnec of albumen add dilute itcclic acid to the spuiuin to 
pn^ripitnti! all the uiucin, filter, and then preripilat* the albumen from the filimtc b>' tlie 
aililiiion ot potniwium fcrtocyanide. 



albumen, x fact of great diagnostic importance in doubtful casee. These 
^^ymptoDis conalitut^ a aigiial for iiiimo(Ji»t4> action, 

Trealmenl. — The HtnJn upon the left ventricle may be reliev-ed by 
inltalntiotiK of amy! nitril*, and its stn-nftth nmy Ik- incrpiised within n few 
minuUtf by intrKvcuouB injection of strophanthus. The moat tcrtiiin pro- 
cedure, however, ia venesection, wnce it dimnuohes the work of the 
ri^ht he-ftH at once and thus enables the left ventricle to equalize eonditionit. 
Aocordingly pulmonary oedema is the signal for venesection in any except 
the most anjenuc [icrsona. 

For the sdema itiwlf atropine (0.5-1.0 mg., riu to j^ff gr. hypodennatj- 
cally) should Ix^ given, inasmuch as it diminishes the bronchial M^retiontt 
and thus docs away nith the (edema. In desperate cuncs larger doses 
should be used. 


As a result of engorgement of the pulmonary capillaries or of per- 
inaiWDt injury to their walLs. heiuurrhagei* from the lungx may occur in 
any At^tv cardiac ovcratrain, but they are most frequently wen in cuw^ 
of mitTAl djsea^. In itwif such a pulmonar)' hemorrhage is of no impor- 
tance, although by relieving the congestion it may bring u great deal of 
subjective relief to the patient. On the other hand, the conditions which 
bring them on acutely arc frequently thow of severe o\iT!«trmn. They 
are particularly common in mitral disease, in pulmonary insufBcieney 
and .scleroiMS, and congenital heart <liwiuwtt. 

Il IB ikltvujii of t\\f f^reotml tln|lorlIUlO(^ to dilT(?renIiate Iwlween (iU(^)i kn liicmoptysis 
and tlutt of na rorly pulmonary Ciibcnniloiiiii, .in>l niily (tie nicMt tarrful trpcntcd cxamina- 
Uona, coupled wilb l\\r prmt'iuv of Oie runliue kviuii and ibe abseiK* of tigm of pulmonary 
duwwK, give iiifliciRnt Kmumln to <^xdu<lR the Intlnr It, n (uirttcularly iinportaiit to exini- 
tne for tulxirclr harilli in the blood spit up. t>ince afwr a hemorrhnicc they may not be pre»- 
«nt a^ia in tlie Bpuium for sovend niouttui. 

Rest and the general measures which diminish pulmonary engorgement 
eonatitute the treatment. 


Pulmonarj' embolism with infarction is a not uncommon complica- 
tion when a clot forming in the right auricle or ventricle is loosened into 
the rireulution and lodges in ttome brunch of the pulnionar>' artery. Theiw 
infarcts may be large or small, dependent upon the artery occluded, and 
upon their sixe deiH'uds the wvcriiy of the symptoms and the onset of 

In all thccp CUM* then U an arm of duln«aii, tubular brenlhtnK. 
and incriMwed vocal fivmiIU8 0«'wrM>nie parts of tlie liinic. soil the rip»ctor»iKin of bulimy, 
bloody or pruiic-iutoc vpuluin, wbicli diflrra from tbal oceurriiijj iii bn>«u 
Induratiiin in bcinx mticb richer, dirprr in ta\ar. and in Hinuininc a grcni ilcjd of mon> or 
Imh clianmd bldwl iiitiiiiaivly niixed with the inuciu limtend of soineu'liat wparnie from It. 
PulnKitury cailioliui) is Mniirtiram fatal wlicn n tarp^ WKtul is occludtnl. but uiiiully not 
•o In ihc flr« iiwianw. Exu^tly wWn a Hnete emlwliis will Ixt followwi by a tihoww of 
triubuti and a fatal muill ciuiiiol be foretold, luid ihtt patii-Dt livM cootJnuuUy uoiltrr a 
Kvnnl of Dnmoclra, nltliouRh in lamc cur* ho tnay live for «»vcral jvam vithout ftirtlicr 




Chcync, of Dublin, describeil a peciiliiir form of n^tpiration in which 
there are occasional piiuws of variable duration, from sovt-rnl wirondK 1o 
half ft minute*. foHowi'il Uy insiiirations at firel nlow. then moiie rapid, then 
again lapxin): intu h puusi'. Il wns nguin civwrribcd by Sto)M-n in is46 and 
if) very common in bad ca«es. This phenomenon is particularly freciuent 
iu heart cam-g, esix-ctiilly in iiorlic dLwa^*, and is usually neeii when the 
patient is asleep. It in also common in cases of brain lunior, apoplexy, or 
any eoiidiiiuii where there i« ah in<n'ahe<i inlracnmial lenwimi. Not infre- 
quently, in canliac discast. the patient 'i» in u ittati; of coma or semiromA 
during the periods of apntea but fully conacions during: the jjeriods of 
dyepna-a. During the furnier the pupiln are conlnicled and do not react; 
during the latter they widen and react once moni. 


curvn. iAiirr Kyut^t.} A. Inlrm^nuiinl prvmijQ lype—spniMi ■cpohi^ilic* ^[ovidc of the piil>a Knd 
faJl uf Lload-pmauir. R. Tli« aMIh lypt — ■puu-a uKitlBUd with rlH ut blDod-pnaaurc uul (guigk- 
Miins ol titt pubo-nttt. 

b'ytit«r has fouixl thai the MttUfrence ot (.lieym^-Stokra rexplration is ulwuyii luwo. 
ciat«(l nitli llu; bIout periodic changM of hlooij-pnimin! known na Trnubr-IIorinK wavm. 
H(! (tlatiUKiiiHhr'ti twn typcM: In the flret, which is nlwavK njuiociaUHl with incrmMH] iiitm* 
cnuiinl Ivnfioii, on In brain lutnor, meiiiniciliii. unL-miu. the pi-riuii of mpir- 
Htory activity in tuwodnlixi with n fine (if bloiMj.pnMSure and quickening 
of llie piilHc, the period of a piioita with a fall of hlood-prossuro auil nIow- 
ing of tlie puliw i¥[g. 122, A). 

In the •oconil type, the oommon farm in cardiac nn<i arterial diiKuuic, the respi r- 
atory activity w luwncintcil with a fall in blixid-ptw«un> aiid Blowiof- of 
the pittic. and thu Kpnuea is tuBociutfU wiih riau in blixMl-pnwiure and quick' 
enInK of puUc-rntc (t'iK- 1!^. Bj. ICyntrr ws» ahln to rppmducr thr fin-1, gm»p in uninmls 
by rainiiiK t^"-' iiilracranial (enaion, and found tlial whtnev«r tin.' iiitmcraiiial pnaniin! 
wa« above thi- niwin tjlood-prmsure upnuru uccuircl. Ilicn Ihcbloiid-prt'iuiiirt! rwrlhrouifh 
aaphyidal litJniiitntion of Ihr vnwiniolnr ix-nln', anil whrn it ovcnrtpiicd the inlrBcnmin) 
ptcBrtire, mpintliona atn^in lei in. The converse wtu nol IrUH of the second Rroup of 
caw*, nnil neither he not any olhe* obiiiTver hu bitn nh!c to tepwducw thin moro com- 
nion type or annl}'Kn ill cjiiiahI fncton. 

Btot luu( deocriliMH] another l>'pe of NHpirvljon. ui which ii .■H'rir'.i of InripiralinnH «iqual 
in rain and in titx are piinetuutiKJ by loni; npaicie pnUMw. Thia i* only u «niall variety of 
llie casM shnwinjE (he Oiej-np^^lokcji lype, and its occurrence a"d eiiusal faelon (CCia 
to be nbout (he mime tut the tutler. 

Mniuo hn* alun depiclcd onolbcr ictniip of periodic rmpirnlion^ occurritiK at bigh 
■ililuiiec, up|.>aii^ntly from low CO, mnt«ni of Ihe blood reaehiiii; Ibu i-»wimotor centra 
(aenpniu), in which tliere is with each renpirutory grnup ride of blood- 
pniMuro and «lou-inK of the pulse. Thi:< does not ainn to occur in cardiac or intra- 
cranial caaea. 


Eyster concludes that in the ititracrttnial pressure type the Cheyne^tokes reapiratioo 
is due to the tact that the respiratory centre is more Bensitive to aniemia than is the vaso- 
motor centre, and rapidly loses its irritability, regaining it when circulation is reestablished. 

Therapeutically Eyster has attempted to remedy the condition by 
increasing the irritability of the respiratory centre, (1) by injections of 
strychnine (1.5 mg., Vtt gf), and (2) by inhalations of CO,. Both of these 
measures seem fairly successful, but more observations are necessary be- 
fore conclusions can be reached. Pembrey was able to cause the periodic 
breathing to return to normal bj- causing the patient to breathe either 
pure 0, or Oj containing an excess of CO,, demonstrating that in this 
case the action of the respiratory centre could be restored by either im- 
provini^ its condition and increasing its' irritability through increased 
aeration, or by increasing the strength of the respiratory stimulus by in- 
creasing the concentration of CO; in the lung alveoli. 

The occurrence of Cheyne-Stokes respiration is a very grave symptom. 
It is often a harbinger of death, as claimed by some authors, but the writer 
has seen many patients recover from it and even live for several years. It 
should therefore be classed with several other symptoms as indicating a 
grave weakening of the circulation but not necessarily an incurable one. 


Patients with chronic cardiac trouble are very apt to suffer from a 
mild cough, even during their periods of remission, and especially every 
winter. Sometimes this may even be mistaken for a primary bronchitis. 
Primarily the condition is due to engorgement of the pulmonary vascular 
system, with increased secretion of the bronchial mucous glands as a result. 
It represents a state of mild loss of pulmonary compensation. 

In Bomewhat worse form, and particularly in bad cases of chronic mitral disease, 
the alveolar capillary walls become so much injured that there is diapedesis of red blood- 
cells into the alveoli. These die and are taken up by phagocytes which find their way into 
the sputum in the form of " Herzfehlerzelien " — large endothelial cells containing vacuoles 
and numerous brown granules of hemosiderin. The expectoration of "Herzfehlerzellen" 
is usually associated with a condition of brown induration of the lunge, a chronic interstitial 
pneumonia with dilatation of the pulmonary capillaries, tortuous condition of the vessels, 
and deposition of hemosiderin in the tissues. 


(Edema. — When a case of heart disease reaches the stage of broken 
(systemic) compensation and the right heart fails to perform its function 
properly, cedema of the feet and legs sets in. This occurs at some stage 
of almost every case of heart disease, but not always at stages of equal 
severity, sometimes setting in quite early, sometimes only as a terminal 
event. Consequently, although a grave symptom, the presence of oedema 
need not indicate a desperate condition. 

The di.'itribution of cedema of cardiac origin differs characteristically 
from the nephritic type. This is readily comprehensible when it is recalled 
that, as Cohnheim has shown, cedema occurs only when there has been some 
injury to the walls of tho vessels and capillaries. In nephritis Heinecke 
and Meycrstcin have proved the existence of a substance in the blood which 



injurcA the capillarici, and Ka^t hax cl«moni«t rnt4Hl that the bloud of nephrit- 
ics contuns a substance with lyniphagogue action. As might be expocted 
from a jwison circulating in the blood, ihc injury occurs siinulluiR>uu»ly 
tliruughout the body. Hence in nephritic tlie cedeiDa bepns quite irre- 
apectively of the action of )i;ra\'ity and U eeipccially ituirkcd in (tic fxcc and 
eyelids. In cardiac ccdenia there is no such lymphjigogue poison at work, 
and the injury to the capillary walls is the result of iocai .-■ta.'*!.-'. lack of 
oxygen in the celU of the i-ajtill.iry walln under the influence of the slowed 
circulation, AccordinRly it bcjiins where circulation in .ilowest, i.e., in the 
dependent portion!*, — the feet and legs, — and either rt-Tnaine localized there, 
or, if the condition becomes worse, progresses upward to the genitalia, to 

the nhdnniinal cavity (portal stafiis), 
giving rise to intense a-tcites, to the 
subrutaneou:* tisnue of the body wall, 
.■md finally to the production of fluid 
in the cheat (hydrothorax). 

Occasional ty nli*n Ihe uMluma hiw been 
long erinttnurd tin- liinbs tr:U'h 1 roniendinu) 
pmimrlioiis. Soum four ycani aico the uriter 
liiul uiiiicr liut curv HI ihe Jobiis IIupkiiiH 
lla*liitiil n patient who irjich^l ihc wunl in 
n conililion of %iery nmrknl djupiia-n, with 
Ipgn nwtilleii to Ddiuinetrr of 101 iiiche« and 
ahHolnlHy eli^ihaiiloid in npiieutHiicv (Fij. 
12^i). The^kiiioviT (liei-nlirF li^gs nni covrrvd 
uilh p.ipillnmnloiiN oiilKruwiliB mi nUHpJeiouii 
tliul itip 'li.-u;[iiiniB uf rlcphnoliucis ^-^m u-fls 
serioinly nilortsiiicil hy nonic memberaot the 
hoHpit»l oliitT. Tlio |.intieii( liuti liccii sulTcritiK 
from u upverc- nurlic itimfliricnpy for uliout 
a >wtr, snil (or MX ninntlii' >m<l tieen no orlbo- 
pnreio lhu( liv tiuil iitil Imwii ulile tn go to hoi), 
but hail ri'iitril *il.liii;f bolt upright in a chair 
uu<l UBtially with hH down. Tlierc wctv 
Irrmeiicious erypl-like ulcers about 10 cm. (4 
inches) in iliftiiieicr in lM>lh less, eHcli coveted 
with a dwp layer of necrolie liwue. The iwilieni hiih j iliitcd in \i<r<l with feot miseil to tho 
huriioiilo), and the U'ounil dmHK^d with a I-IIHKH) pntnuiiitm |>rniinnennntr iiohiliuii and 
tr, diKitnlin m. xv ndiiiioiiieretl pvpry four hcirn. He wax ininro'l freely with E|wuiii luUlii. 
He hiipruvvil »o ropiilly that within twelve hoiim the eiteumfereiiee of ihe legs had nppre- 
oiably tliniininhcd and nilhin a Tew wepkn IheV were ahiiOAt normal. The palient baa 
remained i|Viile neil ever iiiiice and in at prejxriil uiunnging a fumi in ntvttcrn ilatilniul. 

Unfortunately, <edema dot^s not always disappear so satisfactorily. 
It hiis been shown that the a-denin fUiiil J.* richer in .lalt:* than i:* the blood, 
and that resorption of the cedetna is somewhat favored by a practically 
stilt-fR-e diet, such lut one cciiwiifliiiji; of milk, Autcar. eggs, nieal:*, bivad, 
sweet butter, and cereaU prepared without the addition of salt. The diu- 
retics, wjwciwUy t}\iMK of the calTein group, also favor resorjjtion;' free 

' Fl^iaher, Hoyl. acid Loeb lia^v »hown lliat the prmence of cnlriiim taUi^ in iiiftwion 
fluid iliniiniihts the formation of tt-dnna. but this olwenalion hail not yel rvecivi'd nn 
application in iherajicntics, and tlietc otwtrv«r« have found that tlib dorni not applj- to 
tanlinc tvdenm. 

Fla. 133. — Ltgt of ■ pBliniil villi ntcmw 
adflma (aliDuUinns tl^plianiiji*'.] itni] ifrr»pn- 
dOU* Ul«n. CNaJnFlcr d( llir kfl Irn lUj mctip* 
l2SJi eiu.). (Draaii [rum ;iliuiuiiruph> lent by llii«tncu»ii, Mel.) 




purgation nida in removing fluid from ttie body, nometime^ is much mSOOO 
c.c. per day. and digilnlii< doc;^ the fiinie by increasing heart aption. Besidt^s 
this, ihe (Edema can bo combated by raiaing the li'g» In ihc honKonlal or if 
po«8iblc A link- above it, thereby increasing the drainage from them. 

Orsiaagc ol L«|{>.— Sum^liiiiCB aIao a light apani rlnotic liandngc til rubber 
may bo applinl ui liir kip. liPKiiininx at tlie f«el and a«c«niJii)i! to tht uniin, ihe 
uwisliii^ the drairiaco and r«|iUcliiK (ho Itvit rln«ticit}' uf Ihi- nkiu. Whirii thtwr nivalis urv 
iMiUtliciL-tiC. iH.-vcnLl iiicisious may l>e iiuidu awpticiilly in tiii^ hkin of tlir Ifg* nnd ilr)Un:i«w 
aided by sppl.viDK Bicr>auctiiHicup»,DralargP lru(-«r utih niden pcrCuruItxl (CurschinAtin'a 
modiGcaUou ot Soiiihey'f tubes) may be inwrnnl m briii^ uboui fnv ni(^liiuiicnl drainage^ 

Tb(! bnit Rsulta ure obluintxl by ihe following n>rlhi>d, ijiwcrilt^ii by ItoiiiberK: 
Boil a loiix rublit'r tuho 6tt4<il wiih a pinclwoi-k in |iliyHioloi[iciil biJi aoluijon. After 
n-uiuvint: tbe [wiiil from (he InK-ar, attacli 11>p rublief lut* to the metal tube of the 1alt«r 
nnd* ibi' lon'cr i^nd uf Ilu.> rubber lube in a buein 
of boiled wni«r ii[ioii (be floor next lo the Iml. In 
tbU wuy a Bi|>hufi is (.■stablisln.Ki. lit'lpiiiu (b<? liratnnite 
of the fluid. The lubp of thr Irocur »hcmlci Ijc kept 
in place in tlie le^; by lyinjz with n gilk lifcatuiv, itio 
end* of wluch are tbi-o inserlni in u Ktrip uf adlie- 
fflve placed lumwly nlKiut llic leg aiiavp. the. tmcnr. 
Romiiere tlate* that fmn) '2 to 15 iitre« of Riliil raa.y 
be miiovtd in 24 houni 1 

The cedema ofuin involves the scrotum 
and pi-nta until tlicy are vnlnrgi-d to two or 
three times the ordinarj- size, and phimosis 
or paraphimosU may cause considerable 
difficulty in micturition. 

Ascites. — .\.iriu>* is common and may 
cauae distress by pushinR up tho diaphraem 
a» well as by im})eding the abdominal circu- 
lation. It is often advisable to remove it 
mechanically by introducing a trocar in the 
midline midway between the umbilicuit and 
the symphysis, under aseptic precautions (afKr firiit emptying the patient's 
bladder), and allowing the fluid to drain out. In t<o doing care must be 
taken to keep a many-tailed (Scultetus) bandage tight across the abdomen, 
reailjui^ting it seveml limc.i during the lapping for fear loo much blood 
may enter the relaxed abdominal vet-seU when the pressure about them la 
tliminlsheil nnd shock n-sii!t. therefrom (see page Si). 

Hydrolhorax. — In cam-s with severely impaired compenKation hydro- 
thorax (usually right sided) is eommon. Starling nnd loathes, Stengel, and 
Dutton Steele have demonstrated that i)» frequency upon the right cidc 'u 
due to the position of the great azygos vein, which drains the intetcowtal 
spaces and the pleura?. One of the factors producing stasis in this vein in 
the fact that the latter enters obliquely into the superior vena cava (Fig. 5) 
and thus its mouth is readily closed off. Another is probably the fact, 
which the writer ha.* noted, that the mouth of the vein is not as distensi- 
ble as the wails of the vein above it, and hence imposes .some obstruction 
to the blood flow. In all cases of heart failure in animals the axygus vein 
may bo accn to be dllattnl above its entrance into the vena cava. The 
heart in hydroihorax is usually displaced to the left. The respiration shows 

FoJ, in, — Ciifichitiuia'> niikniin- 
tion of tliK Snathrf t.iibM for dnlnlitc 
oilfovk of th« UttL (Alter Kombws.) 


much cmbarraflsment : (I) frora retnoval of a considerable part of the 
right lung. (2) from ri)nipri's«oii of ilic left lung by t,ho iliHpIuix>mvnt of the 
heart, (S) from embarrassment of tbe heart itself from the displacenwnt. 
(1) from poinpreajiion of ihe v«iitt cava> esixTially <Iviring defttculton «n<l 
exertion. This may prevent inflow into the heart and eauxc euddco 
death. (Calvert.) 

The fluid should alwayB be removed promptly by paraoentt-sis thoraeie. 
ThtH prnees.1 is unfortunately not without danger, sudden death occatuonall)' 
rvKuUiiig in t<pil« of thv great«i<t can;. 

"nil- writer hu »ccn t<™ limtln of this kind, an<l IhcT occur mili about the same 
fit^uency in the experiracv of mo"t clinlciiirn, A ^«-ry valuable roiiiribut.iuri lo (Itis Md 
hui Ik'cii iniulo l>y the Bludieu of (.'appa unil Lewiii, shuu'int; tluil »he viiicerul luyirr of thci 
inlinmril {ilntira i* rapncinlly fcniutivp, ntid upon liiimlllTiK or totichinK il Ivo rf (lex 
plieiiometia renull. a vH^nl ■"l^it'ilioii. aotiietiniM tia liiUiwo a« to elup tlio 
bt'iirt . uiid a panilyBiaof tli« vaiiiintutor n-'oirv n-Lich Riven risr (o tiniiiTluHi fall of lilood- 
pnwailtv. j\econlinK to thcno otiKTA-nllonii it ta thrrrforc adviwiblf lo <liininish vnsitl ton« 
with a preliminary h,viio<lennic injection of 0.5 lo I mic. a( ropi ne (jcr, I'o to c'n) uliout 
l.S ininulos bvfuiv bctcitminu tlie tappliic. ati'l lo liavr at huii-LJ a liyimiilvrtini? syriiigu Imulcd 
with t 100(K> adKnnliu chloride solution lo rcGton: promplly the vtuoiaotor toDO in can 
of oollapM. 


' Albuminuria and diminished ftecretJon of urino are invariable rff»ulti« 
of broken compensation. They may also occur after severe exertion, 
probably a,-* the result of fixcctaive pressure in the veins. The stains in tbe 
vena eava and renal vein ha;i been shown to give rise to albuminuria, and 
the slowing of the circulation through the kidney is siitfieient to account 
for tho diminution of the uriuo secrt'ted. Such urino. though diminishod 
in amount, is highly colored, normal or increaaed in specific gravity (1016 
to 1020), and eonlainit a normal concentration of NaCi and ureii. The total 
excretion of tho latter in 24 bouri; is, of course, dccrcaised. As in the experi- 
mental stasis numerous finely granular and hyaline casta may be excreted. 

Thn liiilntTit of wich rjme* (0«lpr's nrtcrioMrirrt>lle kidney*) arc iigiially of ihe largo 
red or "beefy " lype. wilti Imtii corttrx niid iriedulla ii)Cc«8«cd in size, the ca|i«ulc silhurrnt, 
and dilTiHc intcrxtitinl nhangtii a* well nn wmw parendiyniBtoui dcgracrulion. The rrd 
Dolor la probably due lo liie vcnou* ror^ntlon. 

It is of great importance to difrerentialc between a primary cardiac 
disease with secondary renal involvement and primary chronic nephritis 
with secondary arteriosclerosus, cardiac hypertrophy, and cardiac in.-^uRi* 
ciency. At an early stage of tlie disease a careful study of the chloride 
metabolism and its relation to urine concentration may lie of };reat help. 

In carfiiac cases tho power of excrotinK NaCl is, as a rule, not 
na much impaired an in r#nal caaes. If 5 (iiri. KiiCI t>e nddcii tu the ilk-t on 
one occnxlon tlierc iihould bp an nbrupl risr in ihfi NnCI conical of Ihp urinp. If thn kidney 
CoUb aro danutict^d it will be Kradiially excrrlcd during 2-4 davit. Ilourver, jl iiviut bf 
rencmbcred that in iiiuny cusm of priinuiily cardiac orii^iti ihc kidacy ctlla may be tw- 
pitinHJ. The urinary fiiidingii, as cbon-n in the case* cited on paKo 
'iW an<l paec 33fi, may lie practically identical ; and Mice all Ili« fea- 
ture in cliology. hlMory, and mcuboliiiin muat be ttioiviighly voiuudered bcture a ilecinon 
ut Ti:nclicd. 




Palpitation. — t'lulpr tiormni con<Ution8 one U not. conwious of scnsorj* 
imprps-iions from the rogion of ilio beart. Einthoven. I'lohil. snd Bat- 
luvrd have shown, however, thitt im alTorent impulcte in tranftinitled up tJic 
vagi by ench hviirt-bcat, Kiid tltorv arc probably siiiiilnr impuWn Iranemit- 
trtl ihnnigh th^ intercostal nerves from the parietal pleura, me^liasiiniim, 
Jintl phest wall, ii}; nhitrh the hoftrl i.-i U-iitiiig. VihUt iiorinal <'oiKli- 
tion^ 1hr-.-K^ )^-n»utions do not reach consciouniiess, but tltey occa«onally 
do «o wtien the f^eneral nervou-s t«!nMl>ility U inrroai^d, tw by coffee, tobftci'o, 
or h}-pertliymi(li?im, tn nfuro^thpiuc and hysterical Ktate«, or when the 
beat of the heart is more forcible than ti!<iia]. The distinct senwuion caitsi'il 
by each beat of th<! htnrt is known us jmlpitution. It i« frequently nssociatcil 
with cnrdiiic weakneas and irrefcularities, and has been thought by some 
writers to be clearly associated with R 

extrasystoles. But while it is true that 

Fio. 12!l. — KIwiriea) rveonj <if ■flnnnt imimlan tnvallina up tlivvMi. (A(ua EinOiai'm, Ptaliil. 
■Dil BktusnlO VifS,, mwnt of ivntTtpn*! ritvlnml nvcin <lin vikcu>; KKSf.. tvpintlon ; CAKOT,. 

111* mnmll udq to tlip ««filinc rvuUvcUUD, 

cxtrasj'stoles frequently give rise to palpitation and also that ihe patient 
can often distinguish between Mlrong beats and weak Iwnts, ncverlheli'M 
there are many cases of extrasystolea without palpitation and of pal- 
pitsliun withnot extranyfltolea. UirKchfeliler hn.t t<houn thiit palpitation 
may occur without any motor disturbance in the heart's action and with- 
out any change in the reHex response of the heart to various stimuli. 
Hewlett has found the r wave unuitually large and sudden in a case of 
palpil»tion, and believes that the "earlier movements of the ventriclfl 
wen* exerted with uiiu.-<ual !«l»eed-" However, ihi.t findinf; is not uiuforni 
in cases of palpitation, and. moreover, would not explain the occurrence of 
palpilfltiuii from weak extrasy.itolen in which th«w mox'ements are executed 
slowly. Such changes in the venous pulse arv often found in vigorously 
bealjng hearts wilhoul any palpitation whatever. Palpitation is therefore Ix) 
be reganled as a puivly senKury phenomenon, which, though it is frequently 
associated with cariUae disturbances, may occur quite in<lependently. 

The catceory »f iwiunliniui in nliich [iftlpitalion ihouM lie |il^>ceil anil Ihc tiatli which 
tlietenMtiua im^'^rtini urv imX [ivrtivfiy clrar. It Ueviiteiuly u pnwauru or (uucli imuwljoii, 
pnrfnctly distinct ami tiniittil to thp prrjod of ■yslole. It in Aln-s>-s ftlinrply lofaliznl, 
UKiiall}' rpfvrrvd li> cilbcr the apes or (lie biflirraiiiin of Ihe Itttchea— (lie two silea nl which 



Ihe bMTl exVTiB direct prmaui* or tracUon upon the ■urrotuidinjt otnictunw. In this (tl»- 
linclncM It lUffet* rntircly fram other viMcral MliRalions, which are letn dermite iii time 
and ill Hite, Aud ulm, as a rule, more nearly lUlied to puiii scnsution. It thtw difTcre kivrUv 
frutn the pain ■Frutttiooi nriiinfc In nnd »bout the henrt. and h^nre tMiaK»t« thai il chuuld 
be pbeed in & dlfTerent category. \Miether the path of the deiisutluii is ufi the vugl or 
through the thoniric ncrvm ciuinot nt pmciit Iw iiiiitcil.' 

Allot hrr point In fnvnr of the \-iew that palpilntioi) in an exlracardiae seniuttiun in the 
fact tliul <iUile siniilar seiuuitioiui may lie (elt in the abiiominnl uorin and radial art^rieo 
whpn Ihrrr ii vixlhio pulwitloii (io-iinil'(ii> niollon) of ihc lailcr uiih prrature ant) traction 
upou the skin and BUrroiiiiditig stmctureH. 

The continuance of tlie scnHation U very wearing upon the patient, 
especially when the heart is irregular. Often he ia able to diettingiiiKh be- 
tween large anil Nnmll b<?«l)<, nnd i.-* con^tmitly reminded of tlie pathological 
roniUtion a»c! usually much worried about it. The xenHation is not entirely 
dependent upon pitychic ph<-nonionA: for in one cam; under the writer's obser- 
vation (I.e.) it disappeared for live minutes, while the blood-pressnre and pidse- 
ral« rot<c aft«r exercL'tc when the patient wast under examinntion, although 
he had hiK mind fixed upon the disturbinicc throughout the entire procedure. 

Palpitation is frequently the result of tea or coffee drinkitiK, smoking, 
digestive distiirbances; it often occurs with various forms of cardiac diseases, 
but seem8 to have no relation to the latter. Itelief is very difficult to obtain. 
Except for removing the oauftal factor, uppHcation of an ice-bag or a cold- 
water coil over the heart is about the best remedy. The bromides of potas- 
Mum. aiiimoniiim, an<I strontium are of .-lomo value, a» are alHo vibratory 
mUB&ge and the application of !iinusoidiJ currents. 

Precordial Pain. — Precordial pain is a lesw definite scn^tion than 
palpitation. It is continuous throughout the cardiac cycle, is leas definitely 
luealtseil, and Ino^(^ commonly as-suciated with referred sensory disturb- 
ances reeenihling other types of visccnil sensation. It seems to bear a 
somewhat closer relation to dilatation of the heart, and, as a rule, accom- 
panies more severe organic diseases, being especially common in aortic and 
mitral lesioiiH. There is somelimes, but not always, precordial tenderness. 

The most severe form of preconlia! pain, angina pectoris (see page 
285), in which there is, besides intense pain, a feeling as though the heart 
were held in a vise, seems to be associated with sclerosis of the coronary 
arteries, but a definite relation Ix'twccn ttiiit and other forms of precordial 
pain has not yet been established. 

Frtiqilently In hpsit diwiuice. an<l CKpcrlnlly in c.i>ieii of .incutiam and nnginn, them in 
marked puln radiating; down either or Imth anno. In fart 1bf»e may It llie 
fint^nptoms given by lui iincumm. It iiMvily aeeii Irom the dint ri but ion ot the cunlino 
ocrwo <pB^c H. Fix, 10) thai a Ie*icn In ihc rlcinity of ihc iympathi-tic fibres might j(iv« 
MrnHitions u'liJch. reiurlung one of the evrvicul s|>iiuil mnuliu. uuuld be refertvd to it« 
p«ri|>hcral ili*tributlon In tlir eutaoeotui rricion inncrv.ilci! Iiy tli»t iwgnieni, usiinlly down 
llieami. Hence the fttKiucncy of ihewe pHiiiH, Not iiiilycafiliac condition, hut high Uood- 
prewun; in the aorta tnuy cnune Ihl* dislnw. Il is difliciill lo reliew this BViiiptom. It 
loworiiiK of the hloorl-pn?>wurc wItIi nllrogtyctrin fail* to bring It ahoiit. eoddnr, 15 to 
20 mg. to 1 gr.) iibouid be tried, uud. if tluit does nut sullice, morphine may bnve to bo 
traortml to, but ahould nlwnys b« avoided as long ae pofsiblc. 

* Id this connf^tion It would be interesting to not« whether palintation OMiun In canea 
at tranareree letuon of the curd in Ihe lower cervJeal or upper thoracic region, or whether 
it can t>e brought on iti such persons by large doeca oS coffee. 




One of the first eSects of weakening of the heart is engorgement of 
tho veitiH of the portal flyHtetn, niul thi.t in turn brings about u r»tftrrhnl 
coitdttion in the mucosa, and especially the gastric tnucoHa, with consequent 
Bymptoms of indigestion. Fernicntatioii frequently takp« plare, and the 
itiflatJon of the stomach witli ga«, disphiciti); Ihc diiLphragni upwards and 
lifting the heart more towards the horizontal, tends t,o increase its enibar- 
r».s.stiK-nt. Ovcrlowling the Mtonmth, liic Iransdiuphragniatic nvighhor 
of the heart, shuuhl therefore always be avoided; and the patient will be 
8Aved much siifferinK if he ts kept on a light, easily digestible di«t, eonsisl- 
ing largely of eggs, milk, and en rbohy<! rates, just enough in quantity to 
keep him from lo«<ing weight. Frie<lrich .Miiller has shown a diminished 
power of ubMirption of fats in heart di^-HM.'. Perhaps this may be A\n' to 
the fact that the high venous pressure prevents the thoracic duct from 
emptying il^i-tf properly, or porhnp.'t bccausi-, as H. M. Evun« has shown, 
>i high portal pressure causes the lymphatics of the intestines to collapse. 

t)n the other hand, nieali* and other food.** containing purin bodies in 
large quantities (sweetbreads, lungs, liver, etc., also cutTec and tea. and 
alcohol in all forms) do distinct harm by raising the blood-pressure and by 
increjwing the viscosity of liw blood (pa^ 3B>. 

The engorgement of the gastric and oesophageal veins sometimes leads 
to exudation of blooil into the stomach and to vonuling of blood. 

Abdominfll Pain from Distended Liver. — One of the commonest symp- 
toiiw of fiiitiiig com)>i-n.-«ntiun i> very iiiu-n^ abdominal pain fell over the 
region of the liver. This organ may become much distended, and, as shown 
by Balnnian, may Iw expanded unlil itn bloo<l conlrnt is several degrees 
above the normal. Vndcr this expansion there is marked tension upon 
the capsule of the liver (tilisson's cap.sule) which, in turn, gives ritte to 
pain. This symptom is really so clearly bound up with ttie failure of com- 
pensation itself that it subsides with resumption of the latter, or after some 
tJme the capculv of the liver will have become sufficiently stretched and it 
will then cease to be painful. 

Abdominal pain also re.'tulls from arterio.'«'Ierosts of the gastnc and 
mesenteric arteries, from vascular crises us well as from abDormally great 
pulsation of the abdominal aorta. 

CalarrhalJaiindtce.^LJke the gastric mucosa, tlio bite passages undergo 
ca1arrh!tl inlhmuiuiiion from the venous engorgement, and a definite 
catarrhitl jaundice may accompany the failure of compeusaiion. Usually, 
the jaundice is mild and barely perceptible, the color being sallow and icte- 
roid rather than ict<^rie. The pre:»ence of this slight icteric hue in a patient 
with tieart disease should always lend to the suspicion of broken compen- 
sation or tricuspid insuthciency, and is always a sign of danj^r. 


.\n anxious expre.wion is so commonly manifested by patients suffer- 
iag from heart disease that a certain type is spoken of an "the cardiae 
fftcies." Tliis facien is difTicult to describe, but may be said to be charactei^ 



ijcd by bright watery, somi'tvliat staring eyca. wide palpebral slits (without 
definite exophlhalmus or other siftns of Basedow's iJiseiktc), rather (/;ji«;ly 
held mouth, ttixi I hi- rest of the faev a little Nuiil^eii, though Qot to thedefj'**' 
present in the "abdominal fades." Many cardiar eases, perha|»s from the 
<hffieuHy which thi*y are conHtnntly cxpcrivndng in getting their breath, feci 
irritable and peevish to a considerable decree, and not infrequently the onsei 
or increase of peeviidineRS is aii early itign that the cardiau condition hen 
become woriK'. 


Oeciisionully, especially in patients with irregular heart aetion, definite 
pe>'cboses set in. Tbest> arc enpedally common during the night iLtid early 
momiug, diwippenring »gain during the waking hours. 

Tlip pnticnl UHiiiilly iiuHki^nn fruiu liis nlvvft unable (u n-co|:nii« tlie plan.- where he U, 
which lie UBUally locuiiw sonifwhcn- vine, luid then tripuila tlic iliiciotn. nurwi;. mid attcnil- 
ADM OK inhii}>iliiiils of Ihc in»n: fniriiliHr (ccnrn, (iFif-n niiM»krnIy rm^riizirii: ihrrii mm 
people of hi" uci|iiiiiiitiini.'4' In iLuw [iliu'pn. Ho u^uully rvinrdn his cuiiliiieinFiiI in lHr<l iik 
a nign uf soint- uUeiupl ii|»ii his lifr, iitiil the adminialrstioti of niniieinc luc it rrrtain nt- 
IcmpT lo poiHon him. ("H ihin fuct he tn always cerlam, altlmuiili he inaj Mitiriil tlis) tliert- 
in HinrK.- duiiirt in his uwn niiiiil as l':i t\ii- t'ormlDesn of niiini' (i( liin iither iduw. I'ur 
(■xanijili'. (-nr tkhritiiw patient llmier the writer's cnrp n» hnllsr jihysiciiin niiKlook him for 
an old (ri^nd (miti home and suiil. " He llki'il — — . ami iiuil en-nt eonfideiice in him. bill 

lie poiild not are why did want (o jioiiHiii him." Bill iiL- woiilii pcoitRni** "w "llier 

powihic motive. 

I k'Cii^Lonally ulitn daylight ramen or ■oniv i^iie taiuiliur ubjevl appeani, the (wtlHil 
suddenly rceoRniieii hi* mirmunditiK*. wakej up ni< from n dmnm. and mny even ex|diuii 
exactly tlie nature of and rcaxjiiH for his <)eIUMioiw. Uii<ler tlie Influences of iheae 
di'lusioiin, palicntB an- iiftcti »vr>- hnni to iminiiBP. but their ultilude in more tsunrnntilj- a 
defpnwive thiin an i)(Icnptive orie, pwinlinjt erinfineirient and troHt.ment, and alt<"nipl(ii)t to 
leave llu^ ward ur room peaceably, rallicr ihaii sliowin^ iiianiaeal pugiiaciuUBntm pniiiarity. 
Tbpy can iminlly be perEiuulcid by mantle meanii lo remain where they ore tor a titnc, 
wpwinllt' as their rninijs art- aUnust alwuy* i'nnfii»«>l ; (hey tvuliie that ihry arc not 
perfectly well, und the niime or phyniciaii eon lea<l ihe uigunieiit along itd logical 
conchislon]! In a reaoikii wiiy thry thnuld return to bed and lo rrcl for the time beinK. 
After Mine iniiiMI«H' arKimient uf this kind the (lulienl cnn iixiihIIv be jiiveii a hyjio- 
dermic of morphine nnd Rotten hack to bfd niili much Ibbb injurj' to liinuielf than \1 
fiweihle iiienns were alirinpled. lie ean then iiHially lie kepi in l>ed by an ntleddant 
coiulnntly preAenl. 

The reiuHjn for these delusions is not very ccrlHin, but in some caws 
they may be regarded as "waking dreams" not ver>' different from those 
of snmnaiiibulinis, end jMrhtips like Ihe night terrors of duldren wiih ftde- 
noidi^. They may be asphyxial in origin, assoeiated inon' or le.-w with 
cer^'bral arteriosdcrosis luid rcrebral nniemiii. of whieh perhaps the frequent 
high blood-pressure may be snot her expression. This ileltLsioual innnnity is a 
bad omen, nnd it« onset often (ireoedes the fatal outcome by only a few days 
or weeks. Duroxiez and H. O. Hull have called attention 
to the fact that in some ca^es these delusions may be 
due solely to the digitalis and may disftppear entirely when the 
drug b diticontlnued. 

Definite halludnations of sight and hearing are also not uncommon. 

Henry Uend hon olwenwi ihat tlinw ate isjHvl^illy coiniuoii in aortic diwusc about 
the time of t«'ilif;lit. nnd are uvMally quite citiqile in character, the auditory hatlueiimtJOTW 



.WIBri*lin(E 1° Mimplc rhythmic nouiuU (aMoci(ttc<l wllh thp hrArl-lxnui?), mith iw of kunck- 
iag Dr ol t>eIU lolling. Ihv vistiul InilhicluftTluiu usiiatly lakiiiic vhv tomi of tbv I u o i- 
of n man nr nomnn nrcii ntalioaiir?- at Ihr foul of Ibn br<l or ulnwly Bt-ilkic^ nf rem 
the ntmii. The face is afttiy white, the cyi* black »rwi Atsrins. nnil ihe vnnimir iiiv»iiiLlily 
indchoitc and surrduiulod by ii uinaa of vinvy lilufk hair. If Ihc boily is trvu nl ult. it in 
pooKy oiilliiieil a» thniiKh drapoil in a lilnck K<>*''n. llmi) found this hathicin.irifln quilr 
oonnliml nod iccn hy inuiiy pulieiils. Lliough llicy. lu it ni!v. rvcciiEiiixed ihi- hiLlliictimtor>' 
chnraCtsr »nil tipnkr of Jl only aftpr thr phyoiciiui h.n! gainnl Ihfir «-otifidpncc, Thowritcr 
hiiK also clidtiil the Biuijt- uncwen' fn>in a niiinher ■.•f |>]itienl(i, afl«r prpfa<-inj! the qiie«iii>]i 
by a f^tarpmrnl vinuiil hullueitiBliuiw u*«n- nut lUicoiDnioii in Ihtrir cliH-iuic itnd wtriv 
to tx! ^^^arTi(^d tin^tvly aa (R)iiblMK>ni« but not i>if[nif>cniil fenlumi of ihr' diitonitr itM>lf. 
All who lEnw ponitivi; uiutwen Bccunt«ly tleacKbed llii- halluciDUtucy viaiou » ahovt. 

Uoad states that highly colored nnd rnpully moving visioim do not 
occur frernicntly in heart raspa, but the writer has neen one ver\' marked 
exception lu tliiM rule. 

Tliiii wDtf ill tli« caac quoted oti faEf 508 — a yotini; milmad eriKinoor. 23 ycon old, 
of lempnnil*" hahil* luid excelliMil fmiiily liiiloty. who hud a very adhirrni iirricnnliuni. 
For iTveral year*, npix^i.illy wl>cii hi* cnrdinc roniiition hocantc wiiriie. lie tnitTervd from 
BMiajI ■ (cR fM-i lwfot« hiiu Bwamui of lar^iie aiiinialB. tiuii.i. lim'ni. etc., nil highly culumi, 
Itmpine rapidly nluiut. !(r rccc^inixcd thnw lu halhicinalionu nl. the lime, bur alnltid Ihai 
Ihp Hfltit irrilalttl him mi that be lost hi» ^elf-f^ntrol, and he heuft'd to Iw platvil in ralt- 
lajy ronliimncnt for a few duyn until tlit lialludnatiuiui paaied off. H« wiw lhrn onrr 
more a perfectly rar tonal berntE- 

Ijkv the deluMoiui, these r^ardiac hallucintition.i arc jirohnbly due 
either to anaemia or venous staios in br»iii, but psperiully in the special 
centres, or in the retina, middle ear, vnsual or auditory wntres, giving rise 
to rudimentary Bciisaiioiis which the mind tranidotc* or distorts into the 
above-mentioned picture-s. 

Syncopal uttackn altio occur in Momc fonntt of heart dlsciuse il» a result 
of cerebral anaemia and will be discussed in detail in Part III, Chapter XI, 
under the head nf AdaniR-Kloke^ disease. The feelinR of fnintne^et and 
wcirincMa uiinceumpnnteil hy syncujie will be discusKed under "cardiac 
neuroses," etc. (Part I\', Chapter HI), 


SrupTOMs Of CAriBiAC I>[BEiaB. 

(irowniaua, Bctielheim, aad Ivaudcru. Quoted on page 1-46. 

Eynler, J. A. E.: Clinical and fcbtperimenral OWrvatlono upon Chejme-Stokee Respira- 

lion, J. Exper. Ued., N. Yoi^ Hnd Laneanter. lOUA, viii. 2S3. 
Welch. 1. c.. pa«« US. 
EDiMsoit, I!.: Artificial Rmpimtlon in the TrexiiDenl of OMerna of ibe Lunge. A Sujf 

gcMion basnl on Animal ExperLinentutUui. Arch. Inter. iUsi., Chteo^, 1009, ill, 30(1. 
BarrinKH', T. H.: I^dnKlnB^y (l/lnnn Trcnti^d hv .Vnificial Re«piraliar>, Re|iort of a t'aae; 

[bid-, 1909, iii, 37::, 
Miller. J. L.: Traru. Amue. Aiii. Phyx.. Pliib.. 1000. .\Iiu>. Miller, J. I... and MaltliewB. 

8. A.: A Studv of tlie Jiti^haiiinal l-'aernn in F:xperimental Actile Puknonarv (Ed^ia, 

Are*. Int. Me.1.. Chicajco. J»llO. iv. 358. 
Holler, Fr: Die ErkrankuuKen der Uronehim). Die di^twhe Kllnik., Berl. and \1enmi, 

iv, 270; quoted from Roinherft. 
M<MHo, A.: FisiuluKia dell rmna siiUa Alpi, Arch. Itsl. dc Biol., 10O.\ xlili; and Mher 

artklea quoted on page 33. 
Pembfey, M. H.. Beddanl, A. P., and French, II.: OtMerratioiui on Tn-o Caita of Cheynr- 

Slokea RcBpiraiioa, Vvtx. Physkil. itoc.. Lorvl.. 1906, p. vi. 




Kiutt, A.: LVbcr lytuphiiKaf^e SloRe im Biiitwrum NicraDknuikcn, Dnutccti. Arcb. f. kljn. 

Mcii., lATipx.. mn, Isxiii. 062. 
Ueiiic^kc uiid MjiTBtsin: tlxprriQiciitelle l.'ntersuehungcii ut-bpr ilen Hj-ilrDji* Iwi Nieren- 

knuikhHtrn, Dcuurh. Arrh. f. kiln. Mcil., L4Upi.. IOUk, xrii, lOt. 
Fnnvoti^Kranok, Ch. A.: C-ontrlbuliuii A I'^tiiJu i^x|wriiiitiilu](- tltn atrvrau^ rvD^xn 

d'origiiic uiualp, Arch, tie phj-fiol. ilcn hiimmcn rl <1» iinim, Par., 1SS9, 5c nfr^ i, A3S. 
Starlinx, K. I!.: Phv»iolo|[ic FRCUtra Involves) in tl)e Caiwalion of Dropftv, Loncei, Lond., 

189B. rl, IMT. 
MpUji.-r. S, J.; aiioan. Am. MhJ., I'hiln., 1904, iii, 111, 53. I.M, 161. 
Pwirce, R. M.; The PrwJiicrion of (ly|(.ina, Areh. Iiil. Miii,. Chicago. litW. iii. <23. 
IHmrce, K. M.: An Exjieritiipiitul Stinij- of ilip Influcniv erf Ividui-y Kxinicla auti of the 

Srrura of AniniAlH wiili liriuil liCnioiiH upon nioml-pivHtiin', J. Kxper. It., IDOfl, xi. 430. 
FletBtier, M, H., Huyl. D, M.. and Lovb, L.: Studk-e in (IJleniu. I. L'umjmralivi- InvMli- 

galioii JDlo Ui« AetioD <if ('nlcjum (Thloride and t!a<liuRi (.%)oriili! on the ProducUoii 

of Uriiir, tni^ninal Fluid, and A«ci(M, J. Expcr. Mod., X. York and t-aaeaMtr, lOOft, 

xi, 2UI. 
Flrishnr, M. S.. and I.ocb, L.: The Influ<!neR of Mvocnrditie Lcnom on the IVoilurtion of 

Aaciin*. Inicwiinnl Fluid, und I'rine in Animals Infiuei) n'Jth Soluu'ong of .Sodium 

(.'hloride mad of Sudivini (.'blonde •nd (.'•Iciuin CUoride, J. Exper. Med., N. York and 

l.anc8i>lcr, 1900, xi. ISO. 
Ronib^r]!, E.: l«brbiich dpr Krankheil«n «1h ller»ns iind der Blu^cefftuM, Stiittfcart, 

Oftppa, J. A.: Scanc OhciTvnlioni on the Effect on the Blood-pmvnirv of Withdnkwnl of 

Fluid from ihc ThurHX and AlHlorneri. J. Ain. M. Ahoc., Chicago, IWT, xiviii, :!2. 
StDfling, E. H., and Lcatliesi. J. B.: The .\rriit and <iulc Jxciumi on Some Vmnlv m tlie 

PathoioRV of Ilcail Dif>p«*r, I^knci^t, lx>nd., ISO?, i, 5li9. 
Steiig«l. A.: RiKht-Bided Cardiac Hydrolhuras, Univ. Peim. M. Bull., Pbiln.. 1001, zlv, 

Steele, J. D.: Pleural KiTiuilon in I{«art Dim-nMr, J. Am. M. Atsoe., Chieago, 1004, xHli, 

Calvert. W. J.: Sudden Dc»lh In Pleuriny with Effusion due to nionge of Poution, John* 

HopkiuB Hosp. Bull., Ball.. I»08, xix, 44. 
Cappti, J. A,, and Lcwin, D. D.: Ohirn'ntiunB upon ('erlnin Blood-prvnurt-loweriiiju; Hs- 

fioxni thnl. Arior fioni lrri(ntion of ihc Infinmed Ileum, Am, J. M. Sc, Phila. and 

N. Y., IBOT. cxxjuv. 868, 
Bnthovnn, W., Floliil. A . and Bnttnerd, P. J. T. A.; On Vagm Currenlti Examined with 

the 8trinit GaU-nnomeler. Quitrt. J. Exptr. Physiol., l.ond., 1W8, J, 24^, Uebcr Vogun- 

■trAme, Arch. f. d. ^m. Phyiiiol.. Bonn, IWHS. cxxiv. '.U6. 
Hirechftldcr. A. !>.: dncrvation* on n Cncc of Pnlpilotion of the Heart, Johtu Hopkina 

Hosp. Bi.ll,, Bnii-. 1900, ivif, 2«9. 
Hewlett. A. W.: The V'eiiuUH l^lav. Scienee, lancnistpr. 1IH)9, xxix, 615. 
Mllllcr. 1-'. t^liolod from llonilitTie. 
Evand. H. i'.; Pentoiifil eonimunicalion. 
Salaman. R. N.: ITif Pntlioloj^ ot the Uver in Cnrdiar Diseaac. Laneel. Lond., 1907, 1, 4, 
Duroiiei, P.: Du dflirc rl dii eoma digitalique*, (!iu. hclwlom,. Par.. 1874, xi, 780. 
Hull. U. O,: Tlie Hal hid nation" of OiKildliK; Ooeti Di)oiah« Cauac Hnltuei nation*. Delir- 
ium, or Itiiuinily under tVrtnin fondiiioniiT Am. Med,, Philii , 1901, I, 598. The 

Delirium nn<l Kitllur.inntioii* nt KidtaMf., jhid.. 190,^, ix, 489. 
Head, H.i Certain Meniid Chiiiij^ that Accompan;' Visceral Disease; Brain, Lontl., IDOI, 

xxiv, 315, 



The b^Rt index of the treatment of the patient in bis own mpdition, 
sen.intton!<, uiul general Appearance. Phy^kul cxaminntioiis, (li>U:rinina- 
tion of blood-prcsBure and pulse-rate, as wc-U aa of increase in the product 
of pulse-pressvire by piil»e-ral« {velorily coeffiueiiO, vcnoufi trnciugs, and 
g»s anulvfltH aid in llic interpretations of the condition, and particularly 
in discovering where the fault in the niechani.nni of the circiilftlion lies; 
but the changes of eonditioiM thiunsclveM aro often very subtle and mani- 
fest themselves in the general condition of the patient before they can be 
detected on examination. 


The most important clement in the treatment of cardiac failure is 
rest as complete aa possible. In all cases of heart failure or disease in the 
heart the patient should be confined lo bod. if necoiwary propped up with 
pillows, and siiould be kept there until the scute symptoma have subsided 
and have remained (iiiieacent for several days. 

As Morton Prince ha« shown, menial excitement and worry are impor- 
tant fnclon ia briiistD); about acute dilatation of (be hnrt; but Ibcf are uaiully 
oontribiiling [actor* mthnr than aolp cauMW. 

The effect of menial Activity ii)ioii tlio circulation ia to briiii; uboul vusocoiutriction, 
of both extrcinilicii and rincera, u sligbt rise of blood-ptaBurc. and incrmBc in tlic pulao- 
rale; all of wiiicli taken toiwlhrr ronaiiicmhly incrcaM- the total work of tbe heart (lA, 
nmgbly apealciiis. Ibe pruitual of iiiaxiiunt prevsun- by puliie-nile). 

A good night's sleep ia often the best remedy for the patient with a 
weitk heart, and almost any method by which it may be procured nmy prove 
a good therapeutic procedure. Small doses of bromides, if necessary aided 
by a little trional, veronal, or other hypnotic, often suffice for this purpose 
and allow the heart a few hours reiipite in which the other therapeutic 
measures may have opportunity to net. 

However, it must be borne in mind that in persons who arc much 
worried, mentn] rest and absence of distractions or occu- 
pation are not necessarily synonymous. Indeed, the removal 
of otlier subjects for thought may sscrve only lo centre the patient's mind 
upon himself and his ailments and may increase rather than the 
nervous strain. This should be rarc'fiilly guarded against. The daily routine 
should therefore bo accommodated to both the general condition and the 
temperament of the patient. If possible absolute rest and isolation should 
be secured for the wont caws of heart failure, but even for these patients 
a few minutes' conversation with a cheerful fticnd, whose demeanor is quiet 
and eoothiog, may be of actual benefit. Reading should not be allowed to 




patii^Qls in the worst staKos, but a little reading of the lightest and Icoat 
exciting sort may otherwise bu ftllo"'i>(i. 

Rest, Distraction, and Spa Trealment. — As Mackenzie states, it ia chiefly 
due to the cli^iQuiil of mental tlistrarlion combined with the judicious 
Biipervision of a physician and the favorable climatic conditions, which 
make the Spa trefttiiii-nl.-i of cardiac diiwaae so successful; although, as 
he states, each Spa physician has evolved some method of troatmcnt which 
he rcgnrds as nf special beneflt, when the actual benefit has been due to the 
air and restfulncsa ittM'lf. Neverthelow, it must be confessed that the treat- 
ments at Nauheim by the late August Schott (pai;e 194) have been of great 
boniifit, and bi-iiig founded upon »oun<l phy^iiologieal doclr'mos have been 
applicable elsewhere as well. The physician must always realixc that, 
however little there may he in the Spa treatmenLt pt.r »e, the combination 
of the nientni rest Jinii chnngi? of air with the both* and dietetic rreniiiient 
ia one which the patient whose condition warrants a trip, should not forego. 

Rest ici Bed. — The bed should not he so high above the floor «c to makv 
it hard to get in and out: it should if possible have a metal frame and a good 
rather firm maltreaa. It should be provided with a good back rest ready 
for use in case the patient finds it more comfortable, and plenty of pillows 
should be available. 

In dealing with cases of mild cardiac failure it may be imposnblc Ju 
private practice to compel the patient-s tu remain in bed all the time, and 
then it may suffice to insist upon their lying down for several hours a day 
without abaolui4rly remaining in bed. L'nder these circumatance« the 
phydcian must insti'l that the patient remain <piiet nil day upon a sofa 
or in a wheel chair with legs raised. A short period of such absolute rest 
is better than a much longer [leriod of relalive invaliilisni, for it enables 
the dilated heart to bail itself out, to regain its former dimensions and 
tonicity, and permits the heart-rate (o return to itornml. It is important 
that the patient should remain horizontal rather than in sitting or in stand- 
ing posture, since tiie latter tenils to slow the ciicnlatinn (cf. Krlanger and 
Hooker, quoted on page 2fi). The n>st should continue until all symptoms 
have subsided, until cardiac distresci, pain, and palpitation have di.'<ap]>eared, 
and respiration has again returned to normal. If possible the subsiilencc 
of lachyciirdin or irregidarity of the should be awaited; but the.ip may 
persist for some time even in spile of the improvement in the patient's 
general condition, and may have to be disregarded. After the symptoms 
have subsided (in sevxrc eases after the symptoms have rvmnined quies- 
cent for a few days), the patient may be allowed to get out of bed and sic 
up in an arm chair or whwl eliair for a little while. .\l first this period 
Bhuu1<l l>e very short, to avoid exhaustion, hut it may be gradually increased 
and he may soon be allowed to walk. (For rxcrcisei^ to be taken by patient 
with cardiac disease see page 199.) 


The application of cold to the precordium is of value both for the 
cardiac sj'mptoms (palpitation and pun) on the one hand, and for diminu- 
tion of the heart-rate on the other. TbJa may be carried out by the applica- 



tJon of a simple ice-bn(t (especially containing a mixture of ice »ii<l italt) 
which may be kept in close iipplication to the skin by tying it around the 
cheat anil .'thouldcrs with a strong elastic four-tailed bandage. The iov<bag 
vhould be changed even.' hour or two in order to keep up an inti'UBC cooling.' 

In tiospilal UM or in wcll-«iippliiul hoiiw« thr luw or ihti caniiac lube in moot Mttitfae- 
tory. Thi« oaiiitiBtji of a wiU of thiii-uBllwl niliber or uluuiiuuiii liibc npplicil oytt & wM 
coni|>rrM» tii ihr prrwontiiitn, A ulnmm i>f n>UI wntrr frciin s coolrtr in k(<|'l flowiiiK hlowly 
ihniu^ti tliF lulje, Ttto iixiliivt of Ihc f^kin ihiw oblaiuMl it- exivtluit ■oil withi>ul any 
di.ii«nifort to tliC' puUuit. Its i-rTerta tiuve bmi Uatcd l}oUi ciinlrall)' luxl cxporimcnMlly 
I'j- n'iiil«niit« ami "in .'*ilv». 

Thi!ap uljBvrvrrs (ciumi thul tli^ application of coUl lo ihe pivcordiiun brouftbt nboirt 
In lirwi a oootinic of Uilh (ho aiitrrior mid pmlcrior huKiimh of tlic p«rictinliiini, Amounl- 
iuii U> l°-S°, ttiiit viHS ac(onif);\nieil by n i^lowintl o( the fioJfif- uHd rise of t)lu>ji!-|>naHUi« 
rrotii 120 Wi 190 mm. tl|;. In luiui ihe pul«'-nile iliil not begin to faH for fi(l*m minutM 
afwr iho n|)p1lcntion, aiiil rmrhrd iu hHf(hl within nil hniir. liwIiiiK in Iiim alxiiil iin hour 
■ftrr ivmovul uf tlii- cold. In noniiul imllviiliials t\»v found Lhi* piilpw'nitf fiilltng [rain 
72 lo IVI, (iS to S2, JS lo fiS; in other <-iwn>. rlilcmiMii si to T2, (icricnrilitiK S-t to 78, mitmJ 
Blcnwut 60 to JO. JSiiniiltaiwoisJy the l>looii<|>rvM)nn? rinw and tli* piiW iricrvuMv in voJ- 
itmn. Tlu-rr in evidinitly both u rvflivt tiuiocuiiBtriclioii from slim tilul ion o( llic vjuumolur 
pcniro un<l a rrlliui (liiiiiilnlimi of llip vagiiH. Ilniidis thin, da Silva thinkf- thnt thcrr i* n 
dirc'tl Ktiimiblion of the heart [iiii><'k-. Il will he nn(4?d (.but the»e etTwti* are exactly thooe 
hnniKhl about hy itigitulu. uiid hence cnlliuuiuitic h.vdroltiempist* utr. in Uic huhil of 
speakinjc of the ice-hoc n» " phyiiialoKical diKitaliM." 

Its vuse i» alt«Dded with Iciiit danger, but in citseH of extremt} 
fibrouH or fatty degeneration of the heart, cyanoBis 
nod collapite occasionally oceur. Hence il should be ap- 
plied very mildly in cases where these conditions are tiuapecled. 

There ran hr no iloubt (hnt the icr nppticntion ii not n* officiciit an the line of 'llglMll 
in .i|owiii|i; and «tn.'iiKlhcninK <^<^ htgirl. but when the two arv viicorootily used at the i 
limn they rony ^really reinforce one luiutlier. iinil llie vij^roiw uhp of a good irr-hnjt may 
etutljte Balisfactory oflecl* lo b«' obliiiniil uilh Hm.tller do«e« of ditotAlia Uian Mould olhui^ 
wtw iTiiliw. 


When the patient is in very bad i>onditJon, deeply cyanotic, and rcat- 
less or nervous, and the urea of cardiac dulnct» is increased to the right, 
a ftwe venesection will often bring the greatest relief.' 

TKhnk o( VciMKCtion. — Vmnm-tion in biwt prrformrd in Iho fnllnwinic maiuiei; 
The ckin o^Tr Ihe flexor surface of the rlbow-joinl in iwrubtxHl with crve^i Bonp uiul wiwhod 
with wnmi nnt«r. thtn with alcohol, iind loally with 1-3000 bicliiuridc solution. .\n elimtic 
or^^M tMUi(bu[p i>i licl nlx>ut the upprr.tiru litthlly nnoiixh tocniiM' the veiiii to Mtiind out 
but not to oblii«rutv ilie piibe at the wriHl. The laricmt vefi) vkibL- (luuully tlui inediiu).^ 
OcphftUc) ia rtIpcIhI luid n nnmll nlit in ihi- Hkiii jtwt Dlou^ide of (not over) the i-dn it mo 
villi a curved bistoury. w)iieli in tlim puahcd in thrtiujih the hIiI in Ihe 8kin and UDiJer tiMM 
vein. Il ia then lwiHt«<l wi that (lie rf\gv is iiini#<l upwani low-anbi the skin ii^nat the 
vein ami tbi! vHn cut Ilirnugb iritliout n^in pierdn); the akin. A verj- free flow of blood, 
la obtaifwi. eni^ecinlly by kerpinK flie .imi drpnnileni anil If the pstjent in made lo den 
and opan liia hand* rapidly. From itlXI to I'JOO ex. (13 ounctt to 'i\ pinl<} can thun iwl 
romovod in Ion thtui tmmtj' miniitca, nMuU}' witli great xtiiei to Ihe patient. RmalliinK 

' Wbec a mixluit^ of ice anil >ali is uMid It 18 pOMlUa to actually fneie the iikin, mi 
iwridcnl wUeh muM be carefully at-oidMl. 

'The luDinofflibin hhonld .ilwnys hr- ti^Cful before perfomilntc u veneoertion; and it 
tbiMitd tK)<, at a rule, be pcrfonned if Uie lucmoglobiii is beloir 70 per cent. 



bccomm Misier, the bend clcnrtr. and the eeneml condition beci«r. bill the rnwlttl pmat i* 
■voctiHl irlipii the rulor rlianin^ nini the f^yuiiiwis ^ivM way to a, bcaltli}' rony color in tlw 
li]w nnd pWwIiPfr, This iiidiemtB lliot thp nvrmtraiticd hiain has b«>tn unburdened, nitd 
the bleeding iwieil not he. piiHlicil niu(?)i fur(ht^r. Indeed it should not be. for lo cuuan an 
■nnmin i> dutifenius. All lhu< isdrvircd i«Iu ivtii-ve thp distention o( (lir right h«ar1. 

Fw. 134^4— 'Ihmtuiai r»t tlmknifn in vuiAioctiou- A- Lstarml vi«w, B. Cron atcrnoa 9t •nn. 

Eftect of Venesection on the Clfculatlon— Thy value of i-eneupction can often be seeit 

in rxperimpntji upon nniTniil.i. It is itol nt oil iincoinnion to hrid a heart railing; BDd An 
auriele iiln-nily paralyied from overdi»I«ntion, in which n free veiieB«rtiori Kiv« immpdint? 
relivf, nnd tlii- uuritle us well an tin? ventririe resume* forpibic emit nwi ion*. The effect of 
this pmcwdure uiioii the l>ioo>l-pri!«eurp is ^-unable and dc]iends lo a certain extent u|xin 
ibe phenomena preaent before the vciioi»cctioii. 

Btlan VmMncllon. 

A(wr VtimnUtiu. 



1. Nomml or elevated 

2. HiEh 

Henri distended but ctrcultition 
xtill iiifhpicnt 

CirculAtion slowed- Vtu^ocon- 

Fall of bloTHi-preMUre from einp- 
tyiiij; uf vascutur sygtcni and 
(Umiiiishcd viscosity of blood.' 

Fall of blooii-ptvwun^; occiunon* 
ully cuinppiuuiii^l by inereaaod 
force of heart-l>eat uiid diitiin- 
iiilied visccnily of bluod- 

Bloo<l-prPiwurr riimi on account 
of marked inoneaoe in forec of 
hcart-lwDt ill *pit« of empty- 
Inn of VMCiiliir *y»lein aiid of 
rvluxaliouofpeiiplieral vpeaela. 

3. Low or normal . . . ■ 

MtricCinn thmu^li utiiiiiitnlion 
of niedlillu by expuia of CO, 
in tho blood 
Clrculuiion tinwed: heart fail- 
hut- l-'niibli- tci knrf> up cir^ 
ruintion thmuich nipdulla in 
■pile of vacoconstrletion 

Quite independently of ihlM chaBjP* th« right border of cardiac dul- 
neits recrdps one or more ceotlmelrCB toward the Btemuiu, tin- venoiu prrwiirv 
■hould full, and the Keneml condition nhould improve (cf. Fi«. 127 nnd Cftnc on fyUfK 239), 

Conlraindicalions lo Venesection. — Howt^vcr, it must be borne in minii 
tbiit vi>tiiwi<'cl i(Hi (iin <lo harm as well as good. CusMng htts sliown that in 
conditions with iiit-reased intracruninl tension, among th*m apoplexy, rim 

' Jfcubner hiu shovtri that two-thirda of tlic \i«cf«iiy of tlie blood in due lo the ror- 
puteIcA, hence »-eiK»eclion cunnot (ail to reduc« the iruooaily- 




high blood-pressure is a phenomenon of phyMoloKical compensation, which 
tfl necessary in order to niiiintuin the circulation lhrotij;h the niedulln. In 
ronititionK with long-otjnlinuoii hi;^h blood-prewiire, psiwcially chronic 
nephritis, this may also be the eaae. In thv^e coudttious vcncseotion with 
H vi«w lo lowering th* urU'riid 
pressure is contraindicatod ; but 
iu the*, iia in othi>r (■<)nditionf, 
it is sliU the procedure of choice 
to reiivve pulmonary (iik-nin or 
acute dilatation of the rishi heart. 
The vonctwction should Ix- curried 
only to the point of relieving the 
venous «tiisis. not to that of low- 
ering the arterial pressure. 


Rest for lhi> (^tro-inteatinal 
tract is quite ax important for 
the heart as is rest for the mus- 
eiw. Erlangcr and Hooker have 
shown that " an increase in pulse- 
prestnire becomcd manifest within 

Fin. J2T. — KfTwt of veneHctioD on l]j«c&nli&o(iu1- 
]in#. thowiruc rlimiuutioiL in hc« at riKlii f>a*ri. iChB* 
<A G. G.) &vUil liuf* idfljf*!'* mriljikfl nutliu* bviott 
vKisMcrtlon. brakm lia**(tvr vtnmvUoa, 

a few minutes after the beginning of the meul, rraches it.i maximum within 
one or two hours, and, as a rule, declines somewhat more slowly. It seems 
to pass off n-ilhin one or two hours after the maximum bus been rcftchcd. 
The puli)e>ral« is always distinctly increased with the iogetition of meals. 

.... The product P. P. X 
P. U. , representing the velocity, 
follows the curve of the pulse- 
pressure," hence the velocity 
of flow nnd the work of the 
heart arc increased. Accord- 
ingly, the dif-t should be light, 
ju!<t enough to keep tlie patient 
nourished without ever giving 
him ft sense of fulness or to 
allow gas to form in the stom- 
ach and intestines. Distention 
of the stomach pushes up the 
diaphragm and causes the 
heart to lie more transversely 
in the thorax, embarras.ting 
its action, causing a diminution in the systolic output and an increase 
in the pulae-rate. N'ot infrei[uently this Li also associated with onset 
of precordial pain and constriction. Accordingly a very light diet 
U neeessar>* for the patient suffering from heart failure. The lac to- 
cereal diet is the best, consisting mainiy of milk, eggs, custards, 
junket, toast, sweiback, crackers. The nunterous prepared cereal foods. 
















V i;:^ 

' w ~~-— U 

( v^, --a* 



Fio. lfift.'*-T3rpiaKl «ff«ct of Yvnnivctiari opon lh« anu- 
iMiOfi* AfTOvvlbitkfBtachMifftifj blood 'pr«wiin. 


which conn»t of partinlly«(l flake» of wheal, com. or rice, arc 
particularly good, eince much nourishment may be gtvpn in smnll bulk 
and in a form which iloes not 14^011 to form thick, imppnel.ralilc. doughy 
maaaes. licHid<rs they contnin the bniii tut wvll a« the titnrch, «ud hence, 
by U-Mvinc considerable fecal rpsiiliie. tend to keep the bowels niovinju:- Meat 
ebould be given iipunnf^ly, partly bec4iu»c the purin bodies (xunthin, hypo- 
xanthin) tend to rwse the Wood-preiwurc and increase the work of I he heart, 
and more particularly bftcautte the moat fdircs are relatively slow in diges- 
tion. Kor tiii» reason it i* better to take tlie prot^id food in the forms men- 
tioned above. Fmely haslied Hamburg steak, lamb ehops, or chicken are 
the best form:* of meat. 

Liquid and Sail. — Liquids should be limited to t.^00 c.e. (thme 
pint)') 11 'lay in ifls*-.^ when* n-dema is present, ssinec nn cxwss of liquid 
inpestec! causea further accumulation of (edema as well as brinKinK on a 
Kli^ht overfilling of the blood-vesselH, and thereby increu-ning Uie work of 
the heart. 

Salt shtmlil also be withheld from the food as far a» potwible, since 
Widal and Jtivnl, Stniu'*[* anil KiclUcr have .-diown that It i» a contribulini; 
factor in the production of u-dema. and liarii^ reports good results from the 
diminution of NaOl iii the diet in diaeaites of the cireulMion. 

Barii^ recommends the following articles ae a basis for a diet low in 
Midiuni chloride: Type I — L'nsalted bread .'lOO (Jm. (IS ox.), raw meat 400 
iim. (It OK.). l)utl«r NO Cm. (2* at..), hugar IIX) Om. (3i ojt.). Type II— Pota- 
toes lOOO Cm. (32 oi.), raw meat 400 Gm. (14 oz.), butter SoOm. (2J oz.). 
iiugar ISO Clm. (5 ox.). 

•Sample Did. —An excellent diet for severe heart cases, which may at 
least serve as a basis for other variations, is the follfiwin({, »Ii|;htly modified 
from that used for cardiac caaesin the wards of the Johns Hopkins tlospituh 

8 A.M. Cereal, soft egg. loa«t, coffee 200 Gm, (vi ot.). 
10 x.ii. Milk 200 c.c. (vi OB.), soft e;^, crackers. 

Dinnvr(nouu). Soup, cliioken, potatoci*. 

4 P.M. MUk 200 e.c. {vi os.). 
Supper. r.M. Milk 200 c.c. (vi oz,), soft egg. crackers, prunes.' 

9 ivM, Milk 2U0 c,c. (vi oz.), bread. 

Limited Milk Diet. ^ In cases of broken compensation with extreme 
(Edema great Muccesw hiw sometimeJt been attained by limiting the diet to 
(iOfl to 800 c.c. of radk in 24 hours (Catell, Hoffmann. Jacob and Hirsch- 
fcld), even in caites in which all other therapeutic nieu-surcs have failed. 
Professor Barker has occasionally obtained excellent results by increasiuR 
the proteid intake upon thiu diet through the addition of nutroite to the 
milk. However, striking rebultx with this method are by no means the 
rule, and it ia to be used with caution. 

AlcohoL — .\ very little alcohol, either as wine, or as brandy or whiskey, 
may be allowed to persom! accustomed to its use. Beer is k-»w advisable. 

'It is imporlaiit touv(iitli;ivinK>'trwfHi [ruitswhEclicoritaitiuiucti ucid,niic)iafliM?iu-li(v 
luid nprioola, oluitg wit)i ihi- mills. lu Iht liigmtioii uf putitMila with bniktD cotnprniuilinii 
iBWryranly cliiturbrd. andiui attack of vnmitinKplaCM nconndcniblr'i'lnunoii (he heart. 



since it carries with it large quantities of litjuiil and o(ien tlUturbs the 
cli((v«tiuii iu< wvll, vrhvivfu, wiiu^, whiskey, or bmndy in sninll quantities 
improves il. Against this is halanrcd the delclorious offect nf nlcohol upon 
the h«art mu»cl«. Lurge quantities tend t« prmiuce fatty de^neration of, 
ilie latter. Wliether small quuniitifji have any ««i'h elTi^ct in the individual 
case is uncertain, but it must he bonie in mind that the injured or^an is 
much more siiwi-pttble to ilflctvriou.s infliicncc^ thiiii is the healthy organ. 
It is a siifc rulf that, in pontons not aliva<ly addicted to its use, brandy or 
whiskey be pvcn oidy in dowi* which n^rvv lut r»rmiiiHlivei>. and not in 
(loses intended for stimulation. Even the psyrhic effect may often be 
secured (lit w-ell by small <lowei* as by large ones. One paint in favor of alco- 
hol in man as a^inst animal experimentation lies in the fact that in such 
personi* it greatly inrr(ra!«e,-i the wn.-«e of well being and n-mnvcs psychio 
depression and worrj-. The latter may be esperially atraininu upon the 
heart, and heme every effort .-should lie made uw> of to wanl It off, esf)ecia|]y 
during certain crises; but it should be borne in min<l that the patient may 
easily beciime de|>i-tidt'iil iipitii the dniik to arou.-v his spirils uni] in this 
state mcire harm than good is done. The greatest judgment should l>e used 
in the adminint ration of alcohol even in small quantititrs, and it should even 
then be reserved for crises when the stimulation of every fibre is all-impor- 
tant. On the other hand, alcohol .should ne^■e^ iw withdrawn suddenly from 
persons addicted to its use. since this procedure often precipitates an attack 
of delirium tremens, but moderate dosi-s (whis|jey 1-5 r.c. or § or., every 
four hours) should be ^ven. 

Tea and Coffee. — Whether tea anil coffee should l>e given depends 
largely upon the patient. In some persons these cause marked general 
nervousness, slecplessneas, tremor, and even palpitation anti irregularity; 
others ha%-e eslabliithod a lolerani-c such that no effect at all is produced. 
The caffein ttseU is an exeollcnt cardiac tonic of the digjtalis order, and 
where it." i-fTeets on the ner\'ous system are not manifesi it may prove an 
excellent adjuvant to the treatment. {.V cup of coffee or of strong tea 
cont-aimi about 0.1-0.2 (Im.. U to 3 gr; the pharniacologieal do.'te of pure 
caffein being 0.05 to 0.25 Gm.) As a rule it is safer to remove them from 
<liet, but in this as in alt other rules individual exceptions can be made. 

Tobacco should not Iw usi-il under any circumstances. Besiile.^ the 
nervous symptoms, it produces vasoconstriction, and often irregularities, 
palpitation, and even precordial jiain. Hence it is particularly 
to be avoitled in coses of cardiac disease. 


In patients with cardiac disease, and especially in those with broken 
compensation, the question of purgation as.'^umes unusual importance. In 
these patients purgation seems to have a threefold beneficial action: first, 
by eliminating tlw products of waste and putrefaction, to which they are 
parliculaHy aensitive; secondly, by relieving the distention of tlie boweia 
from gas which tends to push up the lUaphragin and to end>arnu!s the heart 
by placing it in a more transverse position; and thinlly, by removing fluid 
from the body through the boweia. Thi.'* last effect is probably of con- 



8iderabl« importanr^, since Aakanaity, Kast, and others have shown that 
broken ci>inpfrisut ion is ai-comiMiiiictl by hytlriwinic plvlbom. Hytlra-mtc 
plethora causes a rise in vt-uous pi-esauro ami a tlilatation of the heart (Koy 
«ii<l A<laiili, CamcroiOr thus cmtmrraj«<ing thi* circubttion. Moreover, in 
broken sjstemic competifiatioii the venous stasis also affects the kidneys 
ttrifi dimiiii^tie.-i the excretion of fluid, so thai the bowel becomes an impor- 
tant accessorj- channel of elimination. It is therefore the hydraRORue 
pnrxative^ which are indicated in cardiac failuie and not nierrty the )>ur- 
giUives which incrcun? |M-ri»t»l«L«. 

In moat canea the bent method of procedure is to start movement of the 
boncls with valomel in cither large single dwi'ea ( Gm., grs. v-x) or to 
small divided doses (.00(1 Cm., pj. jV half-hourly). The dose of calomel 
should alivay.f 1« accompli nicd by & simdl lio^c of bicarbonate of soda 
(0.3-O.0 Cim., gr, v-x) to avoid disturbiuR the dif^ation. Stil! more certain 
purgation is obtained by ^i\'inK a .-litigle dose of calomel anil rhubarb in 
equal quantities (0.3 Om.. gr. v). given at night. In all case* the calomel 
should lie followed by a saline purgative the next moniins. Ep.wm salt 
or some aperient water is |»rcferabte to Scidlit^ powders or elTervcsccut 
citrate of magnesia, partly because of the action of the orpanic acids upon 
the renidium of calomel, but chiefly the carbonic acid in the drug 
distends the bowels and pushes up the diaphragm, thus embarrassing the 
action of the heart. However, Epsom salta and ft]>erient wfttei:^ xonielimes 
cause nausea, and in such cases the advantages gained from the mildncHH of 
the Seidlitz powder may outweigh its deleterious effects. 

After constipation has been overcome purgation with salines should be 
continued vigorously until the tiilema has completely' disappeared. Just 
how vigorously this purgation should be maintained is a matter of some 
dispute. Some clinicians, who regard presence of fluid as the most dele- 
terious factor, believe that the best results arc obtained with ten to fifteen 
fluid stools in twenty-four hours, with the elimination of two or three litres 
by the bowel. Most observers, however. Ix-tieve that the beneficial advan- 
tages of such extreme purgation are more than counterbalanced by the 
strain which they place upon the patient, not only by disturt>ing his rest, 
but also by causing a considerable ri.-<:e of both arterial ami venous [>ressure 
with each movement of the bowels. Indeed, each effort at stool constitutes 
atypical Valsalva's exi>eriment, which, as has l)een.*een (Fig. 116, p. 132), is 
accompanied by tremendous rises in blood-pressure and in weakened hearts 
by acute dilatation. 

Mr. W. E. Dandy has shown that the rise of arterial pressure during 
tlw act of defecation is from 30 to ■'JO mm. Hg, and Mr. C". (". Cody ha.* found 
a corresponding rise in the venous pressure. These observations are sup- 
ported by the fact that sudden death at stool la by no means uncommon in 
cases of cardiac di.-«;a.'<e, especially in cases of aortic insufficiency, and 
occura even when the movements have been kept soft by daily purgation 
with sails. 

In this, as in most other therapeutic procedures, extreme measures 
arc tu Ix; avoiderl and treatment should be directeil to secure n few easy 
bowel movements without too much disturbance to the patient. In many 
cases one or two compound cathartic pills (colocynth, jalap, gamboge, and 


calomel) at night and a dose of Epsom salts or aperient water in the morn- 
ing maintain just the correct number and quality of stools. Compound 
jalap or compound licorice powders are also useful from time to time. In 
stubborn caaes elaterium or a drop of croton oil may be resorted to, but 
should be used with extreme caution. 

On the other hand, cascara, aloes, strychnine, belladonna, castor oil, 
phenolphthalein, and the other purgatives which purge by increasing peris- 
talsis, are of less value in the stage of broken compensation, since they do 
not deplete the portal system nor relieve the hydremia, though they are 
satisfactory enough when compensation has been reestablished. 


General Principles in tre Treatuent of Cardiac Dibeaseb. 

Erlanger and Hooker. Quoted on page 35. 

WintemitianddaSilva. Quoted from Buxbaum, LehrbuchderHydrotlierapie,Leipz.,1903. 

Widal, F., and Java), A.: La cure de d&hloru ration ; son action Bur I'cedtoe, sur I'hydra- 

tation et aur I'albumiDUriB & certainee pfriodee de la nephrite epith^liale, Bull, et mem. 

Soc. MM. d. hdp. de Par., 1903, 3 b., xx, 733. 
Widal, F,, and Lemierre: Patbogeniede certainMcedimes brightiques; action du chlonue 

de sodium ing^rf, ibid., 1903, 3 s*r., xx, 678. 
Widal, F.: Die Kochsalzentziehungskur in der Brightschen Krankheit, Verhand. d. Kong. 

f. innere Med., Wiesbaden, 1909, xxvi, 43. 
Strauss, H.: Zur Frage der KochsaU und FlUssigkeitszufuhr bei Hen und Nierenkran- 

ken., Therap. d. Gegenwart, Berl.-Wien, 1903, N. F. v, 433; Sympoeium on Thera- 
peutics, Med. News, N. Y., 1903, Ixxxiii, 673; also, Die Chlorentziehung bei Nieren- 

und HerawasBerBUcht, Verhandl, d. Kong. f. innere Med., Wiesbaden, 1909, xxvi, 91. 
Die Chlorentziehung bei Nieren- und HerawaBserauchC, Verhandl. d. Kong. f. innere Med., 

Wiesbaden, 1909, xxvi, 91. 
Rtchter, P. F.: ExperimentetleB ueber Nierenwassereucht, Berl. klin. Wcbnschr., 1905, 

xlii, 384. 
Bari^, E.: The Dcchlondation Treatment in Diseases of the Heart, Intemat. Clin., Phila., 

1906, 16th ser., i, 26. Cf. also Symposium in Verhandl. d. Kong. f. innere Hed., 

Wiesb., 1909, xxvi. 
Carell, quoted from Romberg. 

Hoffmann, F. A.: v. Leyden's Handbuch der Em&hmngB therapie, 1898, i, 579. 
Jaeoby, L.: Ueber die Bedeutung der Karellkur bei der Beseitigung schwerer Kreislauf- 

stOrungen und der Behandlung der Fettsueht, Muenchen. med. WehnBchr., 1908, 

Iv, 839. 
Hirschfeld, F.: Die Kareil'sche Milchkur und die Unterem&hrung bei Kompenaations- 

Btorungen, ibid., 1908, Iv, 1587 


It docs not lie witliin the Hcopo of this work t« enter Into n detailed 
dit(CUE(»ion of the pharni neology of the drupt used. The reader is ix!f«rrwl 
to the tcst-boolM upon this subjcet, especially — 

Cuslmy, A. K.: A 'j'ext-lxjok of Ptiunuaculogy uiiii 'Ilicniwutitv, fhilnddpliiii oiwl 
New York. 

SultiiiiiTiTi. Toralil : ToM-book of Pluiniiuixilncy. 

Huiclicr, H. A., und Wilbert, M.: i'iur I'lmrmimipivia luiit tlie I'hysiciaii, Cliimgo, 
lfl07 (pul>li«bi'il hy iho Amrrimn Modical AuMicijilion)- 

Hoitit. It.: (I»ii<lbiieliiiorFX|>frini(riiiulloii I'ai liulugie mid PliamiiU'ologie, Jena. IDOo- 

lloBTvpr, since it is fn-qtirnlly inronvpniwil to refct lo sucJi books, u brief stiniiiwrj- 
of the arlion of each drug wili \iq Kivcn nilli riiN^ciitl rrgnid to itJ^ t'1inir«l applical km. 

The drugii used in the treatment of cardiac disease may be of value 
through their iictlon on the following syalcniK: ■ 

I. Upox the Heart MoscLE—^ij^UliB. BlrophuiilhiM, slrj'chninc, wjuillii, caffeine. 
II. lJi'o« TMK PtaurnKBAi, Vkssbui — evnAlriclon: OBnipliur, »trycbtiin», Adrenalin, 
ergot, digitalis, nicoiino (toboitco), caffeine; dilattir*; luiiyl citritc, nllroi-lyccrin, Mxiiiiiu 
nitrite, erytbrul t^lruoitnite. 

1. AcTisii TTPON ■niB Cardiac NenvBS. 

A. aUnpinff ttit lieaH tlirnngh Himutation of the raguji: acoiiile, digitalis, atroplianlbui, 
Koinetlmoi ulrj'cbninc and oafTrinr, nic^otinr, vcratrum \'iride. muxcarin. vet; Inrffc doict of 
polOBiiium BultH. bile sallit, Mood in jaumtice. 

11. Irtcnaaing the hrorl-raU Ikrough paialyting the ixtgi: utro^^ie, cocaine, anijrl uitrile 
and utiier nitrtlM. 

(.'. Inereaaing ratt through itimtilation of un'ekmtnr*; ndranalin, an>yl nitrite, and 
Other nilritPB. 

I). Parali/ting aeederatnrt: apocodein. 

2. DlUINIMUNIi Vk.M)LIS i'llKsBllKli AMI .S'J.tntil ftV llKPl.irj'I.VC PoRTAL SmSM; 

pui^live ai>ric«, rAprninUy calomel, t)ie nuline luid tlii? vcgvlulih pursiMtive*. 

3. UmoH WHICH 1\CBE*SK THK ToNtOTV oi' Titii Gardi*i: Mvnci-R in phanna«o- 
logioal doiieii: di)cilulia, slropbamliuH. Btr>-cliiiine, amy) nitrite, nilraglytvrin, calduiil 
chloride (tratwiiory efTcci). 

4- I>Hi'(ia WHICH Decreasb ToNtclTi': potntwiiim ^alta, chloroform, formic aci'l, salt 
infusion, etlier, udretinlin. 

Tucicity ui j>ractieally iin:UIeclcd hy Hniall dam* of aeoniI«, though iliKhlly <liiniiiiiih«d 
by larger one*. 


Foremost among the druRs used in treatment of circulatory diseases 
are the proparations of digituli^t, introduced into medical prattice by Wilher- 
bg in 1785. He says of it: "In the year 1775 my opinion was asked 
cont^rning a family receipt for the cure of the dropsy. I was told that it 
had long liecn kept a secret by an old woman in Shropshire, who had Kome- 
times made cures where the more regular practitioners had failed. , . . 
The medicine was composed of twenty or more difTerent herba, but it was 
not very difficult for one convcreatit in these aubjecte to perceivi; that 


the Active herb could be no other than the fox^ove. ... I soon Tound 
the foxglove to be ft very powerful diuirtic. . . 1 use it in ascit^'s, 
anai>&iYa, and hydrops pcetom." )Iv thi-n (-it<>» the rc^ts obtained in 
ihe treatment of over 100 cases, many of whifih would lie worthy of 
modern therajR-utics. 

DruK« of OtEhalk .Serie*.' — DigiUiliii. Klrophnntliiin, apoeynum, conraUnrin majalif, 
sf]uill (scilb). tr>(hrophl<vlnr, hellebotvin, anliarin (anliaria (oxicara). 

I>i<UTAi.i» c<miri»U o( Uie dripil lenvea of Digitalis pvrpuna colh(>lnl from the flower 
nt t)io comnipniTinrnt nf tli« nrfioni) ymr'H tcmwlii. It nhoiilii not l>c kept more Itian one 
year.' Av«raet! <lua« pulv. digitalis — 0.03 tim. (1 grain)- 

Pacpta*Tloim. Da t. 

Fluid ftxlrnctiim di^uliii D.05 n^ ' 

Exlracliim •Jisiiallx 0,01 gr. 1/S 

I nf lis mil digitalis 

(1.5% >tigitali«-|'10^Da1cahid + I£% dnnaroon n-at«T) 51.00 3 ii 

Tiootura digitalis 1 .00 "V jtv 

(10% of erode digitalis in dil. uiooliul) 

A very oallflfiirl'try dirm (or n<lmmiKtirrin2 digital!" and a purgalivc at onoe (a 
.Vitclixon'ii (or NirmuyiT'a) pill, cnade iiii arouniiiig to the fulluuiiii: [>KBcriplioo : 

Pnlvi. diptalU 1 ^ „^ 

Pulvut BCilta- .. \ * 

Hydrarg. ehlotidi roil 0,08 gr. I 1/4 

M. fiat in pH. x hrii capanla* x. 

iiig. One pill every three hours. 

Tbe calomel may be Inrmuvd lo gr. x, or may he ivplaeed by blue-nioan (maMa 
hydmrs.) or gniy ptiwder <liytlrarayrum cum crcta) io uapHuloa. 

Thp eflicary of .\<l<ti»on'K pill de[ipntlt upon ihr ciirr tnkrn li> MYnrp an active prvpu' 
rolton of <liinl>ili« ■!> niuhing il Morriivor, ll« action may be uncertain, ualtig lo tbn (act 
thatnCprlutiianKiunlordiuitulis istliininatrd with ttipstuid u'illiout having lipcn ahMrbed. 

DciiiVATnrji iii* lini\i wm^ —Oi^iiotin — ilie niost active sulwiancc derived from 
<ligitaUa. producing alt the digitalis effocitt; aoluble in alcohol; Insoluble in water, except 
in the prcaence ■>( digitonin. Pc«pared in soluble (unn with digitonin under the trnda name 
"Digalcn''(Clortta). "Diaalcn," done 1 cc. 

IHfUalin (digilalinuin veriini Kiliani) — a white amorphoui gluooajde, lea* toxie than 
digitoxin but othcrwiw imcnibling it in phyvical properties and pharmacological aotion. 
Dose J-O mg- [gr- 6'M 

Roughly, digitoxin la six tbnoa more potent than an equal weight of digiudinum 
varum (Frncnkcl). 

DigH^u"Grrman" — amnrpholM powder, soluUe In aater and alouhol; a mixture 
of pare di^taliii, digitalein. and digilontn. Dnm.' 3-A nig. (gr. I'l-iV). 

fhgitnlnn and digHomn are olfaor comowliat iriniilar nibslanccs which have no pliBr» 
raucological sctiuii, 

SrwutiAVTM LB— the ripp »ee<lii of Slrophnnthus Kornh^. Tinctura Ktn>pli«nthi, 10 
percent, of the drug in IW per «:nt. nicohol. Dote 0.5 c,c. ("V"!'). 

'A very full diHumiou of thai! drugii ia given in Cutbay's artido. 

*ll is mo^t dilfirull to obl.-un a prrparntion of digitalis leaven of which one can bo 
(ertaiii. und upon tliln nlone tlic ti-sult of tlie wliule trvuinicni dejiemln. Owing to the varia- 
tintw in IcuVDi it in IhvI in Dhtnin pn^paiattnns Imm man ii fact tiring chemists alio have 
Btai»liir<)ixcd Ihnm from phitlnldgical effecta upon frogs or uianuiiuU. (The term "fmg 
luiii." " t''nHchi-iiilii?ii," n-fcm lu the amount of dtug whicJi mil kilt an average frog, 
leaviiqc the hpnrt in Kysti>tr; cf. abo Sowton and fopecially bjdinundtf and Male.) 
Ed&umd» and IIuli^ have flhowii that in frogs tlie drug act* chiefly on the heart, in maiD- 
mnU largdy on the nervou* »jMtm. 


Dfrivative and Aftive Principlt. — Slroplumlhin — a wliEic orysl.tillinp jclucaside of cOD- 
■Innt compoulion and action. Koluble but undcrguinf; dccorapmilion iu water. Hence 
b«flt preMriLed in di1ut« Rlcohol: 

Stn>phnn(lun i...... O.Ol gr. 1/5 

Alcohol.iil I. SO 5v 

Sig. T^Hupoontul p. c. in bait glaai of water. 

R. .A, TIalchcr hiu nhnwn rmintly tlint thr nhanrplion of itiophAntliut and strophsn- 
thinrroin llit-Kiiatru'iiilvvtinul Iruct i» very uncertain, and Ibat it ia liable to set in luildeiily 
aftrr tn!iiic:ndoiiM ilow* have Iweii giwMi without t'ffect. Hwicc ibfse ilnig* abouU be 
adminiM^^nvi iTiI.ravviKiiwly or intminUM'iiljirly. 

For intniviMioiiH ur iritramUM^iilar injdctiUTis olropbantliln (amorphous) i« |»it up in 
omall iit«r)le phiaU (Bopfiringcr 4 Co.). U in \tr)- useful for ihv pbyuclon to carry a few ot 
thoae Id lua emcrxmcy caw. 

Stnpliuntliin (TlLOina) a aaid to be crystalline and la a more stable and more uni- 
form pivparatton. it act* indcMtsof ) to ) mg. (gr. iiaU> jit). 

EfTRcr OF dicitaua ok the normal heart. 

Fraenkel and Schwartz and also Cloettu have shown that in thera- 
peutic dosfs digitiU'iK haa no effect upon the normal heart, either in affect- 
ing the BtrenRlh of the bout or in bringing ubout hyi>ortrophy. Neither 
has it any elTect upon the perfectly compensated, undilated heart with a 
valvular Icttion. Its chief effects are seen in dilated hearts whose myo- 
cardium still retains some reiierve power. In the severest stages of cardio- 
Bclernsi!* and fatty degeneration it may atimiilate the fihrea to the limit of 
their power, and thus do actual htirm, itnd even biuttoii the end. 


DigttAlitbM the following actions: (1) it Atimulates the vagus, both 
centrally and peripherally, brings about slowing of the heart, and dimini»hes 
conductivity ; (2) it increases the irritability, force of contraction, and 
tonicity of the cardiac muscle in both fturicW and vciitridos, slightJy 
diminishing conductivity by direct action upon the cardiac muscle even 
in atropiniKcd heart.-'; (3) it causes the peripheral blood-vessels to constrict, 
thereby railing the blood-pressure; (4) a diuretic action, mwnly through 
increase in the mte of jceneral blood flow ; {'>) it pauses a eonstriction of the 
coronary blood-vessels and diminished flow through the walls of the heart. 

.■\s nhown by Cushny, the action of digitalis may be divided into three 
stages, characteriwd by the following phenomena: 

I. Therapeutic Stage. — Slowing of entire liearl, increaso of blood-pres- 
sure, increase of systolic output and of cardiac tonicity, peripheral vhso- 
constriction, dilatation of coronarj- arteries, slowing of eonduetivity, 

II. Stage of Irregularity. — The heart-rate becomes somewhat acecl* 
erat«d ^nd irregular. Cushny thinks that this irregularity is due to the 
fact that, besides following impulses from the auricles, the ventricle begins 
to beat witli a rhythm of its own. .\ pararrthymia thus sets in, and 
the two independent rhythms occasionally produce interference and pro- 
longed pauses. In this stage the blood flow becomes slowed, although 
the output of individual systoles is much increased. 

III. Stage of IncoSrdination.— Kxtreme irregularity of both auricW 
and ventricles has now set in, both beating indejiendently of one another 


(ii1>soluU> hcart-bloek) . The blooil flow hns now mnrkcdly slowed and beats 
become irregular in force and rhythm. Death sets in. 

Action of DiBiUili* on the Coronary Arterie*. — Aiioihrr t^fffi^t of <l)([iliiliii, nnmely, 
marked constriction of mid lewcnwi hlcHHl flow throujch ihi; coronary venMik, hax been 
itemoiuilmlod by Uiwulit Loeli upon the excisoil liearl. Tliiw is iluu muialy U> the cli(ti- 
t«icin, Mid oocun cvcd nt it tjtnr when Ihr hUc nnd Forvr a! the mniinc r-onirnctiniui arv 
deRnilely incmuied. Altl)oii]i;)i Hr, <j, 8, Bond in t)ic writer's laborulory hati been unubtu 
lo nbtnin nny nuch chnnne in flow tliroutcli Ilie coronary arlcrim of lliu dog's ht»rt in lilu 
after ailniiniklRilion of ilitcitAlii nnd iitrDphaiithii*, thctv t* connidcrablo dinioal evidence 
ihat tliKiiulin sutuetiineB dues iliiitiiici harm In pati«nts ulioae 
myaCBrdium bun undergone ex tensive fatty d«s«neTation, or 
ci>rilioiirleroi>iii, or wt)i>«e Nrt«ri«ii are aclorotic. Strophanthin pro- 
duces the xatiie elTecta though In lem marked degree. 









A B C 

Fiu. 120.— Tne >n«i ihowiait theuilonol dlgl Ull* upon th« >lat'> Mood-pnHDrb (Altn- ru>hny.> 
^,noniul^ B. IbrrBpiiutic ivUica^ ivitn lncr<*svd blcHld-prtiuur* Jdul riKicloniln ■Ifawiud ot thw piil4^ \ih\ 
OplldUnail blottl-flov^ <'. Ficcmvs inhilulien, i«ijHin( liiw blnnl-pnwiir' uiil jilovnl cirralaUon; t>. aiili 
turthet ilovina. "iUi rhflii kirtiytluiiia; E. Lliinl ruac trnsularitir sith furihei rku of blooil-praBUn 

Effect on lh« Blood-pressure.— The rise of blood-pressitre due 
to digUuli)) is in part due to the invr«as«d force and out- 
put of the heart, in part to the constriction of the periph- 
eral and, ospfcially, the abdominal blood^vva^elic. The 
velocity of blood flow (as shown by product of pulse-prpsaure X pulse- 
rate') is usually increased when this effect is brought about (Fellner, 
Fnicnkcl). Strophanthue cnuscs liss vasoconstriction than digitalis, and 
hence usually affects the minimal pressure less than the maxima), but 
iiicrwuscM ihc velocity of blood flow without (■nii.''ing so givat a 8tnun upon 
the heart. Unfortunately, the preparations of Btrophanthus are less, 
reliable for continuous action. 

Occasionally it is found that both digitalis and Htrophanthus,&ctuaI)y 
lower the maximal blood-pressure. This occurs espe<'ially 
in the ca«cs where the circulation through the mcdullai;)' centres is 
impaired by ii'eaous staaia or arterioscleroas, or failure of the heart, 

' Jaaeny luia reported caaM In whlc^ digitalis produced icreal improvumcfit without 
incKMt^ P. P. X P. H. CMuidi-ring the error wliieli may be involved in thi* calculaiioo, 
Mich exocplioDfl tn not aurprising (we page 21). 


^H And the KikK blood-pressure U merely the result of RenemI reflex vam>< ^^^H 
^H constrk-tioit from the isduniiia of thi* wiitre (hi^h-prr-SMun* stiMU). When ^^^B 
^H the force of the hesrt is uicreiL»od and the blood pa.tiilng throuf;h the ^H 
^H centre u* (xttu-r aeratfrl, the vanorontttrietor influence in uo longer exerted ^H 
^H nnd the t^nprnl blood-presMurv tlini fHlls, ^H 
^H Effect of Digitalison Tonicity. —Clinically the moxi important ^H 
^H action of di);itulis is it:« effect upon the tonuK of the ^| 
^H cardial! mu^^cle. in preveiitluK nnd in ^H 
^H *' " 'O'm n M -^ nvercoiniii^ diliitation, and it is in diluted ^H 


^^^H ^-10 ^ — i— - 

' ■-■-f-' 111. lii la lliUli llJl" Ut^UUJkMUL Ulitlvll HI CII)tll4Ulri ^^^B 

^ in mnrtt TirrknniinrTil Kmnrrtiii h rnrirlr i 1 SH'i^^ ^^^1 


> demonstrated that the administration of ^^M 

^^m £a} k ~ 

■j i digiialiHdid awnv wiih <he iran.iiwirv tune- ^H 

■ - m\t- 

Mt a "" tionni InciLipid iiiHiilficu-ncv which rc«iiltpH ^H 

iI/tOI" T if^om stimulation of the vagus. Cushny and ^H 

'irv ~yt~ f ~ v.'ainenjii nave rinowii marKeu in<'rea»c ui ^^^l 
iTO%^|-%' tonicity, as shown by iliminution in cardiac ^H 
j^ j|\|i^|TjSi" volume. Moreover, Cloel tji has demon- ^| 

1^ 'iW 1^ struu-d that the prolonged administration ^H 
J i VlS& I of digitalis preventii the heart from dilating ^H 
Tn\_n^_- '" experiniontal uoriie insufficiency {posi- ^H 
_L->^^/-n- t^vg intraventricular pressure diirinir dias- ^H 

^^^H iau 'R'f 7*i / 'i T 

_| . L, Iftl^^ 'I'li^ hf'Ar'l4 fti iLiiiFTifilri u^hifih Imvi* ^^^H 

^^^H r: %tf S*? / ' ■*■" 

^^^H I*" ?■ Tr ~ "i 

1 i-ii 1.. - j^ ln^rn tTpalnCd witli liffriinim arr* firnallf*r iiTifi ^^^1 

^B 110 '^--TfT* 

'tJ. ' L-^ slroiigiT that) thosi- which have nut been so ^^M 

^H mil Ml 

^^^m 100 ^ *^^^ i7^* 

"\, 1 /? treated (sec page Sii). ColbecJc, dossage, ^H 

.A ' if iind othem have nUo emphiL-iixed the inipor- ^^M 
-SrVHs^ tancc of this effect on cardiac tonus. ^_^^B 


^^m \t- t 

^H A 

la ] ll ] .li.tilulli. til >..lmitil>ili>r f \iii.i^niii. ul li.iiinli. I» ■oil. ^^^^H 

^B ~F..,,i30.-V«i..ia„.i,.l,1«.i.,.«.- l"'"""*! udmini»l*r lliu piirilii-U uctivc prindplc^ of ^^H 
^H #ai«iD>pi>t'»<< »mUr ih«miliim<vir diiiilnliH hnVR ilrmoiii>tni1rd thnt. though iwvrnilMich ^^^H 

^m iii«l l.i««i-i.r».ur=, MIS. m.r..ii)iil Yxavt 1««, ii«f<l. .liRiioxia com(» c!o»sl lo thr crude ^^M 
^^B PPxl'll. p>ilH-p(iwiir* X pill'*- drufr, I'nforliiniitcly, (lUtv digllnxin IS innnlublc in ^^M 
^^H rftM: DISC. DlillTAUS, dlHoDtinuv water anil in tliv tiHiuc jiiicve. bul lwcoiit*^n sotubli! ^^H 
^^H diaiialii. jn the prntcnci' of Hif[it<miii. Tlip mixlurr of tlw Iwo ^^M 
^^H KiilMttinccx knnn-n ao "dtKuIi^n" (Clootlti] or "soluble ^^^^H 
^H| diiciloxiii" LH on the market, nnd in widi-ly usod, (spociully Tor iutruvi>uoiui iiiji-ctiun. vim ^^^^H 
^^1 rapid dTnrtti arc <Jc>iiin>d. Di|[italiii, nppciatly tbn Mi-callcd "Grnunn" dittilalin, hM ^^^^| 
^^M bc«n much niorc uidcly luvd ihiui di|[''ox>i>. hut, wi Itt altio Kiliani'i) diKllnUnum vcnlin, ^^M 
^^H \a tuT tow ccrtniii and Inu nclivc. ^^H 

^H However, the recent enncal studies of Alliert Fraenkcl have demon- ^H 
^H i<tral<>d that the crude digitalis in at lea«t ax Hatisfactory ae any of its deriva- ^| 
^H tivea, provided itK toxicity (lethal dot>e for a frog) hat* been determined ^H 
^H Knd the therapeutic dose standnrdixed aveordingly. This is nil iniportunt, ^H 
^H »incc digitalis leuveH from difTerent sources var>' greatly in their content of ^H 
^H digiloxin, digilalin, ett:., and a mere knowled^- of the weight of powdered ^H 

L"" — — J 


gives no uleu of tho actual potency of the drug. I'raenke! also found little 
or HO diFTorenre 1>etween diftitoxin and cnidi* di||:ilnli.4 ns rc^ard-t lh« time 
at which their ofTccts set in. both bi'coming manifest in twelve to twenty- 
four hours after sdminiM ration by mouth or intravenously. The absence 
of imnie<liatp olTpcts from <ligi(uU^ [>n-j)aratiunM may be obviated by the 
use of Ktropliuiithin intravenously. This dnig acts with Rreat certainly 
and its action usually smls in within 1ch» thnn htilf an hour, so that it U 
very u^ful in caaes where immediate effects are desired. Fraenkel reeom- 
mcndH a single dose of strophanthin intravenously to be followed within 
twenty-four hours by digitaliii by mouth, so that llie effect of the latter 
may begin as that of the strophunthin wears off. Of course if the patient 
has recently ivi-eived digitiUi:^, xtrophanthin !>liould not be uiied fur fejtr of 
cunndativc effect. 


Vrii.. Lixi 


Plij, 131,— Kflret uIiliKil"1i» "•' amVmr lonlcily In ilifloi. 'I^vpcrlmml by Or, CnnisKHi.^ Upper 
J voluni* af thf kunil 1*^. tsk«n vrit'i ■ c^' '*>'■■>■"' "I'll. itiu^ickK vakuCMutridjijii: vocnrKl furva, 
volumt of thp vniini-ln-- E.»w«ir tiurt*. blood >pr«*Aurr uiktiit wifli (bi^ llunftUl*' iii«Rihruii*t iitari<m>4<tf*r. 
ilni*lBMCOniit. A •niitll dovl tinoliir* nl ttiKitalia inimol >nl" ilif tiiMiiUr vem nt Dip arrow. Ths 
•fFiwt upon UHkirit)'. T*, ouUvU ticAh th» ritv ia blood. prcHUfv Bail tVie VMO»Dstricttoo. 

All examplei of Fmcnkel's rrmarknblc ihi-raprulif! cftrela may he quotpil liptir: 

i'midit, wc«d 57. aiali'. lulmlltFil lu StnuwhiirE llunpiliil Nuvirtiit>er 17. U>0^. llud 
rhpumiilid [pvrr in l.SflH nnil iiicniii in ).S8fl, hilpitaliwi when nt work, anil ucciiBional 
■wdling of leE" cine* HKXi, Viilnkf. coiwidcnibly, 

Prttent i'ortdiUon, — (roiiBidt ruble inli'mu uf \ve», Ihislis. and BCroluni. Mtxlc-rale 
aacltM. DtilnnA and ■tiiiiiiui.hiMj brmlb H>un<Li nvrr rifihl hiuu!, X-my diowii lirnrt> 
slioilun F[iian:i-<l (o left sni) riKhl : tlyiiainir >lilntitTii>n of nurta. PuW iirrgiitnr, UW \»t 
nuDiilr, iiinxitniim prtasurc 180. Pulv. folii (liKtlalw 0.1 C!ni. (!} jir.) ihn* liin™ mlny 
tiroottil |>ii1«i- •!on n to Kll in 4 iIuvh, to 76 in 6 (Jayii. inciv&tinx iliurcsin from 2000 to 4AIXI 
uiuJ aSOO nwtK.Ttii-('ly. 

Anolhrr nltnrk pf paiin in juintiiun IVc«nl»r I; Wl clinic " improved " on IX-cciiiher 
II, Kelurtictl Jiiiiiiar7 :!>'•, lOliti. (Ivdcmn am bcfnrr; ajviim mnrkcd — ululnmcii t(M cm. 
in circumtiTtmrc, Liver |)Bl|Mibk' fo<ir Unircni' brcaillh lioUiii ciwliil niniiciti. Spicvn (liil- 
pabln. t>u1noB utid diniiriiiibed fremilus over lasp i>f rii-lil lunj-. Hcnrt diliiliil morr than 
before; iin|Hil>H> nol iKtlpablr: first (ntind nt ap<Mi mliipliciiipil; nrrond nnM>nl>iatnl, c*pe- 
eUlly over ptilmunMiin-a. Slictit callap rhythm. ili>Hit acliiin ni|iiii»n<l rvciilnr, Marki-d 
orthnpixra and vrry dUlrrtBiiijt coii);h. Purient huA hod ao iilii.-p for «'»Tml ni|;hl«. 

Tlie fnllon-lriK lahW nhnu-t lh« cITccta of llw inlmvcnoui lulniiiiiitrntion of »ilmpiian- 
tliin u|ion \\is MiKKl-preMurv, urine output, and Hymptnmi;, The pnxluct of pul»-pmi- 
aiin; sl><l piilHc-rulc fumuibes a very nnigh iiid«X of tlic vutoclty u( tikxxl-fluu'. 




Jan. 27, 10 .tO 


Jbd. 31 . . . 
FiBb. I., 

Blood- pHHUr*. 

Mu. Vta. 






X PutiV'ntc. 

t/rin# in 
m houn. 


92 SftlO 

84 7490 

I mg.atropbnntliin intmvenaiuly 

80 I 7904 I (mo 

Dyitpntrtt inertwdng. 
Piiinc ttth Urjc^r. 

Ko r«eli nfol coiiBtric- 
tion. tiloeps well. 

(Edenns almcmt <li88ppM>r«l. 

rnlioni make* uninterrupted rnxivcry with no further mcdicalkio. 


Flavorlnjc. — GuRtrlc iliiiturbanc«8, such as n&U86ft and vom- 
iting, DC'caHioDnlly r«:^uU from the iidmimMtnttioii of ilifiitHliM prepara- 
tions or (lerivativen. This ia in part due to the direct irritating action upon 
lh<* ga-xtric mucous membrane and in part to the extnemeiy unpleasant la.-<t« 
and aft*r taste of the druR. In order to obviate the former the drug shouW 
always l>c given in a lar^e (|uantity (at least half a tumbler) of wat^r. The 
intensely disagreeable taste of the dtgitnli:^ and Htrophanthuit preparations 
may be disguised by the addition of bitter orange peel (tinctura auranlii 
amari), compound tincture of cither gentian or eanlnmom. or tincture of 
quaKsia or ealumba. It may also I>e given in albumin water flavored 
with lemon so that its taste is bandy noticeable. The use of any of 
these disguises greatly lessens the discomfort of the patient and frequently 
minimises the gastric disturbunccs resulting from the drug, 

Rectal Administration. — When the gastric symptoms persist in spite 
of these precaution?", the drug may be administered per rectum, being given 
in 100 c.c. physiological salt solution with a little starch. This method is 
very satisfactory (Janeway). Dr. t'inley informs the writer that he has 
seen the pulse-rate slowed and the patient's condition greatly improved 
within two hours after the administration of digitalis per rectum, 
whereas the effect rarely follows adminisi ration by mouth in less than 
twenty-four hours, 

Period of Administration. — In the administration of digitalis it is impor- 
tant to obtain a definite effect and yet not to push the drug beyond the first 
stage of its activity, — that of slowing and increase in siw of the pulse. — and 
to avoid the onset of the second Mage, i.e., of irregularity. Since different 
hearts vary in their susceptibility to digitalis, and since, on the other hand, 
the drug begins to act only after twenty-four hours and may have a cumula- 
tive effect, this task is by no means easy. To avoid the onset of lo.\ic effects 
various routine methods may be resorted to. Thus, Professor Osier and 
other authorities recommen<i giving the drug in "courses" consi.'tling of 
eight doses of ITi minims of the lincture (0.1 Gm. or I) gr. digitalis) every 
four hours. The course is to Ijc repealed if necpssarj-. It may be said that 
this method often falls short of the effect or brings it about too slowly. 
The writer has found it very satisfactory to order "0.3 c.c. (5 minims) of 


the fluidextrftft three times ft day until the pul»e-rat? rcarlwM SO. when it 
should lie diBconlinued without the necessity of a special order." Albert 
Fruenkpl BUggestw Kiving several strong doses e<iuivHlent to O.I Gm. (2 gr.) 
of powdtTfd digitalis (about twice the uKual dose. 2 c.c. or 30 minims of 
the linctura diKilalis) to insure prompt efTeet (slowing of the pul.-<e), nnd 
thereafter drupjiing to .sk-iuly dosage of .113 Gm. (J gr., 0.5 cc, or 7} 
minims of the tincture) to prevent cumulative but retain the therapeutic 
effect. This seems to l>e the most satiefaclorj' method, since it insures 
not only the immediate but a pcrmanient effect. Indeed in many chronic 
(■as<'s " the strength of the heart begins to fail a short time alt4>r leaving off 
the digitalis. Here the continuous use of digitalis (0.05 Gm. or 1 gr. digi- 
talis), as recommended by Kussmaul, Naunyn, and Uroedel, for months and 
even year.*, has an a<linir«blc effect in keeping the eanlinc activity at lis 
necessar\' height" (Homberg). 

Oisitalis and Nitrites. — In many eases digitalis and nitro- 
glycerin, so ilium nitrite, or crylhrol tetranitratc may 
be (riven together with great advantage (J. O. Hirschfelder). This com- 
binution of drugs does more than merely nnnihilate the constrictor cffeel 
of the digitaiis. for the nitrit«s also increase cardiac tonicity and the two 
drugs unite in bringing about this henefitial effect. Moreover, it is a well- 
known principle in therapeutics that the combined effect of two equivalent 
doses of drugs having a common action is often greater than wouhl be pro- 
duced by using double the <fose of either one. .\« will be seen, this combined 
action is particularly important in the treatment of aortic insuiliciency. 


Mackenxic and later Hemlctt have investigated the nature of arrhyth- 
miae which have been produced clinically by slight cumulative action of 
digitalis. They found two forms: 

First, iho vciitricic orrnxirinnll.v (nilo to rwpond to contractions of the auricle (par- 
tial Imrt-Muck). V. Tubom Iiim funnel in miimiLlii timl ihii bluck u brought about moinljr 
by ■timiilntioii of llic vu|{i. If ilic vimi >inV4- hnrn »ncli(inr<l or paiulyicd with alrojiine, 
it appr«ra only after a miicb en^ivr iJo«e lias bmo adininiit ten-it, llenoe (liis ijiptiili» 
block niay hr rvganliil as twIouKitig to the finl atagc of di^luliB eBeri. To obviscc this, 
Nrnloll rcc»nimrniliH) jnviiifC slri>|iinit alonji with the diptitlifl, n comlHitnlion siijckmiciI by 
Ciishriy htit itiHCiLnleil )>y him in fu^vir of liiicilHliH miit K|art<'iri, a ilriit; whu'li parulvEoi tlic 
vu^ciu without the unplcMiini netioii ufiilnipiiictCiinhny niid Mot thews). Nrithrrof tlirae 
combiRHlioiu luic tircn UK'ii cxtnisivoly, nnil , mnrrovirr. ('ampron'H experimentH xliow that 
sttopioe pivvelittt dixtlaJiB from iinprovinii ttii- cnnliiic tonicity, uiid bi'iice robi it of iM 
Diost iiu|M>rIant t^lTcct. The ureonil fomi of irtcf^ilnrity foDowinic tlixilali* in tlw occurirac* 
o4 vcntricuLr cxiriMrDioles. tiicti hh were obwrved in uiiiiiial^ by (^lnh^y. Ah stated \>y 
this (ibtervrr. thin efTect lielungs lu the ikoiiiI >tagr of digiluliH nction. and aocorilii^y i* 
a nwtv undent siftn for diiieontiniiinic the diKitaliit than la aven the partial bMit-block. 


The relation of digitnlLs to the arrhythmias has recently lieen investi- 
gated by Omitrenko. who claims that drugs of this seriea are always con- 
trftiadicat«d ta cases where the heart is irregulnr. This is certainly im 
extreme view. Hcring bus .■•hown that certain irregularities, due to extra- 
8>'stoles arising iu the ventricle, disappear under the uee of digitalis. Mac- 


kpnxic has ^hown that where the irref^ularity arises in the auriele cligitalU 
may somctinios do pyaitivo harm by (liiiiini.shiiis i'ondu«tivity; but lii« U 
comparatively rare. On the other hand, da Cflsta, Leyden, and the later 
writ^rH have i>hown that in the jiermanent irregularities digit.ili.-< tlwif not 
cause the itrrhylhinia to disnpix'iir, but utmally increases the force of the 
indiviilual contractions, causes iheiu lo become letw unequal, and increa»CH 
tlio velocity of blood How. The effect dc[)cnd» largely upon tlic conditioD 
of the heart and its susceptibility to the drug. In general, the more diseased 
the organ the more flcn^itive it is to the action of snmll quanliticK. A very 
weak heart with intense myocardial change may thcn-forc pass to the second 
BtAge of dij^italis action under smaller doses than would briti); about n 
physiological effect in one whoi<e fibn-s were le»» itiU'nsely degenerated. 
The effect of disitalia upon the patient must always be carefully watched, 
and if the rhythm becomes mor« irregulsr it must be discontinue*!. On 
the other hand, where the myocardium is reduced to small amount in ex- 
treme fatty or fibrous myocardilis, the increased strain (and |M'rhj»])s also 
the coronary vasoconstriction) cauned by digitalis is often too great, and 
the failure of the heart is increased and the drug does distinct harm. At 
preM^nt no alwolute rule can be laiil down for the border-line cases in which 
there is doubt, except that when an irregularity is present, especially one 
which has its origin in the auricle nr great veins, digitalii^ shouhl be used 
only to treat cardiac (lihttation, and even then with great hesitancy and 
extreme precaution. When any djiiturbance of conductivity occurs, digi- 
talis is absolutely contraindicatcd. 


Another toxic effect of digitalis lies in the production of mental symp- 
toms, delirium and ilclu.sions, through il,t action on the central ncrvou* 
system (Durojtiei!, Hall, see page 180). The onset of these symptoms 
therefore constituteii a contraindication to continuing the drug. 


Aa between digitalis and strophanthus, the choice lies with the former 
except in the following conditions: (1) when rapid action is needed, in 
which case strophanthin should be given intravenously; (2) in cases of 
myocardial weaknei« or fatty degeneration, when it is important not to 
incre!i.-<o jK-riphcral n'Mistance; (U) in cu^es of aortic insufficiency and of 
mitral stenosis, where the same la true; (4) in some cases with aneurism and 
broken compensation. 

Besides digitalis and strophanthus numerous other drugs and their 
derivatix-ea enumerated above have been introduced, hui none seems to 
have any decided advantages which warrant supplanting these two. 


Professor Osier's epigram, "Broken compensation is the signal for 
digitalis," about summarises the use of the drug. Its applicability in indi- 
vidual diseases will be discus^sl under the separate chapters, but iu general 


it may be mid to be useful iu llircv H»»iic!! of conditions; (1) in cases whiTC 
com [xrn«i linn in broken; (2) in cases where acutft dilatation is present and 
baa per«ist*d aftor rest iiud other mode^ of ircalment; (3) in eases with 
per^idtent or (lii)tre»sing tachyrardia, which dues not yield to other means. 
It is in general absolutcty conrniiiidicalod: (1) in cajie!* with heart-block; 
(2) where the amount of heart muscle has been diininitihed by fibrous or 
fatly uiyocarditir cbangca, or in a ea-* In which ditdtHlLs ha.-* Ijoen known 
lo fail already. It should be used with caution: (1) in arrhythmias due to 
(Euturbanccs arising in the atiriclea or sinus re^on; atrophanlhua is equally 
eontraindicated ; (2) in cases with coronary sclerosis, owing to the coustrici* 
ing action upon those vessels, strophanlhin is here less uade^rable. 



Strychnine (ntr^-ebninn) i* nn alkaloid obtainol from aux vomicn. Tioclura nncia 
vomiep n>nl«inn 2 jwr cwit. cxtmct of nux vomica and in aMuvMi to conl.iia 0. 1 [irr cont. 
■(rychniiie. It ia v»eM nion' ta a Hloriiai-hic liitt«rs (liiLn ii» a cattliac nlijiiutunt. T>ow, 
1-2 C.C., i!> In liO Riininis. 

Siry^liiiinn- siilplinH conuins 3 inolcculwi of water of crysinlli station and 7S per etiat. 
of ■lr>'cbniiiiT. soluble in 3 (larln uf nalrr, ATcnmiv dftw, U,001.> Gni, (i"] Er.}. 

StiyeiuiJiuR Ditnu U ro1uI>Ic in i2 paiui uf wulcr und 120 jHirla nlcolLal. Dote, ■■una 


There arc many case.i in whirh the circulation is bpRinning to show' 
acme tugns of slight weakening and yet where it <locs nut seem necessary 
to Ui»c digitalis. In these eases other dniga are resorted to, — in AinericA 
usually strychnine,' in (Jermany usually camjihur; bolli apparently yielding 
good clinical results. It must be added. howc\'er. that according to most 
phannacuIogtst» Ptrychniiie ban no effect whatever upon the heart and 
produces the rise in blood-pressure only by the vasoconstrictor action. 

Effect on Cardiac Tonicity. — Dr. P. 1). Omeron has recently investi- 
gated the subject under tite writer's direction, and has found in the dog 
that strychnine in doses of .00003 (Im. per kg. or i^tt gr. per lb., corre- 
sponding to U02 Gm. (Vs gr.) hy|K>derniicHlly for a man, alwa^"!) produces 
an increase in tonicity of the heart muscle, though without affecting the 
force of the beat or markedly changing maximal preitsure. Mean and 
minimal pressures are ui^ually slightly increased (by 10-1.5 mm. Hg) and 
pulse-rate a little slowed. Larger doses increa.w the »y.'*l«lic output, raise 
the blood lire, slow the heart, and increase the tonicity. 

Clinical Effects. — In view of the nnde-spread and often indiscriminate 
uee of thiii drug, it is importnnt to reatixt- exactly its clinical use before 
prescribing it. As has been stated, strychnine stimulates both vasocon- 
strictor and vagus centres, bciice raises the blood -pres.-?un> and slows the 
puLae-rate. These effects, however, have been observed mainly in animals, 
and few exact clinical studH»i have been made upon man in oonnvctJon 

' In view of the wide uto of •tr}'cbninc in twarl diteiuMa in lvngli«b-«{icnktn|! eauntrio*, 
[I U nuit* HlrikinK that lbi« ilniK U nni nientlonod io conncotton with ihornpy of ibu df- 
cululory HVitnii in audi «xteoait'c Uvniimi tvxi-booka u thcne vl RomlKr); luul llvins. 



n-ith observatiouM -of the chango of bloorl-prosstirc. Brings trnd Coolc, who 
were irnwl enthusiastic over the use of the <inig, did not obtain riwi* of 
blood-pressiirc t-xwcding 10 mm. Hg from dont-s of 1 to mg. (j^ to i^j gr.) 
and in no rase slowing of the puUe. Cabot and K. P. Drayer. on the oth«r 
^liand, failed to note uny changes whate%'er In mnny enscs. The writer has 
lade a considerable niimber of observations, determining the blood-press- 
ure with the Erlaiigcr ap))arutu)i. He injected stryehiiiiic in doses which 





VotoM or 



Fid. 132. — Turve iliovinc tlie *lltct of ftiTetinlnr upon (wrillHo lonieltr. (Gxt>*rmit.iii liy t>r. 
C«m<iroii,i I.vrLiiriEii( u." in Fia, Lll. Kjm- t >Ii.jw> nicrrBwiTi fe>*toElcompiiCfln.] iim\imftl l.>Lond-pm»u'^ 
Fic EJ AhiTVfi ii>r-rT«Ar in Kininlv, *\\U ■<jir»ir]utic>ii in lliv *j»tulicoul|mi and * (nil iii O.t minim&t. buta^ 
ebMiSc ia Ihe mailmal blood -PdHUr*. The eHrti upi.ii lonkilr ■> tha mint ran-Uiil sITkI <■( the ilnir 

roae lo 15 mg. (i gr.) hypo, without obtaining any effect upon maximal 
or minimal pre-ssure, pulse-rate, or rate of rctpi ration, and from Ringle 
do«rs scarcely any jncreji.** in reflexes. These test-s vrere made upon hearts 
which were not dilated, and hence no elTects upon tonicity roulil l>e noted. 
Sincv the rank nnd file of Kiigh.-ib and American physimns entertain 
an almost superstitious belief in the efficacy of this drug, it i;* ovi<lent that 
cfTeel in each nijie .should l»e controlled l)y I)iood-pressure determinations. 
Cameron's vxporiuent.5 upon animals have »hown that a distinctly bene- 


ficiaJ effect upon tonidty may be obtained with but little rhnnge (5-10 mm.) 
in the maximal biooii-pnjssure, but thnt often when these changes are 
very flight ihp effect may be mueh more distinctly shown by u rise in 
th^ meal) or mininuO i)ri.-.sNurP. Both should bu i-arefuUy watched in eases 
in which strj-chnine is given, and the doise should be suHicient to be effec- 
tive. If no effect in obtained it should be di-scarded for some more potent 


It is probable that strjxhnine i.i of particular value in the disturbances 
of re.ipiration following extreme heart failure, such as ('heynp-Stokir.-« breath- 
ing, cardiac asthma, etc., as claimed by Hyater; and tu ttuch ciuicjs it should 
be given whether digitalis i» being administered or not. 

By virtue of its Htimulating action upon Ihe va.-'omotor centre, jrtrych- 
nine is particularly indiruted in c»se» in which this centre is bcRinninj; to 
fail. Thi!> i» parlicularty the case in all infectioun d)M-usc.'<, in many vM^g 
of neuraattieniu, in niiUI shock, in some ca^» of anscmia. asthenia, and in 
mnny convalescents. Strychnine should be used not to replace digitaliit, 
but may be ^ven ai* a prophylactic to prevent the heart muscle from wear- 
ing itself out upon a relaxed vascular system. When the heart muscle 
once shows signs of giving way, when marked cardiac dilatation, etc., 
have set in, its period of usefulness is over. Small doses of digitalis will 
then do the .tame work better and will do more. It i.t aUo valuable when 
given along with digitalis. The value of strychnine again becomes mani- 
fest in the later i<lage3 of heart failure through it.'H action as a stimulant 
for the res|>iratory centre. Kyster believes that it is ])articularly u.seful in 
warding off Clieyne-Stokes respiralion and also iu the treatment of the 
latter. It bi probably stil) more useful in canline asthma, more tu* » pro- 
phylactic measure in mnintaimng the activity of the respiratory centre 
than in stopping Individual aitneks; and it may also prove of value in 
warding off the distressing dreams that result from mild asphyxia dur- 
ing sleep, as well as (he attacks of tachycardia and other nnplejisant con- 
ditions which may occur as the result of waking "with a start ■' (asphyxia 
during sleep) . 


Camphor is a white substance, soluble in alcohol, ether, and chloro- 
form, whose structural formula is^ 





Avorage <la*c 0.12 Om. <2 gr.). be*! pven as linimcntum eamphonc (enropbontrd 
oil), wliich ntntaiiw 20 por cent, of camplior diamlved in ci)tt''ii-«ce<l oil. Av*micf dow; 
O.Ta to 2.0 c.c. (20 to 46 uiialms), available (or byfod^rmio uee or by iDoutli. 

;^piiriui* eamphorn', n 10 p^r kui. Hulution of caniphur tn aleohoL Done 1 c.c. (IS ' 



Ounphor, like xlrychninR. in a itiinulnnt tn t ho vnMonioltir eontre, 
but, aeoottlini; to Cainorun, litien no I HOCin lo h u v« ho ptuiiuuncuil aii efltvl uii t an ic- 
ily. Like iiwj-cliiiini! il ulmi vuhm ill i[« nHecla un iliiTcrvDt Individ u.ili. Sorar pcmnnii 
re(|uire tlo«c« twnniy timm lu larjtc ui do otiiera brforr iin flilwrl wl« in, Mpecially nlji«n 
tbe dru); is Ki^'t^n '>)' Cainphorin nUMit ii[it>ortuiil fur its um? in iibofk. Il i> given 
deeply inln ilio musclcx in uidcr Ui nvoid siiliEHiiui-nl inHuinmnlioru. It is nni en valuable 
(or poiitlriumis ii*!. As rw^nlly rthowii by Winicrbent. Sclucniioi", and (lotllivb uai) 
Hflf^iiuii. cumpiior liiu ulto a vi-ry diHlincl action uiion llie hi-iiii niuack'. cnu»in(t thi- flbril- 
InUnx i»:Pinc(l heart 1o revive from librillnty ron I motion*. After rniiigihor liiut Ik*ii ad- 
miiiiBtereil to a doc ()io vvnirlcle (in /ilii] ciiri Ihi ihmuti iriTu tibrilliiry coiilrai'liotu by 
««ak fatadic uliniidi hik! yi--t rwuvi-r. On ilii- utliL-r Iiaud, u direct tberu[H;utic effect upon 
the heart miuclo in man ha* not yvt been {iroved. 


Oilciiim chloride and other suIib oi ealeiuni have been rL-cummended recently as 
cardiac slminWitJ- by I,aiider Bninton and other Kn^cUsh elinieiniiK. AlllioitKh the action 
of calcium u|>uii Ibe exciwd hL'arl i» inditpiilable, llv *^f(eot ii|Kin tlie bearl I'ri itfx hiu l>ecn 
supixnod lo l>e too tran^ilor)- to (w of fuelieul value. Tin- writer hut been iinnbte lo find 
Hiiy «ITi>ct u|<oi> the omximal and minimal ttloo<l-pmu'iire« and |>idi>e-riil<w of a number of 
eiutu of typhoid fever who wvre rveeiviiiK calcium lactate in Kiillicieiitly iarge dene* lo 
liiMlen eriatci'lation. tilnden alio found in a large variety of eowi ihal euleiiiin Inetnle had 
no effect u|iiin pulne-raieof bloo'l-pre*siurv. On theolhcr hand, in auiinaUeiilcitimebloride 
lias .in elTeet. especially upon lunieity, which eloaety siniulatt^t tliHt of nlrycluiitic. Injec- 
tion of ci>n8ldorBblc qii.tntitien directly into Itie cavities of (he iieiirt revivea ihal ori-an as 
nothing else appCAra to do. 1*he wriler has found Ihal in uinic rnK* liaic^' heaitn that bad 
«Cltinlly nlopped beating and even luit Ibeir meclianieal irritability revived to Midi nn 
extent sn to n^mime a regular rhythm with a iiioUerulvly liigh bloU(l-i>re«iurR. The mailer 
in, bowewr, still in the «xp«rim«atal ttoKe. 


From the results of experiments upon animals, cafToinc would take 
rtuik noxl tn diKitalia in cardiac therapy. Like dif^italb it acta upon the 
cardiac mujsclo. incrciising the .-<!«• and fori-t' of thw conlrmitioii; like digi- 
talis it has a vasoconstriclor action, and raises ihi? blood-preasurc by bring- 
ing about conflriclion of iho pi-riphernl bluod-vesspls. It is thttix-forc p*r- 
ticulariy vaJuable in conditions of collnpsc and shock. In this regard it is 
more reliable than camphor (Romlierg) or strychnine. 

On the other hnnil, eafleino doe* not exert a conntrietins action upon the coronary 
ar(«rie!i ((). I.ueb). and lience in not eoniruindicaicd in c»h(» of coronary K'lfnjttiH, Upon 
the pnlse-tate caffeine cxerta a variable eflect, in n-latively enml) doBca (0.1 Cm., 2 gr.) 
■lowing the pulM by nlimiilntinjc ibc vajti- in InrKer dnnes acreioralinn. The aeeelcrntion 
in npparcMtty due to direct uctiori U|xii\ itic heart iiiumIi*. nince il uccim »l«o in the e.\ciiied 
butrt when caffeine la nilded lo the I«eke'* solution. Howevpr. aa cvgarda ttie effects oS 
a given <!<.>«■. thcr» i» the grcaleiit varinlion ainonic different individiinlH. some peraons 
bring extremely ncnsitiw to 91111111 duwa. ollieni extremely resintnnt. Even in tite Mime 
indiviiluiil tolerance varies. Thus a eonsider.ible dt-gree of tolerance may be developed by 
the constant um> of coffee, ao that throo or fnur ciipe (O.lfi to 0.2 (.int., 3 to 5 gr, calleine) 
a day rnay he taken with no sjinptoin.i whatever. Thus, in a cane under the writer's ob- 
ivrration. after Mveral mnnthii of absolute nlistineiice from cnffn', marked pnlpilation, 
lachycardia, and «leeplct»netui reqiilleil from a einule cup in Iwcniy-tour boun: a few «««lui 
bier one Clip nnd after a few muntlui two cij{h could be inken without any apparent effect. 

Unfortunately, the therapeutic use of caffeine is often accompanied by 
palpitation, Hlvcplca.tiics.-<, and even natiaea, vomilJng, vertigo, and dcliiiunt, 
which occur with particular case iu coses witli cArdiac disease. In using 


cafTeine one is therefore usually In a dilemma between a hypersensitivenesa 
and an habituation. Unfortunately, the palpitation and discomfort usually 
eet in at about the same point as the therapeutic effect, or even earlier; 
but there are certainly many cases in which this is not the case, and in 
which caffeine is a valuable therapeutic agent. 


Theobromine has a much leas effect upon the cerebral cortex and upon 
the vasomotor centre than caffeine, but has a very strong diuretic action. 
As shown by 0. Loeb it possesses a much more powerful action in dilating 
the coronary arteries of the excised heart. Upon the heart in situ its action 
does not seem to be pronounced. Indeed, G. S, Bond, in the writer's 
laboratory, has been unable to detect any effect upon the outflow from the 
coronary veins as the result of intravenous injection of agurin (theobromine 
sodium acetate). The stimulating action of theobromine upon the heart 
muscle, though not as intense as that of caffeine, is still very marked. It 
has therefore been recommended as a cardiac stimulant, particularly by 
the French clinicians, who found it of considerable value in the weak 
hearts of fatty individuals. Kaufmann and Pauli, Brewer and v. Leyden 
recommended the use of theobromine in attacks of angina 
pectoris (stenocardia). Pineles advises theophyllin. Pal has 
found that theobromine is occasionally useful in the treatment of vaso- 
motor crises, but that it often fails in cases where iodine and potassium 
thiocyanate help. Romberg is not able to detect any beneficial action of 
theobromine apart from its diuretic action. In using theobromine it ia 
preferable to use those compounds which are free from salicylates, since 
this radical has a certain depressant action upon the heart and an irritant 
action on the kidneys. Acettheobromine sodium ("agurin") and 
acettheocin sodium are therefore preferable to theobromine sodium sali- 
cylate ("diuretin"). 



Aconitum, the dried tuberous root of acoaitum napellua, collected in autumn, 
and yielding not less than 0.5 per cent, aconitin. Dose 0.05 Gm. (1 gr.). 

Tinctura aconiti, U. S. P.. now representB 10 per cent, of the crude drug, 
formerly stronger. It is the moet certain and moat stable of all the aconite preparations. 
Dose 0.6 c.c. (10 minims). 

Aconitina, the crystalline alkaloid. Dose 0.00015 Gm. (0.15 mg. or t)d gr.). 
It is so irritating that it is usually preferable to prescribe the simple tincture of aconite, 
since this is assayed according to the last pharmacopceia. 

Pharmacological Action. — Aconite has three pharmacological actions 
upon the circulatory system: (1) it stimulates the vagus promptly and to 
a high degree; (2) it diminishes the size and force of the cardiac contrac- 
tion, and also accelerates the heart when this organ is liberated from the 
action of the vagus centre; (3) it slightly stimulates the vasomotor centre 
in very small doses. However, it also diminishes the activity of the respira- 
tory centre, and may thus bring on dyspncea. 

Therapeutic Uses.^ — When carefully given in therapeutic doses aconite 
slows the heart by stimulation of the vagus, and has little action upon the 



heart muticle. It ia therefore of value in the acceleration of the puUe in 
fevers, whpre the heart imiacle itaeif nwds no ntimulatioa and the heart 
needs Btoning. Owing to the variability of the tincture under the old 
pharinacQp<eia, the tiw of aconit'e han fallen into duin^pul4>, and enough 
time has not rtapscd ^iacc- the adoption of the last pharmacopcpia (1900, 
adopted in 1905) for its real utility in physiological therapeutics to have 
been investigated. There is no doubt that it i» of value in many caaee of 
tachycardia, especially those of nervous or postfebrile origin. Da Co«ta, in 
I8frl, found it of ewnie value for the iftchycardiii of acutely overstrained 
hearts, but particularly useful when given with digitalis. 
7^8 combination contains two drugs; both stimulate the vagi, the one 
tends to diminish, the other to increase the force of cardiac contraction. If 
the latter cfTecLi balance each other it may be powiible to obtain in Ihia 
way the purest and most intense action in slowing of the pulse. 

1i ia cerlaiit tliat tbc «iniulianeoua iisc of iwo (Irujc* linvmic certain aciion* iii common 
often bhiijigi about mi i-ffcct Dot obtuiimblt- with citiicr drug iilone; but ninci- llic n-nccion 
BCiiJn»i ibc |xil;^[>hnniiucy ihnt nigncH during tlii* miilillc of Ilic lii^t cciitur>', tlit teiid- 
«n('y Ims t>iM.'ij luutirii iIil' use of psiniile iJrU[!«, Ttlen^ in no <!uubl lliut inucli cnii lie Imrncd 
in ihi^ Ircalmcnl cif cardiac liinrnws liy judicious conibinnlionii «lon^ the tine* niappcil oul 
by plianiiHCuliiKicul cxperiiiicrt'a. jii^I. :ifi in nou found uitli hyfiiiolic«. aiiulicwiw. and 
purgntivH. Thin i» radically dilTercnl frtini tlic uiicient (loiyplinmmcy. in ntiich hcMm- 
gltfUioiis drum were mixcil wilhiiiil regard to their action or antatn^ni"")- 


Adrenalin (auprarenin, epinepbrin), the active principle of the 
'cUIHVieQal ^land. is also u»d occasionally to raise blood-pressure by its 
fttntstltctin): action upon the (peripheral blnod -vessel.'* an<l .'flight stimulating 
action upon the heart, but its action last« only from one to two minut^^ 
and hence it is of little value, except to tide over a sudden failure unld 
some other drug can becomi- active. 


Ergot has been recommended by some writers for its vasoconstriclor 
action e.\erted through atinmlation of the vasomotor centre. It also slimu- 
latea the v.^gal rt-nlrt-. (^i-onyn and Hendorsnn have founii that these effect* 
are very uncertain when the drug is given by mouth, but occur quite uni- 
formly when it i.-* given intravenously. Since this is rarely nw-Ciwarj-, the 
u«e of ergot may be confined to patients with vasomotor failure, in which, 
like adrenalin, it is used as a last resort. 


AinjI nitrite (oniyliA nlirin), » liquid contaitiinn nboui SO pet cent. o( amy! nJIrit*. 
A\-cnise dofc 0.2 ex.. 3 minims (inliiiW). Usually la be haii in iicarU. each pearl coDlaio- 
ing our doae. 

Nitroglycerla CH^ONO, 

1 . 



in Kold in lahlrte of varylns mm, usually onp tablet cont^nine iJg Kt. (O-S mfC). Ttow- 
er^r. in tubitt tonii tlie iiitroglyceriii is liublu la iinder^ more or lots rapid deleriuntioii, 
Diid ticnci: nilminiiilntion in this form in iiiirvliatitr. li ii bml ipvrn iw ipirilu* )t1.V<vtyl><i 
nilrailii (Kpiriliu f>loGUiiiil. ft I t>^r pc'DI. solution of nitta{g;lycerin in alcohol, which should 
be frmlily pwpiifwi from n 10 per omiI. stock ■ulution. Iiutitil draw 0.05 c.c. (1 minim), , 
incrraslnj; if nccrMuiry I minim »l a limn. 

Sodii nitri« (iwniium nilriie). NbNO„ b while fu»ed inuas. verj- iteliqueaoenl and 
•lowly l)pcaininit o(i<liMH] to KKliuni nitmie on ttxpcwun to the lur, thiM bccoailng 
uariew. Pom* UOtMJ.l'J Cm. (gr. i-ii). 

Thore are (il^o SK-vernl noti-phurinAcopceiul »itriit«« which iiiv ^-ery 
satisfacton-. Erythrol tctranitrate, CnjONO,-CUON(>,-CHONO,- 
CHjONO,, has about T.h(> same action as nitroiKlyerin, except that it Acts 
more slowly (aflion tasting three lo four hours). Sold as tablets, each nm- 
taininK -O-'l (Im. (t gr.). Done one or two tablets every four to six hours. 
In iho raxes in which the writer has used it erythrol Ictmnilrale has been 
vcr>- efficient and satisfactorj'. 




In practical therapy lti« nitrites arc drugs of great importance. In 
animale they are fotui<i to act upon the muscles ami nerves of the blood- 
veHselfl to bring ithoiit nn inrenw> vafodiJatation,. thereby diminishing; the 
rcsist'Uncv to blood (low and lessening the resistance to the action of llic 
heart. As far aa can be judged from the studiei* of C). Loeb, they do not 
influence the vnsocoustrii-tors of the coronary arlcrics unlcs.^ present in 
concvutratiou which is absoUitvly toxic 
to heart mu.tcle. G. S. Bond has found 
that the outHow through the coronary 
veins of normal dogs is ditcrcased rather 
than increased by nitroglycerin and 
amy) nitrite. It is therefore qufstion- 
able whether Ihew drugs ever bring 
alK)ut dilatation of the coronary arte- 
rioe. as has been supposed from th(>ir 
efficacy in angina pectoris. 

The relation of the various nitrites 
to on« another a.-' n-Kard.-" rupiility 

of action is shown in Fig. 1^13. The effect of amyl nilrit« »cUt in within 
a minute and pa.sse.i off within five minutes; that of nitroglyrerin lasta 
from about the sevenlh to the twentieth minute afler administration, 
tiodiuni nitrite from the fifteenth to the thirty-fifth, while erjthrol tetrani- 
tral« Ijegins lo exert an effect only after about fifteen m ihiny minutes, 
but this continues for three to four hours. 

Ani)1 Nitrite. — Hewlett tarn reotintly nutde a careful climcal Bludy of tlie effccU of 
amyl nltrilr inhnlnlion, nnd fotini), U) *n immciliatc fkll of tupxitnid prw- 
tun, at-enixv V.i [nni. IIjc. Ustin^ Ina Ihun forty MyximJH. and iiccom|>anied by a luaa 
fall of minimiU pmnurv nnd on inen-jur of puW-rulc. ThU ia followed tiy » ■ « e o a d* 
a ry riki- (nlimii 2^ n>m.) of maxiinn] |>rc^<in.> lo conslilerahly abovio thporiicinnl height, 
accoltiptuiieil iiy u Imt iniulu'd rise of the miiiinLal pnuBUn* ami by a tvtum of pulnomtc 
to Ihn nntmal, TTiix' rhanjrni in blooH-prr'iuiiirr corir*pon<l loan iticrcaoed »yit- 
lolle output and incr^-.n-v^l force of hcarl<t>val (nugOMiRlor effccll, and Hpnli-tl wua 
able lo NV with the fluDro9C<)))c Ihnt. "ns the n«lion i>f ihe beul •loii«d down the cxcur- 

Fio. 133- — I^ITteu of ilmc* of tli* aiiTitt 

reprvtvnuiite l\^f nniiihai tif II#«1«U mini Hau 
Ihrn.) .UfiV, Diinum. 



Biutia of tlio lefl vpniriclc brranic wider by onr-hult npiiiuiwti*, but ilie.v soon n>tume(l lo 
tKimiul." In odicr words, bwiilea ln-itiK a MiwHliUior nrayl nitrite in u very 
activ« cardiac ilimuliint, moiv rapid ilmn uiiy except (wirpnalin, Thp*c 
Tiudiu^ aceurd well with the rmiilin of Camcnrn on lio^ tliat nitn)Kly'-'*^^n both 
incrcuKcH cardiac uiitpul nod cardiac tonlcily tn s markod <lcgn«. 
Relaxation of ihn itoripbirnl hlood-vnwJn umlfrr liii? iiilluunot: of iLu uniyl nflritr. a« shown 
by tlw plethvMnut-rttpli. man present tliroiiKlioiil. nil Ilirwi^U'a cxpcrinirnia in •pile of Ibe 
poriiliar variations iif blooil'pnwiun?. T\m vuaixlilatallon t«sehe« IIjh inaxiiniini uillun 
llie finsl niinule and very HnLdunlly Kuluiilcs nficr the »ccond. but a (lelinili- pfft*! in still 
noticeable ton or IwtItc iniiiiitai after. In older pcnu>n» ilcttlrll fnniid that the piiinr- 
rat« oiUm liid not change, probotbly wing la Ibc atuence of the luutc adivily of the vugu«. 

The rolIowinK represent U-pical pffeeta in normal men its obtained in 
the very ciuvful cUiucul investigations of Hewlett and ^tatthew. 






1 raia. 
ii inin. 
H miiL. 



Sodium or potflMiiiiiii nitrate .li Om. (kt- tj) ■ . 6 mm. 

Erytlunl tetnuiitrate .03-.0d Cm. (gr. f-i) G} mill. 

Manihd telnutitmc« .06 Gm. (gr. i) 12 

Nltro£l}<«rln. — .Vx to nitroi^lycorin, thcrd in tretncndoiw %'ariation in ita effects upon 
tiUhnnt Individuals, A. Loeb havtnc i«porti?d a caae of collapw aft«<r O.G mg. (tig gr.), 
wbaeu ). SUwnrt luw Kiveo 20 gniiuii a day to a lingle pntieiil. 

In «onic caae-H it ia impOMtiblo io obtain n fall of prmsuro with any or<l!Dary iloaM. 
The wrilor'n enperii'nte agrees wilb that of Mattliew. tliat ibe effects are often bckiiig in 
caM« of nephritia in which high blnod-pmuiim ha^ pcniiiitnd for som^ tinic. To tiiis roi^t 
alao bo a<liled a certain Kruup of artifrioiielerotica in wlucb Uie renal syriiptonis do not pre- 
dominnlv. aUhongJi it ii pnssibtr that nrlRrioMlcmtic changes inay b« pn^^vnt in ibr kidney. 

In Prof. J. (). Hirschf elder's wards it was customary to begin with a 
dose of ) gtt. (^ C.C., i minim) every half hour, inercnaing 1 gtt. at every 
third dose until palpitation, headache, or buzzing in the ears warned that 
the phyaioloKieal limit had been reached. The noxl tlow was then omitted 
and a i>ermanent dosage of 1 gtt. less than the dose la^t given wa^ then 
kept up. In some oases as mneh as I e.e. (1.^ minims) nf the I ))er («nt. 
snlution wa.i given every half hour with only the mildest subjective symp- 
toms, the average permanent dose being 0.3 to 0.0 c.c. (.j to 10 minims). 
The effeet of thew; <io)<C!< is very variable. 

Effect on the Circulation.— A fall in minimal blood-pressure is the 
most con^HJit, Ufiually iierotn pained by a rise in pulsw-preswurc, and the 
maxima] pressure sometimes rising, sometimes falling. Hewlett thinks that 
there is combined dilatation of the bluod-vosseU and increawd sy.Ktolic out- 
put of the heart. In a series of observations upon the fluetuations of blood- 
pressure after the ftdniini.Htration of these drufts, made with the Erlanger 
apparatus iride[«'ndently of and some yeara before those of Hewlett, the 
writer had noticed effects quit* similar to those above mentioned. There 
Beema no iloubt, then-fore, that, as '•tixtvtl by Hewlett, the beneficial effects 
of the nitrites in man are due to something more than a nmplc vasodilata- 
tion, and indeed it is poseiblc that the latter may play often even a minor 


rtle. Certain it b that in many cases they are id<Mil drugs to relieve the work 
of thtf hfjirt ovi*r nhorl pcrioil-s whon tho blood-pressure is not almftdy too 
low to admit of iheir use. However, it must hv borne in mind tbnt indi- 
viduul suMn-ptibilitit^ vary, and the patient should be tested with amyl 
nitrite, whose effects can bo controlled, before any other nitrite should bej 
given. Wiieii ii.-tcd ovi-r long periods of lime, moreover, the production:.' 
of metha^moKlobin in the blood may be brought on (shown by the spectro- 
seojw, or liy ii choeoliite tint in the blood), which is distiactly harmful and 
a sign for immediately stopping the u-'«c of the drug. 


Potussium iodide is the drug which is most widely used in the treat- 
ment of all forms of artcriosclcroais, and tliu clinical results are 
so definite «s to render its usefulness pertain. The manner in which it 
e.xerta this lienefieial action is, however, much lesj* definitely known. It 
was at first supposed by Fotain and others to lower the blood-presaure by 
some direct action upon the vjisoniotor or cardiac mechnnUms, but this 
action is slight if any, and the writer does not recall over having seen high 
blood -pressure depre»»e<l by potassium iodide without the intervention of 
some other factor. It was then sup|K)fied to have some effect in diminish- 
ing the vi.tcosity of the blood, jis was claimed by Olfried Miiller ftn<l Inada 
in Romberg's clinic. A careful pcrsual of their statistics shows that the 
results were absolutely negative in about half of their caties and within the 
limits of observatiomd error in the others. Determann. who repeated their 
experiments, found the effect upon viscosity entirely negative. 

It was then claimed by Konmyi and others that potassium iodide pre- 
vented the pro<luctinn of adrenalin arte no necrosis, but this claim also fell 
to the ground when tested upon u very large series of animals by Leo Loeb 
and Gilhens. 

The phitrmticologieitl action of potassium iodide is therefore still to 
be classed among those mysterious actions termed "alterative." 

SoiDi- liKht is tlirun'ii uiioa the acljon of poUuaiinn locliiie by ihe reo^nt xtiidim of 
Collins anil Sni-liH :ii>tl l.<>nK?i>(io ii[iuii l)ie ntfcular cbanicta dtie to vyphLlis. Thi^w oh- 
nerviMii obtaiiiril » pooiliit' \^'uBsrritiuiiii rtaclion in many cum of nurUc inBUlTicieiicy 
in irliich Ihrtr nui no ottipr ttRn of active luetic lesion. In Ibcw caur* mill bUo in nimpio 
srterirwclcfostH uf tiivirc oriciii. tlic iioiuHsiiiiii iudiik- pnilMitily faciliiatoti the ttrmovHl of 
thi- luelic cxuilulionn nml Ihus <limimiliL-ti Ihv ill rffrctii «f the BrtcnDl lisioii. Thin mouldl 
4ix|ilnin why no nriion ena he ilrlectnl njxin ihc iienlihy ^yvsct or ii])oii the niccliknicalj 
tACtuni ill tlic rircululiuii. 

It must be admitted thiit the mode of action is entirely unknown: but. on 
tlie other hand, administration of pota.'tHium iodide does lessen the symp- 
totas of stciiucardia aiul other painful and disagreeable symptoms in many 
eases of arteriosclerosis, and may even cause them to disappear |iermanently. 
It may therefnre be adminislered with advantage in all ea-ics in which the 
above-mentioned symptoms arise or even where they are threatened. 

Poia-sxium iodide is Iwst given after meats in large amounts (half 
^assful or glassful) of water or milk. The unpleasant taste may be dis- 
gubed by a little sherry, elixir of cuhHaya, or gentian. Doise potass, iodi 
0,3 lo 2.0 fim. (gr. v to xxx) (reached by increasing doses). 



When not well bornp by the xtomach or when the heart i» very weuk, 
sodium iodide, the ludizvd fatty acid "iodipin," or new iodised organic 
acid "aajodin" may be substituted. Their actioD does not seem to differ 
much from that of potassium iudide. 


AnutliM (Ini|; which tta<l» to louer (be bloud-prt-Mure gmtly \» iwlOBxium thiocj-A- 
iwtr (KCNS). Thd UK »{ thii ilrug lu ii wilativp to Ihc nprvoiu ayntcm vaa firel Hiifu[ip«tcd 
by W. Paiili (1903). who bolipvcd fhal hn obtniiieil pome onc«lleiil iwtTilta in eleven urtcrio- 
■ticrolics iind in two ciweii of heart faiiuav It wub iiwhI more corcfvilly by J. I'ul (IflOA), 
nho nrilc*: "1 havr br^n ni>)r In obtain a iii>n<i rffrrrt from thiorynnalo pntpnralloM In 
Ktitii! cuoGs in which even |K)tastiiiJiii ioiiiilc wax uittioiil cITcct. Thin cyaiiatc often grail- 
ually nductv n hiRh hlooil-prrHure, hul often brici);!! on (symptom « of intox* 
icalion in arWriosclcfoiiot, cspecinlly in ihowe with renal comiilicalioiw. niece loxic 
►ytnptoniH ore e r y t h c ni u t a mid mental c o n f u a i o ii , which (lisni>|iror. n* 1 
have foimij. when the Ihiocyatintr ia kfl olT ami oiiiuni given. . . . DiiirvCin anil jixlitle or 
thiocyniuit« are of value (in va«on)o(or crisea) only when adniinisWred ovec loug period*." 




Withfiring. W.: An Account of the Foxglove and Some of its Medical U»e». etc., Kmiins- 

hHm, nay 

For litcraiurv and important experiment* U[ion tho tlinilnli* eeriea. cf.i 

Schniir<lcl>cr];. O,: Bcilnig xur KenulniBs tier phHnnacologiache Crilppe dea DiKitolinn. 

Arch. f. exp(>r. Palbol. ii. Pharmnkol,. l^px.. xvi. 149. 
CiiHhny. A. K.: On ihe Action uf the Dignalia Series on the Cirttilation in Mumuwbi, 

Joum. Ex|*r, Hed., N. Vork, 18517. il, 233. 
Hrinx, U.: Hondbuch der experi men telle Patholofclc tind Pliamjakoloffie, Jcua. 1905, 

lid. i. iwrilr Htlltt<5. 
Hoinbere. B.: Lehrbuch der Krankhrilen den HcfMnn iinddor DIutiiiifnMe, 8Ciitt|cari, 1906. 
Ijoeh, Chwntii.: tJvlwr die UeeinllilnutiK dea KorvtiarlireiBlatifB (lurch einige Uifle, Arch. 

f. expor. Pathol, xi. Pharninicol,. Ix-ipx., 1901, Ii, t<i. 
Gottlieb. K,, and Siilili, II,: IlerMnlltol und Vasomotorenmittel, V«rh, <l. Kfing. t. fno. 

Mcrl., WJMbadim, 1001. xviii, 21. 
Boehtn: Uillcrsueluiniien uplier die iihyniolopuchc Wlrkiinit dcr Di|[iUli* und des Dl([i- 

talins. .\rch. f. d. g». Phyniol.. Bonn, IST'J, v, i;j3, 
SchniiedelierR, O,: t'ntcniuchunt;cn uebcr die pliarmukulogiiich wirluamcn BcclnndthcJIe 

der Ui^ciluliti purpurea. Ar«h. f, exjier. I^ithol. ii. Pharmnkol.. Ijeipi.. iii, Jli. 
Praenkel. A., ami Schwnrlt. ti.: L'eber Digital is wirkung an UesundVD liud an kompen- 

nierlen Hertkranken, ibid, 190S, Ivil. 1S.S. 
Frncnkel, .\lb.: Vemleicheiide I'nIeniuchimKen iieber i)i« Knmulallvn'irkune der Di^ 

tMtifk'irper. .\rch. f. exper. I'nlhol. u. I'lianimkol.. I.e:ipi.. iWKi. ii. 84, Ucbcr Digital- 

iB«-irkii!iK an ift'Biinden Monschen, Munrhrner med. Wrhnwhr,, 100-V Vil, 1.M7. Di« 

phyninlosiM'be Dosimng vein Diplalinpriipiiraten. Tlier, d. (iccenwurl. Berl.. 1002. 

Benierkuniten ziir int«rnrn DiRitnllNmntikatimi. Arch. f. cspcr. I'athol. ti. Phnrmnlcnl., 

Leipi., Isr-1. iii. IB. Bfitraire Mir Kenntniiw dpr pliarmakotogiechcn Gnippc dc« 

Di^ilfllliw. Ibid., 1«S2, xvi, U9. 
ClocHn. M.: Kinlliuw der chroniwhen nigiialisliehnndlimit aiif dan normalc imd patholo- 

(tischr Ilcrx. Thcrap. d. Gcaenw,. Berl.. 1908, xlix, IST, 
For the ntandAnlitalion of diaitalin prrpnmtions. connilt: 
8owton. S. C. M,; Some Experieiiceti in the Testins of Tincture of Digjlalla, Luicct, T^ond., 

1908. clxxiv, 310. 
Ilnicbcr. K. A.: Tincture of Slrophnnthnii, J. Am. M. Awoe., Chleaxi*, 1907, xlviii, 1177. 
F.<Imiind«, C. W.; ibid,. 1007, xlviii. 174*; but particularly Edmuntb, C. W. and Hale, 

W.: The Plivalnlotrcil Rtandnnlixntion of Digiuli*. Bull. No. IS, Uvg. Lnb- U. 8. 

I^lb. Ucnlth'and Max. Hosp Scrv., \Va,h., IflOfl. 


Koppe: I'nieniurhiinicpn uober di* phftmkkologisrhe Wirkung (Im Diciioxins. Digitml- 

dii». unil UipiiiliiiH. Areli. t. exper. Psihol. u. I'hamiitkol., Lcipt.. isTi, iti. 27*. 
V.Slarck: ZiirthcrmpciitUchc VcnrftidunRiins Diicitoxinji, Monchcn. mfxl. WrhiMchr., lSS7.j 
Cloetla: Uelwr nig:aleii (n%iloxiii Boliitiile), MUnclu^ii. m»l. WcLruchr.. IWt. li. HB6. 

Dfrbcr die Kumulativwirkmis lUs Di^itnlls, ibid., 1!H»6. liii, 22S1. 
V. Kehle; Ueber lisn ihrrnjH'uiiiirlicii Worlh ii«i Diifultrns. Therap. MoiiatoliKfte. 1008. 
Fraenkel, AIl>,: Abliandhmgtii xur DifEitalbthi-rnpiir. II. Ziir t'ngr tier Kumulation, 

braondcn bdm Digalcn, Arch. f. exprr. PaUioI. ii. Phannakol., Lcipc, 1907, Ivij, 123. 

Killanir Arehivm dc Phnnnncir. 1^02-1809. 

DeuchKr: L'«b«r die Wirkiiiii; lirs DiKitftltiium venjiB bei CitkulaiioiuisturuiiKen, Dculacb. 
Arcb. [. kitn. Hud., Leipz., 1806, Ivii. 1. Md. aUo Fncnkd, ciUd above. 

FTawr: The Action and Vtt of Disilftlii nnd ite Substittiln. Bril. M. J., Lood., IS8S, U. 

904. Note on Tincriin^ of Slrophnnlluin, ibid., XiVT, i, 151. 
Popper: U«tier die phyBiulof-isclie Wirkuiig dea SlrupliuQtliiua. ZeiUclir. I. kiln. Meil., 

Bert., xvi. &7. 
Fraenkcl, Alb., and Schwnrx: Ueber intravenOM Slrophiuntliiutlierapie bei llerzknnkeD, 

Arch. f. wper. Puthul, u. PFiummkul, Lcip*.. 1907. Ivii, 79. 
IlaMhpr, R. A-. nnd Uoilrv, II. (',: Tinctum of rilmphnnlliuii and Stropbanlliia, J, Am. 

M. AtMOC., C^iraco, l^Ui), lii, 5. 
(Wer, WiUinin: U'lip l'rincipli>« und fraclicc of Mrdicine. New Voric, 1901. 
Frani,'fii(i-Franpk, Ch. A.; t^uolcd on \>tifK ^0S. 
(.'aiuvniii. P. D.: Pii>BiulO|u;ical mid PtianniKulogk'nl i^ludita oa CnTdiae Tuciidtjr in 

Mnmmnli, t'AMt. Thnii, 1908. 
Colbeck, E. H.: IHIaialinn of the Hean, lancet, Lond,. 190t, 1, 990. 
rxiiuiiA''. A. M.: ThnTune of the (krdioo Muaelc, Ptnc. Roy. Soc. Uod., I.c<nd., 190S, i. 144. 
Hi[vchri.'ld)^r, J, O.; Unpiihllshed ob»erialion«, 
Hftckt-niie. J.: Xowcr Mi-Iliods, etc. IJuoted on page 78, 
Itcnlclt, A. W.: Ditcitalia llran-blork, J. Am. M. Awoc,. ChicaKO. 1907, xlviil, 42. 

Dinilrvnko, L. F.: Uebvr die klinittclie Bedeiilun;; dv'r lUgilaliit-Allorrliylhiiiie, Bert 

kiin. Wchnwiir.. 1907. xliv, 392; J32. 
Herinic. H- K.: Ueber konliniiieiiiche llereblttt^iinie, DeutMhm Arch. (. klin. Med,, l^pi., 

1904, Ixxix, 175. 
Da Coaln, V. Ix-rden, itec p«ffe 128. 
Peiloer, B.: Kliitiwh^ Beobaohtun^^ u«ber den Wert dcf BetitiinRiunK dcr wahran PuIh- 

grABV ( PulHclriickmcHune) bd Hm und Nietenkranken, DeuUch. Arch. f. klin. 

Med-, l>-ipia., lOiMi, Ixxxviii. 36. 
JanewBT, T. C: Tlie Vi» and Abuse of DiKiiulix, Am. J, M, So,. Pliita. and N. York. 1008, 

cxxxv, 781. 

Heia>, R. Lehrbuch, qiioiod on pi^ce 173. 
Cook, H. W,. aiul Brixjt*- -I- ^-- f'linicol <ttMicrvation8 on Blftod-prcMure, Johns Ilopkina 

fioiip. lUp., Ball,, 1903, xi, 451. 
Cabol, R. I'.: McaaiireiutrnU of Blood-prcfiiure in Frreni brtoiw, during, and after the 

Adminimniiinn of Slr>-chninp. Am. Moil., Phlla., I901, vjll, 31. 
Diayei". F, P.. Pctwifial commiininitiuii. 
EjTfter. J. A. E.: IVrsoiml coinmunicaiioo. 


Heubndr: Unber ilin Wlrk-uiu <le« Kanipfcn auf die Leiotung dca Frtwchherttna, ArcU. 

d. Heilk.. I>'i|^■^., If<70. xi, 3.'M. 
Ilimuck and WitkomkJ: Iliarmaknlnffinibe rnterMiehiiii)ni> iiebi-r da« PhyMMrij^niin 

und da* Kahham. Arch. f. expcr. Palliol. n. llmnnnkol.. Wipt.. 187a. r. 401. 
Unki: L'eber den EiafluM den Knmpfcni, Kaffrin*. uod Alkoliola &u( daa II«n, In. Dim,, 

Stmm., IS»1. 


natltf, H.: Experimrntvik trnteraucbunffpn uebfr Aim allfremeino Tlieraino dor KniiJaufa 

MOruiiKGD bei acuUrii Infekliuiuikniiiklicileii. Deuiscli. Arcb. !. kltn. Mnl., Lripi., 139D, 

WinttrtwrK. n.: Ueber Ho Wirkung de* Kampfen. Arcli. f. d. ges. Physiol., Bonn, 1903, 

xciv, 465. 
SftliRmsnn : Ziir KrriiiUttfn'irkiinfc <lc« Katnpfnni, Areli. f. «xpnr. Pnlhol. ti. PhamMkol., 

I,eipt.. I!KI3, li[. X{3. 
(lo(tliet), It., anil Salili. II.: Hcninitlol und Vwomotorrnratltel, Veih. d. XIX Konjt- f. 

inncni iietl, Wic«l>., IWl. 

Halthews, S. A.; A Study of che Aellon of Aconitin on the HnmDialian UcatI nnd Cir* 

ftiilolion. J. Exp. Mrd., HaliiraorP. IS37. li. il93. 
D» Caaa. J. M.i On Lrrilal.k- Hi-url, Am, J. M. Soi., Philii,. Ixi. 17. 
Uiraehfcldpr, A. D.: ()l>«irvntion« upon I'nroxyHRiaJ TnehycBrdia, Bull. Jcilios Ilnpkias 

Hm|>., Bult., I»OG, xvli, 3:{;. 

Waipwr: ICupnriitionlplIc Unt^r»tichiinKrn uplxr den KinfluM dm KafTplns auf Hen und 

GerAMtappanit. In. Diss.. Birrl,, 1883. 
Glupc: licbiT (\iv Wirkuii); dtr KnfFi-iiiKaUE bc'i K«rxkrnnkhcilrn, In. Diw., B«rl., ISM. 
Ciuhny nnd van Nntcn: On (lin Action of Cndoin on ihn Mammalian Heart, Arch. int. da 

P'tiunnucodyn,, I»01, ix, 169, 
Cualiny. A. It.: .\ font ri but inn to Ihn I'harmncoiofty uf the Mommnlinn Ili-nrt. Brit. U. 

J., IK98, !. lOOS. 
Fneiik<.'l: Kliiiisclu' (j'nti?rBUcliutii!vn iii-tx-r die Wirkiing von KuITi^iii, Morphiuri), SccoIr 

CDmiiluni inid Disil.iliH niif dm aftrrir'Ilrn Blutdiuck, D<;nt«!h. .%rch. t. kiln. Med., 

Lei(ix.. I!!i8»-!)U, xlvi, 542. 
Bock: Ui-bcr die Wirkung den K«ITeinii und Tht^otironun* auf doa Hen, Are)), f. ezper. 

PathoU U, Ph.irmnkol., Uiju., IflOO, xiiii, 367. 

Cau-ium SAL-n. 
Brunton, T. I^iuder: I'ac of Cnlcium Sail* an Cardiac Tnmirei in Pneumonia and Hrart 

DiBfUM-. Bril. M. J.. 1907, i, 6111. 
Stark, J.: C'nleinm Sulu u Canlinc Tonic*. Ijincet. Land., 1907, t. 1701. 
Barr, J.j On the Ci* of C'skiiim Sails aaCardiae Tonica in Pheumoni.i and Heart. DiwaAp. 

Brit, M. J.. I^nd., 1007, i. 717. 
81ad»n: IVmnnal (ommiinioation. 
Bogg6, T. K.: Vuriul ions in the Cnlriuin Cont«nl of the IHimkI fnllnvinii Therar>eiilte 

Mciuurra, Jtilinn Hupkinx Ho>p. Hull., Kulliinon.'. lOOS. xix. 301. 

Brynton, T. L. (^uoteJ on (i-iiip 1S4. 

Hewlett, .\. W.: The Kffeet of Aniyl Nitrite Inhalation* upon the Blond •prcKU re in Man, 

J. M«d. Rescarrh. D«>kI., I'JOU. xv. 38:t. 
Canicmn- CJuotcd on pUK*" M.i. 

Matthew: Vnnodilntors in llifch ItlotuI.priiHure. Qiinrt. ,1. M., Dxfaid. 1M9, ii, 
Ltxfh, A.: Kliniselie rnteitniclitinircii tietwr den Eiiifliiwt viiu KreisUututenderun^Q auf 

die Urinim«irnnien«eljmnR. ItetitBehw .\rcb. f. klin. M«l.. I.ei|«.. litxxiv, 570. 
Stewart, J.: Tolerance to .Nitro)(l>Terin. J. Am. M- .Un., <liicaj[o, 1905, xtiv, 1878. 

PoTAft»ittM Iodide. 
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HliU«r. O., und Inudjt: Zur KenntiiiM dcr lutlwirkiiiiic Ik*! dcr ArCrriotkleroae, DatlUcba 

mcd. Wchnichr., Ix:iju.. 1001, xxx, 1751. 
D«lt<niiuiiii. l}iio1ed on pajce 40. 
Komnyi, Lovb and (iitheiw. (jtioied on page 189 

PoTASHtltlil Tiiio<:t.\s.*tI!. 
Pauli, W.: Ueber tonenwirkting und ihro ihorapenilache WrwendtiriK, Miienchen. ined, 

Wehn-eliT.. 1!KI3, 1. l.W. 
Pul, J.: [>iv Gedrnkrisen, Leipi., 1005. 





During recent years gymnastic exercises have come to play a major 
rftle in the treatment of cardiac diseases. Although this treatment was 
introduced empirically, its physiological basis is found in the fact, shown 
by Frank and Hirschfelder, that a strain upon the ventricles which does 
not exhaust them tends to act as a stimulus which gives rise to more forci- 
ble contractions, increases their tonicity, and causes the residual blood 
(and hence the dilatation) to decrease. The guiding principle is further 
given by the experimental evidence produced by these writers, that when 
the strain was excessive it had the opposite effect, and caused weakening 
of the contractions, diminished tonicity, and dilatation of the heart. (See 
Fig. 119, page 136.) 

In dealing with normal individuals it is observed that the strengthen- 
ing of every normal individual, the training of every athlete or laborer con- 
sists in the habituation of the body, and particularly of the heart, to gradu' 
ally increasing muscular effort and exercises. (See page 198.) To a great 
extent, as has been seen, page 129, this consists in securing a greater increase 
in output of blood at each beat without calling upon any of the accessory 
nervous mechanism to bring this about. Such exercises have also been 
used with great success in the treatment of patients with heart failure. It 
stands to reason that they should not be used at once when the patient is 
brought in with an acute heart failure; but after a sufficiently long period 
of rest, when the acute condition has passed off and he can sit up in bed 
without discomfort, a few of the mildest arm movements may be begun 
with great advantage. It is often better to train the patient by a few mild 
passive or resisted movements while he is still in bed than to subject 
him at once to the strain of getting up for an hour or so after his sojourn 
in bed. Moreover, many other muscles may l>e kept in tone, the blood- 
vessels in the muscles may be kept dilated, and the resistance to blood 
flow may thus be diminished. 


In accordance with these facts several systems of exercises have been 
developed for assisting in the training of the heart. In all of them the cru- 
cial point lies in the avoidance of the slightest fatigue, holding of the breath, 
or increased breathing. Hence the actual result obtained depends more 
upon the vigilance and intelligence of the physician, nurse, or attendant 
who supervises the exercises than upon the exercises themselves. 

13 193 



In fiencral the pxercifies may be divided into four clnssca: 

(1) Pa^wivo inovoments. 

(2) OontractiuQ of antagonistic muscles. 

(3) Resisted nioveinents. 

(4) Mccliatiicfd gjniiia^ilics. 

Passive Mo>cmcnls. — These arc- the mildest pos»bIc formi! of exercise. 
The nttcndiint grusp;« ttif linlieiit by the hands or feet and moves the^e 
members (gently and slowly alx)Ut, while tlie patient tiiuk«s uo efTorl at 
contraction n'hatvvcr. Such movvments'huve the effect of increasing 
the circulation of lymph, the abBorption of cedcma. and, to a. 
certain extent also, of increasing the nipidity of blood flow. It is impor- 
tant to avoid all exercises in which the arms are raised high above the 
head, since this hydro-itatically Increa-ses the pressure iu the vena cava and 
may cause momentar>- dilatation of the heart. 

The following exercises or modifications of them may be carried out 
while the patient ii« still tn bed, provided the greatest precaution is used 
in their execution. 

(I) Aral* horiiontnl. lo ihn front and buck (n thp IJnr of ttic^ fthouldera. 

(3) Arms horixonlsl in line of Hhoulders, tlionce iluwri lu t1i« eidw of the tiod}'. 
(!)) Ami* horiioatol, lieacribe i^jr^lm u-ith hand*. 

(4) Amw vflrticslly dvpandmi at nidi-n, flex anil rxicnd elbows. 

(5) Amm depeudeiit ui sidM. proiiuiv auil nupiimte ulMmuvel}-. 

(II) Clinch nnil op<-n tittn. 

(7) JA^ta HlraiKhi. abiliict; ihcn oddiict thijtliH. 

(S) Flex And I'xit'nd knw at Hide of couch, never nuviiig knee above level of body. 

(It) Flex and <^xt«rLd (out Ht aiikl^joiiil. 

(10) Kotnlc Ihislui inlpmally nnd cxtcmilly. t 

(11) Bxecutr «maU circlea with feet without ralslnx tbem mora than ono foot; leica 


Contraction of Antagonistic Muscles. — Subxtanlially the same exercises 
may be carried out by allowing the patient himself slowly and simultane- 
ously to contract both the niuaeles concerned in the inovenient and tiiose 
which antaRoniie them, — i.e.. biceps and triceps, flexors and extensors of 
wrist, ftc. In thi.-" way little movement is nia<ie, the pul.*«'-rate Li .slowed 
rather than accelerated, and yet a good deal of energy may be expended. 
The blood -pnrssu re i.s raised, however. If the patient can be trained to 
avoid all difficulty in breathing and all discomfort, a good deal of improve- 
ment in ninscular strength and in cardiac tonicity may be obtained by 
this method. Its main drawback ties in the fact that the intensity of tlie 
exercise is controlled not by the attendant but by the patient, and that 
the latter is most likely to do more than is iKiue&eial. 


Probably the most widely usetl of all the cardiac g)*'''"*^''*^ *re the 
passive movements introduced by August Sehott of Nauheim. These are 
generally used in connection with the Nauheim baths. This combination 
is particularly advantageous and permits at once of all the advantages 
of mild exercise, of baths, of rest and stimulation to slctrp, of psychic 
sedative, and of the psychic suggestion to the patient that a great deal is 
being done and a grvat effort is being made for his welfare. 



The Srhott movements consist of practjcally the exercises described 
above carried out by tliv pati«nt himsL-U, bui wit)t an attondimt who makes 
a !*light retdatance to each movement. The rosistancc should be just enou^ 
to pncvont tho movi-mt-nt from being niiidt- rapidly, and al no lime should 
it caiiso the patient any apparent effort or increaa; his respirations. Each 
day the restslatiro may be incrcastd sli|(htl>-, *o that in « short time the 
patient may be doing a good deal of work without realizing it. In «xe- 
cutin)! the re«i(itanc4> tho attendant'^ mind is kept fixed upon the eondition 
of tho patient, and he is consequently more likely to notice ovor-cxcrlioa 
in the latter than if he were merely supposed to watch bim without doing 
anything himself, lii carrying out tliv Scholt movements tlm following 
rulcii are prescribed.' 

Prccaulloni for Schoit Encrcixe*. — (I) Ench tnorcmoat U to be iwrformcd alawlf 
and At unitunii niiv. 

<2) No inovcraent in to b« ivjieitii.'d Ivnoe in auoccMJon in t]ie name limb or group 
of inuscl«n. 

(3) Eacb ainKle or ruiiilnntd inuvi-nitMiL in to be foUoiniil by no iiitfrval u( rvsl. 

(4) Thn movement* .ire not to be nilowed lo accclcrnle the 
palleui'a broaihinc, tinil Ibe operator muni, watcli the face for the »lijchu«t 
imUc4ili(iiut of {a) (liUlatioo uf llie auiilrilii, (A) ilraning oT the oomcre <if lliu muutb, {,<) 
duakindn or pallor of Ib« ehwk* or Hpa. <rf) ynwning;. (() HWmitiniE. If) pnlpltstion. 

(3) Till? U|>]ieunuice of anj one uf the above iiifrnii of dititmM sbuuld be the idpial 
tor iminisli.'vtcly inictruptini! tlie movptiieut ill procem of rxtviition. ntid for either wip- 
ponin^ the linib wbieli ig bcinji moved or allowinK ii lo wibeide into a slate of rort. 

(6) The poti«nt miiitl be di reeled to bri-athe regularly nnd 
unintomipteiily. and. tihould hn find nay difficulty in doin^ *o, or for nny ntaaOD 
■how a tendency lo hold Ills bn-ulh. he niusl be iuatrticted to contiDue, counting in a 
nhlnper throughout thn proftreM of ench inovMOpnl. 

(7) No limb or portion of the Ijoily of (he patient is lo be so conKtticted its to coinprcM 
the veawts and check the flow of blood. 

Schott Exercises. — The following is a list of Schott exercises in the 
ord«r in which thvy arc given. The riMtstance in moderate and steady, the 
operator's hand always being applied upon the surface of the extremity 
toward which the movement in made, even if that entail* gliding around 
it gently during the mo%'crocnt. Usually the operator's hand is at one aide 
of the patient'tj limb at one phase of the exercise and at the opposite when 
tho movement is reversed. 

1. Arms exieiideii in front, palnu fadng eaeb oilier. The uperaior'ii palmi mi upon 
the hnckii <if ibc patient'^ hanib. Pnlient'* arm* carried bnckirard to tine of f>hniildcrH, 
the nio\Tinctit Iw'inK ccnily rcsiBted by operator (Fi^. I^), The operator** palnut utp tlien 
RBtetl ii^Dit (luBL- uf tlu' pMlienl, and the return of the acnw in front of the cheat in re- 

3. One arm at side, elbow-JoBDt fined upmid to alioulder, ibea extcmled to original 

3. Arms at sjde, raistd outward till thuntbs meet owr ihe head, then brought bncfc 
to Ibe originid posilion. 

4. ITandii nt level of pelvis in midline, Rngun •1i)chlly flexed. Aniw raiaed lo tfae 
TBrtcot of the hea<l, then back. 

5. Arm* at aidn. then raised fonrard in pamllel planta until they are vertical, then 
movtd baek. T>ie hand of ihfr operator iniist glide around Ibe wriat so ttial it i* always 
ap[died U> aulagmiixe the movmieiii. 

'Quoud fitND W. Beily Tbonie. 



7. Tnink roiatnd without movanenl o( t)ii.' f««t. Opcrslor cxerU remrtiince aeaiut 
tl'ie alioultttMs. 

fm. IM^^IcbCiIt naiital movunaiU. Otodjfidl f ram W. Betty Tliuina.) TtiBnitmxUiK'aliATidi Arcludi- 
e&ivd ja btftck; tha ilinciliun of thsmoviiiih«ntRittl4l>ylhop>ti«btBtiiiti(ainibx(liB black jurfiwv. 

S. Truuk QextKt lal<^nilly, finit to our iiiile tlii-n to thu ullirr, lliu tnoveuicnl beitif; ao- 
tA^nixcd b)' roiiiitiincc appliod in llic aniUa, (hr nprrator's otlicr hand rMtiDg ou the hip. 
0. Hnvvnifnit lik« No. 2; Cuts cliuclied. 

10. Stuue, but ptUmiu' surface of fist turned outvrnnl. 

11. Arm cxtnndrd from hide, pului clovn, nktatnl forwnrdH iind upn-unin describing 
aaenuciTCle until it Is rauml vucticully olons nidt- of the ear. The mowment is then revere«L 



12. Arras at sides, palms inward, moved upwards and backwards in parallel planes. 

13. Patient rests one hand on chair or table, raises koee to horizontal, flexing at hip 
and knee. 

14. With one hand resting on table, patient swings extended leg Torward and back- 
ward from the hip-joint. 

15. nesting with both hands on chair in front, raises foot by flexing knee without 
movement at hip. 

16. Heating one hand on chair at side, patient swings apposite extended leg out- 
ward from hip-joint, then returns to normal. 

17. Arms rotated outwards and inwards from shoulder-joint, operator grasping the 
metaca.rpal portion of the hand. 

18. Wrist-joint flexed and extended. 

IB. Ankles dorsofiexed and extended alternately. 

When these precautions are taken the exercises have an excellent 
effect in a considerable number of cases, bringing about relief of the dilata- 
tion and more or less immediate improvement {increased tonicity). An 
example of this is shown in Fig. 135, illustrating the diminution in the 
cardiac shadow under the X-ray after 
a very few resisted movements. On 
the other hand, there is the greatest 
danger that the treatment will be ap- 
plied in cases where it could not have 
been expected to do good and where 
it actually does harm, producing over- 
strain and decreased tonicity of the 
cardiac muscle, 


Movements may also be carried 
out by means of the elaborate and 
ingenious apparatus devised by Z an - 
d e r for regulating them in direction 
and intensity. In these exercises the 
movements are semi-passive, being 
determined to a great extent and car- 
ried on by the apparatus. Hence it 
becomes more difficult to control 

them accurately than is the case with the resistance movements. It is 
unquestionable that excellent results have been obtained by this method, 
especially in cases where there is mild dilatation but no serious heart 
lesion; but it is certain that the limits of the patient's strength are too 
readily overstepped; and equally certain that, in the large institutions 
where this is carried out, the superintendents usually pay so little atten- 
tion to the individual patient that these exercises very frequently do dis- 
tinct harm. 

Fio. 135. — OrthoiliBgrBphic outlios «f a 
patient with dilated tieart. ^honiaB the elTect of 
Schott maveiaenti>. (AlUr W. BciLy Thorne.) 
Solid liDB. oulltne before treatmeat; brakeo liae, 
outline after reaieted movemeaU. 


The question of walking involves not only an important form of exer- 
cise treatment but also the regulation of the convalescent's daily life. As 
has been stated above, walking up and down stairs frequently introduces 


the greatest .itrain upon the patient'fl hpart. 11 i-t moiit important that this 
Htrain should bo minimized. Thit; may be done by cuu^ing htm to rci'l upon 
each step long enouf;h lo count five, ten, or twenty, thus injuring him against 
hurry uud bf«athle«8ne>» (J. O. Hlrschfvldvr). Another method which hai 
been found useful waa suKgeated by the writer's wife while climbinfi moun- 
tains in the Sierra Xcvada-s. She notirvd that she eould ciimb quile steadily 
up the Btecpcfit trails provided she took a deep or normal inspiratioa each 
time the same foot touelieil the grouml. In liiia way a relation was estab- 
lished between speed and respiration, the former waa regulated by the 
latter, and a certain balance maintained between the rat« at which oxygen 
wu^ used up and that ul which it wax supplied. As the pulsc-ralc is often 
yrame definite multiple of the respiratory rate, this procedure also tends to 
rwgulale the former. This rhythm is one which is very satisfactory for 
patients with heart disease. It is Teadily acquired, and, having once 
rbeeomc habitual, doct> much, automatically, to keep the patient within his 
^hysiulogical limits, thus enhancing the beneficial effect of the exercise 
while e«tiihli.«hiiiK a snfegurird overstrain. 

Oertel's Mountain Climbing. — Long walks and mountain climb- 
i og were introduced as an after-treatment in cardiac disease by Oertel . 
Oertel found that patients convalescent from heart failure, and Ci^pecially 
those sufTering from fatty infiltration of the heart, were much benefited 
by long walks taken slowly, interntpt^'d by freijiienl I'e^t.'^. Walks along 
gradually sloping paths in the mountains were most iK'neficiul, and in fact 
became a feature of the method. This is designed, however, only to put 
the finishing touches upon the treatment, and to fit the patient whose heart 
is already in good working order for the more strenuous life to bo pursued 
after his discharge. 


As regards the choice and use of t^crci.*!.' in Ircntment. the following 
general principles may be laid down: 

(1) No exercise should l>e l>egun until the patient hast Ijeen under 
observation for a few days, so that his general condition is thoroughly 

(2) If the patient is not improving under absolute nrst, exercises 
would only increase the work imposed upon the heart and would do harm. 

(3) If the patient has improved under nl>solut« rp.'*l, he may Iw given 
one or two passive movements (each carried out five or ten limes) two or 
three times a day, and the exercises very carefully increased in number 
and intensity each day Iwfore allowing him to get out of Ix'd. Even a few 
mild resisted arm exercises may be tried, bearing in mind the same princi- 
ples, for it must Ik- rememlien-d that the patient may obtain mueh more 
complete and immediate rest after these exercises while in bed than when 
out of it, and al.4o that he is not at the same time subjected to the strain 
of standing.' 

' The rrUtivc mildnew of »uch exeitiiwi in palicnU still bpd-rittilm U *een lii ttw 
fact ilmt their piils^rftU and mpiMtion rMum at once to nnrmnl on cnaation of the cxer> 
ciae. PhjuLulogi cully, to exerclev iii the liurisonial poHttir« incrpa«(« lh« syeloljc output 
motv nnd chiuigca the pul««-rate lets thun in the erect paiturv lErlongvr and Houktrr). 



Onee out of bed the patient ehould at first be Riven a day or two of 
couiplvle rc.-<l lo Accommodut« htnisclf to the new jioititton. Then he may 
be allowed to beein gradually u-ith a few of the resUtcd movementH, if a 
comiMitent atiendani or phynirian can supervTse them; if thii* in not avail-j 
able, he may be nllowed to practise a few exerclsi-s in contracting antaso-^ 
nUtie mwscles (Sftlbrtthemmungsbt-wppinceii), at first under the direction 
of the phy^c'ian. later under the observation uf a skilled attendant, or of aonic 
reliable member of the family who has been carefully infttnicted in the pre- 
cjiutiona given nbove. About this stage the bath treatment itiuy be Ijegun., 

(4) Mechanical g>-iiiiiastic8 (with the Zander apparatus or modifica-' 
tions thereofl can be recommended only when 8uper\'i8ed by persons of 
great experience and excellent judgment. 

Training at Euid of Treatment. — (A) When the patient baa recovered 
somewhat, but not sufficiently lo witlistjiml the w-ear and tear of daily 
life, he should be encouraged to take short walks, gradually lengthening 
the »pacc eovered, at first about the hospital grounds, hiter about the 
city or countrj', keeping recorils of the distance traversed each day. He 
may then be allowed to walk up hill. Pari pa»«u with this the reM-ited 
or antagoniiicd movements and the baths shoul<i be given. Before dis- 
charging the patient, he should be compelled to take some regular gj'm- 
nastic exercises cverj* day and made to do work at least as strenuous us 
that which will form the routine of his daily life after passing from under 
the physician's care. It i.t no more fair to the eonvale.-'cent to put him 
directly back from the sedentary life of the Iwdroom or the hospital to the 
deadly struggle forexistenoe outside than it would Ije In match the average 
citixen against a priie-fighter. He must be gradually trained for the effort. 
This prineiide wm* verj- well recognixed by da Costa during I he Civil War. 
Before sending his patients back to their reginicnts where they were subject 
to heavy fiehl duty, forced marches, etc., he kept them ai lighter dutiesJ 
about the hospital, upon local guard duty, etc., and from time to tim«1 
during this period subjected them to testa of increasing severity (running 
races, elr.) until he wmt quite certain of their ability lo stand the strain. 
The magnificent results which he reports from his large series of caaes 
treated un<ler otherwise unfavorable conditiorm conslitut* a fitting monu- 
ment to one of America's greatest clinicians, and merit the careful study 
of all who would learn how cures should be obtained in heart diseases. 

Treatment and Occupation. — On the other hand, the training to which 
the patient need be subjected should be suited to the life that he leads. It 
would l>e unnecessary lo train a clerk in a store up to the point of muscular 
strength that is necessary for the ordinary laborer. But it is necessary 
that he shouhl not )>e exhaii.'ited by n few hours' stniuhng lest the cardiac 
ovpntlrain return. On the other hand, when rfstilutio ad inlesrifn has not 
been possible, the patient's life must not l>e the same as it was before his 
illness. His work nmst Ix- cut down. This may often be done in the more 
well-to-do without changing the business by employing assistants to attend 
lo all except the more essential afTain*. Poorer pen-ons must change their 
occupations. It is as much the duty of the physician to see 
thai this is done after the recovery a» it was his duty 
during the height of the illnpss to give correct treat- 



m c n I . Otherwiai! ln> has merely piopareil ihe patii'iit foi- another break- 
down. The difficulty in finding suilnblc o<;cu|>ulion tind the ucuincu itcct;)*- 
Hitiy in meeting changed conditions increase ratlier than decrease the 
t'epotiHibility of tin; phj'siciaii in tlii« rcgttnl. He must sev to it thiit, ii» 
stated liv Professor Osier. " the patient must always live within his inconie 
(if ciirdiae enorg)." His modo of life, nnd ^•.■<J>«^^iIdiy tin' .-(ijeccl of hit move- 
ments and the intensity of liis efforla, should l» so regulated that lie no 
longer foeU at any time palpitation, shortness of breath, or precordial paiu- 


Although the healinf; power of mineral eprinKX and hatha was thought 
by the older physicians to be well-nigh utiiver«»I, the flcienlifie npplicution 
of hydrotherapy to heart disease is due largely to the studies of a small 
group of men at Bad Nauheim, Cierniany. Benecke, in ISlfl, noted the 
fnvorublc action of bath^ nt thi^i wiitering-plnre, but it i« to August Schott 
that is due ihe real credit for introducing into cardiac therapy what is 
Jly u very valuable nielhoil of tn-atnicnl. 

piivitior>}oiCAi. AcrroJi or baths. 

i'hysiologically it has been found, especially by Erlanger and Hooker, 
and * little laUT by Jacob and StxiLsburger, tlinl all batlis given at about 
the temperature at which the body neither gives off nor loses heat (02* F., 
3S* U.) increase the pulatvpressuro and slow the pulse-rate. Strasburger 
found this to W particularly true ai* regiirds b»th« of the «ame composition 
as thoHeal .Mauheini, or indeed any otber baths in which COjisclTervescing; 
and ascribes this action to the diliitati'in of the vciwels in the skiu over the 
whole body, as well as to the cardiac reflexes from stimulation of the sensory 
nerves by the prickling sensation of the CO,. These effects in them^lves 
would be suHicient upon a priori grounds to indicate a probable value of 
such baths in weakened hearts. Scliolt's treatment has, however, long 
unlcdated these explanations. Sclioll, Thome, Schiiiiiikc, and a host of 
other observers have demonstrated that the area of cardiac dulness and 
the X>ray slindow of the heart diminished after such a bath (eanliac tonicity 

An excellent treatise of his results and those obtained by other ob- 
8er\'en is given in r-jlcnto in English in the monograph of W. Be/ly Thome, 
to which the reader is referred for details of the method. Other excellent 
accounts are ^ven by Satterthwaite, P. K. Brown, et al. 


The baths should not lie given to patients who are in the extretn* 
fltages of cardiac break-down, nor indeed to any very weak patients, until 
they have Ix^en prepared for the slight strain which accompanies them by 
some course of mild exercises, pri'fenibly resistance exercises (sec page Hl5>. 
They should never be taken leas than one or two hours after a light meal 
or four to five hours after u heavy one, and, on the other hand, should not 
be given upon an absolutely empty stomach. 




The Xaiihcim ballw are oblstiicd from envcnJ mincml uprinipi t>f ililTttrcnt coin- 
(KwiUuii. A vounw of tiuliu is Wgiui in tlii' Gnat Spmilel (cuinjioiiitioii 11,0 UHXI, NsCl 
:2.1s, KCIO.^, (rail; 1.7. MitCI,a4.ca1niunihicarbai)Ut<!2AC:u, 3,17; tcnii«;raliirp31,8''C., 
8b.8* F,), iiiiwt of the (."O, Ijeiiic HikmivJ lo wicnj* l)i!-fore immewon of the |uiiiriit. 

The t^Ti-cl of tlic Nuuhciiii buiha cliii bv iiiiiluUKl at Loqif or in tlip hi.apji:il by add- 
Inc the fame >altii to the vnter in the Imtli-luli. A smit v:irirly of tiich iirtifi- 
rial Natilirim sails are ou iLe luurkf^t, laii ii[i in packflicn reail.v fnr iim. The 
nioBt wititJaclor)- known lo tlic wriitT' ccmluiiis: 

OrBmnm. rnunil*. iVr ont. 

Sodium chloride ^SOO 8 2 3 

Colriiim chlciriiJe (mnKimiuot diloride) 900 3 0.S3 

Sodium biciirboniite SOO 1( 0.1 

Sodium bisiilplmtc ykldiui; CO, 1000 'i-i 0.2U 

In (inicr to prrvcnl thr bitiilphate from injurint; the tub it in ndvipinhlp to cover the 
walln and Hm>r ot (he lal.l*r wllh a lanW shfwt o( nibbcr cJolh about x N (|. in wzi-. The 
bntli in lillril with narm wiitcr, !H)"-93°t'. (u i;oo(t-4im] bulb refguirm 40 lo4i5^. — 150 to 
17Ji lilrr>) and the t^aU* ndiled— tinii chi? soHinin cbloriilr'. then the mlriuin chloride, then 
the wxliuiii liic4irbonaI«, aiid hint ly the atid wilphate |N«IK'0, f^ NaliSO, — N3t,SO,-fO0,'f 
U,U). The clfcrvencuioe coiiliiiucs Ibmughuut tlie bath- 

TAUTIOSS IS nivtxo BATns. 

In preparinf! the f t r b t bath it is bc^tter to begin with b a I T 
strength of the sails or even less. The pntient is allowetl to remsun in 
thit; bfttli not longer tliiin fifteen m 1 n u t x , being wati'hcd c»re- 
fully (luring thii) time nnil removed at once if there is the slightojft 
increase in c y a u o s i s or real diBcomfort of any kind— (lushinR, 
exeit<'iiient, or syncope. "Th« immwiinle effect of the fn^i few biiths in to 
produce a sense of oppression at the precordinm, under the influence of 
which the patient breathes slowly anil deeply for two or ihree minutes. 
Itespimtioi) then becomes eiuty and continues slower by from two lo four 
breaths a minute," after which the symptoms subside. In general the effect 
should be fdmilar to that in llie following cose quoted from Thorne: 

"A pniieni. aiccd W. whoe« henllb had been ilMlininK for years, wao found to have 
a ptiliK- of Ml in the rveuiiilieiit , an<l of SSi in the BiliiiiK. position. While lit Htuod it varied 
from 100 lo 10), and if )u> n-nlked ten pncvH it me from I'JO 1^ 130. The npes va* found 
lo beat aa Imh ouleid« the nipple hue, Wiihjn tu'o uiinutM of Inimcniiun m hin firat 
thermal balb tbe pube hod tullen to 7Q. nnd jiiilsed by the tint^r appcorrd to have doubted 
il« volume;' at Ibe end of four minute* it was 68, In tax minutex liS, in eiabl minuiM 68, 
and while eiandtDic after the luilh it van 1*0. Before he left the bath after mi itiuner»an ' 
of ten niiiKim, the apex bejit nnc foimd in bnvr n>ce>Ird half aa inch id the direction of 
the mminl line, and nnils uifl finKem. ubich hud been Hiidn-ivblle tip to Ibe Junction of 
the aeoDBil with tlie firsl pbnituix, lind uvumed n hcnltby flesh tint." 

Thi.-^ healthy reuction of the skin shoidd Ijc present within a few minutes 
after the bath. Its absenc4> indicnU's thai the Ireniment hus been too 

' Ptil op by R, R. Roeer* CbfnnieKl Co,. San Fmneisco, TMb prepamllon Is partic- 
ulariy useful, owing; to llie excellent gnide of lotiiuai biiulphnte pre[iuml anil tbe pemm- 
ueul and convenient form in which it io put U|>. UonM>ver, the untlium hisulphai« is put up 
in litmpii the sirn of a ha«ebnut, wliicli uIIowm the CO, Ui be gciienil«il uniformly tbiou^i- 
out the baih. 

* Probably tbe pulMvprra«ure had adually doubled. 



violent, too prolongc<], or in oth«r wayg unsati^tfuctor^-, unci unleeit this can 
Lbe obviated after tlie next bath or two the treatment ahould 1m- diHcontinued. 
After the bath tlio iintieiit cthould lx> made to lie down and rritt, if 
possible to sleep, for at least an hour before leaving the buildinj; or doing 
anything clae, and ujion thid rest a.i much aa anything elac dejwndd ttu; 
KuccO'tfM of the trcatmcut. 


GrxsAvnca ami* K v » roth era rr. 

lera. H.: Lphrfmcii Oit Hdljrytniiantik. Brri. nnd Vicnnn, I!W3. 

Rehott, Aug.: Ziir Thornjiic drr phTOiiisdicn HrrKktnnkhciloii, IJorl. Win. Wchiwcbr., 188&. 
Thome, W, B,; Ttie Weliutt Melhotli) in die Trvutiiiynt of L'hroiiif DiwuBtvi of ibt- H«irt, 
Ncbel: BewrgiinftnkiirfU niitttlsl »clm-ciii«clipr Ufiiij>*mniiiilik und MiiwaBP mil bnuioctnrM' 

QprllcksichtigUTiK dpr mRchuiiikchirn ilrhamlliinKdn Dr. (i. Ziinder, Wicitbiiikri, ISSH. 
Oertel; Ucbt-r Terrniiikiirurtt'. L(.-ip2., 1S86. I'fbtT itii! cliniciisFhen UerziiiUKki-lerkrunk- 

ungrri uml ibn.- Hpbarollung, Vcrhamil- il. Kong. f. inn. Med., Wjcsb., ISSS, v, 13. 

Alljcmcino Thrrapin <fer Kt*iBlaiif»lorunKeii, l^OI, 4l,h ed, 
Benekn. V, V!.: Lipl>er Nuubdtn'x Suoltlicmirn, Murbitrg. 1S5(): Wcitt-rn Mililii^iliuigpn 

upbnr dip Wirkuns dc-r .S.iolthrrmfn .N'mihrimn. M.irhurK, IXfil; NniihMm'n Soolllicr- 

iiicn ei'if') Gel e ti k rheum at iMniujs mit oder uhne Hi>rxalTection., Berl. klin. Wcliosctir.. 

IS70, JfiS. 
SehoU. A.; Dio WirkiinK d^r HSilpr aiit daa lien, ibid., ISSO. xvii. 3B7. 372. 
GrlkiiiRT mid Hooker, i.e., \iaKV 35. 
Slra»bur([rt. J.: j.'ebnf Blutdriick. Gr'^kwlonui iind lli-warfiril bri WiuMwrhOdem vct- 

dclilmier Tpuippmliir iind M .Snibiiderii, Deiitsi? bp« Arcli- f. klin. Med., [jtlpz., Ixxzij, 

.^nttt^rthwnitc: NitiihHm Mrthoda in Chronic Hcnrt DtiwnM with American .\iIu|itnttoiui, 

Intpmat. Clin,, Phllu,, 1903, 13 «er.. i, 113. 
Brown, 1". K.: Arliliciul -Naulieim Bntlis iu Cliroiiie H«irt Cuam, Bovloii M. and S. J., lOOB. 

civ. 270. 




To enabl*" the hpBrt to recovpr front an ovorstmin and the consequent 
dilat'ation, to muintain the eiioululion in tiie presence of a valvular leaion 
or diiatjition, or to retstahlish compeneation onw broken, it must put forth 
an increase in forcf. The .stimulus for this seems to lie in the increase in 
rvadual blood in the ventricle, which art« as an 'increase in load upon the 
heart muscle, and thua tends to inerease both Initabiliiy ami force of con- 
traction, as shown by O. Frank (;** page 13o), and particularly to bring 







n-1 Pe<tlROPHitD 
750 O i*/-it 





rsoa sm. 


^^^■h ^m 




w- -- y 





M / \ 


^ 1^M 



' 'fli^^Bl 


Pin. IM.^Il>pcnrD|»It1^. uukileI. nml niiutilui' liraru. tKrom fpwJDMUtn ih* Amy ItadSMtl llwran. 

WuhiiixUiD. I>. C.) 

about an increaae in tonicity. It seems probable that this increase in 
tonicity i.s of primary importjinre ai< a preiti.*|K>iiing factor to hypertrophy, 
and Barcroft and Di.\ou have shown that increased tonicity is accompanied 
by an incrcaaed CO, metabolisui in the heart. 


ChsRKCt In the FifcrH.— Tiic mnin viniblp chrniKc which the hcnrt miiaeic undornoM 
la a RwolUnK or the individunl fibres (Tait^l, Goldenb«r^, Deliio. R. M. Pi>aK«) mitk little 
if any tiiiiltipliciitiun of the inuiclc'««ib. Uulduubcrg liiiila Ibat ibe iuu»rk-colU in tlic 
wnJt of the bt-prrtn>phic htmrl hnvf a ilinmctcr pr 17.ll.' ", in liio normnl hntn 12.86 ^, 
anr) In the atntpltic heart 10,51 ^. Tlii- Htriulioo of Ihi- tiiim also bvcoiiieq I«k« tiintiiiiel, 
aad vw!U(^ apptar in the mrcojilaxni. chanirai wlikh arc lintibr to nliat it olucrvcd in 


a clriatod muacte lu the m-iilt or pmlonKnl L-unlRtRtion. Ranku hun sliown ilml ui skelelal 
miucle these rh&nttos »w tlve to ini)>il>ilii>n or endoiinom nf W8t<rr, which, acconlins to 
the boiiilifu] pvpcrimeiit* uf J. I.oeb and liia pupil, MiHB Cuukv. is bruuglil about in the 
follovinR wny: fhirinK 'he niii»cular contmction Ihtv niorv nomplrx dioIdcuIm hrcnk down 
into Hctrnkl luinpli-'r on«. (litMvby iiicniuuiig Ihu iiuiiilwr at inulf^cukis in solution in the 
miiKlt! pliuimn, the oannntii: prcwDirc riwa, nnd heacr tirintpi nbout an cnrlosiaoiis of water 
into tlie fibres, llavini; once Mildred, the wniii-r iiiuleeiilM tvmain anil tlic^ miiiwlp (iw<>llx. 
Tberv cuii be little dotibc that ibu xaaic proeeu ■■ goioK oil in cunliiui muscle, tspocially 
when iitibi«ct<i(l to overwork, but no obmrvalionii have M^UAlly been nude upon lhi» 
pluue of the dubject.' 

Id cardiac hypertrophy thn-c anatomical changes may be sftid to lake 
place aimultaneously : (I) nii iHcreaKe in sikc of the individual miisclp- 
ceUs, but apparcully no increase in thvir number; (2) u corliiin amount of 

FtOh 1ST, — PholAmicmffntiiht nf mmptiir uiil liypffrtrophi^ h^art mii»rl«. A- Atniphic hvairt 
bctwMru Liip niii>cJc tclbt. U. Uvprrtrf^ptkkc l>r«rt n»u«cLr <howtiiE lait* orllt VLitt twoU«ij nutlet. 

(Icgcnoration is almoxt always present in some of the iniutclcHiGlle; (3) a 
proliferation of the strands of connective tissue between the bundles of 
inuM'k'-fibres (intcrfasciciilur niyofihrosis, 8cc page 23^), 

Dehio and P«arce have shown that each fibre may pass through the 
following stugt's: normal — hypertrophy -• dejtenpration, the latter vlagc 
beiuf; associated with proliferation of interstitial connective tissue (myo- 
fibrosis). Accordingly, we may Hnd the heart-cells in the following con- 
ditions : 

(1) Nonnul'f li,vpcrtroplii«t (hi^uri BoniL-what mlurgtsl: tut in atlilelett, ulio to KORja'a 

(S) HypertKitihicd -f do^neraloil; aoitu* prulifcratlon of connective lismie (heaK 
much enlarged — cot boviniitii; still »(n>«g). 

(3) |}r<cn prated, Marked prnlif (^ration of connoctit-e tiiwnr. hlnrkcil m-ftknna of 
the heart. Litn^ failing heart. Hypertrophy + dilatation C<iig;itahii often hanaful). 

' Pleinoher and Leo Loeb have advanced the same explanation. 



Types of Hj'pvrlrophy. — Hypertrophy waa supposed by Cohnhoim to 
U8ume three lypoa; 

(1) G «.' n c r n 1 conct-ntric hypertrophy, involviag all the 
rhambora of thp heart about otiually. 

(2) Local i-on ceil trie hypertrophy, involving the walls 
of one or more chambers of the heart which U subjecU'd to oxtrii work. 
The fibtt?* am' not especially eioni^at^Hl. 

(3) Local (excentric) hypertrophy with elonKfttion of 
th« musele-fibres, «» in aortic innulfieicncy. The elongation of the fibres is 
Komewliat out of proportion to the inercaHc iti size of tho heart. 

The existence of thaw three types of hypertrophy as wparatc euUtics 
was ulreatly illj^put^'d by Cruveilhier in 1S33. It is probable that the sise 
of the eavilies an found at autopsy bears no constant relation to that prcA- 
UDt (luring life. Moreover, the ventricular cavities in cases of chronic 
nephritis an- often (puto as lari^ as those in hearts of aortic insufficiency, 
though the foiiner typifies the so-called concentric, the latter the excentric 

Otxumnce and Sites of Hypertrophy.— Tlic relative frequency with 
which those factors occur in cases of hypertrophy is shown in the following 
statistics compiled by \V. T. Howard from nutopNies nimir in the Patho- 
lo^cal Di'partinont of the Johns Hopkins Medical School upon 108 subjects 
showing hypertrophy of the heart. 



ValvuUr Irwons o( the hran . 
Adhoiviit ppricanliiim . . . . 

llnnt work 


Aneuriaiii of tlie lieurt wall.. 
Uicaiic picthota 










7 6 












The right ventricle showed hypertrophy in 70 cases (66 per cent.), of 
which there were — 

ArterinwIpTonin (nhcn of [mimnnaty nrterj), S2; adh««ivo poricanliUs, 6; vulrular 
^leiioac, H; ehruiiiu iiephritiii, 3; hvdmiiiu plutlium, I. 

Hypertrophy of the auricles (atria) was ntost marked in mitra) stenosis 
and adhesive pericarditis. 

Strain. Exercise, and Hyperlrophy.— In normal individuals the weight 
of the heart is almost proportional to the wei||;ht, not of the entire body, 
but of the niu.-«culatun! (W. Muller, Hirseh), being relatively low in fatly 
and relatively high in muscular individuals. The absolute wcij^hl of the 
heart is about tH (OO.'iU) of the body weight in men, yii (-00546) in 
women. The same general principle applies in animals, the most active 
animals haviug the largest hearts, especially race-horses, hares, etc., as 
compared to Iftss active members of the same species. 

When, however, the henrt ts subjected to abnomuU strain, especially 
as the result of valvular lesion, it hypertrophies and increases in sim to 
dimeasioas which are often enormous. It ia not very uncommon to find 



beuls of twice or even Ihrne liinet* Ihc normal aiie (500 lo SOO <lm., 17 to 
26 oz.), and in thr Army Medical Musfum in Washington tluTc- is a speci- 
men of onfl weighing 1000 Ciiii. (33 ok.). .Another heart of 1400 Gin. (IGJ 
ox.) hajj bcf« rf|x>rtcd. Such a heart is usually designated as a beefy 
heart or cor tiovinutn, indicating the Animal to which ita size would be 

\\'ork Hypertrophy.— Whether a Inie hj]tertrophy occurs in a per- 
fectly healthy hciirt has been much disputed, many writers taking the 
stand with HomberK that, "though the possibility of a'work hj-pertrophy' 
CMinot be denied, mure pruofs of its existence arc necvs^ry." 

FM. lis. — Heart tA) n( nnmul doc and <B) cif dnR wliirli tiiu run for ibr** mniillK on ■ tread-nilll. 
(.Atl«r Kulb*. A'tft. /. rxprr. t'ath. u. Pharmatol.. ]v.) 

RMcintly, hnwnvrr, nbi>n1iitc ^irtinf of a work h)-[>crlraphy without myocftnlini dr^ti- 
eraliun Idu been bn)<i||!lil ti.v tlie beauliful )^X|>e^inle^l« of Kfllb«. This obaervi»r louk two 
(!»gB of ihi? Buini! lillcr and o( c(|iiul «i«.-. kciit Ihcm in ticiKhburiiig (^tl£U■ upon Ihc tame 
Uicl, bur, coiiipclliMJ one of Ihcm lo run ii[>tici a lre»ii-mil! ilnily fi>r thnw lo MX inonlhs, 
while the (itlier vnid krpt quiet aiiiJ uik.i1 ub u cuulrul. At ihe end ut thin liuiu both <li>^ 
wccv killril in thr mmr mnnnrr. 

Work d<«, Coiiirul. Work Jui. runtrol. 

Toll.! wpighi 15.2(HJ l."i,i)0« J9.20O 20.400 

Muaculaiiiii- . - j.Witi :>,;J12 «,4S0 I5.T"« 

Heart 152 flS 172 113 

KQlbfl'a imilU han bMo oonRrnird by GrObcr sncl Iqr JoRcph. 

The inctean in lin of the heart » lu nut uccompairfBCt by uii,v change in Die Hkeleial 
muBTulnliirt', nor were nay pnlholciuica) dinTiKi'* ptraciit in the lienrl or nrterie*. The 
niiutcle here siniply undortconl an incrviwe in bkc, i he piirc*t form of hyimrlrophy. Knlb»'s 
daigt wrv simply in tnining to run on u Irciui-iiiitl. Ttie procMs una exuclly the suitif n» 
the "tmimtiK" of an athlete, and. dinicnlly, it iit often Coiind Ihiil ul)iU<t<« buvo mildly 
b>'|ierlruphied hearfa. 8chi«tTer han ili'indiiftraUvl with the nilliodiajtraph tliat the site 
of ihc. heart if iacrriuFd in pcrxiiu wlioec oMUjialionii n^iuire liani wurk and decrcBwd in 
llHMe with «ed(<a1«ry callinin. II* has also ahown that Iho heftrl« of rlu> yoiinit mrn dtung 
military aervicis in. the ticrmaa .4nny increase in siie somewhat during; tlieir ijcriud i>f 
Mrvion. lIowoVRr, thpw tni-n often indulge in cxcmu of nicohol or tobncvo. m> thnt bitfom 
lhi!>' die i-nudgh niyucardiiit chiiiij{<! iiaB set in ti> iuslify the scepticism uf men tikn Kn^hl 
(I.e.) and Roinbrrn (!-<'•'- Nnvrrlhclraw, thntigh n tnie "work hypt^tlmphy " must be 
admitted, in these expc<rinMini« It is noticeable that the incrcate in weight of the heart 




nnioiint«(t to only £3 per cent, ns rompare*! with cltansm f( 100 lo 300 per cent. otVa 
obsurvFil i[i TDun. Ii is doiiblful wbelbRr a oomMpaodiiig degree ul liyperlrophj' would 
be noticeable clinically. 


H>'pcrtrophy in Chronic Nephritis. — The most remarkable and most 
import^iiit of nil llit-st; (oriiw of hyjwrl ro[ihy is tlint taking; place in chronic 
nephritis. This was first noticed by Iticliard Bright in his classical descrip- 
tion of dropsy in nephritis. 

In 1SJ1>1, Wilkm thoiistit that the Iwinn* of the ](idiie>ii nnd artcjic* •mt* part of tlitt 
MOW morbid euiiiiilion; wliilu Uiili uiiil button ntavimeil tlial ihe iKneraJ an^riornpLllary 
fibnw* bnni)clit kbout an incrrmuHl mtifltiiiKri.- (Iiitiugh nnrrou'liig of tbc uni-rinl biii, and, 
aa • fMult of thin, liiith bloiiil-prewiiirc an<l hypt^rtrophy cd tlic hrjirl. Srnntor wirntiiMl tluv 
hypertrophy to u " dyacrcuic " property ul tlie blood iii neiplirilli, sliiiiulatiiiK ibi- beurt 
(o contRiclUinJi of abnormal foKc. t'llmlc'r ntid llc-tn^kc ha\-c recently iiubjr«l<!ij the 
matter to criiinti expcriiticni. They (omul rhat i( ihey cut am pjacee trf kiiln^y fruni a 
dog bit by bit until frnal nuiiitnnco i-rjunl lo 1} kiiliieyii bad been removes!, tlie beari tlm 
iK^Ran to hj-jicrimphy nnd Ihc blo<nl-pmuiirv to ri»c. If Cfnwidprably mon; tiMruc wm 
rviiiuved. (he aiiinial bei'uiiie cacljeclic, the blui.>il-pn«»ur« r^'niainc^l low, and the heart 
did not hypcrtmphy. They nacribvd tliflH.- rnnliae obuugni, <u (ii-orgc Johunon had done, 
lo the pTmeticc in the blood of tome substunce h.ivini: n <iigitiilin-likr action, licinfc cither 
retained in the eirluUlton in abiiorniidly lari^e ((uaiilitiea tut tlie rvatitl u[ dislurlwd exci<e- 
tion, or brinK n true imemal ncerction from tbc diwavd kidney.' 

NunieroiiH other (heorint of canliac hy|)«rtrr>pliy in renal diwase have been advanced. 
Chief among tlirw in tla- theory of J. Cuhnheiin and Truulir lluil Ibi? sclcnwiB of runnl 
vcswln narrowed the anrrial hni in the kitlnry, ihereby intn»lucinK an increased rcBinljinco 
into ihe K^iicral circulutiuii. aiul tlmt iticM* changes in ihe renal vesxelB uere ciioijkIi to 
raiae tbc grnrml blond -preiwiurp. It would apiienr in the lijcht of more modem rewnrch 
that (hiB eutliiiK off of the blood «lream in in itoetf inBUlhcient, On ihe urh«^r hand, BuIJ, 
Huchard, njnl .\lbfrcht liavc nuRaraitrd that Ihe hypertrophy m not n Inir one but niinpjy 
a [iseiidohyiiertrophy (inlrrfa*ciciilap rayofibroni*, we paje U34), Ihe cnlint incnrojic in 
»i»e of the heart bi'liiK iluc to Krowlli of cuiii)e«li\n lisue and not of the lieart muscle, but 
histoloKical exaniinaliono do not bear out thin view. 

Hypertrophy from Ovcrdrinkinc. — Closely allied lo this condition is the 
tremendous heart hyperlroi»hy which is univcr.'<ally found to result from 
drinking; lar^e quantities of beer, and, since it does not accompany excc8» 
ill luiy othvr form of nicohol lo the -tame <^\t«nl, it is thou)iht to be due to 
the large quantity of liuid ingost^tl. That increase in the Huid in the blood 
at once resulu, not »o much iit a rise in arterial blood -preneure as in rise in 
venous blood -pressure, dilatation of the heart, and inercow^ in the 8>'atoUc 
output, even to the point of doubling or trebling it, can eawly be shown 
with Henderson'.'' cardiomeler, and this no doubt illiistrKtes the mechaniiim 
by which the change is brounht about. 

Hypertrophy and .Arteriosclerosis. — The relation of hypertrophy of the 
heart to arterioHclerusis independent of any renal changes is also of fuiida- 
mental importance. The coincidence of the two conditions in the same 
individual has long been noU-<], nnd both have l)cen brought about experi- 
mentally by a^i ministration of certain poisons, notably adrenalin (Josu^, 
Erb, Pearce, et al.). 

'Tigentcdt aiul fi«tgniaiui (Sluuid. Are4i. f, Fliyaiol., Leip*.. 1898, viU, 3»1) found tliat 
injeotmn of r«nal extract actually ruiied the bluod>preMui«, nwing to tbc preaence of a 
sutwtanM which lliey named " renin." 



Cardiac and Adrenal Hjpcrtrophy. — A new liRht has been tbrowti upon 
thp subject by th« Mtudicn of Viiquex ami AulxTlin (1905), Aubcrtin mid 
Cliuct, Wiesel, and Gaillard. 

Auborlin ow nlik to produce cantiuc lijrpertrophy in rebtnU by rariuuH mcfto*. 
anil r<iunil in rvprv cmc a Mmultanroiix hypcrplnitin nf the mndiilltir)' 
Hulistsncc in itie udrciialn. A siitiilur finiliriK liu<l bei-n iiinde by Vaqiiei aui) 
Aubvrtin in ciih* of chronic iipphriti* mwocinti^ wilh hyjiprtrwphy of tlif left vcntricic', 
which vitui confirme'l by Witwi in IW7- In DMpnilier, 11KI7, Aiilwriiii luid ClunM ntade 
B BtiKly ii[ IW iiimvliwlcd uutupay canal. Uf theae IS HbouFd t'ciT,' dvlliiilc Lypcrtropliy 
n( tlic nmlulla nf the admi:ilii. and Ift of thrae lH iibowdl miukril liyjioilroiihy of ihr 
hrart. On Xhf other harii), but 10 of iLeoe hy|i«rlTOiihi«>l henria nt^r« aMorifiI«^l with naiii 
tliiteaae: the olhctm uccurred in conjuiiftioii with vulvuliir lumonn. cmigtnilal iltrfi'ct in ibc 
•Rptiiui vcntriciiloruin, ni>rT.ic wlfmuH. ntc. Aiibenin, huwrvcr. slntn very ilnliniiply ihitt 
btttides tliCMgrou[ielliey i-nt'OuntcnHl ciuxs of CHiiliiu' hyix^rlrophy witliout ihc niiil^iiFV 
of Hdreniil hypcrpWin, «> thiil thin tuxocintion in not invnriiililc: nnd they conclude ihnl 
It JB lie pivMnt irii|K>wibli^ lo decide whether the cnrdtac hyiHirlrophy oocun sa a resull of 
ovGmcc^^IiDn ot mlrennlln. or whether the hypcrpliiniii of ihe adrcnul* ucciirn ub a, rimll 
of stifthl venoim ilttMit in ihciw. nrjcnni- while the hypertrophy ix Kninit on. ArlorinseleroMii 
wiu the rvile but not invariably in thew cnutt wilh adnriiul hr|>ertrophy. 

It miut lie noted thai the nction of ndrcniUin is juil that which might be expected 
to hrfne wlioiit hypertrophy of the heart, for it cniiw*. (1) a jtenera! vanoeonMriction; 
(2) u tnurked inervunv in (lie tonicity of ibc hvail; (3) an iiiereaite in the furcie of the bent 
■nd in the iiyiitolii; output. 

However, the results of Cohn, under Aschoff's direction, are !psa favor- 
able to tlii.-< theory. In V2 chutrn of hy|x>rtr<ijihy of the left vontiide with 
chronic nephritis, lie found hypertropliy of the adrcnul corU'.t in only 3 
(25 per c«nt.), while in 23 catvn of chronic nephriliH without hypertrophy 
of the heart he found hypertrophy of the adrenal cortex in S (^4 per cent,). 
Tlifwe findings tJ'nd to throw con.-«idemble doubt upon the theory of Vmiues 
and Wiewl. 

Hypertrophy and Abdominal Artcrio.sclcrosiih — Hni<enfeM ba» found 
that no hypertropliy sets in unless arteriosclerosis is 
present in the aorta above the level of the superior 
meson t eric artery . Practirally nil the substances which are known 
to bring on aiterioBclerotys are vasoconstrictors, and beginning arteriosclero- 
sis in man M'eni.N uj^uuliy to be ncconipanicd by vaffoconslriction. It is 
readily conceivable that any sclerotic obstruction below the mesenteric 
would Iw! Pttsily i-om|>eiisiited for by dilatalion of the alKloniinal vesjfels, 
and, consequently, would bring about no increased resistance lo blood flow, 
while at the higher level the presence of 8clcro»is is more or less equivalent 
to clsniping the abdominal aorta.' 


It would appear at first aght to be extremely easy to determine clini- 
cally wheth«r in a given <'fti*e hypertrophy is prowiit or not, and the older 
clinicians laid down vcrj' de6nitc rules for its detection, most of which were 
fallacious. In general, we may agree with (libson that the most important 
signs of hyixrrtrophy of the left ventricle arc increase in cardiac dulness to 
the left, with a more or less steady, forceful, and ** heaving" impulse, and a 

' An rxe4-Ilmt diKUMJon of the theoretical and eicperi mental iiidc of the qiic*>lion la 
given by R. M. Pt-arce. 



buoDiing fintt sound of low pitch, and an acceutuated second sound at apex 
and aortic area. These sigDs iirc do|)rndent lurgi-ly upon lliv runtucl of tlic 
lifjirl with lh(! wall; and if, as is often tho case in an emphysematous 
individual, the luug int<?rveQC« between the left border of the heart and the 
chest wall, all the signs may be diminished beyond recojpiitiou. The diag- 
no«ifl may, however, often be made from the history in spite of the clinionl 
findingH. Thus, if an aortic or 
mitral insudicieney lia» ]>er!4iittcd 
for some time and the heart is 
in a condition of moderate vigor 
with a normal pulse-rate, it may 
Ih* fts-tunied that hyjiertrophy of 
the heart linit bud to take plaeJi 
in order to maintain the fircula- 
tion, in fpitc of diKtiinl heart 
sounds and absenee of the apex 
beat. Prolonged high blood- 
prestnire is ustially aesoeiated 
I with some <legree of hypcrt rnphy 
«f the left heart, but not invari- 
ably. In differential inj^ from 
dilal-ation it may 1x^ Ktated that, 
except under unusual conditions 
brought on by stimulation of the 
vagus, the factors bringing on 
dilatatiou quieken the puluc- 
rate, and an enlarged but slowly 
t>eatiiig heart la almost always 
hypertrophicd. In hypertrophy 
of the left veiilrifle, in eonlra- 
distincttoQ to that of the right, 
the maximum impulse ih uMuitly 
a systolic protrusion, wiiile iu 
the latter case it is a systolic 
retraetion. The latter in aUo 
frequently the case when both 
ventricles are hypi-rlrophii^d. 

Hypertrophy of ihc Left \'cn- 
(rklc. — Palpation of the apex 
iaipuUe, which many wrilera, 
even as late as Romberg, con- 
wder a most important sign of hypcrlrojihy of the h-ft ventricle, need not 
be decisive, since, as Katwnstein has shown, the weakest hearts may oft«n 
beat the most violently, especially when iK^ating rapidly; the strotige«t, on 
the other hand, may 1h- separated from the chest wall by s layer of lung. 
Dulness is, however, increased to the left. 

H>pertropliy of the Rigbl Vcnlrick. — The hypertrophy of the right 
ventricle is not no easy lo <Iiagnii.'i>>. lis pn^senct- may Iw inferred when 
the nrcA of cardiac dulness is enlarged nod a ayetolic retrsetion ia 

Fifl. 130. — Amu nr imlMUon niul rcnmctliin hnMr- 
Lipliy of tli« riftlil bii'l itii vntinttr*. ... nftnFl^an; 
'\ jHibstiuii. TliB Utiht liiiti i„4lif4(A t^D nnm nf Ihir 

H. 1 1 vpsrwophr ol (to niht vtatrtcU. 


noted at the poinl of maximal impulse and over thv inicrspaccii between 
it and the sternum as well as in the epigastrium. The heart need not be 
t'liiarged toward ihe right, siiuw thp right voiiiriiK- ran-ly piL-w::? ihi- su-mul 
margin. Indeed it rather tends to lift the apex and shift it to the left. The 
area of eardia* flatness is increasi^d to the right, n*ttching 
to the sternal margin. An increased area of duhiess to the right of the ster- 
num is due to the tight auririe. The second pnlmonie sound is intensified 
and ringing, but this may also be the en«e in iiiiy condition in which then.' 
is some obstruction to the pulmonary* circulation or some insiifliciency of 
ihu left heart. 

Hypertrophy of the aurioles cannot be diagno«i(^d from 
<|bjcctive signs except in mitral stenosis, in which an hypcrtrophied iiuricle 
|;!tcs rise to a loud presystolic murmur. This is not present when the auri- 
cle is weak. Hypertrophy of the nght auricle is sometimes shown hy a 
high presystolic wave upon the jugular venous pulse-curve ami very rarely 
by a pre:s}'st<i!ic wave upon the liver pulse (Maeken2ie) ; but, as a rule, it 
8how;< 111) signs. 

ProKnoMS. — A certain amount of hyperti'ophy is neceasary whenever 
a valvular le^iion or any other nbnurnia) factor tcntUng to iucn-axc the 
work of maintaining the circulation is present. lience failure of the heart 
to hypertrophy under these conditions would be regarded as an unfavor- 
able condition, and would probably soon be associated with cachexia. On 
the other hand, an extreme degree of hypertrophy is evidence that the 
heart is doing its mu.ximul work, that the hbrcs ere long will begin to 
degenerate, and the heart must be spared as much as possible. 

Hypertrophy in itself docs not demand treatment, but diminution of 
the causal factor as far as is possible is advLsable. If this be nephritis or 
arteriusclerosis. a ()uiet life and diet poor in salt and purln bodies should 
be re.wrted to, with occasional courses of pntaAsium iodide. If a valvular 
lesion be present and the hypertrophy is slight. Utile attention need be 
paid to it until the patient reaches the latter half of the fourth decade, 
when he should begin to span? Ins heart and arteries as much as possible, 
should abstain from alcohol, coffee, and tobacco, and should in every way 
avoid thiise influenees leading to the production of high blood-pressure and 

Reserve Force of the Hyiiertrophled Heart. — One of the most impor- 
tant questions that arise in connection with hypcrtrophied hearts ia 
whether or not a hyperlrophied heart pos.'H'ssi-s as much reserve force as a 
normal one. This question U variously answered in the text-books, most 
of them agreeing with Krehl et al. that the reserve force is lessened; while 
the cxpciimenlal work, especially that of Homberg and Hasi-nfeld, indi- 
cates that the strength of the hypertropbied heart muscle itself is actually 
inereasi-d. However, a great deal depends upon the stage of hypertrophy 
in which the individual heart happens to be. Thus a heart in the firrt 
atage, with fibn-s normal and hypcrtrophied, would show an increased 
strength (as in athletes' hearts, or in hearts of early hypertrophy after 
valvular lesion as compared to the same hearts at the very onset of the 
lesion); while a heart in the second stage, with fibres partly hypertrophic, 
partly atrophic, would in most cases .show a marked diminution in 



streDRth and still Rreator loss in retserve force, and an inrresscd effort would 
hajtU-n tht- ile^i^'iit-nition, 

Another and really main factor in the apparent weaknefut of the liypcr- 
trophied heart ia that iti pracUtialiy all hearts the hyptrrlrophy la brought 
on by some v^ilvular lesion or by some persUtent increase in peripheral 
re^is^tanee ; so that nuch hearts are continually waiiting much of their energy 
in overcoming them^ palhotugk-ul corulilioiiif. bcbides bci-towin);; the usual 
amount of it upon the maintenance of the circulation. In hodily exertion 
or oUier conditions calling upon the reserve forcr, not only the actual 
circulation must bo increased, but the abnormal factor 
inducing wasting of energj-, the valvular lesiun, (.•[■v., ^ 

becomes more severe as well, and hence the extra call 
upon the diseased heart ia double the extra call upon the 
normal and rcqutrcM double the reserve force to meet it. 
Otherwise the reserve force, thouRh actually more, may 
be apparently ie-ss thun in tin? nunniil hciirt, iw !«hown 
diai^mmatieally in Fig. HO. For practical purposes, 
however, it may be regarded as indispulflble thai, in 
every ease where a cardiac lewon \» present, the hyper- 
trnphied heart has less available reserve force than 
normally, nnd in mmc ea^cs (i^tagc 3} less than if it 
had not hypcrtrophied at all. 









































Kiii, 1*0, — D.aiiiaiu 
jiliiiwmft lM»*f»f ctf nor. 
miJ knil liypcitn-plilol 
litnUts'n) bcAftMrwt 
lliAl of ■ iltvfvfni bpart. 
I'lir keacllt of tttt arr^w 
iitclii-jtinH (Ije Ff>vrvo 
fitrtv. Tilt unAliiHl«d 
porlKin indiiwln the 
cmxtiac MirrRV ei- 
firiKlixi. but vrftklpdi 

Atrophy of the heart is more or less the reverse 
procowof hyjKTl rophy. Whenever the body dtminUhe^ 
in weight from cachexia, infectious disease, or starva- 
tion, the heart muscle diminishes with it, and according 
to Ilirsch in about the same ratio. The vpicanlial fat, 
on the other hand, is but little diminished. When the 
atrophy ts the n-sult of .starvation it may be of very 
high depree, but the size and condition of the heart may return to normal 
when an adequate diet is resumed (Snhieffer). 

.\s in the case of hypertrophy, there eecms to be little ehanije in the 
number of the muscle-cells, but the latter diminish In size (lO.M /i in.-<tead 
of l2.Sb fi. Cioldenberg), and the removal of substance is marked by the 
deposition of brown granules of hsmatoidin in fusifonn arrangement about 
the nucleus. These granules am formed when part of the musclc-rcll pro- 
teid is broken down during the atrophy, the ha-nmtoldin portion being 
left. Mac rosco pi rally ihey impart a tobacco-brown color to the heart, so 
that the condition is often deMgnati-<l as "brown atrophy of the heart." 

To a certain extent a diminution in size of any chamber of the heart 
may occur if it* work ;s Icsseneil by obstruction to the blood Rowing into 
it; as, for example, the left ventricle in pure uncomplicated mitral stenosis. 
The atrophy J.'* rarely .to marked hen' as in starvation, phthisic, or cachexia, 
and is indeed the exception rather than the rule in mitral stenosis, for other 
factors, luchyi'Hrdia, irregularity, or mitral insufhciency, usually contrib- 
ute to keep the left ventricle doing an at least normal amount of work. 



like* hypertrophy, cachexial atrophy of the fibres may lend on to growth 
of iiitenititinl coimcflivv tissue and fibrous myociirdil i», but true brown 
atrophy is not so common a forcriinner of tuyocarditis as is hypertrophy 
of ihi! iicftrl, Funrt ion ally, the fort-c of IIk.- hciirl in inipuint-d about propor- 
tionally to its diminution in weight. The biood-pressure is usually low 
and the muscle eanily fatigued. Overstraio readily occurs in such hearts; 
And sudden death is not uncommon. 



Tborpl, Ch.: Pnlhnbuir der KrpUkufDrjtnne, I-iibnrech-OsIiirlag's EntebniMe der Patbo- 

lufcie, Wiesb.. 1W)3, ix, Abrh. I, aJV. 
Koinx, K.: Hniulbucli der mpcriini-otelleD fnlholc^in unil Phnnnakolojiir, Jniu, 1005, 

i, iiUi IlAlfte. 
(iibiKio, U. A.: DitmuH-ti of lljt^ Ilcurt iiiiO Aurtu. ludinb. and Ijiudon, lS9<f. 
Itarcroft, J. 1... niid DixoD, W. K.: Tbn Ciucaua Mrtnbolium o( the M«ninisliaii Heart, 

J. PIijmM., l^ond.. HWe-7, xxxv, isa. 
Tnnid: Arcli. f. pnlli. Annt., t-lc, Berl-, 1889. cxvi, 432. 
Uolde[ib«rx, B.: L'cbpr Atrophi(> und Hypertrophic dnr MiuMfnwm de* HerMiM, Attb, 

f. putli. Atmt, vtc.. ISSft. clii. 8S. 
Dehio: IJebrr inyofihrasis Cordin, UEUtachcv Areh. f. kiln. Mrd., Ij-ipt., IxJi, I. 
Pewtw, R. M,; Kxporiinrnlnl Myoc.irditis; a Sludy of llio HiHloitwcttl C^ianjEHs followiriK 

Intravi-nuuii Iiijectimui u( Ailreuuliu, J. I^xper. Mwl., N. York aiiJ Laucuilcr, lOOQ, 

viii. 400. 
I^rce, I(, M.; Tlio Tlieory of Chemical O>rrBlai40n a» Applied to tlte Pailiology of tlie 

Kidney, Arch. IriHr. Med., Cliicaico, 190S, ii, 77. 
Ranke, J.: Tetanug, Etiie pb.vMolojiifiehe Sliidle, lylpi., 1S05. 
l.oeb, J.: Ucbcr die K»tiitph>ing <ler ActivilfttBliyperrrophie der Muukeln, Arclu f. d. gau 

Phywol,, Bonn. 1S!M, Ivi, 270. 
Cooke, a.: ExiA-riiiienlA upon iho 0«motlc Pmperties of the Livitijt Frog's MumIc, J. 

Physiol., Cumb., 1S9S. jiiiiii. ]:i7. 
Pleiahcr, M. S,, nm] txicb, I.,: Kxprrimmlnl MyncnrditiH, Areh. Int«r. Med., Chicaxi>i 190$. 

ii, 7S. 
Muller, W.: Die Maiaen verb ill tuiMte tie* menachtiehcn Heneru. Bert., 1R7S. 
Himcb, C; Ueber ilie ncxiehiinften iwiwhcn dem Hrrxmimkel und dcr Knrpenniigkulalur 

iinil uebcr wriii VerliulU-n liei HerEliyiierlrojibie, PtMitMhM Arch. t. kiln. Med., I«ip>., 

ISW, Ixiv, .W7. 
Homlwni. K.: Lfbrlnieh dn Kninkbciten dp* llerarnR iind der Rhitjnifnjwe, i^ltitlKart, liW6. 
Krahl, !..: Krkmnkuiigen dis HemiiunkeU, Noihna^'l'H Huodbucb des B|>eiielleii lethal. 

11. Tberap., Wirn, ISS8. 
I«wy, H.: Win AfU-it dee BMiunden iind des kranken Ifcraeiw, Zeitsejir. (. kUn. Hod,, 

lierl., xxi, 321 und Kl. 
KdlbM: Ex perimeii telle uebcr Hcnrnuakel und ArttcJt, Arch, f.cxper. Pntbol. u. Pliamii- 

koi., Ij^iiix., liHXi. Iv. axH. 
Groeher: Unlemucliungeri lur Arbeitflliypertrophie den Heneiui, Deutachcs At^ f. klin, 

Ktril, Leipn., 1907, xei, ^02. 
JcMOph, D. It.: Tiie Rilio between tlie Heart-weljchl nnd BrMly-wi^iKht In ^*3r!oU8 Anlmak, 

J. F.%\vt. Med.. N. York nud Uneaaler. ISias. x. 521, 
Schieffer: Uober den KiiiHiiiu der Derufiiftrbeit ouf liie HencffrnBr, Deiil<ch. Arcli. f. 

klin. Med.. Leipz.. I'.'Or^, xeii, :{8:t; aI»o, irel>er deit F.InfliiMdeit MiliULrdienstMauf dia 

llertiiKiw, ibid., I!X18. xeJi, :102. 
Ilwnrd, W. T.: An Analysis of JIJ5 Ca«e» of Hejut Hypertrophy (from Uie Autop«y 

lt«>coni)i a! Ilic Johiw HopkluB Ilonpital}, Joliiia Uopkios Hoop, Kep., Bait-, ISB4, 

iii, 306. 
Vnik*. B.: (*A«eii of UrighCs DIkmuic, witti Itrnnark;!, Guy's Hoap, Rep., tjMid., 16£3, ij 

Ser., viii, 232. 


Senator, H.: Ueber die Herzhypertrophie bei Nierenkranken, Deutsch. med. Wchnschr., 

Leipz. u. Wten, 1903. Die Erkrankungen der Niere, NothnBgel's Hondb. d. epezieUen 

Pathol. U. Th., Wien. 
Paasler, H.: Ueber Ursache und Beutung der Heraaffektion Nierenkranker, Volkmann's 

Sammlung klin. VortrSge, Leipz., 1906, No. 408. 
Johnaon, G.: Lectures on Bright's Disease with Eepecial Reference to Pathology, Diag* 

noeis, and Treatment, Lond., 1873. 
Cobnheim, J.: Lectures on General Pathology, New Sydenham Society. 
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Buhl: Mitth. a. d. pathol. Inst. MUnchen, 1878, 38. 
Huchard, H.: Maladies du Cceur, Paris, 1899-1905. 
Albtecht, E.: Der Herzmuskel, Berl., 1903. 
Joeu^ O.: Hypertrophie cardiaque caus^ per I'adreQaliiie, Compt. rend. Soc. de Biol., 

Par., 1907, Uiii, 286. 
Erb, W.: £xperimentelle und histologiBche Studien Qber Arterienerkrankuug nach Adre- 

nalininjektionen, Areh. f. exper. Pathol, u. Phaimakol., T«ipE., 1905, liii, 173. 
Vaquez: Hypertension arterielle. Bull. soc. m4d. d. hOp. de Paris, Feb. 5, 1904. 
Vaquez and Aubertin: Sur I'hyperplasie siirr^nale des riepbritee hypertensives, ibid., 

1905, jwii, 705. 
Wiesel: Renole Herz hypertrophie und chromaffineB SyBtem, Wlen, med. Wchnachr., 1907, 

Ivii, 673. 
Schur, H., and Wiesel, J.: Beitrftge zur Physiologie und Patholo^e dee chroroafiinen 

Gewebes, Wien. klin. Wchnschr., 1907, xx, 1202. Also, Ueber eine der Adrenalin- 

wirkung analoge Wirkung dps Blutfierums von Nephritikem auf daa Froochauge, Wien. 

klin. Wchnschr., 1901, xx, 699. 
Gaillard. Quoted from Aubertin. 
Hasenfeld, A.: Ueber die E^twicklung einer Herehypertropbie bei der Pyocyaneusendo- 

cardittB und der dadurcb veruraachten AUgemeininfection, Deutech. Arch. f. klin. 

Med., Leipz., 1899. Ixiv, 763. 
Hasenfeld und Romberg: Ueber die Reservekraft des hypertrophischen Heremuakets, 

u. s. w., Arch. f. exper, Pathol, u. Pharmakol,, 1897, xxzix, 333. 
Katzpnsteiii, J.; Dilatation und Hypertrophie dps Hprzens, Muenchpn, 1903. 
Aschoff and Cobn: Bemerkungen bu der Schur-Wieselschen Lehre von der Hypertrophie 

dca Nebemierenmarkes bei chronischen Erkrankungen der Nieren und dee Gefass- 

apparatus, Verhandl. d. deutsch. path. GesellBch., Jena, 1908, xii, 131. 



Fat may be deposited in the heart in two wa}**: (1) In Aolid maases 
of adipose tissue, t-spccially in tlic pericardium in fat individuulu, piirticu- 
larly in thoae addicted to alcohol, and very often associated with coronary 
sclercMLS. Tlii» couditiou is designated as fally infiltratiou or obese 

Fie. Itl. — DutritmtioiKrftBtUiaildkbciUI Ihehuit. .t. uunnal; U, itepoill luuiotuac bean: C. depoat 

in ■ fatty drKmaniliKl h«rl. 

heart (Ma-stfcttherx, Kinch). (2) In fine dropIetB occurring diffusely 
within the heart muscle-cella, especially in nnR-mia, infectious dispases, in 
piTsons poisoned by phosphom:', arst-inic, and mimcrou* other aubstauces, 
and in iissociatton with other changes in the myocardium. This condition 
is called fatty degeneration. 



Har\-ey, the discoverer of the circulation, describes the hearts of certain 
fat persons as coverod with a layer of fat so extensive as almost to ebecurs 
the heart muscle from view, and this condition is one of not very infrequent 
occurrence. In norinnl hearts there is a considerable amount of fat (30 
to 60 Ora., 1 to 2 ounces) collected juiit beneath the endothelial layer of the 
pericardium, along the auriculoventricular and interventricular grooves 
(coronary and longitudinal sulci i. at thi- baac of the aorta, and scattered 
elsewhere over the heart. As llic individual lays on more body fat, more 
(at is deposited in the porieardium, at first, only nt the usual sites along the 
sulci; but later it spreads over and into the myocardium, penetrating into 
it. between the larger strands of muscle, and finally settling beneath the 
endocardium, especially about the ba^s of the papillary muscles. 

Thu wi^ight or odipoir tinur mny nclnally exceed thu we'iKht of cardiac muscle 
(W. Miillcr, llirach, KiMh), a« shown ti>- tlie [ollowing figurea deleniiined by W. Malkr 
((or the metliod nee page 1). 



Tola] miiht 
o( hon. 








P»r srat. 


Cardiac hypertft^W- 

Nature of Ihc Faiij Deposit. -U ml pr ihnne circximstancM thi> fat la dep(Mit«d in 
exactly tlie aa.tiw riiiiiiner aa e-lsuwhere iii dm bmly. The pat)iuiogical chancter COD- 
eista uot in the pruci'iia but in the amount it! the ilnponit. Tli^ iwlipojir tisMie in thia 
reginii iirtr^ iiol differ iiiacfr">wu[iieally or iiiieriMco|>icully from thp fat i-liiew)ier«. Neitker 
doea It (lifTer cliemic&lly. li is onliiiary " iruoalooation fal " (lloaenfcJi], Leiek and 



¥ut, l*i. — flinuxnii'iiianphii n( foE dvpotltfl in Ih* htait. A. Ilniii m<»rl* n( an obfx mdl- 
irldnat. tliovlns (si rcli: tl. Iltdrl mu-clr o[ a {Hillonl whn 'h*H of poruioonia. sliosUia til <lTu;)lrU 
WillilD III* c«ll< ((ally •l«aeuenbaiM- <riiotomicruaraph by [Jr. C'hu. & llond.t 

Winekler), derived directly from tbe food ; tor IjCiek and Winckler liai-c afanwn that if 
dnt|B h« overfed with mutton lalloo'. the fat deponted in the jieHr-anlium lia« an iodine 
atMOTplion coetRclent a|>|>nKi(.'liitix tiiorv nearly to what ici in the slie^p tliim to Ibat of the 
dog. The pericardial fat difTrn from tile fat uloewhere in but one iroportAnt rp8p4ict. atid 
one u'hieh ia e«iiecially to tic l>nnie in mind in tn^ntinx the condition, namely, tliut it i* 
telntit'cly poor in lipase, the enzyiTie nliich foniu and niilita ful.aiul hence ta 
relntively Kin bio. AMnnlinx to l.ocveiiliuK it irould appe^u ttiat lipaae is present 
ill the oelIi<i ill considerable amouiita at tliei time the (at la depoitiied, but in ilieu gradually 
deatrvy«<l; k> thul if si.ibsei|uently ibe fat oi the tiudy ii reduced from inanition or other 
caiiMe, there ia no morr mxyme rcnutiriinx in tJic perirardium to wplil tip iiliiil in aloi^ 
lhet« and lo tvliirn It to the eencftxl ciraulallon. Aceonliiigly, it ii fouml that in ctarva- 
tkm the pericardial and perirenal (ut remain after all the reat haa 
diaappeared from the body (lioovenlmrt, Scluoffor), ThIa matter will bo re* 
(erred to acain In connection with treatiiicot. 



There Arc throe defmito conditionfl which, thouf^ in no way pitrL of 
the general proL-ci<!i of obcMty. arc- often iis»uoi»l<.>d with it; uiicl il is 
lh«8c, ralliiT than ihe obesity it.feif, whirh give ris« to 
the gyroptom complex refcrrtd to as "futty heart," or, m 

Roraborj; more properly dnaignatea 
it, "niniittc iiisufficit-iicy of fat per- 
sons" (Die IIerEin\iHkelinRiilhri4;nz 
(Icr Fcttldibitigcn), Thest- are (I) 
atrophy of the heart muscle, and 
(2) sc'lvro!<i«of thu coronary arto- 
rics, (3) a high diaphraum. 

I. Atrophy and Cardiosclerosis. 
— It )B esptcially worthy of notice 
that the inci'ca.'te in sixe and weight 
of the heart may conceal an actual 
atrophy of the heart mu-icle (Hin*eh) 
(sit table above) and a correapond- 
inR weakneeeof the heart, .\ccord- 
in;: to moitt writ«r)>, lhi» lies mainly 
in the left ventricle, but JHrsch haa 
.■"luiwii thjit not only does the fatty 
infiltration penetrate chiefly 
the wall of tile right ventricle, but 
that the ayroptoma moat common 
anion); fnl pt'r.-wns are tliose due to 
primary failure of the right 
side of the heart. A general cardio- 
aelorosis (see pag<? 235) is often aaso- 
riatt^'d with the deposit of fat. It is s 
self-evident fsict that Buch cnomioua 
dt-positii of fat increoiie tJie work 
done by the heart. 6rst by increas- 
ing the weight to lie moved at each 
Hvstole, mid secondly by increasing 
the total bed of the htood .stream. 
It might be supposed that this would 
in itself bring about hypertrophy, but hypertrophy is rarely demonstrable. 
The tendency to obesity usually occurs either in p(;n<oii8 whose lives are 
!!vdcntary and whose skeletal and cardiac muscles are therefore under- 
developed, oi* else ill tliose addicted to oxcctw^rt of alcohol or overeating, 
factors which in themselves bring on myocardial chanfics and hypertrophy. 

2. Coronary Sclerosis. — The pathologiciil changes nnd aymptoiiis due 
to sclerosis of the coronarj' arteries do not differ from those arising without 
the presence of abnormal fat deposits and will be discussed in a separate 
chapter (v^iK 2S0). 

3. High Diaphragm. — V'. Frcyaud Krehl have shown in animab that 
pushing up the diaphragm, and thus displacing the heart, greatly intcr- 

Pin. to. — An ucMivn tlaixnii of cDl«iillal 
ht, (Frooi ■ tpvirmiAii ih thm Anuy UaJioiL Uu- 
•cum, WuhtDsion. D. U.) 



ferea with the work of the latter. Myers and Schott foiiml that soldiers 
who»c di:iphra;;iu» are pushed up by tifiht belts about the abdomen exhibit 
Bymploiiifl of eatdiae overslriiiii much mure reudily than do iioniml indi- 
viduiilH. Myont found acute dilatation.^ most common in tho British 
regiments in which cuiniiw;* and light beUs were worn, 

Wenckebach has called attention to the fact that a large amount 
of intra'abdomiiiiil fat pushe.-< up the diftphragin and thu.t pii!4hc.i the 
heart into a nion- Iransvcrse position (upcx often in the fourth intersp*ee), 
thereby hamperin): its action. Thin factor must be reckoned with in tbo 
geneaut of the cardiac weaknuiu of fiit persons. 

Oinically, the eardiac manifestations in fat peraons are very vaHable. 
They occur most frequently in aimocintion with (1) general obesity, either 
hereditary or arising primarily from over-eating: (2) in childhood; (3) after 
castration or menopause; (4) overindulgence in alcohol, eflpeeially malt 
liquors, with or without the presence of gout; (5) di«be1e» nicllitus with 
obeaty (Itpogenous diabetes) ; (6) they are roo^t frequent and most inteiun 
after th« age of fifty. 


TTpon phyiucfti examination the mowt ittriking features are the i^neral 
obesity ; the relative weakness of the skeletal muscles; the groups of dilated 
venules, especially the "Bardolphian" "butterfly" area of dilated venules 
about nose and cheeks, as well as similar areas along the attachment of 
the diaphragm and claewhere. According to Hirturh. dilatation of the 
superficial veins in the subcutaneous fat is u premonitory sign of eardiac 
weakening; but thin is certainly not the case always. Often there is no 
visible apex impulse; the relative cardiac dulness is increased to both left 
and rifiht, owing to the transverse position; the cardiac flatness is dimin- 
ished. The heart ^^ounds usually have a distant character and may be free 
from murmurs. Occasionally there may be slight ecdema of the feet and » 
(unall amount of albumin in the urine. In advanced eases of cardiac insuf- 
ficiency the pulicni may Ix-eomc much thinner (owing to dimini.-'hed nlworp- 
tion of fat from the intestine, see page 150), but the pericardial fat may 
remain undiminished. 


The treatment of cardiac weakness of fat persons depend-f entirely upon 
the stage at which the patient is seen. If ccdema and persistent dyspno^i or 
palpitation upon slight e.xertion are already preseni, the case must be treated 
exactly like one of cardiac overstrain or henrt failure from any other eau.'V 
manifesting similar symptoms, except that, owing to the frequent atTX)phy 
and infdtriition of the heart muscle, drugs of the digitnlLt group are often 
of little use and may even be harmful. The patient should he put upon rest, 
rest ric ted diet, with liquids restrict<"d tn IIXM) cc, purged freely, and 
bled if symptoms of failure of the rii;ht heart sot in. Aniyl nitrite, nitro- 
glycerin, and erj'throl tetranitrate may be used to relieve attacks of dysp- 
na-a, and masMige, pn.ssive moveiiients, and fiiudly ivsi.'»t<td movoiuents, and 
cold water or Nauheim baths when the patient is able to get out of bed. 



When, as U uuuully the cast.-, the putiiMit is seen before the sta^ of 
actual heart failure has set in and is aufTering only from whut muy be con- 
sidcnHl ae the premonitory ^yniptonim of i-ardiao affection, — palpiution 
and shortoese of breath on exertion, weaknciw, and giddiness. — the treat- 
ment should then be difected toward the obesity rather than toward the 
heart. A main indication is then gradually to restrict the diet to n heat 
equivalent of about 1200 to 1700 ciilorieB, of which 500 calories (about 120 
Gm.. 4 OK.) should be proteid (v. Noorden). 

(1} Reslrlcled Diet. — Numerous restricted diets have been laid down, 
cttpcciuUy by Banting, Ocrtel. Hirschfeld, Kiach, and Kbsl«in. The restric- 
tion should not take place suddenly, for fear of weakening the patient, but 
should take place in several Htagea, reducing 500 calories each week until 
the lower limit i-n reached.' 

(2) Liquids should be restricted to less than 1000 e.c. (1 quart) per 
day; thisabo should be done gradually.' 

Sanqilc Dial. — V. Xuonlen gives ilic following outline diet, which !s very satJiifactory 
BB a txMJa capablu ot modiliciitinii : 

' BiMkfart- 

80 Gbl eolcl lean meat 

i white roJI {25 Gtn.) 

1 e«t 

1 cup luiui boiiilloii 

I ctniill plnU^ clear M>iip 

ISO Qm. (A 01.) lean meat or tiakt. ... . 

1 MI. i 100 (!rii, poIul»e9> 

Pew, beiuw, caiilillowor. lutparagtw 

100 Cni. frenli fruit 

Btnck coffpfi .,,.... ^..,...... 

aWJGm. frcnh foiit 

250 c.c (1 kIiub) skim-niillc 

Supper — 

126Grn.eo1dleanme«t wlthpIcklM 

Rmi \ieeia. rtulislm. fic 

30 (im. jirnhnm htriul 

'i~3 t«a«iioonfulii bolM fruit (no eu]tar}. 

10 A.1I. 
13 U. 

3 p.m. 

e P.H. 






ST. 3 









I * » r 




' n , 


' . - ' 




. . » t 

' 180 



. . ■> 


. «.. 

< . - - 






p ■ ■ ■ 
















' 100 t5m. (3 ot.) raw ineul (protdd 30 per oeol., fat 1 .7 per cent.) - 100 cal. 100 Cm. 
(3 OK.) cnnlu-d Icnn meal (proteid .17 )«r cent., fat 2.5 prr c<!DI.)— 175 cal. (nhniu 25 per 
cent, higlier in well-dune ruusled niealo). 100 Gm. (3 ox.) cooked meal of HlaJI-fed animals 
(no viBibk' fal) (proteid '-id [kt ct-iil., fat 6 per cent. ) — 200 cal. 1 pk6 W-S dm. prot«id + 
e.2 Gm. fal)=S,Scsl. (.'liPfKc (proleld 2.S per eenl., fnt 30 per cent., enrliohydmto 2 per 
cent. )— -100 c»l Milk ([imteid 3,4 jiercent.. fal li.O [lerceiii,, sugar i.h per cent.) -80 cal. 
per 100 t'.c. 120 cal. pi-r oujiee). PotalucH 100 Gm. (3 we.) -80 eal. Bn-nd (prolrid 7-9 
per cent~,cArbohydrAtc35TD SU per cent., the Intler in iwiebaeksnddry binuls) 100 Gm.« 
300-350 cal. Sutiiiir 100 Cm. • 100 cal. Bullvr 100 Gm.-&30r«l. 

'Oertcl and .SehweninKcr ihouichl ihnl drinking wnlrr i* n fnctor pmdndne fat. 
Siraub and ollierv have shown tliat (hiH in \>y no mean* the care. Ttie only influence of 
the n-nier IIh in the fnet ttinl wlieii a meal is taken dry llie appetite is Icm than when water 
is taken, «nd conBeiiueintly lew i* ealcli. TIow^\-er, conKidemblo amoiimn of flniii inerawe 
the roluiue of blood and tlie work of the heart, and hence ihe liiuilatiou of SuJd nroi 
the heart in thii vny. 



(3) Increased Eixcrcisc. — Ineronxc exerrise gradually as much as pos- 
sible, oapci-islly by walking, cither on the level or on gentle grutlutil ascents, 
interrupted by frequent rests before either weariness or shortness of breath 
sets in.' lu this way tlic encrg}* uwd by the body, and hence aUo the fat| 
burned up, can be materially increased. 

Wdght of pnticDt 

R«t* 2.7 nii)p» pot hwit. . . 
Rale 3.4 mil« |*r tour. . . 

Walking on I«t*I. 

Pir mile. 

160 lb*. 

75 wl- 

200 ItM. 
100 cal. 

Per hour. 

ISO Ibi. I 200 lh>. 

170 eal. (It* Gm. tat) 23Seal. (« Um. fat) 
330 cal. (30 Um. tnl) 310 cal. (40 Cim. fat) 1 

In walking up itnui^ the ener^' tised up i* filial lo elevatlonxweighl of patient 
plus the ciii>rfi:>* exiKiided In InremnK tiiv dintuncc; but tliii a IbcoMlieally f(|ii.ilb<l 
by the ^aergy snveil in lh« aubseqiienl ilpqc^nl, ami on tlie other haod, both tire 
incnMLsvil l)y bringing into pluy ii ilifTL'rviit group of hiuh'Iri: Itiiun^ facturii cuii iirarccly 
tVfXi be spiiroxim.ili'ly pvliniatt^il in ihn individual cnjtoi llnwrvcr, Ziinli pvw the lol- 
lowing einpiricul liuiirM: a man, 150 Ibi.. climbing 3 kil<lnlt^ttv< (1.8 iniloO ■« oDc hour 
upon s 1(1 p(T CPiii . Kmdc use* up about 2S Gni. (niniosi I ounce) of fal. 

(4) Kesisted movements (Schott) carried out under the supervision of 
an attendant; or contraction of iitila^niHtic iiui!trle.-5 (Hen;) {«¥ page 194). 

(5) Xauheiiii balhs (sec page 201) or daily cold balbs as cold as can 
be borne by the patient without .-iliock. 

(fi) DntK Trcalmcnl. — Str>Thnine may be adminiatered to iiicrea.« 
muscular tone, provided this docs not also incroa«- the appetite too much. 

Thyroiil exlraet antl utiirr "antifat" mediculiun oliould be 
■ crupulounl.v nvoldci). Mclubotium cxprrimcnts buvr iilinwn thnt tlin ndmin- 
iiitrslion of thyroid »ub«1nnro, ihntiKli inercavlniE tii» o)(i<lativ«' procitetce, cailM« a (iplil- 
tiug of protrid lu a greutor iteprer tliun of ful. and Iwiicc lii-fcats its own end. namrly, 
Ihnt of bumintc up the fat wllhoul nITcctina thr ihuhrIp, It also l>rin]i» about pnlpila- 
tion, tachyriitilia, aiii) otlipr iliattVMiiiig BVinptoiiix, Hiid (etidii (o incrwue nillicr f.liun lo 
<llmiiiii>h iho cnnliac fcjilum. vvirn though il ninylir ditiiinixbinK the obesity itarlf. 

In the obesity of the menopause, tablets of ovarian extract are 
u.-ted to ineivase oxidation, as this effect has been deiiuin.-<t rated in animals, 
but clinically the results from its u« ore ratter uncertain. 



Pathological Anatomy. — In the condition known ns "fatly ilegener 
tion" llio fat i.-* de))o^ik-ii nut by an inrreaw of adipow tissue but in the 
form of fine droplets within llic liearl musrle-pells (Kips. 141 and 142). 

In some cases these ilroplcts can iKr seen to alinont fill the entire cell, 
in other» they appear as a few diffusely scattered droplets in tlie sarcoploam. 

' It miwt be borne in mind that i>cl«rmis of the corunari- srleriM is u frequent eoo- 
eomllanl of lieaK ii«akiiens in fuT ivogile, and bciiff suddi-n ovi^rfXLTlion or wvcrc vxvr- 
eiMai Icnitt until tbr physician has thoroughly acquainted liHiMetf with 
lite palienl's condition aiut cndiiMnoe. 



Kot all the cells «rc invudcil by the fat, but with the naked eye y«Ilow areas 
of fatty deRpneration may I>e ppen mingled with normal ureas of red-brown 
vulor, wliitrh appear noruiol in sliuctun; under the niicroMopc. 

As raeanlii di§tributloii, fitbbcrt racogniw* thr«e type«: (I) diffuse KCDeral 
fatty dcgnwration, in which ull tlie cclh are iooilcd u-ith Sal; (2) mottled dc- 
([oncrik t ion , occurrJntc in ihn «rraji which lip midway belirtien or at poinCs 
miHil <li8UDt from ttio Ui7;i>r urtcriuH; uoourring «Bpedally in uituiiuo individuals 
nnil in p(.'ni(ini> wboac blcNxl-preinure in very tow, ao that tlie cdlH whJcb ntn nuiKt dixtAnt 
from lh« arl«rie8 «iilTcr from iachatmin; (3) molded periarterial Tally de- 
Seovmlion iitwliicwl by (he Hclioti of puinoiioiiii BUbitanco in ihu circulaliiift blcimi. »iich 
M phcnphonu), anrmc, bnctrrial polsoiui, rlc, in which ihoHn crlln fniffi^r mnitt which nm 
brought most c!ow<1y iulo cnnlact wilh the ijuImimi. i.r., the C4^lls lyiii^ in tin- vicinity at the 
larger art«ricii, white- Ihu sfku mnute from tlitsc vwaeU tm narniol or involved to a Icnapr 

Nature of Fatty Dcgcnvration. — The fatty degoneration may go on 
in hearts olherwbe licidlliy in conncftion with iiifct-tious di^-usCK, or in 
chronic myocarditis and in valvular heart diseases. The exact nature ot 
the process i.s not clear. Virchow tinned it a "degeneration," but this 
term, although in very general use, docs not seem to designate accurately 
the process. It appears to he a difilurbance of cellular melal)oli.'im rather 
than a degeneration uf cell protopliu^m, and it has been suggesu^d that 
perhaps this is due to some interference with the oxidizing ennj-mea such 
that the fat cannot be oxidized, just us the sugar faiU to be oxidiitcd in 
diabetes. But this suggestion is not foundod upon any experimental data. 

It ii^ therefore most important from the stand-points of both pathology 
and prognosis to learn where this fat comes from and how it is formed. 
Vircliow was the Tir^t to teach that there wa-i a true fatty degeneration, that 
ia that the fat was formed from non-fatty (probably proteid) substancea 
of the sarcopiasm. It must Ije home in mind that the fat might be present 
in combination a.t it us in lecithin without being visible, but that it may 
become visilile when it ia split off from the lecithin molecules and deposited 
as highly refractive droplets of true fat. 

However, the nnatynes of niimrrmis observer* (BiStlchcr, Krehl, Rosenfclif) dhow a 
dctiniliT iucn^HHv in lh« fat preeeiil in the heart niiiBCle in fatty di^xt'iifratiuii. Indeed, 
according to ItoMrtifckl, Ihc muscle nhowii "fntly dcgi-nrttition" whi^tii'Vi'r it contains more 
than 15-17 |X'r cent, of fat wiitiin th^ munck'.Ci'll* (in marked fatly di'itenerolion uf^nally 
2ft-2t in-Topnt.). An he put it, " there is nu true fully de^eiieralion, but 
the cell tx-eonim poor in proteid and tat enter* it." That this fnt is 
nut derived from the brcakiojj <lown of cell eulelance. but ia derived eitlier from 
the (lit of the food or from tliat transferred from the Bul>cuUini-ouH tinaue el»i'- 
whert^ in the body, biu> been shown in many wnyK. In the iirat pinoe, Krrhl denKitu>tmlcd 
that llie lecithin content of the heart muM'Ie uds praclicully eouHianl aii<l qiiile indegien- 
dcnl of tlic dcgre* of fully dcgenerulion. unci hrnce Ihni the fat wn» not deri\ed from ihia 
source. Secondly, RoHenfeld nfiowed that in a wliose left ventricle «ppe-nml normal, 
hut niioiv right veulricle waa very yellow in a|i|>earHnce (ami ■hou'eil fatty deeenerallon 
oniteelionj.l.he naturrof ihcfnt wiu idenlioul in l>e)lh. Thirdly, it wiu shown also by llusen- 
feld tliat if dopi were ftt«rved nnlil their wibciilaneniis fat had di«ip|ieared nnd were then 
poiaoned with pluHplionu, llie fatly de^enerulion did not tlien uptx'nr ua it did in well- 
f«I dojn- Thia fact vran further demon nt ml e<l by I^^iek nnd Winekler, «h<) jioisoned their 
dogs with phoaphorus and then fed ihein on mutton tallow (loilinc af«iori'tion encflicicnt 
3K.2), nm! obtained a drpusit within the lieiirt niuBeli- not of duK fat (1. A. (.'. 38.6) but of 
mution tallow. Thin s^rma to provn that tlie "fntly deRenernlion" of heart Riuscle t* 
■imply u depoiiit uf fat williin the uiunele-cell, jiiM aa it oecuni within lhec^onncclivc-tit«ue 
cell under iiormnl dreumstnnccK. The tleijonition of this tut is not associated with any 


c)iuiiji;l- ill Ihi- lipaw i>( Ihp hparl mu»cl» nor o( ihc liver. In spiW of ihe apparent increase 
in fnt mi^tAljoliBiii. 'the uullior iUhi found ihnt Ibi' umoucit of lipiuw in Ihn Iran nnraii uf 
a buinuii liver molilnd wilh fatly ilngoner.iliim wns i.Iip Mimr as in ilir" npighliorinn y<Jlow 
arra*. It wouU) apj^eur, tliererfore. tlmt. cheiiiipully. tlie phmuiy i'huiiK« being aLumt, fatty 
detune rut juii Her not in the hcatt but cWwhen? in tlip body. Thin in further borne nut by I 
thb fnct that in nnitn«lii poisoned with phocplioniH, oil of piileKon. He. ihr total amount 
of fat in the body iit iliininished, while l}iiil in lliir hemt und livtr in iiicrriuUfd. The latter 
orsaat necm niercly to dcpowt the fut ihrowii tnU> tlio general clrciilnlion. 


Fatty degcneratioB in the bunian heart occurs most commonly in 
oaiiociation with alcoholimn, cither acute or chronic, primai-)' and .terondary 
Aiiu-mia.'t, aftvr hemorrhages, in ovsociation with myocanlitiH, valvular 
and other canliac leuons, in moat inft^ctioiiii difleattes, in minera. smelters, 
anil many tuctal workers, a» well a» in aumeruus other industries where 
[toiiionous subetancpd are employed. In a number of ca«ea of death 
from rhlomfonn aniratliesiu fatty degeneration ha.'* I)fcn found and is 
usually ascribed to the action of the chloroform, but Rosenfeld believes 
that in these riLse^ the fatly degeneration is alwayn jiresent before the 
cliloroform was given, and that thia fact accounts for the death of tlic 

Not infrequently, as in cusea of phosphorus poisoning and of tnfccttous) 
diseases, the same aj^nt which bring.-^ about the fatty detceneration alcio 
Rive* rfai* tn dtmiui^lu^) tone of the vasomotor centre. Failure of the cir- 
culation may result from the latter factor, but thia need scarcely be ascribed 
to the fatty change in the heart. 


Tbc»C results of chemical investigation also find their parallel in tho 
effects upon muscle. Welch, in 1S8S, wa« able to show that the hearts of 
rabbits rendered fatty by prolonged cxprwure to hiyh tempcralurei* were 
quite normal aa regards preservation of blood-preaaui*, reactions to vagus 
stimulation, etc.; whih? Hiiwiifcld .iml Feiiyve.<*y ten years later ahowed 
that animuls poisoned with phosphorus withstood the strain from cismpiug 
the abdominal aorta quite hm well as did normal animals. On the other 
hand, de la Camp compelled his phosphorus dog)? to run a tread-mill until 
fatigue set in. and found with the X-ray that their hearts had dilated, 
wherea."* those of normal dogw did not dilate under these cinunistaiiceK. 
T li e tonicity of the cardiac muscle was diminished. 
I)e la (^amp'rt expcrimenta have not been rei>caled aa yot, but they seem 
to have lie*n very carefully carried out. It seems certain that, ais Kraus 
clainii), there is a cniLsidernble difTercaee Ijetween the endurance of normal 
hearts and of those with fatty defeneration. 

Moreover, patients with fatty lie gone rati on of the heart are very sen- 
sitive to digitalis luid are frequently Injured by it. Sudden death from 
o\-i;rdoso of digit^tis or from acute cardiac overstrain is more common in 
palienl^t wilh fatty itegeneralion of the lienrt than in nlmo.sI any other 
condition. The relative frequency with which fatty degeneration is 
ciated with s|)onl«ncoiifi ni|)lure of the heiirl is aliw evidence of weakneM^ 
of tlie walls. 



srilPTOMS AND !<ION»l. 

The moat rharacterUtic s>-Riptoinfl aRmcinted nith th« condiUon are 
tbottP of general ik-bility «iui fwblctH.'f;'. more or less lunguor ami MOinno- 
lence, as a rule without markpil cai(lioi'e,tpiralor>- symptom!) except short- 
ness of breulh on t'N«rtion. The puW t» usualiy small, mllier collftpwng, 
and feeble : the blood-pressure is below normal, except when complicated 
by chronic myocarditis or vulvular legion (mnximal pressure SK) to 115 
mm. Ilg); the pulse-rate is increased. On physical examination the heart 
may be either normal or dilated, the soiinil.-* either feeble and distant or 
short and sharp; the apex Impulse may or may not be well marked. The 
liver and spleen are often enlarged as part of the (teneral malady of which 
the cardiac condition also forms a part. There Is sometimes (rdenia of the 
feet and ankles. However, it must be frankly admitted that none of these 
is either constant or characteristic; ttud the diagDosia may have to be 
made from inference only. 


The diftiinosis of fatty deReneraiion may often be made with more or 
less probability from a knowledge of the etiological factors, but not from 
any of the phyiucal signa, so that, ax Krehl puts it, there are no clin- 
ical si^ns for tlie diagnosis of fatly degeneration of 
the he art. 


When the condition is recogniited, or rather suspected, the treatment 
consista of absolute rest in bed for at least two weeks after the acute dis- 
turbance has paM«e<l off and until slowe<] respiration and increased tolerance 
to mild but gradually incix-a^ing arm exercises show that the heart muscle 
has regained its normal condition. Whether it is possible to owrcome the 
fatty degeneration of a chronically diseased heart is questionable, but in 
that, aa in other conditions, treatment must be guided by the general 
response of the patient, and over-exertion must i-onslaniiy W- shunned. 

It must be borne in mind that hearts which are in a state of fulty 
degeneration are particularly sensitive to digilalis; so that, when this con- 
dition is suspected, digitalis should be either avoided or given in smaller 
doses than usual. 


Spontaneous recovery ts the r\ile if too great a burden is not imposed 
on the heart; but in spite of the results of animal cxpcnincnts, especially 
those of Welch and Hasenfeld ami Kenyve.'is}', attention must be called 
to the fact that sudden death is far from a rare occurrence in hearts with 
fatty degeneration. It occurs most frequently after or during exertion. 
One can scarcely avoid the suspicion that iwrhaps the eondition which 
brings abont the change in the fat metabolism is also one which limits the 
total metabolism of the heart nuiscle-cells and<niently their contrae- 
tjlity; so that after a certain limit is passed they suddenly cease tlieir func- 
tion, just as is the case in the eellidar &sphy.\ia of intermittent claudiea- 


tion antl coronary ttclcroMui (sec page 282, Fig, 166), or in toxic myocarditis 
from diphtheria. Spontaneous rupture of the heart is par- 
ticularly common in eattos of fatty ilegencration. The latter was present 
iu 77 per cent, of the cases collected by Hamilton. ~ 


Dkart or OnBfltTT. 

Kivch, H.: Zur Lehre vom MaBtf<!ttberz>^Ti. Miuniolii^n, innl. Wchrmchr., 1003. lii, &46. 
Mtlller, W.: Pie MnjuicnvcrhilltaiiwR de*. monarlilichcn iler»^ng, llaiiib. u. Leijn., tft$3. 
Htncli. K,; Ueber ilcii tCCKenwiirliicen dianil der Lehre vom mgiMiniiiilvn Kcltberaen, 

MurDchcii. niptl. Wohnncht.. 1901, xlriii. 18B7. 
Leick «nii Wint^klcr: Ilrrkunft ilm FpIIps hoi Fellmetaiiiorpliose d« Ilenlleiwcbai, Arch. 

r. t!X|N>r. Putliol. u. l*liHr[iiiiki>l.. Lvi|>i,. 190:2. xlviii, 103. 
Loevi^nhnrt. A. ».; Ou tlu- llclntion of I.ipaM to Fat Mctabottsm— Llpogen««!ii, Am. J, 

Phyiiol.. Bo*i.. iWi. vi, :{:n. 
8chi«ffer: Ueber duii bjiilluiw di-ii EniilhrutipusiiitamiM aiif dl« HcrtKrOiiM', Doulach. 

Arch. f. klin. Mrd., Uipz.. 19VH. xni, H. 
RombeiB, E.: Lehrbucb (l«r Knuikkeil«n dm Heraeua uud <ler BluiKcfiUw. Sluttgnrt, 

V. Noordett. K,: Die Fett«ucht, Nolbnaxpr* Spec. Pathol, u. Hierap., Vienna, 1000, wt. 

vii. lit liulf. 
Buiitini!. W.: I.ptl*r on rorpiilencc: nddrnu to thp puMic. lStj:t, ISW. ISflJ, 1868. 
Uertel: Kriti»r)i-pbyniului;iM^li<^ Btwprrcliiiii^ dcr EliBltin'ni'lieii BrhiLiidltuig der Fctt- 

Irihigkrit. I.cipi,, ISS.V Olwuily. T»-mliptb Cpfitiir)- I'rnclicr i>( M«i,. \. Y., IS95. 
Biiwbffkl: nii> BfliHiKlliini; 'ler Fct1lcibiKkdi.Zi>«hr. f. kbn. Med.. Bvrl.. 1S03, xxii, I4i. 
KiMch: Dim Miuitrvlllierz. I'ra^, IS94. Zur IiwuRicietix dcs Hutfnlthcnnui. Thcrap. d. 

(k^nwan. I8!>9. xl, 29«. 
Eb>t«jn. W.: Dio t'«tlUebi|;keit uud ibrv Bvhandluiig, Wicebadeii. 


Ribbi'rt. H.: BcitrilKi? lur put IioIo^rc lieu AiintoiDic den ficnwuo, Ardi. I. path. Annl. ate., 

Berl., 1S97, cxivii, 101. 
Krelil, L.r I'pbof (euige De^mration dea Heraeas, Deuiaoh. Arch. f. klin. Med., Lejpi., 

180.1. li. l.-ilB, 
ItownfeUi. C- Per PfoirM der VerfHtiinit, Berl. klin, Wrfin»chr.. Berl , lOW, xli. 587., 

Ui-bcr Hi-riverft^ltu>i,>; bcim MimiH.'b''n., ZL-iiitiilbl. f, iniiciv Mrd,, Lnipt,. 1901. xxii. 11,1k 
I.oick arid Wiiicklnr; lltrkunfl d» I'Viui* bri FrllmpliunorphoBC drw ItcnltciwhBK, Arch.) 

f. ex|H.T. P-.iibol, II. Pbamiskijl.. Leij.'* . lUW, xlviii. 103. 
Ituiiow: t'fber r!ie Lecitiiiiip-'huli d™ IIt'ra>iiii und der Nicrcn untcr normalen VerhAU- 

niwen, IlnnKerr.iiHtnndr' iind l)ri dfr Fctli(wn Ppjci^nefation, Arcb. t. Mpcr. Path. U. 

I'linmiukol. Leipi.. 1901-3. lii, 173. 
Wclph, W. 11.: CattwriRht I.4«tiirPii on tliP Nnliirr of Vrwr. Mcdiral Xrw*, N. Y,, IftfW. 
Haaerifeld. A . ami FenyveMV, B. . Ueber die leiHtimitHfrihij^kcit dw ItUig enlartetra Uer> 

tem. Bet), kliu- WcbnMhr. 1S99, xxxvi. 80, 12.5, 150. 
Pc bi r»mp, O,: (Jiiolrd on pagr NS. 
Kraui. F.: Dii' klinii>cbe IVdciilutiif der fHtijfvn DeuentrHlioii dee HenniUslurLi «chit«r 

anirmlnehi^r Individucn, Bert. klin. Wcba>c>ir., 1005, xlii, p. 44A. 



cprtain amount ot degeneration in the fibres of the heart mufwle 
occuiH (luring the course of ever}' aculo ft^biil* (li»cji»e or intoxication. As 
has been st-eii in pn-vious chnpu-rs, the hi-art andcT these conditions exhibitn 
aigna of overHtrain, and the dia);nosi» of myocarditis, ihvnifore, dcpcndH 
upon the dcgrcw mrlicr ihun the more existence of cardiac weakness. 
However, in certain cases the signs of cardiac weaknejta overshadow tboM 
of the original <it»ca»i> and it ix in these that ucuto myocarditis is usually 
recognited. The chronic changes, however, which follow long after the 
original disea-se ha8 aul^^idcd, present a less complicated picture and there- 
fore are more easily rccogoieod. 


The legions of acute and chronic niyocarditia are merely different 
stages in a process wliich i» nioit- or less continuous. The lc«ons of chronic 
myocarditis iire always preceded by the acute lenions, but the degeneration 
may not bu so sevens at any of the earlier periods as to give rise U> symp- 
toms of eardiftc weaknes-t. 

In the first stjigc of acuto myocarditis there is injury and degeneration 
of the niu.'tnlft-fibrp,-;, with cedema about them, and infiltration of polymorpho- 
nuclear or monoiiucleikr colls into the cedcmatuus spaces between the Bbrcs. 

Ocgcncrallvc Changes* — The degenerative changes which take 
place in the heart muscle iint; (1) parenchymatous degeneration, 
(2) fatty degeneration, (3) hyaline and amyloid degenera- 
tion, (4) calcareous degeneration, and (.'>) fragmentation. 

Parenchymatous degeneration of the heart muscle was first 
dewrribed by Virchow and Itoettcher. The muBcle-fibres swell, lose their 
striation. and the plasma eontuins numeruu.s gninuU-M of an albuminous 
niuterial, probably altered muscle protcid (myosin). They retain their 
contractile power to a certain extent, but its force at this stage is somewhat 
impaired, and the cell may subsequently return to normal without under- 
going complete necrosis. In the more severely injured cells the nucleus 
la destroyed, the sarcoplasm ln-comes filled witli vaciiokut, ttikc^i on a basic 
stain, and Ls gra<lually absorbed, leaving only the sarcoiemnia. Often, but 
not always, pHrenchymatous and fatty degeneration go on in the sunc 
fibre, the fat being deposited as the proteid is removed. 

In some cases fibres undergo hyaline or waxy dngeneratioD 
(Zenker) and present an absolutely homogeneous appearance, taking up the 
acid stains (protophismic) with great avidity. In rarer cases there is a 
calcareous degeneration witli deposit of calcium salt^in the muscle- 
cells. These cells then take up the basic (or nuclear) stains (description of 




a case and diaouBsion of the literature is to he found in the article of E. K. 
Culleii). The dogi-m-niliori is nvvvr uniformly distribulid thrniijRhout the 
cells, not all tho cells being affected at once or iu the same dogrec. 

OccuBuituiIl.v tlif liPorl iiiuscIC'CdU sbuw pi>culiar Hpliu exUMiiliii^ Iran-Hverwlj' BCiun 
tht! H'hnic or pnri of The CfW. ThU cnnilition in known si* "Iragnirnlaiian." The 
librtu may :<liow ilu ut.her Bigliii uf iJviRiicnitiun, tlip tniiis\'erM^ HlnutioiiH tiui}' l)0 cicflr, antl 
Ihc IcinRilU'linnl Hiriic tna>' im dUtiricl up to the line uf the fracliirv. Fragmvniiilioii hiu 
liivn foiinit after ilcalli from a IrcmrndutiH vnriMyofwiuw*, ex-en ininrfividiiJiliniyiiiKfrom 
ucotdvDl. U duot nul srrm. tliervfuic, to bv a aipi of spt-cilii' di^l^neniliun. Liiclrich'ii 
altnnjits l« pnivir it. nit nrtrfiicT. an<l nilhitr In cxcliKle il ivhnn once prrarni or In lirictiE on 
fraifmentalfon by alltiwinu tin- ht'url to |xu8 ihruuirli I'liriuiis Btu£i-8 of <kcuin|i(»<itiu[i. liavaj 
bwn iiruiiccuBful. nod BiihliK in a very careful rcw-nrch seeni* to hnve ihown (iiat it] 
» »n artefact wliich i« prmliiceii when the niicroioine tnifc cum ai rinhi atiKki* lo th» 
muHcle-ribroi. Thin iibscrviilioii still n.i]Uirai ruDlinnalioii. Othemiiv the conicdiiuK of 
optDion aeeniE i» he that frnKTi'entnlion it the nsiilt of ■onie ehnnitr in the musclc-fihrca 
ncciiirini: diiniii: (he dcnih ai^iity, and (hat k m riol to )>e r«i;unie<l sa a dee*' ne nit ion, 

A!i illiifiirBtiti)( the fn.i(uc^ncy of ihe ■c^-rml lypen of Riyoninliul ileguneniiion Romberg 
find* Ihn fnltowinK frixiucncy in '2tl caws: 

Tgphoid /eitr — II cata: ParvDehriiiatoiiii (uttiuniinoiu) fleKeoenilioD. nuK(eral« or 
inlcrue 10: fntty. prccenl A. ahtcnt A; hyaline or wnxy (■lishl) 2. nbacmt 9. 

SrarM /iivfT — 11} r>ui».* Albiiniitioun d<<eeiiertkliuii. prment tt, absent 1. nut n<>l«d 1; 
fatly, imetine I, tnodfrnilv I, iduent S; liyuline or mtxy, motlemte 3, alKwnl 7. 

l}iphtkrnii~>i (ami: Albuminous, intntine 1, modcraCCi 4, sl«cnt 3; fatly, inleiuw S, 
sbMDt 'i; hyntiri« or waxy, pn^eiit '!. abnent li. 

Fm. 1*4. — liilllmiioD 1.1JIIK ilio cuuna ul Ihr lilnul-visavU In •obntnl* mvinnliil'- Blmid-i. 
lnjm«d. A. ixi« |»«Br. B, Bwu*, biclipr pi>n**r, 4 Pliutimiipm^rvtih br 1>T. C 1^ B"iirL> 

Dislribulion of Myocardial Changes. — In man. actiordinf; to Krehl,' 
Hcute myoi:ardial U-sioiist urt* )Mirticu1»rly i-ommon in thtj 
papillary niusclo» of tlio loft vflnlricl« and in the mus- 

' Ex'iminalion of Sfteimrnf.—ln ca*t-n in which the stale of the myor.anliiim H 
ol iiiipnttnnee, the niierTHcnpic Klruclutf of Ihe heart, inuscli- ntioiild alu'ay!i be e!i.Hniiiicil 
by Ihe nielho"! of Kreh), Krvht cula Ibc hcurl inio cubicut blcickn 1 cm. in mv. numbcrinfl 
thcni in onlcr to I hat theex.iel location of eiu-h block ran be acriinilely dctcnnin<rl. ^bcnc 
blnck« arc tixnl in Motlcr'" Koluttuti and a aeclioii or \wv from ciicli in cxuinined. In thi.i 
«uy n v«-ty lh«ni'ii:b idea of the extended diKtrihutioiiof kviont inny licRninnl, anil aotudy 
of « veiv ten he^ris tiuiii revcnig morv MOUraiu kflowlnlce than cau olbeniw be ^ovil 
front a large Dumber of ui^iis eiamiiMd lesi thoroughly. 



cHlatiire about the K>ft nuriculo ventricular ring. Pcarce 
ami FU'ishcr and Ixjcb have protiueed in rabbits myormiiial Ipstons having 
the same distributiou by tho injection of udrcnalin (Pcarce) or ndrcnalin 
with »))arUHn or caffeine (Flcisher ajid I..oeb). Roy and Adami bavo 
shown that wdcma occurs moitt retidily in thcsu rrgionx during <!x|}cri- 
niciiial rnriliac ovei-strain. 

In contrast to the k-stons upon the valvei*. thi* toxic or infi-ctivc ugcntM 
giving riHc to tcsions of the myocardium <io not spread through tho walls 
from tho cavity of the ventricles, but arc carried into the heart muscle 
through the coroiiarj- artoricR and dii^tributed tltrough their finer branches. • 

The foci of in tl animation whoiher nf ba<^lcrial 
or i.oxif origin usually arise within the lymph 
'Spaces around the arteries, which they 
Kurround in slecv«, cuff, or signet- 
ring distribution. 

Abscess. — The form which the foci as- 
sume depends chiefly upon the nature and 
properties of the infective a]e;cnt. If the 
virulence of the germ i» great, ubscesscs may 
be produced in the heart muwle (suppurative 
myocarditis) arielsewhen^ in the body Thi-se 
abscesses arc usually produced by small septic 
thrombi which plug the niinuto branches of 
the urierics. Under the influence of the fibrin 
fi-rnii-nt secrfrted by the bacu^ria, the vessel 
Boon becomes completely filled with a throm- 
bus, an area of i.tehii-mia nrriultii in llu: heart 
muscle, which quickly becomes infected and 
brf^aks down to form an abscess. Thrae ab- 
scesstrs vary in aixe from a submiliury nodule 
to a cavity HcparatinR the muscle layers in the 
entire int<Tventricular septum. They are 
usually produced by the pyogenic cocci in 
t)Cptiea>mia or following rrauma to tbt^ heart (aee page »i9). The outcome 
i.s usually fatal. Occasionally there i» rupture of the ventricle through 
the necrotic portions of tho wall. 

"Kheumalic" Foci.^In the less virulent infections, such as rhcuma- 
tiHm, typhoid fever, iuDuenza, the foci do not undergo suppuration, but 
the lymph spacer around the arteries and capillaries are fiheil with i-elUdar 
infiltration, polymorphonuclear in most of the acute infectious diseases, 
while mononuclear cells predominate in myocarditU from typhoid fever 
and subacute rheumatism. 

Since rheumatic fever is perhaps the moat rommon cause of myocar- 
ditis, the Ic.tions which it produces arc of particular Interest, Romberg, 
Asphoff, tJeipel, and Coombs have called attention to the pre-sence of small 
Mubiiiiliiirv foci 0.1-0.2 mm. in lUameter, which occur with great frciitieney 
in rheumatic patients, especially in the musculature? about the mitral ring. 
Each focus conaistH of a hyaline centre formed by agglutinative thrombosis 
within a capillary. About this there i» a zone of ^ant colls each containing 

Fii],t4S.— BepiiomrocBTdltitwlih 



2-4 niirH, and thfiso in turn are Burrounded by & wider zone ot mononuclcur 
cells intereperscd with cosinophile.*. Thfl writers mentioned regard these 
foci as paihoRnomonir of rheumftlism, ulthough thcv miiy bear only (lie 
general fciiturrs of » subjieut* inflammatinn ubuut an area of hyaline? throni- 
boaia. Indeed the most typica] specimen of these found in the John» 
FlopkiiiM Put holu^cral Museum was seen in a case of non-rheumatic myocar- 
ditis. On the other hand, Kreund hiw n>portfd n kokc- of aeute rheumatic 
myocArdttis in which the infittration was mainly polymorphonuclear. 

Brscht and Wachlcr liavp reccnlly pmiluced nrlhritii, trwlorurtliiii". «ini niyorardlti* 
wilti lynipliocylic infiliral iciii.i in miinuila hy injection ot ciilliimi of difiUicorci ubrsiticd 
from two ca>«i of Aentf articiikr rlifunmiisin. Thew iiiRllmliona contr«»i »happly with 
tho po)ymori>liuijuc]i.-»r Infill rat ionk tuunlly |>ruducvd t>y pyoguoic >liv'pCoovcci. 


ris.140.— I*houauiat«ci*pl>flwwiuKBii*ti-ef>«inll>|i|>ra(tinuMic. A.Lowpowtr. D.8wd«. hichwpoKn. 

5>iibjil(lcncc ot Lesions. — The change's which occur in the myocardium 
when the pa(ii-nt o^rovern from the ucutc tiifevtion or intoxication, which 
is the caUHsl factor, vary both with duration and intensity of the dltoaao 
and the rapidity and completeness of the recovery. If the cuu»al factor 
completely dtsappcare and Itii nojoum in the body has beea a short one, no 
permanent chanRes may have taken place. The (vdi-mn of the fibrea diitap- 
peiu^, the eellulur evudute may be nb<<iorbed in tola, and the myocanlium 
may resume Us normal appearance. If areas of fibres have bi'cn destroyed 
their place may be l-aken by scar tissue. But if the duration of the process 
has been so long that connective tissue has begun to be formed in the 
exudate, tl»e traces are no longer oblil«micd and a chronic myocarditis 
has Hct in. 


As has been seen in previous chapters, hearts whose muscle 
is injured become diluted upon comparatively slight 
exertion, while healthy hearts resist dilatation in spite of tremendous 



exertion, Moritz and Di<'tlen, whose X-r«y studicj* hnve demonirtrated 
that the Dortmil lieart becomes umaUcr in severe exercise, have shown thai, 
on the rontraiy, the heart whow mumble ia <li»easf:<i tinilorgiten treitientloiLs 
dilatation. Xcvorthcless it may iimintain n normal or even heishienetl 
hlood-iiresftiirc without uppitreni efTorl, and exrept for the dilittHlion may 
present no other signs of abnormality. It U more common in conditions 
of a(riiT« myorardial change to have a low blood-prcflsure. but ihU U due 
to the fact that the toxic substances which injure the hvart muifclc also 
depress t he va-somotor eentre. The low blood-pressure is due to the latter 
inlluetice and not to the wcnknet» of the heart. 

Tbew facts were brouelit out br ver}' inlcrMliiiiE studies of tlie phj'giutuvj' u( tbe 
heart muiicle after injccticHm of dipiitlieriu tuxiii n-!iicli m.'re nimle by I{d1I,v unij later b,v 
V. Stejskal- ttoU.v ilHCii n do^ of toxin whicli i^M killiul hid mbbilx in Iwriit;,'-fi>iiT houR'. 
and then bi^un tiU cjipi^riiDecilA ubout tweiity-twu )iout« iifli>r lb(< injeclion, H« fuunij 
that lit thin litno the blond- pressure uu'l pulsf-r.iip uf the nnimsl 
iKfTH Hiill quite Dorniftl, nnil llini ilir heart tea*. ^tUi nble to respond uell ii> 
inertftned work thrown upou il bycoriipnisaitut: tbe abdominal uorla.vtc.. and Ihat itiubloiid' 
prmsure incmaiioj rnnhidirmbiy, A1h>iiI half an hour liefon drnlh, howrvrr. the hlooi)' 
preitture Ix'pui tu faJI, uwliic tu liw* iff vaHoniotor (one. hh ha>] beon sliuwii b>' Rutnber^. 
Evpn at thU time the heart wtw itiU fllraue (-rioM)!!] U> n-sponii by u ■rcoad riM of blacH]* 
|iR«tur<^ upon clanipiHK the ohdomlnal aorta. \rn wxin nflcr ihii. howrvcr, within a 
lev/ niinuivs, I hi- rate became irr^Kular and the lieart weak- 
ened eomplelely. V. Stci^kaVn resulla wure Hiniilar. Tbe iiclion of the diphthnria 
loiiii bud not been iiiiTnediiit*, but it bad re*|uin>i neveral hoiint ii> combine wilh Ihe heart 
muwtp. uftcr which Ha wcakuixa was tiiuiiireBl. 

The conclusion reached by Roily and v. Stejskal is that the heart 
remains competent in spite of muscular vrenkness until 
a certain degree of strain is imposed upon it, when it 
8ud<!cnly rrot«iH>s the thivshohl that leads to failure, dilulation, and even 
death. The threshold of cardiac oven<triun in the lieulthy heart is at a 
much hij{hpr level. 

Arrhythmia in Acute Myocarditis. — Irregularity of the pnW- c&nnot be 
brought alK>ut by injurinu the myocardium by injection of alcohol, iodine, 
or evi'u KCN, but often occur.* in man as ii rt-nuli of myocitrdial lewioni*, 
especially after exercise and overstrain. (IcrluiriU, Miillcr, and Schi>nlierg 
have railed attention to the a.ssociation of irregularity with structural 
changes and pariJyscs of (he right auricle. In mitral diM-nse it is probable 
thai irregularity arises in the left auricle rather than in the right, since the 
latter is then not Ihe went of piithologtcal conditions.' 

Bradycardia U met with iu the late forms of diphtheric, influ<>ni;a1, 
and pneumonic myocarditis and occasionally during the febrile singe. Il 
is often vagal in origin, but is sometimes due to depressed conductivity 
of the auriculoveni ricular bumlle, the ventricle responding only l« alter- 
nate contractions of ihe auricle (2 : 1 rhythm). Il is prohabk- that under 
tliesc conditions to.\ie myocardial changes have taken place in the bun- 
dle (Mttckenxie). It im not unlikely that itume of the sudden deaths 
during convalescence from diphtheria may be due to this cause (Dunn, 
sec page -178). 

' More fully discUMed In chajHer on Mitral fl>(eno»is. 



The most characteristic sign of myocardial weak- 
ness is dilatation of the heart (see page 227). The heart 
is usually, but by no means always, rapid, the sounds may be clear but are 
usually short and sharp; they may be embryocardiac in rapid hearts; a 
gallop rhythm, especially of the presystolic type, may be present, 
or the sounds may be definitely split (reduplicated). It is also very com- 
mon to hear soft systolic murmurs over the apex or the tri- 
cuspid area, due to functional insufficiencies at the auriculoventricular 
orifices (see page 140), or to hear the "accidental" systolic murmur in 
the pulmonary area. The second pulmonic sound is usually ac- 
centuated from stasis in the pulmonary vessels. 

Clinically, uncomplicated myocarditis is met with in the course of the 
febrile diseases and the intoxications, especially alcohol- 
ism, phosphorus poisoning, and ptomaine poisoning. It is present 
also in a certain degree in almost every case of acute endocarditis or peri- 
carditis, where it is but part of the general "carditis." 

Its manifestations are simply those of acute heart failure or of cardiac 
overstrain occurring while at rest or upon very slight exertion. The symp- 
toms are, therefore, sometimes those of broken pulmonary 
compensation (failure of the left ventricle, page 139), sometimes 
those of broken systemic compensation (failure of the 
right ventricle), according as the left ventricle or the right is the one most 
affected. In many cases there are attacks of precordial pain 
amounting almost to angina pectoris, coming on when the heart is acutely 
dilated after excitement or exertion, 


Although weakening of the heart is one of the most important factors 
in general asthenia that accompanies or follows tonsillitis or rheumatic 
fever, it does not often kill the patient and hence is not often a striking fea- 
ture at the autopsy table. 

The following historj' illustrates the course in fatal cases, showing (1) 
the gradual insidious onset, (2) shortness of breath, extreme weakness, 
and finally ascending cedema, (3) dilatation of the heart, with cedema and 
degenerative changes in the heart muscle, without either hypertrophy, 
fibrous changes, or valvular lesion. 

Case of Acute Rheui^atic Mvocabditis. 

Annie Jones, female, colored. 43, atlmitted July 5, 1904, complaining of " r h e u - 
m a I i 8 m , " of which she haa hod attacks for many years, eapeciaJly marked during the 
last two years. The knees and ahoulders have been the joints most frequently 
affected. She has had no other infectious diseases and the previous history is otherwise 
negative. No GhortncKs of breath nor palpitation. During past four weeks has been com- 
pelled to sleep nprifiht in a Morris chair, and has had incontinence of fsces. 

Physical Ex,^siin,\tion. — Patient is a very stout colored woman, lying quietly 
on her back in beil. Pupils equal and react to light and accommodation. Chest clear. 

Heart. — Impulse is not vi.sible. Relative cardiac dalness extends 13 
c m , to left of midline in fourth interspace, 30 cm, to the right. First sound at apex 



ia voiy loud luul oat perfectly cIbuf. tliough (lien b no delinilc tnnrmur. SpMind sAimd 
raMtnblcN ihc finit in (jtiiklily but la clear. I'lilw rr^riilar. of Kood volume, niUter high 
lenmuii. 100 ]>er niinute. Veaael null HUiiicivliut Ihicki-niil. 

A b d 11 m e D in cxtrcmety large and iwotlcn; ihrn- n diilnnw In depondont portion. 
Liver In not cnlartced, l^ttn nn extrrmely Rivollcn and iFulumCMl; du nut even pit ou 
pnHBun;. Knee- uiid uiikle-;uiiiLs uiui'li BmilJen aiid ttllt. A round jierfonttinK ulcrr in 
piiawnt at left ttocl. No iltiturbnnep al scMiuition anynlicre. 

TBDiperatufe SU": rod btood-corpuscleH 4,(H6,000; lueuiugloliin 55 per cntt.; Icuco* 

Ordored rmt in bod; foft <ii«i; dliirvlin I Gni, (er. xv) q. 4 li.; ulcer of foot to be 
irrisalcd with boI. poIa«i. pennaiii;. 1:20000 l>. d. On July 7, ordcfml tioetum dig- 
it«li* 1 cje. Clxv) q. 4 h., ad dos. viii; ihiii vim tlicn repeated and conlinued tlinniKhout 
tbc eouive of ditteaw. Spt«. K)ypcr>'1i« nitml. Kit. il, q. 4 h.. ull«muliiig willi sud. nilrit. 
QJl Gin. (£1. v) i), 4 li,; inorpliio. sulph. O.OOS (ini. (J gr.) p.r.n. 

July 12. Ilnart*' notion Jircs'ilnr; fimi sniind mliiplicnied over iriciiH|Md arm: no 
nuraiUR, July 13. Theiv is a Inrce iierTurutiiii; ulcri just bebn* eoecyjc. Ttiis whb irri- 
Sitt«<i with t>otii». periianpinate I : 20000 and paek«ii with iodoform Rnuzr. .luly IK. 
T«mperaluiv lOG"; jxrcUMiinn iioti* imiiaimi ut left baxe behind, where brontli BounJoara 
abMilt. A few riH™ tiuve previously been lieard in thin iin-iu Onlcnil slrycliniiic sulpli. 
fl.MK) Cltn. (]^Kr.)and di|{italin Q.CKKi Gni. d'o Kr.) hypo, q, A h. At T..10 fm-, reipimlion 
iih^illow with ctpirntory grunt. At 11,00 becuine udcoiukmoiu. and died ul l'iA5. 

Ai'iuniY Nbowed about I litre of fluid in [leriioncAl cavity; congnntion of lower lobe 
o[ lunm- 

Heart. — Several opmjue white pntche^ over cpiatrdium, one «iih n diameter of 
3 cm. Coronary nrterim >oft anil timooth. Heart muscle Koft. flabby, 
and of yellowisli- brown color, studded with nu[nerou» small 
opnque white area«. Tne muaele bund lea are widely wpitmtcd nuclei. I'ndei the 

micrOHEopc the m iisclc-f ibreu are seen to be 
• wollen: Ultle new growth of inlvmlilial connective 
limtie. Heart wolgtut 2^0 Om. itlisht sclcroiiii about 
base of aorta, none elsewliere. Kidnevn norma) In tiiie, 
pole and clotidy. Liver shows sonic fatty dcgeueratioD, 


.Aciitp myopanlitis Ih tho chief ontise of dcatli 
in <iiphthori» nnd iiif]u<^nxn. In these conditions 
it may manifest itself either, (1) ji« an early form 
(liirinjt the course of the fever, or (2) as a late form 
which bccoaiex mitiiifest nfl^r thi» temperature 
has fallen. The cases of diphtheric myocarditis 
have hcen most cnn-fuUy studied by Ilibhard 
in SOO cases with 11!) ileatht- (15 per cent.) at 
the Roitlon Gly Hospital. In spite of the high 
average mortality, the mortality was less than 
5 per cent, in thoee cases iti which the pulae- 
nite Wfts below IHO per minute, incretwing »!s the pul.te-nite incifased 
above th«l figure. Death was especially frequent in those cases in whicli 
a gallop rhythm waa noted. Bradycardia (under GO per minute) was not 
a severe sign in adults (14 cases without a death; only 2 with cardiac 
symptom.":), whertraK in ca.*eM under 7 years it was a very grave sign 
ifi ca-HPs. .1 dcuths). In all llibbard's fata! cii«eB there' were both acute 
myocardial change and degeneration of the fibres of the vagus. 

Sudden death is not uncommon in cases of diphtheric myocar- 
liitU; in Dunn'.<) case, from the onset, heart-block (Adams-StokcM syndrome) 

Fl<1.14T. — Urtliulincnphlroul- 
linna »f lliv hcurl of a ehiU} iluutit 

lAllnr Oiollfn, .IfiJifAtn mof. 
irr^McAr. lOOft. 1...) *t--t-++. 
■Hillinp eii Rflh day (UR.-3.0 
cm.. ML.-ejU cm.. I. -U.I crn,): 

. outliu* on veveath iIb)' 

lUR.-.t.A no.. Ml~-R.l cm.. I.. 

— 1^.4 rn*.); , UMilih* on 

twcDly-cixUi day iMR.-JjO •■».. 
Ml.. - a.S em.. U-[l.3cm.l. 



WU tbc result of myocardial chan^ in tlu> vicinity of the auriculoventriculer 
bundle. The slow pulee altto is often duv to [>iirtial liearl-blurk, 2 : I 
rhythm, though t.hi» may be ttiie to overstimulatioQ of the vagus as nctl 
as to injury of the bundle. 

Ju!<l HH diphtheria affects the myocardium in the very young, influcnta 
affects it in the aged. Indeed myocarditis con!<titut«a one of the graveat 
effects of this diitf^a^. and is especially to be feared after the sixth decade. 

The fuUuwiiig case serves &» an example: 


Paiieni, stged '^- ^^ MtlenUry fantiits, mtber atout, but free from all cardiac symp- 
toiiu. i'lilm? hull always bwM of good voiluino and rrgiilar. a nrvtnt aitnck of 
InriucniB in Murcb, 1903, eunfiiiiiiii; lii-r tu IhmI fur u niontli. N'u KjNwiu] cux- 
diuc fcaiurex. Afirr a vhorf. coDralnicrncC' tite nu ngnin ut>lc lu be uji iind ubnut. A tc« 
ilnyi luter, juHi uft«r reilhni;. «bc bnd a »o^Tro aitack of cariilnn khthnia, 
brca t bloRDndia . i> 1 1 bopn ue a , unil alitcbl precoriliftl jitiici. .\u tiue 
ongiDa. tloderale lir^m?' of cyanoci*. i'ulun nniall, rnpiii, irregular. C.'sirduii: diilnrai 
elixblly CDlarg«<l. Sod nyBlotic inurinur heard over tlie enliru betirl. Tin- utlack liia[«<I 
bolf an hour, aympioma hpJiiK niudi relii'vcd by inliulutioiu of nmyl nilrlto. 

I^liMil nan given complete rest in hf<l for a few d.iya, nilh (biidcxlnu'I of disilalis 
"Lv (0-3 c-«.) thtt-c times n ilay unil soft diel. uiitl wiu llii-ri ki-pl al rvsl ]ii a larnc ami-cliHir. 
Graduni eonvafaworiM'. I^oon liccnmr frp« fratn lymploras, but pulse remained TO and 
jn«inilar and iibe wan coiiipellwl to rvfralii from every elTori except, one daily iri{> up and 
down iKTuin;, durinf wbjcii abc rcslnl ul I'ucb s.t«p long eituugli tu vuunt Inenly. In June 
Btid July. 1901, tbt h)ui MVornl niniilnr altaclu. ntid thciUKli *hc inipmvcd nomrwhnt her 
pulse renuiiiied p^mianeiilly irregular. Died suddenly a year and a half later, deatli fol- 
Kunlug six vccka after u sc^-ctc cullulitb of tbe Ick- 

Cmk or SuBActm: htxotutuc Htocakditi». 

B. C. 8.. niporter, married, aiE«>d 30, admitted to the aervice of Prof. J. O. Hineh- 
feldipr. City ami County Huspitul uf Sun I'Viiiicikco, Junuury 33. 1905, compluinitiit of 
iliortnem of br^-nlh and iin'oUiiiK of frrt. Knthrr .iiid brolhi^r are mibjoet to rbeunialJMn. 
and patient liimt^lf had HwellinK oF juinljt F»iir vcmi'h iiao, iihoiit tlie tbne uf a. gunorthiPBl 
[nfnclion. He liail i[ii-n.iles, whoijping-cuii^b, uiid sturlut fever as a cliikl. mid lypboid 
fni:r tmi^a jvara ajco. Dcnicn syphiliii. Married, but. has lind no children. Udw toliacco 
in modcralioa, but drink* wliinkcy In e*ee««, as a proUible nwill of which be hun fnlteii 
from ihc \)vt to the Iiiwcat strain of society. 

PneaEST Im.nrm,— Koiir wwk» wro wltjl* In the midal of * aeries of dettuiieluM lie 
noticed thai bi* shois Ix^iiiiie lii;hl. sod in a few daya bis legs becamo so awollnn 
that be could not put on his drawrtx. lie bail {win tn the \rf^ nn walking, on-inn To the 
a>deinu. He also felt very weak and became exhausted eaally. Ums had nluirtims 
of bmith on exertion. 

PHVsirAt. RxiHtNATioK, — \Vel1-nouris]ied man of icoml color. Tonsno and iiviila 
deviate sliEbily tii the rlicht. General Kl!>"<hdar enlarxemeni . L'pllrvcJiluini palpubli.'. 
CHimt ncKative except for a few inuiat riHes o^t-r rigbl axilla and litue. 

Heart. ~<-nrdinc iinpiilm not vimblr. ltcl.itivi!< ciiriltitc diilncm extendi (o I 3 . 5 
em. from midline in fifth int<'r>|)iuxi (3 cm, outside maiiiniilliiry line), 4 cm. to 
ristil of midline and above tu tbe ibinl rib. fkiundN ore very rapid, the lin.t sountf overy- 
where replnce^l by a systolic niiirmur nhirh is loudest at the »iiex: out tmnnniitteil lo the 
nxilbi: pulmonic H-cond nn-entiialO'l. PuIhv lOB. [V|i;tiliir in forcv and rhythm, low tension, 
faiily Rood volume, Itiulint artery not palpable. 

Liver jiiii pa I pablr . No scar on tcenitalla. Lower extremities am covered 
with pediculi and raw scmtch nuirka. Marked ocdoma of both leipi. Urine oeita- 
tive, »p. Uf ■ H'W. 

Ordered ILi)itid diet: flaldextrttct di][itn1ls0i3c,e. (iiLv)q. IIi.; «pir. Ktjxerylii nitmlis 
1 0L. q. 'I b.; sol, muiiiKs. sulphai. «ut. 30 c.c. (Si): urig. tinci oxJd. to tep. 



Jan. 30. I'titic- «!«»- mnd nomi-n-bnt irrrft"'"''. vrnoiw tmcinic utinw- 
Uig that Mime of die auricular i(n|iul«M (lid iiul tVHcli tlt« veiitrtclc (2 , 1 Fieari -Ijlurk}. 
Givi-n HI rupiri* O.OOlSdm. {i gr.) nt I2.<5 i-.M. At 2 00ir.u„ oiiix. pr. I:i5. inln. 71V- 
8W. Piilu^jirpjinin! «)X [>ulBi-ml€ CO— 3)i0». I'lilwrate nb»olul<ily rpguUr.aa 
Klionn til tlif hracliial arl«r>' tracing taken at IAS p.m. Digit nils n-u nuw 

(1 i H C (I II L i II u c (I . 

Fvb. 'i, ilvlcma none, Softa.vMolicmiinavirstni |>rK4rni iii n|)ex. PulM--ruI(- 72. al«M>- 
Iiilclv rcgiilur. rc^fxitidiiiK Ui ull impulxoi f rom ttic nuntrii?. Il De^-ct nguin lufiimr iin>Kulai. 

Feb. II. Fc«l» i|ull« fnrontt. Up and aIxiuI. Ucarl. hiw born n^ular and lUI mur- 
mutH fpat!. 

March 2. fljut iMgiit iwdlttiK nf fed. Wnn ngjim put to bc<I. The savtUnK 
disappvurviJ nillilii 24 hniii>. 

Ill u few ilii)'!! ibv piilirTil was aiiMn lip iiiid ubotil and in n u*c>i?k or ten ilnyn loltr niui 
alUinrd lo cnnUouc hi* vrnik in the jmiilrv. Wu illicharRtH) nppftrciitiv nirad about 
May IS. ■ . ' 


.\fihafi beon sePTi, tho (Imfnio^is of iicut« myoranlitui in many cases ta 
made more by iiiffix-niT lliuii by (U-rtniU* sigiif". The prt'wnrc of symptoms 
of rai'iiiac weakness in an infectious discaiie, out of proportion to the 
st-vcrity of the lalU-r or to ihe apparent !«>v<!rily of the endocnnliul lesion, 
is presumptive ovidcncc of scwre myocartliiil involvement. The symptom- 
(■oniple.v of rpstlessnes.1 or marked (julnesa, ron^triction ovpr the c hcsl, and 
prcconliiil piiin, vumiting, cyiitioM:", uikI incnraw; in tho arvn of cardiac 
<]ulnesy. duriiiK or after an attack of an infeetious diseajte or of delirium 
trcmeii-s is pructienlly putliognoiiyniic. Tlie preusonw of a fty,*lolic murmur 
at the apex and over the body of the heart, which may even be transmitted 
to the «Nill(i but whirh di.Happp«rs during oonvaleseeni-c. added lo the other 
aymptome above mentioned, would imiicate niyocarditii^ rather than endo- 
(•arditi.-*. it imHt Iw boiiie in mind, moreover, that the pif-.*«'n(-e of true 
endocarditis or pericarditis is evidence in favor rather than against the 
pretience of an additional myocarditis, and that in the arut« form the aymp- 
toms arc quite us liable to be due to the insufficiency of the niunclc as to 
the valves. On the other hand, just as a most acute nephritis may he pres- 
enl without the presence of albuiniii or i-a.-'tM in the uiine, .so acute niyo- 
canlial rhangea may be pi^esent without definite signs of cardiac weakness 
other than a tendency to fatigue. In view of the obitervatJons of de la 
Camp. MoritK. Dietlen. and Hornun);;. myoeardia] changes may l^e diag- 
no(*c<l in rases in which the heart iinderKoes transitory dilatation [with 
or without tnuisitory valvular inMifficieiicies) upon eomparalively slight 
exertion. The cardiac area under such conditions must be most carefully 
outlined, if posi^ible with the orthodiafiraph. In the absence of the latter 
careful percussion may often sullice. Tiie clianges must be I em. or mom 
befoiv they sliouid be con8ideiie<i as definite. 


The management of a caw of acute myoi-arditii! differs essentially from 
that of the chronic form, owing to the fact that in the former the changea 
in the muscle may Ik* of » temporary character, while in tlic latter the 
chan^R are permanent- Accortlingly. in the acute form the aim 
is to allow the muacle to return to its normal slate, 



while iu th« chronic form this cannot be hoped for. 
und the treatment i» directisj townnl obtaining thu bc!<t functional result 
poTisiblo in llie changed muscle that is left. The one nims at hnnj^inj; 
about flubsidencf, the other at imlucinK hyix-rtropliy. 

AwnnhnKly, even in the miidt'st (onn of acute myocanliuti rest is all- 
important^co m plole rest in beil until the degvncrstive 
cbiinges in the muecle have subsided. This ist eapeeitilly 
important, since eaniidc ovcrBlrain seta in very cattily in sueh hcurt». and 
it is probable that this, in even the slightriit degree, increases the injury 
to the mu.wle-libroR n.^ well as the extent of the intensiiiial <i>drinn and 
infihration. The patient should l>c kept in bed at leuiil two weeks after 
any imliciitions of inyocaniial weakneHK have t^ubwded, and if possible 
until the pulse-nile hji» agidri iK-eonie slow. An riiisily digestible diet equiva- 
lent i.o about 1000- LiOO calories should be enforced (see page 167). frequent 
feeding of Hinull iiuiinliliex being resorwdtoin the place of three eomimra- 
tively large meals. 

An ice-bag shuuld frequently he npplied to the prccoriliuni, since it 
tends to slow the hcarl-raU;. Some wrilvr!*, esix-cially Csiton. strongly 
favor the appliciition of .nniall blisters to the precordium and the admlmKtrn- 
tion of small do«e« (O.It (Ini. or '> nr) of potn.-«:<iuni iodide, but il is extremely 
tloublful whether this has any effect upon the course of the dineaae. 

If unu-miu iiri.«i's, irnn should lie ordered in some form, usually as 
Blaud's pills,— ferri carboims sacchanitus (U.W Om., 4 gr.), — or Valiet's 
maivi {i<amp an Itlaud'a pills with honey instead of sugar but more permu- 
nenl).orelixirferri.quininfpetelri.<hninR'pho«ph8tuni(4 c.c. J fluidrachm). 
If cun^tipntion or other iligeetive di.sturbanci'it result, hirinutin or some 
other "organic" iron prpparalion, that is. where the iron is combined with 
proleiil. The patient's boweb should W ko|)t freely moving without effort, 
best by means of Itochelh* salt,-^, sudium pliosphuto, Epsom salts, or Seidlitx 
powders. The effervescent citrate of magnesia umiaily causes greater 
Mbdominal distention llinn is de^iruble, owing to the upward displacement 
of the iti-iphra^mi. 

Hypersensibility to Digitalis. — The usefulness of digitalis in acute 
myocarditis is a debatable question. Digitalis acts as a spur to the bear! 
and r»tM>.-< the strength of the contraction until it enables the fihrps io draw 
on their Ieser^'e force at each contruetiou, but it dors nut raise the limit 
strength. When that hmil is already approached it spurs them too far, 
and drives them to overstrain and even tu death. 

Whether, in any indivt<iual caae, digilalis will do goo<l or harm will 
depend, therefore, upon the degree to which degenerative changes have 
progressed and the amount of reserve force thai is left. Thus, in the case 
of B. C. S., the myocardial tlegeneration was slight and the b«-neficia1 aciion 
of digitalis was marked. With A. J., however, the case was different. 
Degeneration had reached too ailvanoed a sta^ and the (irug was useless, 
perhaps oven harmful. 

Even the heart of li. C. S., however, manifested the abnormal suseepti- 
bility of durh lii-iu-l.-j to digitalis, since it pro<lueed partial biwrk and exlra- 
systoles with doEea which barely sufficed to idow the heart of the average 



Moreover, in acute myocurditis tlic heart i» hypcracnsitivv to di^talU. 
Tor example, in the case of B. C. S.. a Qornml dose produced an abnormally 
intense reaction with tfignu of the first stage of fligitahs poinoiiiiifc—imrtial 
hcarl-hlopk and extrany stoles. I'orluniitcly in this cajw the good effect* 
outvfeighcd the bad, btil it Iwlonged lo the jtroup of eases which prove con- 
clusively that in acute myocarditiit digitalis idiould always bo given in 
smaller dwn'.* thiin would be used for a heart with a valvular lesion which 
showe<l the same degree of heart failure. 

Strychnine— As regards Htr>-r;hnine, both ita benefieial and its harmful 
effects are less Diari<ed than those of digilaltN. It is therefore less liable to 
overstep the limit of tolerance. In ordinarj- doses it tends to increase the 
cardiac tonicity, tts well as to stimulale the cardiac nerves, tiie resiiimlory 
and vasomotor centres, so ihut it becomes a vuluable drug in such conditions. 



PatholoRicttUy the chronic inllamniaton,- changes in the myocardium 
may-be divided into three groups; 

1. CiciLlricUl imichrs or ttan aruinit fn>m tho licnlinif of indlntcd nrnnn nt inSuni- 
miLli'm (ubncMB ur furul infill rHlionii) or fnxn (hi; orcan lint ion of uiead of bfurrlKMi. 

2. Thickrnint; i>f Ibi.- wpiu tliui iH'|j>rate tlip muii-lL- iiiniDili (iiilcrfiuciculni myo- 
fibroBiB. Ik-hio) ocRlirrinit nhoi llin hrjifi niiisrir hy|irri rnphics. 

3. OifFiue dufKneratiun of ilie miixcl^fibreii with iiiviision uf tlic Tibra bundln bj 
•tranda of conncctire tivue (fiordivaderwiia. Huolutnl; intmliCiiil rnj/ufibrruit, Uebio). 


Fin. US. — Spivimfo •hnwina n ^nnlinr nnrurtrai Flo. lit), — rhronie nyocudili* rmnli'»rli>T<iK*). 
cot'CTKl with pQrk<'iirdiul »dhc«ioun. 

Cardiac Cicatrices. — The areas of cardiac cicatrices are quite common 
in coronary sclero!!iH, in which they represent Ihe site of healed Infarcts 
in the area supplied by the iilTecied arlery. The fibrous tissue composinn; 
the scar, relatively poor in elastic fibres, is weaker than the rest of the 
heart wall, presenting the condition termed by Zicgtcr myomalacia cordis, 
and it may bulge out to form an aneuriam of the heart (Fig. 148). 



SpoQt«ne«ii8 rupture occunt in iiuch nreaH. and death occurs froin hctnor- 
Hmgc into tin.- iKTicnrciium, thuu$;li, ai-cordinR to Hamilton, thjjt in not a» 
frequent a cause of riponlai^coii.-* niidurc iis w fatty dcgeiicratJoD. 

On thv olbiT hand, the smaller areoa of cicatrixation may represent 
complete nbl iteration. 

Interfascicular Connvcliw-Iissuc CroUfcratlon. — Interfaarif^ular myo- 
fibrofliei or hyjxrplimiH of the wpta iH-twecn llie bundles In lo l>f rceardcd 
a« a concomitant of canliac hypertrophy, and repreaenls a atrengtlieniiij 
rather than a weakening of the heart. 


W ' "^ 



PlQ. 150.^ — t^pcmnm* <ltowtnE eliron^c mvovafilju^. frhofoniicrogrfeph* br l*t. Ctim*- ^- Bond.) 
A. tnlnlMi'icuW layulibrwii. pairifittiia Ijjiu i)if buu<llai at niu>clr-lil>n>i. ll^ptitniulixul luuia 5l>na^ 

Cardiosclerosis.^ The mo&t important form of lesion in chronic myo- 
cardttU it) the inlcrr^itttial myofibrosiii or cardioscleroais. This 
form I!" met with in senile hearts and in moHt rases of chronic heart failure. 
According to IVhio, it occurs only In tlio.7ic heart!* which have been sub- 
jected to long-continued ddatatioii. frequently in hearts in which hyper- 
trophy ha.-« prcveded the diiatauon. The heart mu«'le U UKlemntous. 
Th* fibres are fouml in all stages of change — normal tibre«. large healthy 
hypertrophic fibres, large vacuolated dogeneruting fdnx-K, and small ones 
in the various stages of alrophy — in a single microscopic field. Many of 
them are undergoing fatty degeneration. In resptjiise to the well-known 
biological law that wherever the parenchyma of an organ U gradually 
destroyed hy|)erp1aaia of the interstitial tieisue takeo it.t place (Weigen, 
Dehio), 6nc strandi' of connective tissue are seen cvcrywlicrc winding 
tlH'ir way between the muscle-fibres and gradually laking their places. 


Lesions in (he Ventricles — Attempts have been made by numerous 
investigators to demonstrate a definite connection between the exact tulc 
of the myocardia] legions and the disturbance of function met with. 
Krehl. who under Ludwig's inspiration was the pioneer in thU lield, inau- 



pirated the method of sludying sectioas from «very part of the heart, and 
found tliiit the papillary muscles and the musculature about tlii- mitral 
ring were affected with great frt-queiiey; but. lu' was unabtv t^jciftabhsh more 
dednitc relattonit. Albrecht'y attempt to do thi» for the various ma-^cle 
layers lUftcovcrffd hy Krehl ami J. B. MaoCaJlum has 
called forth a vigoroua contradiction from Aschoff 
mill Tttwara, who have mado a mont. rjiivfiil study 
ol 1 J() pathological ln-nrls hy Krchl's mcthoil. 

On the other hand, IIU. Krlaiigcr, Sk>iigel, 
Schmoll. and a 1io«t of olhr-rs hove ik-monstraled that 
lesions intliG auriculovcntricular bundle jjivo rise to 
bcari-liliii'li, while Aschrdl, Tawara. Saigo. Barker, 
and Hirschfiildcr have Hhown that lesions afTi'cting 
line branch of thi8 bundle do not nfTeel the contrar- 
tion of either vctilricle. Very recently, however, 11. M 
Hcring has revived interest in thet«» <pit!iit>on:4 by 
showing upon the excised heart that if the :^trand of 
Purkinje fibres l,conduction system) to one papillary 
muscle is cut or injured, that piipillary ceiueit to con- 
tract, although the reet of tlie heart continues to do so. 
Lesions in the Auricles.— ^tndieH uf lesions in 
the auricles, though fewer, have !>oen still more 
itHnimcrativc. Dehin and his pupil. Itadiisewsky, 
demonstrated thai in chronically ililat^d heart« the 
myoenrdial change.-* in the miricles were much more 
marked than those in the ventricles; am! Schiinberg, 
under I), (rerhardt's direction, has shown that per- 
manent arrhythmia with auricular paralysis is asHO- 
(riated with infiltrations of the intervenoua area which correspond to the 
embryonic sinus, the spot at which the vnrdiac impulse probably originates. 

Fi'i. 151, — H )r(Wftftiphjr 
nl tomr murrk huniilc* in 
Ui» ftUfiDk Hitll klHipliy 
(iratiaptnnpy ) ol nih»( 
■nan. <Proiii a <pc«lin(n 
in IliB Arniy H«dlo>l Hu- 
Mum. WuUiniitwi, D. C.) 


The chief physiological features of chronic myocarditis are: 

(OCIirnnic w(»iknnv:iif Ihclienil, villi loiidpncy loundcni^xlilnlatioii nii<l nvnnilMUi. 
(2) Frequency of extnie>'*k)lic or alieoliiic irrt^j^^iilariiipjj. 

Compensation in Myocarditis. — The course ami chnrflctpri.<lic.< of myo- 
cardial weakness have been fully discussed under the pathological physiol- 
ogy of cardiac overstrain (page 134). Indeed, the )>erinstenoe of a primary' 
overstrain with the euneomitant rodema of the heart muscle may be an 
important factor in instituting chronic myocardial changes or in rendering 
the heart esp*rciaUy susceptihle to alcohol, toxiii.4, lobacco, or other influ- 
ences that would otherwise not affect it. The changes in the myocardium, 
the lowcrptl tonicity, the persistent wdema, the reduction in the number 
of efficiently contracting muscle-fibres, all tond to lower the threshold of 
exertioi) at which overstriUn is ushered in. Whether the overstrain inani- 
festa itself as a broken pulmonary or a broken systemic oomiR-nsation. or 
as both toother, (lei)en<h< upon the relative and absolute strength of the 
two ventricles as well as the nature of the exertion. 



Blood-pressure. — The occurrence of such overstrain is, however, quite 
consistent with the maintenance of a normal or, especially, a high blood- 
pressure. This high blood-pressure, strange to say, is in itself the result 
of the chronic cardiac insufficiency and the slowing of the circulation. With 
the slowing of the circulation there conies asphyxia of the med- 
ullary centres, which stimulates them and brings on an intense 
vasoconstriction. The vasoconstriction narrows the arterial bed so much 
the arterial pressure must be raised until the blood flows through the medul- 
lary centres at the proper rate. The weakened heart must thus rise to the 
occasion and sacrifice itself to save the medullary centres. The more it 
fails the more work these inexorable centres demand from it, the more 
they throttle the arteries in their struggle to get blood from the flagging 
heart. The more the arteries are throttled the greater the constriction, 
the smaller the arterial bed, and the less the systolic output necessary to 
overfill the arteries, the greater the force necessary to drive it. The heart 
may therefore empty itself incompletely but at high pressure against this 
high peripheral resistance, while the increase in residual blood within the 
ventricles leads to dilatation and stasis. This condition of stasis with high 
pressure, both resulting from chronic cardiac weakness, is 
usually termed "high pressure stasis'' (Hochdruckstauung) . 
Its factors actually constitute a vicious circle: 

Cardiac weaken inj; 

t I 

Increased cardiac eilort Slo«-eU circulation 

High blood -pressure through medulla 

t _ .1 

Vasoconntric tion 

Piij. 1.53. — riin'p of bInocL-pr&vure in ■ ca^e of chronic myocarrlLtiH, showiDfr the hjflh blood -prvuure pvr- 
BiKting until shortly before dealli. (High-pressure atMin,) 

This accounts for the fact that under such circumstances venesec- 
tion may raise, digitalis may lower the blood-pressure, and, 
on the other hand, the blood-pressure may rise rather than fall as death 
approaches (Fig. l.'>2). 

Arrhythmia. — In many cases of chronic myocarditis the heart is 
irregular in both force and rhythm, especially in the later stages. 



Th« chief lypcs of Hrrhythmia obBerved are: 

(1) Exlrasyetoles of aurieulitr or more frequently of ventricular 

{i) P«rpctUfU ali8olut« arrh>-tliniin. 

The extras ysloleM aecia to result from the ov(>rtoadin^ of th« 
chmnlx'rs in which they arise; the perpeluni arrhythmia both 
from the overloadiiiK of the nuriclp aiid the prpsetice of chronic myocanlinl 
chunks in the muHcle atrands of the inlervenous area (embryonic sinue 
reuniena). (The moohaiUMm and itignificaDec and diagnosis of these ar- 
rhythmias have bt-en discussed on paRe 7ft.) TIu.* irregularity in llwlf 
alflo exerts an iinfavnrahle iirtinn upon the circulation. When the site at 
which the impulsi- arises is diseased, it may be impo-tiible for ilii.* area to 
^■ncrate cardiac impulses in rapid suCM^Kwion, and hence the pulse and the 
circulation may remain slow in spite of the needs of the body for increased 


From the above citod rases it will bo seen that the symptoms of chronic 
myocarditis are uHiiaily thotte of fo'adually developinji: cardiac weakneaa, 
progR^saively increasing weiikncss and dyspna-a. at firi^t on exertion, later 
when at rest, and Unally leaching the Mtage of orthopnoea. Palpitation is 
a frequent symptom; comelimes ihore in precordial puiii, usually behind 
the sternum, associated with sudden dilatation of the heart. Swelling of 
the ubdotiieii and often pain in the right hypochondrium are a.ssociated 
with the stretching of the capsule of the liver as the latter enlarges. 
CKdema n»iconding from the feet and leg!«, diminution in the amount of 
urine, at firwt during the day. with frequent aJid increased micturition at 
night, and httcr marked diminution in tnt«l urine t<ecretion mark the later 
stages of broken systemic compensation, 

Phy.Mciil xigtiB are: cyanosis; dilatjition of the venules, especially 
over the face; general engorgement of the larger vein.-*, oft«n 
with disappearance of the "double" venous pulse, and either total absence 
of the pulsation in the jugular veim" ur appearance of a "Ringlc" venous 
pulse ; often irregularity of the arterial puli^r, usually with jirescnct' of marked 
artcrioMclcroHis ; incresise in area of cnrdiiic d illness to right or felt; occasion- 
ally a catarrhal jaundice is o marked sign of the hepatic engorgement. 

The blood count often tdiows polyt-yiha-mia and high hsmoglobin, 
without change in leucocytes. Blood-pre«Burc may or may not be elevated; 
but in most cjwt^s it is not (lecreased. Pulse tracings from the radial and 
carotid arteries and jugular veins often show ixTwstenl abfloUile arrhyth- 
mia, with paraly.-'is of the auricles, with absence of signs of organic valvular 
temon. There may be a more or less transitory soft systolic murmur 
present at apex rlue to functional mitral Insufficiency, but this !.■« rarely 
transmitted to the axilla and often passes off during treatment. The same 
applies to the systolic murmur, which may be loudvot over the tricuspid 
area. There is u.-<ually absence of diastobt- murmurs except in cases in 
which functional pulroonar>- or aortic insufficiencies are suspected. 

A mild bronchitis with riles and some oedema is common, espe- 
cially at right base. Enlargement of the liver, with either systolic impulse 



((rieUSpid iiii^ufficiency) or systolic retraction (turoulluous action of the 
right ventricle), occure in the later »ti4^i-jt. 

The urinary findings, cardiac aympioms, and clinical course in uuch 
cases may be very similar lo those of ca8e« which are primahty ronal in origin. 

Cask up Chruxiv Mrocjuitirnii. 

G«onp! C, a Intxirrr. agiMl 50. was admitted to Pr»t. J. 0. IlErwlitelder'N itnrdii of 
the Cily and CViuniy HuapUal. Siui t'miidsco, on April 21, 1905, compUininii; of 
antliina. IHh (atlm timl diivi of drop*y. The |tiilieni hml imd tlwumulisiii in iS.H7 
And ISU^f, and has Itad to pam w>(«r dunu); llw njgiil lur nurtii^ jntrri. 

Hxi«pt for ooruaiuiiitl aburtiWH* of breath hn uui well until two wcvka heforc admit- 
rfon. 11) has hail ithortnfliM ot hrsalh for tho paat two yean; WL-akiiet« and a-di^nia of th« 
fetl for the pMl (wu wcrlu. 

Phymoai. KxAViiKATiiiN. — Patient U s fairly ni>ilrisli«<rl man: facp fluBbn! and 
mnuloi diblcd. No iiiark«<tl reniiiratury dinlrea. Heiul in <>! pMiiliar xhupir. i>iif!iU pqtial 
and rciact tn lijcht nnd necomRiodatinn. No jimndicc. Dcfiniln conicvait'd PKIcrnul otra- 
bwmuH of rixht i<y<<. Eym move well in all itirectioiui, I'uiiiiiuv niciti.>d- Thrcwt clear; 
loiisllii not enlarged; iio traoluati tug. No cnlarKemcnt nf lymph -ttlnndn. Thorax 
htirel-aUaped. Votial frcmitiix oqunl escopl below Icvvl of IcntJi ilixx:)] verlobru on right 
aidt, where it i* incwaawl, IVroumiun iiule everyviliere ok-ar oicepl over this btpji, wbvro 
breath soundi are diilniit nnd a fi^w r^l» am lieard. A few moid ruW atn alio heard oi-vr 
the apices. Hear i.— DilTiu« bill h-eHu inipid><« iit aixth Icli ioierapncc l& 
cm. from oitdlin«, frurm whieh jioint uardiue diitne« cxtemla above to the upjior 
border of the ihiril rih anil em. w> Ihn riithl of the midline in thi> fourth intewpaee. Heart 
xotind* feeble and aocornpunied by a auft syntulic murmur. Neither luniiid 
at hofip «pRCinII>- aecetituuted. I'uIhc very feeble, raplil. and irnrtKiikr. Ther« in no auricu- 
lar wave \s\K>n the tracing <if the vn-noiw pulse, and ihe arrhyihiniH is <levuid of any 
ivgularily In K<|UcncG. Kudiid arlerint arc very Klnrolic. Sa (I'drinn of fccL or Iok». 

PalJeiit lunMintiOCoiitth. mtunt; mucopiiriilenl ipuiuni, with laricc numbera of Htreplo- 
coeci but no influeou or tubercle bacilli. Urine negative; ap. gr. lOlOi na albumen, 
eiwtii. or Biiipir. 

Ordcivi): Sufi diet. Pil. cathart. co., ii, q. n.; «ol. maffncali sulphatu nt., 30 e«. 
(,fi) q. A.M.; fluidt-xlriict liinitalis. 0^ c.c. (1,v) <j, 4 h.; »pir. glycetylis nitnti*, i\. i h., 
commenetiu; wiih 1 gt\. nnil inr.n-jutinK 1 Ktt. at each third dowi tmttl patient feel" rlirub* 
biniE of the head or thip^liliu: of face, after which next do«e in to be omitted, ^nd milweiiuenl 
doaw of 1 Kit. Iw than the lust are to be ibcn giitiii. Morphia. Hilpii., O.OOS (im. (^ n'-) 
p. r. n. (for exlieme dyspnci-ji). 

April 2.\ 7.00 P.M. No chauRe In condition. No urgent dyapncea. HKinuRli^n 
110 per eent, lOarv). Cyanoais *till marked. No Muriculnr wave in venous pubw. Hoart'a 
action otill weak atld irT(«ular. 

1100 e.c. of blood were Ihon removed from right arm. afler ahtch 
hiprRoitlobin fell to 6i> per eenl. The right border of cardiac dulnoadi retreated 
1 em. tovard midline: up|)er border niM'tled ,n cm.: left border unchanged, N'ocliunge 
in cnrdiarO aourub nor in |>ul«.' tnieiru!. No auricular wave in veooiia tmetn^. Blood- 
preaxure: before vcneaeetion, 7.00 r,M., maximal 107, minimal 
ST. pube-persmure M. pulserale III', pulae-premurv X puli>eTaie-23:iO: after vcnc- 
Mwtian 8.3tl e.u., maximal 112, minimal 92, puliie-prRioure 21). pul»e- 
rat« 112. pulMt-pnHHuro X pul«e-raut— 'J2U> (koc chart, paj[c 176). Cyanosis ban, lionevcr, 
bt«ii rvplMvd by a henllhy color, and jnlient feelii ilecideilly bet lor. The improvement 
in thin cane ia duo rnlirr'ly to relief of tile over-diilcoded richt heart, purity by diminution 
ot ftiiM, partly by diminution in tbe viscneiiy of the blood from tJw i^fnoral of so many 

The patient pnseed a eomfonnbtn nlKht and for H>vrmT day* tell Himewhnt better. 
The eniime of aymptonM and tlwir lelalion, inedicalinn, and lilnoibprexMirv chanced are 
abowu ID the chart (tig. 130). He wiw bled ( ItSO e ,e . ) again on JJay 14, with 
floadderable beneUt, and from that lime hia condition *teadily improved. 





The cases of chronic myocartJitis with arteriosclerosis and secondary 
renal involvement often very closely resemble those of primary renal 
involvement with secondary myocarditis, since there are both cardiac and 
renal failure in both conditions. 

The following abstracts show the close paralleliBm between the aymptonu and signs 
of two such cases which in the early stages were almost exactly similar: 

Chronic myocmrditis IC. B.). (Diasnoni" on 
fiTBt Hdmi»»ioa "chronic aephritis" ). 

Chronic nephritia (J, B,), 




Shortness of breath, palpitation, cough, j Shortness of breath, orthopncea, swell- 
swelling of abdomen and l^s. Voids iug of tegs. 
during night. 

Autopsy. , 

Pale pasty color. Moist rales in chest. 
Heart dilated to left (15cni,); rapid 
regular pulse 120; sclerotic radials. 
Muximal blood-presaure. 180 mm. 
Hg. Later, two attacks of angina 
pectoris, with death in the second. 

Varying from 2000-3000 c.e. per day. 
with sp. gr. 1007, trace of albumen 
anil a few hyaline casts, to less than 
1700 c.c, with sp. gr. 1020, large 
amount of albumen, and numerous 
hyaline casta. 

Heart hypertrophied 650 Gm., auri- 
cles dilated; intense cardiosclerosJN. 
with some hypertrophy. Both coro- 
nary arteries diseasetl, left descend- 
ing branch almost obliterated. 

Kidneys large, purple, with a few 
depressed scars and retention cysts; 
cortex thicker (han normal; no i[i- 
crease in interstitial tissue; no 
mlirkeil nephritic changes. 

Adrenals — fatty deRenernlion of 
cortical cells; no hypertrophy. 

Pale pasty color. Moist rftles in chest. 
Heart dilated to left (U cm.) and 
right (o cm.). Pulse rapid and 
regular. Maximal blood-pressure 
200 mm. Hg; later ranged from 
130 to 170 mm. Hg. Fundi oculo- 
rum normal. Later, Cheyne-Stokes 
breathing. Delirium; headache; dul- 

Urine varied from 400 c.c, with sp. 
gr. 1022. 2.5 Um. albumen per litre, 
and numerous liyaline and granular 
casts, to 2500 c.c, sp. gr. 1007, trace 
of albumen, and few casla. 

Heart dilated 350 Gm,; pale pink 
walls, with slight fibrosis, Coronary 
arteries sclerotic. 

Kidneys small, scarred, cortex thin; 
extensive epithelial degeneration 
with corresponding proliferation of 
connective (issue. Many glomeruli 
have iindergo[ie fibrosis. 

It may be almost impossible to establish differential diagnosis between 
two such cases early in the disease. The course of the two cases, however, 
showed clearly the divergence, the one toward the type of coronary sclerosis, 
dilated heart, precordial pain, paroxysmal dyspncea, the other toward 
the urirmic, with progressive dulness, oliguria. Albuminuric retinitis did 
not develop in the case cited, or the diagnosis might have been simplified; 

Catalase Test. — Recent .studies of M. C. Winternitz indicate that in 
many cases at least the diagnosis may be made by a simple chemical test. 



He h*» found ihut m uhronlc nephritis the catalog of th« blood is dentroyed, 
flo that, when placet! in conI»<.-t with hydm^ii pcroxidv, no oxygcu ia 
libcraHMl; while llio blood of patientrt with caniiao weakness splits peroxide 
aa before. By this test ho hiu made corn-cl di]igno«is in » number uf doubt- 
ful caws. However, this difference in the eatalasc manifests itwlf only in 
the unernic and preuru:-uiie Atat«s and i.t of value only in di»tingiii.-<hing 
between these conditions and casei! of mj-ocartUal weakness with drowsiness. 


In making the diaRnosis it i» most important to differentiate chronic 
myocarditis from the following conditions: (1) organic valvular heart 
lesions, (2) obesity, (.'t) primary cardiac overstrain, (-1) piimnrj- ohroruc 
nephritis, (5) chronic polycythjemia (erythnemia) with enlarged spleen, (0) 
neurasthenia and pj-ychaiithenia, (7) chronic nephritis. 

in caseti of chronic myoranliiSH It Ri»y \ie extitmely difficult to exclu<!« un 
uritnnic vulvulur discusc. Ttiii in mpi-cially Inie of mitrul iiuiUlFiciMicy. for 
lhcr« is frequently a fiincttonnl mitral insufficiriicy pmiriil nilh nvEtnlic miimiur iinij 
|ii)nR>tiI;il cUluiuliun of lh« hi!Url to the li-fl . VVIij|«' ii m true that Ibc munnur uf u fuiic- 
tioiiiil iriitrnl in>ufliei<!ticx ■■ rnmly as rough on IhiMw a{ oigame origin may hrtnnir. and iit 
an ■ ruk- not aa wttlt transmit led inlu thi? axUln, nev^rlheloci in in<lii'idua] ciiaui iboc 
<lilTcit-iicni msy not he itrikioR. Much more striking arv the ctmiigia in Ibn chnnu-tor of 
■he murmur ut the jmticnrH condition improveti. In oritanic lecionii the niiimiur n-iU 
liecomn lotidcr lu liiipruveinvnt neUi iri, becauiw tlir heiirt hiu becoiiu: ilrongi^r. In 
functioHAl cawa, though it may hpromr! Umdir at lir»t. it will vary itfratly in chnrMCtrr 
and in inttMuity. CHiiecially if the |>ali(^iit ia niude to exercise glightl}', ll iua>' Hhuu* a tvn- 
deucy to diiui|>|K'ar nltnuplhcr diirinic rrcovcry. 

The prmunce uf a larjtc, nlow. hcaviniE spcK iieat irllh «low piil«e and iiyiitolic mur- 
niur •« wwll ■■ It hifj!i? nlow piilsc nfieukti in tuvor of organic mitrul iniutficinncy [maik«l 
hypertrophy of the left ii-vnlriclc). ihoiiKh a functional jiapillary irwufficiciicy iiiiKhl ppr- 
riM fmm localiti"! myocarditis of uiw uf the |iH|.>iIlary iiiiiticluK iti Hpite of ttie hypcrtii>ptiy. 

From other valvular disenneii ihi- dia|nia*ix i« eompnmlivcly cnny. In 
ooMuianal chm-4 tlir l>OHt of the auricle liecomfH awiililr. mtcjieitline the |tr^y«to[ic rumbln 
of mitral (rtruomi (!*ckii!I); and octusioiiully Ijloninx diiutolie nnitinurii at ihc ntcriiat 
mni^n sutOEaxt orfcanic aortic or pulnranic ini^iifltcJrnry. Bill such liilat.iiinnfi of Ihe uurlic 
rinK and cmius Bri(-rtuBU« or caMio|>uhiioiiHiy niiinnut>' tiv mtlicr rare aoil are uaually 
t ami lory. 

.\ functional tflcuapid Irtaitrncioncy mult« co c-atwtantl.v front wcok- 
xninK of Ihi- rii;lil ventricle thai it Li u iMion to he iaoluded untler rather (ban exctlxM 
frinn the picliiw of chronii" myooitililix. 

Primary cardiac overelrfiin may be mcIikIwI tlimiijch the hiiitori*, Ihe 
troubin in Ihc laKpr condition cominj; on HUfiitpiily in a ]>Tvvii>iuily healthy individual 
iliiriiiS or immcitialoly nflcr .t tvvcni strain, while in chronic myocardiliii thorv in UHUallv 
B Diorp fcmdmil onriel of ayni|>luins. frei|Ucrilly traetiible in (cibritc ilittfasr »r inloxiralion. 

Obi-nity in diapiiwcd from ihi? Rrncral nppcunuicc of the tialif'nt, conconulanl 
chninic myncaritilio Ix-iin! exctiideii when the iroulilc M-cmB to bfsr s relntiuii to ton jpiod 
health miller than lo disi-.isr. However, my(K'an.lial cliiinirw niny be very hard to rule out, 

Tlic <hfrcrc Ilia lion from chronjc nephriii* ba* lieen ditciiiiMvI above. 

Chronic poly cy t haciiii n (crylhrn'mia) nilh cnlarveil n])Wn may pr«npnl 
a picttini vcf7 cimilar to pritnnry chranic myncanlitis. nn>l in Ihe later olnce* * consider- 
able cTsile of ni>-ncunlitiii may ()C prtT^ent. The ««■ and har>in(«ii of the nplcvn, the cc4or, 
and the hiK'i bloixi ctnuit are (he feaUircM iijxHi which (he diaenrinii ii made 

Neurasthenia, cardiac nenrosei. or |Hei)dncardiaic visceral (tiataae, 
must b« cnrofiillr excluded (mw pajic .S<i3). In the fonncr (he u'c«kiMwi wbm aelf- 
cnnu-inun awl the tilren^h nhcii the mind ia <li»lraclpij spe to(ally di« proportionate: 
while ihu uiyocarditic is mnindcd of his wcakiiCM by tlic ftcrri hunger for air. 




A careful gCDornl cxuniiiuilion iihu<il<l ulwnyn he tiLulG l» rxcrliidt! (Sardine trpakiinw 
from enteroplMta and aimilar diMortlcis that may rcllrxly give ritie Uj a truu omliuc 

Tlw v*noM« pulae help* mmurwhat, the pr*«cncft of a viinblo "einicio vmoiu 
pulne" of auricular par«lyala or extrasyAtolm sUKf^Miiig ntirocardiul chaogr. Iloii<(!vcr, 
tbcM may not he conduadve. For thn pwt year tbe writer ban hn<l istvler nlwcrvation • 
youug athlct« with iwnnnnently irrcffiilar piilso and auricular )inrvlyK)fl and synipioint of 
olighl nardiac wi-nkiiun on VM-rtiuii. There an', howtvyr, no iiifei'limw diiiruMa nor indw- 
rrflioni lo acmiinl for Ihi- production of u mynmrdilin, and, though thr wriler incliiiw 
luwani Ihe dlagnoxJAof (lie laU«r mndilioit, il nwRiKdifHcuU in so healthy a yuiuig pu«oD 
to exclude a neurolk baaia. 


The tivfttmetit of chioDic myoeftrditi.'< in the main should follow T.h(> 
jElpneral scheme laid down in detail in Chapters IV., V'.. and VI.: re 8 1 in brd 
durinft the severer atageH of faikire, purgation, Il^ht diet, dij:itultB or 
strophaDthus in severe i-M«e». graduitled resistance exercises and Nauhcim 
bathi) (Itirinft convalescence. );r&dually increafflnj; walk-t and moderate 
exercise before returning to evcry-dny life. However, wrtain exceplion.t 
munt be noted, especially in the severer forms of myocanliiJH. Forexninple. 
liigiliiiin only orca-sionftiiy corrects an i rreg ul nri ty which has become 
relatively permanent; though it is ver)' useful in curinR the milder forms 
of irrejiuhirity, such aa a continual bigeminal pulse «r occunionid vciilricuiar 
extrasy stoles. It is less, indeed rarely, efficient in removing the irregiduri- 
tie.-* arixinx; at the auricles. On the other hand, in deidiug with the advanced 
grades of permanent iirrliythmia with paralysis of the auricles, where there 
is UNually advanced myofibrosis and only a few of the heart muscle-eeiU 
have survived the gi-nenil atrophy, it is found that these often respond 
well to small doses (about half the normal), whereas a normal dose 
may give rise to symptoms of definite digitalis poi- 
soning and often hasten death. This is not always to be avoided by the 
apparently mild routine of adminUtering the drug in "counsos," since the 
initial dose may be too large for the individual case. Each case mn»X be 
concidereil for itself, with these facts constantly borne in mind, The moder- 
ate-sized initial dose or two followed by protongi-d administration of very 
small doses, suggested by KrAnkel (see page 179), seems to be the safest and 
surest method in these cases, in order to prcveii( cunudative effects. 

Tbe recent introduction of single doses of strophanthin intra- 
venously, which does not increa-te peripheral re.-qsiance, gives pronuae 
of great results in the future, cs|»eciatly in this group of eases, although its 
use has not yet become general enough to warrant a verdict. 

As lo g r a d u a t c <) exercises, these are useful in many eases, 
but are distinctly contraindicated after royofibroeis has set in and dyspnoea 
]>ersiMts while the pnticnl is at rest. Mere anhythmia, even with paralyus 
of the atria, does not con train die ate their use, but points a warning, and 
in many eases shows that the practitioner is treading on dangerous ground. 
This applies also to Nauheim and other baths. Coronan,- sclerosis, 
on the other hand, stenocardia, and severe pains down the arms furnish 
distinct contraindications to all exercises exwpt ."uch as are necessary. 
Kvcn those of Schott must be carried out with the utmost precaution, and 
the Ix'nding exereises may well be eliminated. The walks, etc., which 



irrminnte the treatment muat be taken slowly and with the greatest pre- 
caution iu avoiding fatigue. 

For the etenocardiac attacks and paroxysmal dyspntea the greatest 
relief i» given by ft pearl or two of amyl nitrite followi'd by nilro- 
(tlycerin and sodium nitrite. Indeed, those drugs furnish a 
good dval of relief where the arteriosclerotic element is prominent. 

When the blood-preiwuro U elevated above HO mm. the salt in the 
food should be reduced as low as posnble (see pa^e 168). 

Venesection may l>e of the greak-st value in tiding over periods 
of acute dilatation, as shown in the rase of (i. (J., even when, as in that case, 
it produeei* no change in maximal or minimal blood-prcfiaure or pul-se-ratc. 
This caae also exemplifies the fact that the venesection may often be of 
great benefit before acute »ignt* of cardiac overlilling set in, and then it ia 
to be regarded as " a stitch in time," the n-licf of the over-dislcntion enabling 
the heart to riKhl itself. This may be owing to the fart that the over- 
stretched tibres are allowed to gain their optimum length, or, on tiie other 
hand, to the removal of a large number of red corpuscles from the circulatory 
systeni, thui^ decreasing the viscosity. It U eai<icr to pust than to seiic the 
moment at which a venesection would do most good. 

In thia every one rotDC day or ulher r««eif« )iii kwan. For cxninpic, the writtr 
bad a patient umler bin rsur in rSiui Pmnriscii wlio one niKlit hn<) a miKlprate doKtte of 
djvpiuni Mid cyaaMU, iIiohkIi scum'ly (.■ti')ii;u;h Iu alarm, uiuj immediate veneaeo- 
IKIO wiui rntu-idrnrd. Ttic righl hcurt wad not mnrknily rnlnn^wl and none of tlic nhJKC- 
tive siiciu !Cvme<l iirfeni. It wa* decidoil la du line vcmni-ciiuii the next *U)', and ibe 

SitieiU w»M givm Rtimn millitframK (n iiaarirr frala) of morphine, afirr which he fell 
to a quiet Bl<^ep nlmixt imme<liut4-ly. A cuupic of houo talcr he hi^aiiie mtlnM and 
lunk sradunlt)' willun an hour. Wc lutd lei Ihi- right mrnncnl for Ihe vcnncctiun psai, 
and had ninHkr<l ihc n'mptonw l>y the morphiiii?'. 

Danger!! from iMorphinc. — Another danger due to morphine lies 
in the danger of habituation (sec page IW), and the further danger that 
in order to get it the patient will simulate a paroxyani of dyspnoea and 
actually make himself sick or even endanger his life by the elTorl entailed 
in doing so. Several patients whom the writer has gradually broken of 
their morphine habit confe.s!«e<l to having done so, even though they knew 
at the time that the simulation of dyspnoea made them feel worse. 


When the rirculation 'is slowed, and especially when one of the cardiac 
chambers empties itself insuthciently, targe clots are liable to form along 
it.-! wall (niunil thromlii). Thi» occur:* etipecially in thone purtionrt which 
are away from the axial stream, such as the recesses between the trabecule 
eame:e and behind the papillar>- muacles, and alM out in the tip of the auric- 
ular appendages. 

Tliromhinis irithiii ihc li-ft nuriclc occum quite fir(|npntly in mitral ttenotxt, 
(wpeelnUy whrn the hlooi] staKnntra thcrv diirinjc |:>«rio<lH of overstrain, Tlicoe ihmmbi 
If fiwh aoRieliitiM Itreak loose Iv fumi einbuti (page 151). Sumeiiiiu-ii thp c[ut loosened 
fnMn the auricular appendix is m lur^tr that it cannot paiw throuxh Ihranrlculoventrictilar 
orlAoe, bill pliiK" the lall«r v^nlirely. prodiiciiv xuddeii death. When ibe clot reniaiiui 
adbereol to the wutl for some time, more or lea orfcaniitalion gonk on. Thraanbi which 



adhere lo the wall b}' u fe«r stnuidt of ncnly formed conncctii'e lisnit' are of ewry-duy 
occurivnce, and constiliiCt' the classical sign for ■Jiffi-rC'nliiiliun iH-twwii icitra-vitutn and 
ptul-murtem thranibi, In older tliminl>i ihr oricnniKntion !■ more romplntr. m> that *' 
Ibramhui mawi may adhere lu the cardiac wall by a pedtcic of fitirous llsBue. Il in quile 
possible that in «om«i ctwo* thtiv thrombi vilimtc to nud fro and cauvn rxtrunyiitolc* by 
Ktrikinft njtiiinit the wulbi of the ht<ar(, Jii»t hk occiirti^l in Camrrtw''' air-bubble rxperi- 
mcnl (i-piolci) on pnK" ~1)- In wvcml ciiws nucli inu»i>a liav(> lieen kiiovrn to net an a 
bftl I- val ve at tlie mitral orifice, givinc rinR lo •iKns of milral atenoii*. 

The ■ymptomx and ngiu j^iveii by such tbiviiibi an), however, >'f ry ubscurv. The 
fact that ihey u»iiiUly ariw <liirin|t the cimme of u cunliac failure add* to the eomplcxily 
of the clinicul {licturv. aiid the dia^ntwi" can rarely be made until embol I am nets in. 
In onp cn»«! of milrnl ktenofis recenliy »wn by the writer, in which the nliok- dnterndinK 
alxloniinat aurta was B\iddpidy plU(o:cd by an emholm and (puiRn-ne of l>oth lower extrcini- 
lim set in, the dinKntwU of a clot within the heurl waa warrantable. Such cvmb are. how- 
•vor, rare, and the diagnoeu is then mode after the harm boa been done. 


In ipltc of the great frequency wtth which tuhereulouii alTectti the Itlnp. pleura, and 
pericDnliuni. independent uFIeulion vf the rayocardinm. endi>e4ir<lliitn. and vidro) ii quiitt 
infrequnnl,' Thiw WilhRk found only 2 nwes of lulwrcle of the myoeardium in IMS 
auloioim on perwoiw iiith tiibereuloiiis. Other olwervew eonfimi lhi» view of its rarity. 

PnlhoUi((ienlly the leHioris iii tubcreuluMiH of the niyoeaniiuni raK-nible Ihone of tuber- 
ctea elwwherf; ihey are Mtmewhnt mort! comnian in acute miliary tnlierrulmiH tlian in 
Ibe ohronie form, but in tlic latter are larger in Mie. The moul cuiiirnon cardinc Irsion of 
luheren Ionia is. however, neither miliary ni>r Inrge solitary luberclca. but .1 f.itty dcnenrr- 
ution of the niyoeanlium. iliie in part lo the nnjemia ami in pan. to the toxiiis BtTivled 
by the bacilli. 

The effect of the liiherciiloiu lexionn upon the circulation is luually maiikofj by llie 
ftenerni c.inliuc wenkncH due lu the intosieation and unu^niia. un<l, on v. I-cyden otateo, 
duOH not prexenl any charoelerintie fejttiirrs. It is sImiHt im|HHsible tn iliaiinoBu clinically, 
for the nympluriui and sijcnH are (|uite im!e|)end«'nt of the tiiln'rele. UFlen. at in I'ollak'a 
caw, a man of fi.'i who hncl a Inrjte luberele in the wall of the nnriele. them are no sictm what- 
ever, even o( cariliac weaknnwi. V. Talmra and Tilp re|Kirt a eii»e in which u Hystohc tnur- 
tnnr witi heard o»-er the upex.bul thin, of course, presenls nolhinu eluinieleriiilicand mighl 
well have been <lne <n the accom{ianyin;; wejikneia 11F the niyiicanliuni or jinplllary nitisrlcii. 
In(liv<t. as lt'>'nl)en: slHt«s, tiiherciiloHlH of (he myoenrdiiim inlcrcBlB the puthoUipi't rather 
thnn the clinician. 


Syphilitic nffMlion of tlie tiearl in more frequent anil pre«ent« a nomevliat niore 
de^nite picture than tul>ercn1ofli<i. The mont common form in which syphilis afreet* the 
heart is the sclerotic lesion of the uurtic valven (mht pum 361). thoiq;)i 
in this ease the ]>nlholoirienl pmceni ori);inntot in tlie aoria rather than in Ihe m>'oeardiuni. 

Grawmann hax called attention to the fre<|nency with which Bijfns of cevcre mediae 
wenknnn nceur durini: the secondary sta^' of nyphili.*. neridental or functional 
•vMoiii' niunniirfi heinR present in 10 |ier cent, of hi? caws. Oilatation, «n(ie<-iatly of the 
Hxht henrt, wan eunitnon, an veil &s ikll(.'raliutw of rhylhni, — ttumciimet arrhythmia, 
somciimeii bmriycanlia. nomelime* tnehyeaniin. I'rccordial pain wnd anginal 
attach were (rwjiienl. The hlooil-pr«wure us" ubiihH)' low, as wos «Isi> Ihe hiemoKiohin. 
It is not imiKMuible thai the major rftli- in ninny of lh<T<e cnidiac m.inifeiiliitiotiB is j'layed 
by the aniemia and the fever rather thnn by apiroeha'ie palliila within tlic heart miiwie; 
but Ihe prenenee of tertiary myocunllul lesions demonsfmtex thai the latter play an im- 
jmrtant fan. The d 1 o )t n o s I s i» luued upon the nbove-mentiuned itymfitums arisina 
diirini the nocondary »if.OB;e- Treatment "hoiild. of course, lie i-JKoroiiK, and as a preifiin- 
lionarj' mcanure the (uitient sliould lie kept in bed until all cnniiiie weakness has i>as8«l. 
If the symptoma do not rapidly subside, a few doset of ilixiialin or ■tn>|>)ianlhttf may be 

' Tubvrrulci.iL'i enilocnnlilis in dtHCiuvcd on fAge .WS. 


given. Indeed, a few small ttosea of one of these drugs may well be given to relieve promptly 
the dilatation and thus to forestall tlie danger that may lurk in an cedeDiatous heart muscle 
(see page 2115). 

Cardiac lesions are rather common in congenital syphilis, though this is 
not true of typical gummata. Thus Mracek found myocardial changes (acute myocarditis 
with patehes of perivascular inhltration of mononuclear cells) present in 24 out of 150 
autopsies upon syphilitic foundlings, but gummata in only 4. The non-gummatous 
changes are well clescribtd by I. Adier as infiltrations of mononuclear cells about the 
blood'Vessete and in the connect ive-tiasue septa between the muscle- fibres. The striking 
feature is early typical chratiic endarteritis with thickening of the inlima, destruction of 
the clastica inlema. This is often accompanied by hemorrhages into and about the vessel 
wall. Clinically hereditary lues of the myocardium pn^abiy cooperates with the other 
syphilitic lesions in bringing about the death of the child, but the importance of its r^le 
cannot be judged, .?ince it is rarely if ever the only luetic lesion present. 

The tertiary myocardial lesions of adults are fairly common. The lesions 
in CO cases collected by Mracek showed the following distribution: gummatous myocar- 
diti.i, 10; fibrous myocardiiis, 9; gummatous and fibrous, 8; endocarditis, 2; coronary 
arteries alone, :i; pericardium alone, 1; myocardium and pericardium, 15; pericanlium, 
myocitrdium, and endocardium, 1; myocardium and coronary arteries, 1; all parts of the 
liearl, 6; cardiac ganglia, 4. 

Judging by the number of cases of Adams-Stokes syndrome due to 
lues (see page 471), the intraventricular septum seems to be a rather frequent site for 
the lesions. Eiccepting such lesions as are so situated that they give rise to heart-block 
or to the Adams-Stokes syndrome, the syphilitic lesions of the myocardium rarely give 
distinct manifestations. A general myocardial weakness, shortness of breath, dilatation 
with or without exertion in persons who liave had lues (especially with other visceral 
involvement) is suggestive evidence of fibrous luetic myocarditis with or without gumma. 
Ttie latter can rarely if ever be diagnosed. Huchard and Fiessinger report a case in which 
dyspnoea set in sudtleiily 15 days before death, due to the groBlh of a gumma involving 
the tricuspid valve, but even In such a case the data are too uncertain to permit a definite 
clinical diagnofiis. A poiiitive Wassermann reaction, which Collius and 
Sachs and W. Longcope have found so u.stfu! in the diagnosis o( luetic aortic insufficiency, 
is of les-s value in the diagnosis of luetic myocarditis, since the eviilences of myocarditis 
are in themselves less definite. However, in case,"! of chronic myocanhal weakness in which 
lues is .siispeetfci, the presence of a positive Wassermann reaction renders a vigorous ad- 
ministration of mercurial inunctions or hyporlermic injection of mercurial salts, an well 
as vigorous daws of jxitas-uium iodide, highly advisable. In oeea.'*ionol case.s it may be 
possible to secure a considerable and permanent improvement by vigorous antiluetic 
treatment, even when (he Adams-Btokes syndrome is present; but it must not be forgotten 
that the cardiac infiltrations are among the most stubborn of all luetic lesions. 


Primary tumors of the heart are so rare that in 3000 consecutive autopsies at Nilm- 
burg Tliore! diii not encounter a single one, and Hektoen, who reported three cases in 1S03, 
states that re|>orts of only 110 cases of cardiac tumors were to be found in the Index Cata- 
logue of the Surgeon-Generars Library, and most of these were secondary. 

Primary Tumors. — Bertheson was able to collect 28 primary tumors of the following 
types: sarcoma i); myxoma 7; fibroma 6; carcinoma 3; lipoma 2; cystoma 1. Unk 
(1909) has recently collected the data of 91 cases; fil of these were as follows: carcinoma 
7; fibroma 7; myoma 5; lipoma 8; sarcoma 13; myxoma IS; rhabdomyoma 1; tera- 
toma 1 ; papilloma I . In addition to tlicse Knox and Schorer and Wolbach have collected 
12 cases of rhabdomyoma; fi of which were associated with other malformations, especially 
cerebral sclerosis and hydrocephalus. 

Hektoen calls attention (o the fact that the heart, and hence also its primary tumors, 
are of mcsoblastic oriain ; which accounts for the relative rarity of primary car- 
cinomata and the preponderance of sarcomata. Thorel beheves that many of the fibro- 
mata found represent merely old organized thrombi chnging to the heart wall, and believes 
that many of the (relatively frequent) myxomata represent merely degenerating forma of 



aucb tlironibi. The lipomatu he ret^nla merely us obuomiolly large pockets of epicnnliA] 
or tnlrAmuMl fat ratlicr than a* true tuinnna. 

Ab rvKsnU sile. IJiiU (on nil in righl nuride 10; left auricle 24; right wntricle H; 
left \*ntriHf S: vnlvuH 16; inlt-raurifiilur si-plum 2. 

Mcisnaiic InvolvemEni of ihc Heart. — Srcomlnry nei>|>1a«in8 sfTfcllnjE 'he heart tut 
ROmewbul iiiun! common, uiid B<;anM>l.v uny ]>atliolo)[idt of experience hiia fnileil lo mMt 
with ihcm. ia{ie<Tiiitly iii casm with niuliiptc mcituitHjus. CK the meLiDtHtir iieoplaama 
careinomata arc tlii> miwl. frequent. Tliorel encniinlered 6 iii«lanc»» ill Iim 3000 uulupiiic*, 
ifac priniury Bitea beiup uturtia 2, ■«'liiiii I. )nill-l'lti(l<it'r 1, kMner 1. luug 1, 

<iej[irl ttateii thiit in a ]ieries of 16 caMv nf ciireiiioiiin of the cetnphaiciiA 6 g^nve inetas- 
ttUMM li> ihe lieurt ; but tliia Lh 3Ii tmiwviatly high |«reentiLK<^ iinil Thurvl Iroia iiis rK|)eri- 
«iicc don not rrganJ nuch uwuphageal tuinun a* laipcctully lialilr to ciTdine mrliutaAeoi. 

Clinieally ihc pfCMno* of a tumor in ihp hnarl in iinelf encrljs lililo influcnee. iiiileM, 
u* tn Luee'n cose of EmreoiRii. it protmes upon the surlciiluveiitrieiilur bumtle and pmiluent 
liparl-hlock. or it in to situated on lu pruduer either utmonln or rri^irxtlallnn nc n vntMitar 
urilice. Tlie beniini tumor- exert llitlc or nocffeel upon ttie (oioe or rhylhni of the heart : 
the molignont luniotn vive rise merely to sit;iis of cocliesia in whieli thr enrdiae wenknno 
MWim Ineidenlnl rather than priniaty- Ii> eABrii of jtenrralixeil carcino*)* and Kareonialoxis. 
Ihuie in whieh the iiietaKlatie ntxliilcw am Diovl corniiiuii. the eaclieelie myoeuniiu] «Tak- 
nnm innliU more inlciisenlipt tier the lumors ufleel thehi-nrt or not. The acejdcnlal findinic 
of a loud har»h murmnr suddenly <levelopin)( and proitreiwinK wilh ihe mola«la»U else n here 
in Ihe huily i,i vrry sti^eslive: but tliia Is rarely eiicuiuitered. 

In ume cawv in which the tumors are siiprrlieial, prrieardiliK mny M-t tn. E f f ii • 
■ ion. e*peeially bloi><l-«i ai neil . i« rather common tinder these conditlnma 
Biid the •ignu of tlip latlcr may tie the linl and only sign of Ihe i-oiidiliuD. 

tn too.') die n'riter anpirstcil a periennlial exudate whirh eonlnined 10 per eenl. of 
hiemuiclol'in am) »ome iiiethu'moclohiii. 'Hie patient dreil llie next day, and autopsy 
rcvealrd carcinoma I oui niassps in the tnyoennliuni wiiU and ptTicariliuni. which were 
netaotHxe- fmni a very small primary eareinnnia of tlie liroiieliut qiiiti^ uiwtiiipeetetl <lurit^ 
life. The finditift of tumor celli in ciieh an exudate would. oF euurse. ^ve Ihe diagiiosiit. 

Tumor* of the heart, even if iliaKno«eil, would, of counw. he inoperable. 


Dim: rmklisehr Diniinostik dcr inncre Krniikheiten, Beri., 1837. 
BoetUber, A., iitid /,«nticr. Quoted from Krchl. 
Cullcn, E. K-: Ko-eiillpd t^jKinlanniui Foeul Myucanlitis and the Oeeurrenci? of Cateift- 

calion of t)ic DeKenorniP MiMcle Flhnra. null, .loluw llo:>pkin I1(»p,, B*ii., 1906, xvii, 

Dietrich: IKe <jucriinien drar Iler^munkdii, Verb. d. Deut«ch. jwlliol. Gmellaeb., J«iia. 

IIMK), X. AO. 
Duhlit;, W. II.: A I'ruliminury Note tiiHxi CVrluin Mechanical JiTieroleehniea) Fadora 

rnneerm-d in the I'rotluction nf Ilic SeRinr-ntalion and FruKiDenlatioii of iho Myo- 

car.tiiini, J Mod, IlcwJireli, Bosl,. VM'i. ii, 4'iS. 
Krelil, L.: Beitrng »ur I'uIhotoKie dcr Herxkiappeiifehlcr. Deulach Arch. I. Uln. Med., 

i.eipii.| ISOO, xiri, 4.M. IVilraa jur Keimlnim dcr idiofisrhiicheti lleramuskdei^ 

knirikuni.1111. ibid,, 1S9], xlviii. 414. Ctinical patholoKy (tronnl. liy A. W. Hewlett), 

I'liila,, 190,5. 
RomherH, K. : I!eher die Erkmiikiinm-n dm TTcrxniuakelH bri Tvphiw aUtondBiiIift, Scbsr- 

laeh und Diphthi-rie. Deulsefa. Areli. f. ktin. Med.. Leiii., ~I><!)1, xlviii, »«S. 
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iMipz.. IMfl, Ixxxv. 7.1. 
CotmilH. C-i The Mvoranlial l.^>n'one of Acute Rhenmntic Infection. Brit. M, J., l^md., 

IWn. ii. Iril3. Rheini.alic Myocanl!li«, Quart. J. Me-I„ Oifonl. IWl.'i-'J. ii, 26. 
BtBclit, t.. iukI Wi»chler: BeilHljri' zur ActiolojoV und pdtholoirisclien Anatomie der Myo- 

eanltti* rhenmalica, DcutMb. Areli. f. klin, hied,, T.elpx., 1009. xevi, 483. 
Cole, R. I., I.e., p. 320. 


Preund, G.: Zur Keantniaa der acuten diffusen Myocarditis, Berl. klia. Wchnschr., Berl., 

1898. XXV, 1077. 

Pearce, R. M.: Experimental Myocarditis; a Study of the Histological Changes fallowing 

Intravenoiia Injections of Adrenalin, J. Exper. Med., N. York and Lancaster, 1906, 

viii, 400. 
Fleischer, M. S., and Loeb, Lao: Experimental Myocarditis, Arch. Intera. M., Chicago, 

1909, ii, 78. 
De la Camp, Moriti, Dietlen, Horaung. Bee Chapter on the Physiology of Cardiac Over~ 

Roily, F.: Ueber die Wirkung dee Diphtheriegiftes auf das Hen, Arch. f. exper. Pathol, u. 

Pharmako!,. Leipz., 1899, ilii, 283. 1 
V. Stejakal, K. Ritter : Kritsch-experimen telle UnCersuchungen ueber den Herxtod in 

Fogle von Diphtherietoxin, Part I, Ztschr. f. ktin. Med., Berl., 1902, xUv, 367; Part 

II, ibid., 1901, Ii, 129. 
Mackeniie, J.: New Methods in the Study of Affectione of the Heart, Brit. M. J., Lood., 

1905. i, 521. 
Hibbard, C. M.: Heart Complications in Diphtheria, M. and S. Rep., Bost. City Hosp., 

Boet., 1898. 
Forster, Fr.: Ueber Myokarditis und Gef&sserkrankungen im Kindesalter insbesondere 

nach akuten Infektionskrankheiten, Deutech. Arch. f. kJin. Med., Leipi., 1906, Ixxxv, 

Hallwachs: Ueber die Myocarditis bei Diphtheric, Deutsch. Arch. f. klin. Med., Leipi., 

1899, Ixiv, 770. 

Zi<vler, E.: Lebrbuch der Pathologic und der patholiqpschen Aoatomie, 9th ed., Jena, 

Huehard, H.: Etude clinique de la cardio-sclerose. Rev. de mid., Par., 1892, lii, 421. 
Dehio, K.; Myofibrosis cordis, Deutech. Arch. f. klin. Med,, Leip*., 1899, Ixii, 1. 
Railasewsky: Ueber die Muskeierkrankungen der Vorhdfe des Hereens, Zlscfar. f. klin. 

Med., Berl., 1895, xxvii, 529. 
Albrecht, E.: Der Herzmuskel und seine Bedeutung fUr die pathologieche Pbysiologie 

und Klinik der Uersens, Berl., 1903. 
AschofT, L., and Tawara, S.: Die heutige I«hre von den pathologisch-anatomiachen 

Gnindiagen der Herzschw&che, Jena, 1906. 
Mackenzie, Keith, Wenckebach, Sch6nberg. Quoted on p. 15. 
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path. Geselisch., Jena, 1908. xii, 165. 
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1904, txxix. 175. 
Marey, E, J.; La circulation du sang a I'^tat phyeiologique et dans lea maladies, Paris, 

Knoll, Ph.: Ueber die Veritnderungen des Herzschlogcs bei reflectiorischer Errazung dea 

vafiomocischeti Nervensystems; sowie bei Stiegerung des intracardial Drucks ueber-' 

haupt, SitzungBber. d. k. .^kad. d. Wiasensch., Wien, Abth. Ill (Physiol. Anat. u. 

Med.), 1872, liv-lxvi, 195. 
Hering, H. E.: Ueber die hiiufige Komhination von Kammervenenpuls mit Pulsus irreg- 
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Gcrhnrdt, D.: Arhythmia perpetua des Pulses, Deutsch. med. Wchnschr., 1907, xxxiii, 

Theopold, J,: Ein Beitrag zur Lehre von der Arhythmia perpetua, Deutsch. Arch. f. klin. 

Med., Uipz., 1007, xc, 77. 
Hewlett, A. W.: The Interpretation of the Positive Venous Pulse, J, Med. Research, 

Bost., 1907, xvii, 119, ■ 
Mackenzie, James, and Gibson, G. A. Quoted on p. 78. 


Polbk, S.: Ueber Tubereulose des Herzmuskels, Ztschr. f. klin. Med,, Berl., 1892, jcxi, 185. 
Broseh, A.: Ein Fall von Her^tuberkulose mit typischen Weilschen Symptomenkomplex, 
Wien. mpd. Pr., 1896, xxxvii, 985, 


v. Leyden, E.: Ucber die Affection dea Hersens init Tuberculose, Deutsche med. Wchn- 

Bchr., Leipz., 1S96, xxii, 1. 
V. Tabora and Tilp: Zur Kasuistik der Herztuberkuloae, ibid., 190S, xnsiv, Vereinsbeil 805. 

Cardiac Sr phi lis. 

Graasmann: Ueber acquerirle Syphilis des Herzene, Milnchen. med. Wchnschr., 1897, 
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itadium dea Syphilis, Deutechea Arch. f. ktin. Med.. Leipz., 1900, Ixix. 58, 2t>4. 

Hracek, F. : Die SyphtUa cies Herzena bei erworbener und ererbter Luea, Arch, f , Dermatol. 
u. Syph., Wien and Leipz., 1893, xxv (ErK^nzungahefte}, p. 279. 

Adier, L; Observationa on Cardiac Syphilis, Trans, Assoc. Am. Phys., Pliila.. 1898, xiii, 
73; and .\. York M. J., 1898, ixviii, 577. 

Sacharjin: Die Lues des Heraen von dcr klinischen Seite betrachtet, Deutschea Arch. f. 
klin. Med.. Leipz., 1889, xivi, 388. 

Le Count. E. R.: Gummatuof the Heart in a Case of Congenital Syphilis. J. Am. M, Assoc., 
Chicajw. 1898, xxx. ISl. 

Huchard, H., and Fiessiiiiter: Syphilis gonimeuse du cojur, Rev. de Mdd., Par., 1907, Tivii. 

TuMona of the Heart. 

Thorel, C: PathologiederKreisiaufaorgane. Ergebn. d. allg. Path, u, path. Anat, d. Menach. 

u. d. Tiere. herausg. v, Lubarech ii, Ostertog., Wiesb., 1903, ix, 1 Pari; and 1907, 

xi, Pt. 2, With excellent biblioEraphy. 
Hektocn, L.: Three Specimcna of Tumors of the Heart, etc., Med. News, Phila., 1803, 

Ixiii, .'iTl. 
Berlhenson. L,: Zur Frage von der Diagnose primarer ?Jeopla.inieii des Herzens, Myxom 

den linken Vorhofs, Arch. t. palli. Anat., etc., Berl.. ISO.'J, cxxxii, ;(90. 
link R.: Klinik der primarer Neubildungen des Herzen»i, Zlsehi. !. klin. Med., Berl., 

1909. Ivii, 272. 
Knox, J. H. M., and Schorer, E.: A Multiple Rhabdomvoma of the Heart Muscle, Areh. 

Fed., N. York. 1906. 
Wolbaeh. S. B.: Congenital Rhabdomyoma of tlie Heart, J. Med. Research, Bost., 1907, 

xvi. 495, 
Geipel. Quoted from Thorel. 
Luce. Quoted on p. 478, 




A certain degree of progressive change in the walls of the arteries 
occurs normally throughout life, and is therefore not to be considered 
pathological. The comlition of the arteries normal to a man of thirty 
would be thoroughly abnormal in a child, and those normal for a man of 
seventy would in turn be regarded as abnormal in a man of forty. 

Thus. Thayer an J Fabyan state that "at birlh the artery (radial) is delicate, 
translucent, cxireniely thin, and collapsing. The surface on opening is perfectly smooth. 
The i n t i ni a cunsists of a single enilothelial layer lying directly on the surface of a deeply 
undulating elastica interna. The media, whicli consists of transveniely arranged smooth 
muscle- fib res with rather lar^ vesicular nuclei, has a depth of seven to eight layers of cells. 
Connective tissue, if present tn the intima and media, is extremely scanty, none being 
revealed by the Maliory or Van Giesoii stains. There is, however, a relatively large amount 
of elastic tissue which npix^ars on cross section as very thin, pai'allel, slightly wavy lines. 
The elastica externa is neither as coarse nor as deeply undulating as the interna. 

" The a d V e n t i t i a , considerably thicker than the media, consists of compact con- 
nective-tissue fibres with relatively large nuclei. The elastic fibres are fairly numerous. 

"By the middle of the first decade, the intima has become thickerowing to the appear- 
ance of a treah layer of ehialica interna, while more muscle-fibres appear in the media. 

"10-20 years. Walls of the vessel become thicker but still collapsed. Intima 
and media thicker, the elastic tissue being relatively less marked. 

"21-10 years. Slight further general thickening of intima and media. A sec- 
ond clustie layer appears in the intima. In the media the connective tissue begins 
to be demonstrable by Van Gieson's stain. 

"41-50 years. Decided change. Lumen of the verssel remains open. Areas of 
calcification in the deep !aj*ers of the intima are frequent. The media reaches its 
maximum thickness. There is a good deal of connective tissue. 

".\fter the fifth decade there is a progressive increase in the thickness of the intima 

.... and a connective- tissue thickening becomes the common type The 

media after the fifth decade becomes on the whole rather thinner; there is a marked 
increase in the connective tissue. 

"Calcification in the deep layers of the intima becomes more common with 
age, four out of five cases In the eighth and ninth decade showing this change." 


Theoretical Considerations. — Pathologically, arteriosclerosis is char- 
acterized by the occurrence of changes in and thickening of the intima, 
which was supposed by Rokitansky to be due to the depositing of cella 
directly from the blood stream; by Virchow to be a true inflammatory- 
hyperplasia as the result of some "formative stimulus"; and by 
Thoma to bo a (compensatory thickening of the wall in order to 
diminish the lumen of the vessel after the stretching which occurred under 
the increased blood-prcssurc with which it was usually associated. Jores, on 
the other hand, regards this as a true hyperplasia resulting from 




the high bluod -pressure but mdvpcndcnt of the lumoo of the vessel, return- 
ing to a certMii degree to the view of Virchow. These observors con- 
sidered the chiiiigcii in the intiniK as primary, and 
tended rather to neglBct the second important change which <hftr«ct«rizca 
artcrioaclerosia, namely iiitlainmator}- ehangt^^ within tliv nit-dia. 

Un the other hand, KuHter and hin pupils called attention to the i m- 
porlnnee of deRenerativc and culeiircous changes in 
tho media and ndveiitilia mt well as in the intima. Kftslor 
studied ll>e inflammatory process very earefully by meanti of wrliil »iH-tion8 
and injected :<pcctinfiipi, »iid clftiiiiwl that the urinioncJerotic lesion alwaya 
took its origin in tlic adventitia an an infiltration h u r r o u n d i n g 
ihtf vftKu vftsorinn like a Ble<^ve. Thir* infiltration followed the 
vasa vaHorum into the nicdia. Kfisler found that in the normal artery 
the vnsH viuioruni do not pass deeper than the outer third of the media, 
though in certain iirteries (notably lliwie of the brtiin and the lungs) there 
was a fine capillary network penetrating the deeper layerji of the media as 
well and sjireailing niong the iiiedial nurfaee of the eliisliea interna. 

Chanses in Vasa N'asorum. — This view is confirnie<i by v. Ebner 
(in KoUikcr's Hundbuch <ler tiewehelehre), who stnu-s that "the media 
of the larger arteries imd veins, according to the consensus of opinion 
of many authors, eontains blood -veascU, tliough in small nundx-rs and only 
in the external layers; whereas the inner laycri" of the media and the intima 
weui to be always free from vessels (in the ox the wall of the vena cava is 
richly supplied with vciueU even down to the intima). 

T1i<^ inriltrntioii about t)ii^ vniui I'scoriini Icillow* Uieae {laltu, wttmiE tip srVM of 
inl\itraltoii, necnxiii, aiiil cnlriiirnli(>n in llii^ smooth muscle anil «la«tic lilirvs ut vtw iiii'ijiu. 
Whi'D it [ii-netrBlm li> ttw vlujilu'ii iiitvrriu u ninull iirva of this is linit iiijitrcd. Ihc inflnmmn^ 
lion ncia n* n utimuliii'. aiul hy|irrpluj<iH of the iiiiimn *rtii In. Thr Jnlinin lioronifw thick- 
eiiLtl until ilB colU iimtwi-Kii fc|H'm!iiietiij»i falty tlcKeiicrnlloii, iiflef whicli ihcy trillii-r calcify 
or r.hf ca|iil!ary nclwork (ifiipl rules Ihrou^li Ihepiuslicuiiileriiuutid a true iirocow of nr(inii- 
ualiun and |>roIircraiinn nf cnnnMtJvn tiiu-ijr gor* oa, 

Kdster ailmii!! tliai il is pomiblo itiut tho ile^netullve niid liypcrplaatic ^iuikg* in 
llie intim.'k may (pi on withoiU the coirancR ot blood- vraistU. n* do tliow Brcn in inAnmnin- 
lioiw of llie cornea; lnJI. ho nlsle« thai if llie legions iiw fuliowcil in serial wctioim itum 
i» almofit alwnys n deinoiMtmblu cuiitiiiuily between tlic jiuicbtit of cndurlvriiia. mear- 
teritU, and iMriartcrltix. 

The nundxir and sIkc of the vasa vasonim and the richness of Ihe capil- 
lary network are always increased in arteriosclerosis and in phlcbosclerods. 
He stnU'N that endarteritis occurs only in arteries that have vasa vasoruni, 
that is. in the turf^er arteries and in the smaller art<*ries of the brain and 
the lunfcs- 

K<i»iter"s version i.-* extremely fn.'tcinuting, wpeeially sincM* it prewnls a 
simple explanation of a complex picture, and. on the other hand, presents 
a clear jjiudoj^j' with the processes involved in myoeaniili.s, endoeardilis, 
and other leiiion^. As far as the media and ndventilia aw concerned his 
findings httvo been confirmed by OphiiU. wlioec careful study constitutes 
one of the mo^t important anil dearest of the rt^ccnt rontributlons to the 
siibjeel. Ophfils. however, was unable to demonstrate any constant rela- 
tion between lesions in tin- media and those in the intima. and believes that 
ihcy are produced independently though from the same general cause. 



Ho etatcf) that " anatomicalty artcrioflclprosis of tho ftorta is & unit. It iii 
A rhix)nic itillBDimnlury prwcss of tin- vciwl wall whi<;}i silliicks jiil thi* coumj 
fiimultEinoously, which as a rule first produces chaoRes in the intima and 
ailvoittltia." He believes* therefore thiil, iis Kostcr suggcsU'd, the changes 
in ihc^ intima begin an parenchymatous changes nithuut the presence of 
blooU-veiuu-ht, like iht- inf)iimitialioii» ivilhiu the cornea. 


I'ollowinK this \iev.'in adopting a pathological classification, one might 
(iii^ttiigitiiiii the following groiip.t of artoriaiclerotic Iiviions, rle{Hrnilcnt u|ion 
the arlvrial coat most nffccted nnil the distribution of Ihv lesions within 
that coat. 

i>aKiaMr:.;BTiiiKj lica.. 



I'l.;. i:.j 

11- lyps at artfrifuvlfirniie 1««niiii. Uichginalle.) 

I. Adventilin chicftjr aScctcil (no woskcniiiff of arterial wnJI}. 

1. Localtted or noiliilnr iiirili.mlioiw (prrinrl«riliit dcmIcma). 

2. I>)[fuse inliUnUoiui abuut Uic viuui viuorum (cnvwitig umfonoly ihiclc- 

eneit art«rlM which gf^n the twaiation of thick rubber tubing). 

II. LMJonn in thr mtriliu piv<laniiaat« (with wealuiliiii); ol the iut«riiil wiitl}, 

rxprriiilly rommnn in nypbilia. 
1. Iioualinetl iii-cfo«ii of «la>tlic tlsauc nilh calcif ieutiun 
(nthcromu) (|npp-aiem or "g<»M>-nM!k" nnc'ric*, SIOiickcbcrB'n urtcrin- 
sclcmii*, flxpcrimeiilaJ Inxic nr(»Tio»cirn>«i«). 

3. Diffime or |iiilt'h}- incdiiil fibruiiis Willi more or leaa oalcifien- 

lion, ofurn Iciiliiig to a,tKunfm. 

III. ChatiKM in (lie Intima pr«doininal« (wilh no weakening of art^rUl wult). 

1. Ujrpeipluiil* uf tnliinu with futty de^iierutluii at il« ccatrr (ii^nilc nortititi), 

(n) wilbiiut. (b) nith ciilcltintlon of ihr area* at fsttyiIc«cnrmlion (athciu- 
iDulouD plaijuc or "iilciT." "onilarUTiiis ilitlormuui." LoiifK^pe), 

2. Kitnpic by ptr r[>laaia of intimu (<UfTiiiie cndortcfitiii) with IncrraM of 

rbwilc flhmi. fittally loading iq 

3. Obli I erali ve ^nOu r l« ri I in. in which tbn proocM In iitill more 

climnic ami intmw nniJ capilloiica entnr fmm ibo viMa va«oniiu. 

Accortliiig to Writs and v. Winiwarter, aixl later Btier^r. this Uil is lu be iiliarplr 
dtlfprtTnliatetl from t hrum bfiungi I In oblitcrnrm. In which intravanrular cn- 
xeillation prrcinJc* or ih in<li>i>rniicnt i>f th* chanitf' in the tnllma. in wlil.-h the liiinen of 
ifae ve-M-l iinaUy beoouiM oblitenteil by sKrinJarily riirmiue Kranulation tlinue dcvMii 
of rhwiie fibm aoil acMng frwu slwiit thct iienty fominl enda of (ho ma vworuni. 

Periarteritis nodosa (Kussmaul and Maier) (Kupra-nrterial fibn>i(j 
nodulcHl. uiic of llic mrcr loriiiH of iirtcrinsclcroinB. iw pnxluccd by the for^' 
mation of small areas of nodular inhitratiouH in the ntivontiijn. and gives 
the \fsSK'l n nodular appearance and coiwislency. It is almost always 
closely associated with inltaniniator>' changes in the media and a local pro- 
liferative endarteritis (Zieglei). 



Diffuse Periarteritis. — The difTuae thickeiiinR of the adventitia {periar- 
teritis) i.t iiioiv I'OTiirnoii, orcvirriiig nbout liie iirUTu-s of llu* bniiii, nboitt 
the coronarj' artorica in myocardiliM. sntl in many other organs in subacute 
inlianinifttory pmcwac:*. In the radiiil am! oilier !ars;e arI*Tii>.H it sw-ms lo 
be quite common. The uniformly tliickoiied artorieji of leallicry conKiBtcncy 
wbirh are so commonly met with in yonnt; or miildle-nKed persons who do 
hard work juH-in lo bo of \W\* lyiH-. ihougli Iht- fact has not yet Ijcen settled 
with <icfinit^ne&s. Whether such ehanges may be transitory or are alwaya 
pcrrniinenl hs.f nut hvvn (Icfiiiiu^ly wtlk-d. The boy of aix cited below 
(page 2.1!)) may perhaps represent such a case. 

b^kcrocmpti* Wv Vt- i'- S. IloruD A, Oov tfOUnik of llm rtiliir Arl^ry Op* pitvrtr^. H. Ijoimr Ufi. 
)iikv(\ i:'jriicr of \hr «ftlnr< npofinicfi Oiisl'lv QiasniJlfU 'li>jvii-f ■ir.'f Fuctkoii cf lite rUilim inremn uu-i 

with t"n*lifrn>TJi»i uf while liltrcmi tivijn iff nttfi UUtKl-yrmpi'ln yBL;- yK[|i[li»»*of Vrxit. Vi . OphiJv-i 

Medial Changes (Me-tarteritis). — The rigid " pipe-stem" or "tioose- 
ncek" nulinl arteries often met with in very old person.-"! are fornwd by ihe 
prenenee u( an-a-t of dep-neratiim and paleifieation within the tunica media. 
Thi.s I'ondilioT) oeouirini: without any changes in t)ie intinin hii.i l»oen de- 
8cribe<l in man by Mimckoi>erR. and represents the type of HrleriuiteterosiH 
or art«rioneerosis produced ex |KTi men lolly in animals with bacterial 
toxins, acids, adiv-nalin. and alkaloids. 

CnlclflcnClon.— AcconiiriK lo Klolt, Wcll». Hn<l Piildanf, thp procnu oF enlHficnlion 
WWUIH lu ga uti in llii^ fullonliit; wuy: As d ntiull uf llii- iiiHiiiiiiiiu<i>r,y rliane^'e, llii? iiiuxcle 
epIU (IrgcnrraU. nmi the WiTliiiw Impnnir *i>lit up iiit« fntly HCidx. niyterupJiiwplLic ocld, 
anij rhotin: csiiKtriff ihc Hpix-uniTKi! of n fallj tlf-j;viierallun. The e-.nii'mni .inii mngnrwuin 
in ilie Kruiii Clwii L-nter into conibinntion with ttia phocphock acid and are precipiTut^d lo 



Fnnn luiltmrooiui plaqiini luid (trnniiidi in thtt modia. KIot> beliewe from hwiivchniiical 
evidi^iicc that there is iiilcmmliulc or MiicomilHiit formnlion of cnlciuin noapx. but Wi.-ll» 
will Bsliiauf liavr not found noap* on chnnicul aiialyswi. Balilaiif nml aUo Scliii find that 
tnoet of thp calniiin i» in ihi- funn al phnsphnl'' niiil nulphntr. litllv us carhuiiH(i<. The aoh 
froro HiK-rioiclrrulic idainies CTinluini'il I'aO 5a,3S4 [d-r cent.. Fc,0, O.H.i pir wtnl.. NiijO 
0.72|irr(i'nt.. K niily Iracra, P,0, 10.19 percent., SO, 0,43 I*roeol.,('l tracf, t' ncRami:, 
CO, Iniuw (!w1i|;). 

Ivlot* liniU that th* calcitim ia bjr no inrarM aluavK (Ifpfwitinl in thp pHtchrs of nihp- 
ntnta, hut psimIs jiUo aa rows of finp imtniiira bi?tuvc-n llw tniwclp-fibfwi, In tliw mmli- 
lion it givHi no inucruBcopic evidence of lia prvst'iicc, and nirrcly causps a uliflii increiuM! in 
ihn riifiility of tht aitcrj-. Whnn ihc nr«roiii> of the nrlfriul 
wall pruc««di> tnoiv itluoly. (lie {>hwipliori(^ acid or (tlyrvro- 
pbacphorie acid derii-cd fmm Ibn fccithin in rvniavi>il by tlio 
blood-^'flMete (capiUariwi of ihn va*a v«>ioruiii) which cnlrr the 
diweuNKl lUvii ut tbu media, iind l)ie iiijiinM) eUxllc tiviiio I* 
rrplacot) by Rbraiw twstic without the depoiution of calcium. 

Whetlwr the ralrium U depo.'<it4'il or not, the 
area of discatted iDctlia. constitutes n weak- 
en (mI portion of the wai! ami is the Ipsion which 
in the liirgc arteries is piirticuhirly resjiiiiislble for 
aneuritiin fortuiition (see also page 521). It hue 
been claimed by some writers (Heiber);. Heller, 
and others) that (hi.* le^on wmt roiifiiicd to luetic 
cases, but both elituenl aud experimental ilala 
ahow that it ia due to non-hietic U'.-<iuti» about 
as frequently t\» are any of the other lesions of 
nrlerioaelenwis (OphiUs). 

Inlimal ThicKening.— The leaon which Vir- 
ehow, Thotiia, iitid iiiniiy writer.-< hiivo regarded 
as the fuTtdnniental one in arterioselerusis in thirk- 
eninjc of the intima. Virrhow believed llmt it arose 
lutan inflamnintory hyperplasia resultinR from Home 
"formative stimulus" within the blood »iii>!ini. 
Thoma btdioved that thi.* stimulus was the me- 
chanical factor of high l}!ood-pit>H.aure, and that 
the thiekeninK of the intima rrpn'M-itCed u com- 
pensatory hy(»enroi>liy lo prevent aneurisms! dila- 
tation; but OphiiU hafl Rhown thai, in marked 
eontrasl lu the !in.\i of medial diwase, there are no 
bulKinf!;^ of aortic wall at the area^ of ititima) 
atfieronitt, even wlH'n ihc artery is distended under 
a pressure of 160 mm. Hg, 

The ■■forniftti ve stimulus" U probaljly not tucchanica! but 
chemical. |»rlia[>s the same as those which have Iwcn shown experiment*llyi 
to give ri--w to arterionerrosici in »mall animals. L'nder the influenw; of these 
stimuli the intimul layers undergo hyperplasia, with increase of both fibrous 
tissue and ela-^tic fibres (Imk, l.W). Sinoe, as Kflster hoii shown, there am 
no blood-vewtoLs, but only lymph spaces or lacuna', the hyperplajiiii soon 
reaches its limit, and under the further influence of the toxic afient the 
pcil.-^ ftl the centre undergo "fatty degeneration" from iseha-mia. Such 
areaa present at first a IraRsluoent appearance and are known aa areaa of 



Pkj. t&S.—ArfinciivlfnwU 
iiic ■UiBrauutloiu ptaqvt*. 


"acute aortitis." Later calcium salts are UHually deposited (as described 
above), and ihey become converted into calcified plaques of atheroma or 
atheromatous ulcers. When the process is more chronic llierc is usually 
a waiiderinR in of capillaries from the media after the matmer described 
by Hosier, and under the iutluvnce of the impfxived nutrition the intimal 
hj-perplasia may go on at an increased rate even to tlw obliteration of the 
lumen (endarieritia obliterans). Thromboangitis obliterana will be con- 
sidered in Chapter IX. 

Unity of Arteriosclerotic Processes. — Although a large number of 
writcTB attempt to put each caae iniu one or tlie other of tliww groups, 
Ophitls has shown, by a careful complete study of seventy consecutive 
uiiMilccted caaes, Uiat such divisioDit arc based upon unessential differences 

FlO. IM. — AUwramatoiu piMiw. (liowiDa ttit «bMiBe> io tbl tntima. (rhnUHnirmoimph by E)r, 

i.^hftrl» ». DoDri.) 

and that, as a matter of fact, any or most of the forms may ariac in the 
same case. This division wiis attempted csi>ccialiy by lleibcrg, Heller, 
and hi» pupiU, who Iwlieved that mesarleritis. particularly when it attacked 
the first part of the aorta and the a.-«cen<ling arcrh, was characteristic of 
syphilitic disease. While it is quite true that syphilis may give rise to a 
mesarteritis, and occa.-<ioiially even to the formation of miliary gummala 
in the adventitia,' nevertheless these lesions arc far from characteristic, 
and very similar »on-liielic atruriurea occur about thrombosed vasa vasonim. 
Moreover, Ophiils was unable to find any difference in the distribution o( 
luetic and non-luetic arteriosclerotic lesions in the seventy cases of his 


The moat important etiological fuctors in the production of arterio- 
acleroos in man are age, bard work, alcohol, syphilis, and the more acute 

' Some wriiera daim to have (outiil the splrocluBle pullidii in tliwe leaioru by niMU 
at Itut rather quntiuiuibic Levadltl's ulvrr nitntr mrthoil, IhouKh Ritur, Bticrgcr. aad 
msny others hav« fnibd in npiltr of puiiislakiiu; ernirch in many eaw«. However. Collins 
Kiid Such*. I Aiiicci )(>■■, and Cloiigh ami (iiithric ul the Julms Ilopkiiia Hasj^ta) have been 
nble to (liugDOsE luetic arltnoMleratiis during lifo by the Wuummiann n-oction- 



infectious diBeaaes, enpecially lyphoiil fever. The pclativ* frcqucDcy of 
theae causal fuctore, nn indicalej by the palpability of thft radi&l artery in 
4000 coneflculive eases admitted lo the .IoIihk HnpkiiM Hottpital, Ims Ix-cii 
made the !tubj«cl of a careful study by Tliayer and Brush. 

Tht»« olM^rv^rs found palpable art«ri«a in the fullowing pcrcuDtnge of the patietita 
uailer fifty yestm who bnil been aubJMt to variou* ctioloKicnl TticUira: 

After acArlatina, nulialH palpable in 16.4 per onit. 

No obuulI fuctur, nuliaU palpubic In ... l^.S pet cent. 

Pnctimoni.i , millnls pnlpnblc in . . . 17 per ceni 

ntpliihcria. nuliubi palpable in 17 per oeal. 

Mulurin, nxlinli polpcUnin. 20 per<«nt. 

T)'pli()iif fevi^r. radiala palpable in . !!0 |ier ceni. 

Khfuiniiliiin. rniliul* palpnbtp in . . . ill [xr rwit. 

AliHihol. niHiaU palpjilile in 48. S pvrofiil. 

HikriJ wurk. radiiilH pulpublo in .>7 5 |km <«nl. 

Ricliard Cnbat tatuti cxooprion in tlieiw fiftdinsx of the high (ivi\UFaey of art«no«e(ornela:| 
afUr aleotiol. basine hio roiic1ittiii>TiF< iiiion itulnpttica uf dijisuiii^iiiiaoi tinder fifty in wlimii| 
tic nay BrlGriutckTUiiii wns not ptc-tiit in niurv Ibuii Iweiity per ccat. Hin RXcepUonii la] 
Tbayct's flndinn* nnr, hoivrvrr. wiiiicwhnl iicaliwt the ip^ncnil canwntiii* of opinion, »« nfll ' 
iu> OKaiunt tlie experinieiiVul evitleiicc of Aubertin, wbo pruducoil arleriosclcrouin uiitl etirdiue 
byprttniphy In rabbits by ilie inirctlon of nlculiol. On the other hund, (.'4it>ol Ik nupturlcd 
by Fahr, who pcriormnl 'W atilopaii* on hikblciial dniiikaniii dyiriit « tlie Harbor il<iti|»tal 
of Hattitiur;; and tuunil arli^riusclurutic ohuiiKiu uu mora cutiiTuuii tliun t[i alBtcinious inili- 
riiltiiila. occurring in 95 east*. '>i2 of whom wnte over 111 yiam of agr. Oi'ly 7 rlrunknr<l» in 
LixMrlnidl^d lieforr 4Ufron>onviMW(vferablo Urartfnorciim/itiit, Si ruiturchaiwnni.- .tinted in 
only MX other jwlienta under 40. t'lilikc Auberlin. I'uhr u*a* unable ta produce nrlerio- 
■oterosis in rahhitA by luIniiniAtrjlion of alcohut for o\'er two years. From this il would 
nppeiif iliiil Ihe evil e(Teel» of ateuliol ha^-e been coiulderably exajntPiultil. at li-ast iw far 
tu ihe nrterie* nr(! eiinettrnnl, Il tnuiil bi^ bornn in mind thai indulifenee In a certain 
■mounl of alcohol i» alniiwl univi-rnat, <w[MM-i»lly in Ibone peraunii who do hard work, hencu 
it i» extremely dilfieull lo »ri;n'gnte ihise fucloni in any Inrp; number of cases. It, for 
example, a pnllent hiw hail typhoid fever, hiw iiHrd aleohol, and hiu done linnl nnrk, it is 
nut logical to euler hix noaie into exch of the three columntt. for it ia nut p(»tible lo det«r- 
mine which of ih- faclorn ■■ Ihc moM important. 

Fortunately, hnwe\-cr, for the decision of ihnw doubtful polnca. the esperimenta of 
Pic aiul Bunniunour (1, c) upon ex |)e rime ii till tulreoalia uiteriunelerons hm'e iihown that 
wherf two fiiclor* arc actinf; t(i|{elber. arterioMrlemil* may he produced 
in con<liliunH in which ii rnul<l not be brouffht aboul by one of ihein lUone TIiuh. tuber^ 
Gulonlii 1- adrMialin yiet-leri BrteriuHlerunia in yuuuK rabbita which would not have Bhuwit 
iin«tio«cleroci* aflor adrraaltn nlono, anil thont ia nn doubt tliat the Mm* J* true ui man. 

8 y p h i li .« i.'* a most important factor, esjjecially in ihf art*rio.icli>rn.'«8 
which occurs below the age of thirty-five. As staled above, it was ^supposed 
by Heitterg, Heller, and their pupils that luetic artcritiH asitumed a definite 
type, the itiediu, the advenlJlia, and (^8lM;cially the vasa vitsorum showing 
considerable small muncl-celled infiltration; but. allhouRh it is possible 
that the nwilia and adveiititla arp attarkcd ixwtv ronstnnily than in other 
forms, this form is not to bo regarded as specific. The tendency to form 
legion.'* above the semilunar valveii am) alon^ the lutcendinii aorta in by no 
meaoa confined to arteritis of luetic origin (Ophiils). though extremely 
frwuM-nt in the latter (Osier, Collins and Bachi*. Ijongcope). A positive 
Wasseriunnn reaction is often obtained in cii»es of 
luetic aortitis in which there are no other active 
luetic pro>cssc8. 



Lead poisoning (especially chrauic plumbisui) uml gout Bre 
important etiolo^iral factors, as U also chronic nephritis. Overeatine 
i» thought tii play iiii importftni rdle, especially when liie diet is ricli in 
meats, swectbrcacis. livere. kiilneys, et«.,— in other words, in purin bodies 
und iu kri-Ktin. The exact nUe of the^' dub»tatice» has not been carefully 
studied, although Croftan found that long-continued injrrtioD of 0.5 to 
5.0 mn. xanthiu into rabbits cauhcd a rise of furly millimetres in blood- 
prciwurc, !v» well as sclerotic- changes nt least in Lhe iviml arteries. (He docs 
not describe the condition of tiie other arteries.) Krom the gtand-point 
of both blood -prcfwii re and gnwous nictnboUsni it has lx*n ithown that the 
digestion of large meals materiatly increased the work of the body, pro- 
dueing thereby »n effect not (li.^riimilar to that of hard phy.Mral exercise 
(increase iu pulse-preHsurc, increast- in pidse-rate. increase in CO, output) 
(effeel of laTRe meal, after Erlanger and Hooker). It is therefore quite nat- 
ural lh»lo\'crc«tingshould r»nk with hard nurk asaniain cau:«nf urle- 
riosclerosis. but the exact extent of its occurrence is more difficult to deter- 
mine ill ft large !*erii',t of caws than in an individual raw in jirivate practice. 

Lastly, and still more important in the etiolog}' of arteriosclerosis, are 

age and heredity (Israel). 

Thu*, tMer BtAtci that "entire fiunilicit samcttinai allow thU t^iulency to eJiriy 
arlvrJOHclerwiiB. a tendency wliicU cannot lie cxjilairicil in any other way ihnn ihat in Ihc 
nuikc-up of lla- niacliinf Ijod nmtcriul wiu iweil for llie tubing." TtiU in npi>cia.lly Irtic iw 
nvanl" nlcohnliiiin. a* hut' liccn irhown in a recent ulnlintical itudy l>y t-^mrnuin. vihn rrnini) 
thut ihin factor was of mure ini |>or(aucL- ihaii tlw drinkliiE of alcohol l)y (lii^ individual 
himself ill dctpnniiiinK iirtcriiwclcrocii niid longevity, mid lliat «ti alcoholic ancntry van 
very fivijiii'iilly followed by ii i^-iitTuliun u'tdi u loiidi-iicy tu early artcriunclf-'tuHis. 

E\periinental Arterionecros's in Animals. — A most interesting side 
light upon the genesis of arteriosclerosis has been thrown by attempts to 
produce il e^iK-nnentully in animals, (•.■specially in rabhili* and guinea- 
pigs. The lesions which have been produccti cannot be termed true arterio- 
sclcroKi.tliko that seen in man. but are confined to the media and ailvontitia, 
the intima always remaining clear. The reiuson fur this is not evident. 
Even the pos.'^ihility that in these entail animals the blood supply of the 
arterial wall is differctit from thut in man, and that owing lo this dilTerencc 
lesions occur most readily in the media, docs not hold, since Ophvils has 
deniijii.*trati-d the occurrt-nce of spontaneoua endart.eritl.'* in rahliil.i. The 
experimental and clinical conditions seem to be closely analogous, but it 
is not pos.'uhle to draw an abt^olute parallelism bi>twoen them. 

Gilbert mid l.iun hn\-c tm-n nbli- to |)n>duci; urteriuicli'raiiit cTficriincntnlly in Kni> 
tiiahi by the Irijerlioii of bacterial loxinti, ami llirii haj> linrn conrirnicil liy Kloti. 
Thi> fact in of Krciit ini|H>rtanM. nut only truin lhe iitnml-|ioint of exjieiiiiicnliil urlcrio- 
sclcrtMiii, but ali>» Ixrcnuur il ut.la1>li*h» llic impnrlnncc of liactcrial disciLv iji the Htolocy 
of art(-rio9clurtBiit iiicl uidi clltiicully. 

Thp c;irli™t oliMTviuion of urieriusck rosin brau;;)it uboul by toxic uction of orKunie 
CORipuiiiidii. aii<l one which e*ilahli(ihcH beyond doiiht liic <lclct<rrii)iiii nction of I nbacco 
iijxin Ihr nrttrrics. i« that of Isiiac Adlrr. lit^tnonst tilling Bcl^ruxiB in the Moaller petiphenl 
*rtcrie»i of rabbit* an a tMiili of fccdiiid thetn with infii»ii«i> of tolucco. Boveri confirmed 
iheic resultn byitivitiK infiwion of IoImicco by utoinach-Iulie, and obtained atlien>rnnT<iil* 
p]nquc> or ihirkniiiiK hI the iNiii' of llip autia in ten out of nixtt^n mbbtls, whilt- Ba.vlae 
ubtained ?clcn>i>i in each of eiicht rnl>bil« into which lobucco infusion vas injeetcl cilhrr 
intravenouily or suticiitancuunly Jcbfonvky and later W. E- l»e have prmhiced it in 
rabbit* mode to inhale tobacco ■niuke. ■•'roni Bayloc's cs|>erinieii(B it would ui>|H>ar that 



in geni-rul the lialijlitj- to occunviioe beam uoiiit- fvlation to ihe chaniip] by which il cotcni 
ihc bmly. Thi» may r'Jipliiin lhi> very marked lU'linn oS lobucro iniiitlcd and rixU^T'inn Ihe 
lirart <lirvtll}- [rum tlii; [luhnonuiy circiilutiDii in itmokcrs, n« «oin[iar«d with tlii^ suiiiewhut 
iiiililcr i-nnrUi of clicwicig tobaccu. uoik-r whidi cunditiuii Ihi' iiicutinf pumcs tliroUKti auii 
IS porhuiK suriiewhal !ilt«niii(lctl in Itio livvr tWoro «-nI«riiix ibi! nysU'inic circulutiuii, 
and hiw sliit t« piua tliruugh Ibe \awf cuva-. ri^ht tieml. aiiit piiIiiiiMury virculutiou befon: 
reacluiiji tli0 coronary circuUlion. In ■nu>king, bown^'cr, the nicotinn enit-t^ ibniugh 
ihu lunipi uad ilrikus ils liret blow iit tbe coronary nr(crit» ftn<l bttst* of tbe uurta. uhcjn Iho 
<-lMt)c ^lirctt niw iinilrr ihn ftn^olot- Uiuiion luul iii^iici- muni liable to (kgnnrmlinn. Ii is, 
thcrefcirv. (.iisy to uiidc-islnnd why nniokinK of heavy cixum Hhould be one of Ibc tnoil 
pOI«nt faclon in ihn I'tiology o( mteriutclcRuin luid vurouuir HclL-roiia. 

An ulaiust new «ro in the sliiiiy nl nrwrioKclcniais van, liowov«r, introduced by th« 
diHcnviiry nt J<a\i6 that the rapealc'd liiiravchouH iiiieeiiuii of ndrcnnlin 
into rabbiU brought nhoill wlorcM* an<l cnlciHcution in Ihc nnrta within a few nievkB. 
Thin n'M vcty suun confinned by W, ICrb, Jr.. who iimduoc^'l ibe IcoiotiB in a lur^ numbrr 
ot unimnl)-. nnd dcinoastmlcd thi^ conaidcrublc unifutniily with which such InioiWL fol- 
lowed thr injectioiiH. .Similar rettiiltfl liavo l>wii nhtnincd in rabbiu by Fitclier by tlic 
Lnlrftvcnoiw injctlion of n vTry Inrgc number of ■iibBiiuit'tB.^by drochloric acid, 
phonphoric acid, ln«lic acid, calcium [ihntphatc, ch lora I n ni ide, 
morcurii^ (■hlurtdc, trypiiln. diurelin. and phy bloI uki^dI suit *olu- 
tioB, to (hal (he effect can acarcc-ly lie coniidcrrd lu upcdfic for niiri'nnlin,' 

On the other hand, I^c and Bonnaiiioiir. an well n» Adier arid lli-riwl, have eallud 
atlonlinn xa thp fuel ihui in none of the oerlen of eitperinienia publLihed did more than a 
certain iiuiulxr of the nniinab- injre(e<l Hhow loionA. ami In a vi^ry lanic Maries the lultef 
shown! ibat it was pnicticallj' iiiipu»ible (u pnxiuco HrlvriuwIcnmiB in rubbjtA by thnw 
pniHonn tintd lh<-y had attained a certain age. Afler Ibat i^[c artcridftrlcnxifi occa- 
lionally oocunwl apiwUneoiuily. bul ooiild Iw bronsht od with coiiHidi.'rulile fns|UFiii-y by 
rhe injection of toxic aubulancas. .\h stated abon. I'ic and t*onnuiiioiir fuive, howewr, 
been it)>lc to prtxhire it in ynuitK animalf whov vitality wa« ihniiniiahcd by luberculuua. 
trie., indicating tlial dianue uuiy bn an nenfoory (acliir in diniiniahint: the rrsiHtance of 
the artericH Ut loxic inflnenor« which ordinarily Ipa\-e no lr*f*<i. This carriw llie clinical 
eofollary ibal persons liable to arteriuwierolic chmiKCfl should jwirliculnrly avoid all eon- 
tributiiiK faetor* (aJrohol, tnliaeeo. tiard nnrk, etc.) for some time afW'r inrfflii.>im<liseaBi», 

It il <iitite remarkahlc thai pMirMi and Daldauf, ax woll a« other in vest i|cii tors, report 
that they have liecn able to product' arte rime leruBia. and that Jcmiif claims lo h&\e 
produeeti |*riiiannnt elev.ttion of bkii>il-prc-««<iitT in mbbitc by a single Itijeclion of odtvn- 
alln, >iine<r Kleislier an<l Loeb fuilcrl to do to tn • lati<;e seriea of osprriinenta in which auch 
inJH'tiorw did produce »ie\'en' myocardili*. 

MechaniHin ProducitiK B\pcrlmofi(al Af IrrioKleriMis. — The nieehanisni by uliich 
iirt«ri'>*lern''i« in produced has been ibe object of eimndpnible study. In ttw caao of 
adrenalin ul least. Erb believes that a spasm of the vniia vanorum tukeii 
(dacr, hrinninR .iboiil an insufficient blood supjJy lo ibe coats of the vnurelt. nnd (hcmby 
■•cha'niic deji^neration of ihr latter, rapeeially of the tunica mmlia. Thix view was ulsii 
Hharrd by I'canw and Stanluii and other olxervers, but Ftoisher aiid Lu«4i have sbown 
that consideiablt! arena of nortn may be kept inchaemic by coiii- 
pnwuon vilhoul pri><hiciii|[ a rierioaeloroaia. The fador must, tlierefore. 
be toxic. It in pouoble Ibal in somenuea with high blood- pnvaiite nrlual niplurc of the 
w«akcneil elaitUc flbrra take* jilace, which nnrven a« a centre fi>r arean of iiecr(wi)>. W. H. 
Harvcy has sliown thai it bits of excised aorta arc fille<l with acnr under various ptisieiinM 
aiul then lnii»planled into siihcutanrom tiaiue, thnie under t«n«lan deiten- 
crate more rapidly. The same i« probably true ot the librm nirhin the artery. 
lloirmvcT. Jnau^ luu shown that rejimted injeclions of ndreiiolin in the rabbit are follnwed 
by [M-nnauenl rim in binnil-premiire. An increaw ID blood-prtMnire h indeed the rule in 
arterimelemdi. altboutth. as HaM-nfeld has |Hiiiiled oecura only in iiersiins wluitr srlr- 
roitiM invnlvcH the splanchnic arteries. Neither inictenoe in blooil-pmwiint ni>r hypertrophy 
of tite lic«rt nenwarily ooetirf in patleniH »Iicre thcMi vmsels atv not Involved. TIh 

' A manmary of the recent Ijtersf iire upon ihi^ point will be fouiul In (he papen ttt 
Aaltykow, AtUcr. nnd BcikId. 



reaaon (cir thii may be thnt the ruinnx dowii of tbn cirriilntinn of »a liugc an nrcn u 
l)ii> »ipJanchnic recion in iuoli iiictvaMs tlie reniMiaiice lo btixxj flow and (hrrcby niuta 
lireHUiv. Tbi'cv in aJso do dtiubt thai, bniflo tbe aiiiKlc attcry invulved in tbe BcleroMC, 
thir latlt^r i* oftra tlie rcHult of proton^d viwoDiolor «|imiii in Ibc Icnioml >trl«ry, etc. 
Oil Ihe olher hand. luoli npuBiii niuy be truiuilury and be aci.>oiu|iiiui«d by liuitpomrj' 
rinc of l>tixKi-pn!«uiv ntui tirniHin' phrnarnnnn whlrh raiiw the sytidrcimni doxribed hy 
Fti aa raMiiiiulor crieea (m» [win' ^OJ, Aubcrtin, Vu(|Ui.'a, Wieec-I, and utliem liuvi- found 
hypeililo*iu of (bi' adivnuls pnwent in niuny cxpi^rinienttd ami rliniciil cnndilionn in 
which hyiiciirojiby »f ibr bcjirl and hif;h blood-jireMsiire air prcH^nt. It tberafure swiiis 
<)ui[« puHaiblv. in ibe h|j;bt of thfwo liiidin]», tliut bypertrupliy uf Lbe beurt luid nilrrio- 
celcnmia may «fU:ii tic lla' nviilt of n bypcriccrct I on n( adrrn.illn, |.>frli!Lpt> 
aliM of ainte olber int<imn] ^ficrelions. Why ihM H>iuidd bv uwiuciiitwl wilb nplanclmie 
BrWrifwfflpnjsisis t-nay toBfV. 'llie laltcrPoiiiUiion teiidii(odimini»li ihr oircHl.iIioii thrmiith 
ihc abdoniinnl vidcrtn, and more blood ii thus ahiiiilnil thn>iij(h (be aiifviial arltfri™ which 
lie juct ttbuve the ine!«nl«ri(^, Lhiu bringiag about aii incrcuw; in adnuul nccmiion. 

It may be a<l<tf<l (hul Buyor, in Kirhl'x cHnir, h«K j<liown that some- 
times the hifih blood-prpssui* is, in part at least, dependenl upon the 
iiiiiuuiit uf »h\{ in the food, being low on Mili^free and high mi diet rich in 
salt, though this m by no meuiut the rule. 


A« regards the ()i.sinbution of arterioBijIeroiic lesions and its relationii 
to etiology, Harlow Brooks hus given ttic following statistical summury 
baeed upon noten of autopsies on 400 cases: 



Etiukjgisl tacWnv 


AJoohol 149, amung laboran 118. nitpbriii* 51, iiypli- 
ilix 38, old aee 38. Blalts 27&, ftmwlM 135. 


ViMcral trunk* 



Aleotel 107, ncphritiii 3i, iTpldlla 37, exctnive 
tobft«ro 9, 



Alcohol 48, nepbriUn 21, ayplulix Iff. 


Atmhol 43, ncphritj* 10. ayphilw 10. 

Alcubol H<. HViibitis 9. BVnililv 9. 



Alcohol 12, iirphrilia S, jvpbiliii l>, *rmhly 3. 



Alcohol i), fcyphili* 7, ni^pbntis 4. enducarditii 2, 
WMiillty 2. lulwrauloniB 2. 

S3^hiliN S, amilitv i. alcohol 4, tubetciikudH 4, 

rippbrilift 1', 

Coeliac axi* nnd bmncbt?* . 


Most of Ihcm with nlcoholinni. Sclcronii of inCMti- 
trric, nil cawv wtih adipoitifi. 


Alcoholic 4. ByplnlJIlc 4, luCBt of tbe rert in primary 

Kpinnt diicaMW. 


Art«rioiiclero«a in infants, children, and young persone while rare is 
not extremely so. 

Accordinc lo Fremont Smith, who ban jtivcn an nxcrilrnl ivvicw of the subject, 
COnc«nital iiyphilis is the cauw in about forty per cent, of the casiw. and dipbtlicria. ncarlet 
fever, and lyphoi<l fever, a« well a> infcctiona in the mother duritiK pn^ancy, aif impor- 
Iniit factum. Tlie blood-prcMiire it not tuiialljr eleraltxl, often being; aa low an 70 DUn. 



Qg. Tbe iiTil«r ho» m^n onp csnt; o! a txiy .iffed nix (nifTering from ncute ntplmtia, coin- 
plicnteil b.v Inbar iniciinKinia. larui- biicLlliui euii uImci-mi at ili« butiockf. ct'slitio caiued by 
■lie i>amp gonn. «ho in »|iilt- <if comitiuoUKl.v low- blood^prcHsiiR devckipwi lortuoiw and 
■ppnranlly lluckeiit'd U-iiiponil and Ihlckenpil mdial iird'rio*. After a few mnnlhn ihcfw 
arlcrini uth- no lonttiT pnlpiiblf. 11 ia (KHiiihln i}uil tlinw chAoeev oiaj' bitve ttuvn merely 
luuiiuDUcluur iiifillntuon about Uic vtwdIh of 'he advcniitja. 


Cli III onll y , the flyniptoms (lin" to urtpriosrleirosU usually expreaa' 
ihemselves in wvcrul group* (k-pcmk-iit upon llic arteries most affccU'd. 

(1) Cardiac, associated with myocanlitis and eoronarj- acleroflis; 
often with rcnid syiiiploriiH (.see Chapter IX}. As ithown by Fleiahvr mid 
Locb, the myocarditis may be produced by the same cause and may be 
more severe than the artcriosclemai;* itself. 

(2) Simple coronary sclerosix, paroxysmal dyspncea, angina 
pectoris, A<larii.'^lokes syndrome, paroxydmal tachyeardia, suiidcn death. 

(3) Cerebral symploms. 

(4) Aneurism, 
(fi) Intrniitt te'iit claudication. 
(6) Vattomolor crises (Pal): 

(a) Abdominal pain from vasocon»triction; 

(b) Kaynaud'a disease; .* 
(r) Piiin diiwn arms and legs. 

The clinical ch!iraeteri.'<tics of the cardiac and renal cases have be« 
tltaeii8Be<d in Chiipter IX under the head of I lie in y o r a r d i t i s whicl 
invariably accompanica them. They may be briefly summarixed lut 
shorlne^^M of breath, especially on exertion. ofl«n asthmatic or 
paroxysmal in character: palpitation; weakness ; occasionally a 
conwdentlile doftrce of nervousness, loss of memory, and iniwmnia. 
In advanced cases with some wlcrosis of cerebral arteries there may be more 
or lens transient irrationality, e-tpecially at ni^ht or on awakening. 
Thtre may l>e pains over the prccordinm. in the shoulders, or down 
the arms, or in the alidomen or legs, which may be definitely assoftutcd 
with periods of hijth blood -jiresau re (the v«.somolor cri.-<cs of Pal); there 
maybe sudden pain and sudden paralysis of a leg, di.-4ap- 
peanng on rest, reappearing after a few steps are taken (intcmutlent 
claudication, Charcot, Erb); or (here may be severe precordial pain with 
a feeling of weight and constriction over the sternum ami an utu-rablc 
fear of impending deaih (antnna pectoris). On (he other hand, the hand 
or foot may lieconw cold or numb, the pulsation disappear from 
the arteries, intense pain M-t in (Itaynaiid's disease), or fmally be followed 
by gangrene (Iliromboangilis ol>lit4.>rHns). Still further the patient may 
Buffer from all the signs and symptoms of aneurism. 

On phytsical examination the radial arteries may or may not 
found to be thickened or be aded (atheromatou.s), det>cndenl parti} 
upon the distribution of the !(ctem.'<is, since the radial artery may be spared. 
Some writers stat*. however, that in men who do hard manual labor tttc 
nuliai arteries are the first attacked, while in those who lead a sedentary 
life Bck-rosis may ap|>ear very cariy iibout the baae of the aorta, and the 
radial, nevertheless, may be jwrfectly normal. 



The Mlery in which the ^lerosia is next Diost resdily olwiervcd is the 
temporal, whifh usually stjiiulsout like iicord oris ver>' tortuoux, and when 
pre^eNNl agaiiiBt the bone feeU thickened and lealherj-, Tht!!i turtiioKity 
may aleo Ix- prc-scnt in the brwchiuls iind even in ihp ubdoniinsl aorta, and 
in probably brought about by the stress of ihe arlerial leniiion exerted upon 
thi* walli<. which are in iwmc p!at-CM weiiker itml ebistic than in othent; 
80 thai we have a forre (bl ood -press uie) which is exerted equiilly on aW 
»idi-« agtiinst n*all« which interpum^ a greuter re.-<i.stKnee on one side than on 
the other, hence the curvature resulte. As mi^ht be expected, the tortu- 
ousneiw is therefore greutor when the dii>turbin(; 
force is high (high blood-pressiirp) and lei*< when 
it is low, as ^hown in the figure (Fig. 157). 

Other mipcrfifial arteries which may be felt 
are the brarhials, axillarie-», faciaif, popliu-ala. And 
dorHatJ!^ IX'dis. 

Changes in Ihc Retinal VciuieEs. — Himchber); 
in 18s2 c&UihI attention to Ihp fact that changes 
in the retinal vessels constitute an early sign of 
arterioi*clero:<i8. and later demonetrated that tlus 
change was normal in old persons and usually be^an 
in the fifth decade, i'riedcnwald and Pre-^tun exam- 
ined twenty-three |N>rsutis ttufTcring from general 
arterioEwleroais, and found only seven normal reti- 
nae among them. 

Dc ScbwniiitR gi\^ni ihefollunriiigcrilcriafflriiclcraiiaof 
the retinal vmsclia: 

(1) SusEWtivc Slf>n«. — ITneven caliber aiul undue tortn* 
ouBnoM of Ibc rrtiiial nrlt'riM ((^o^kllcn.■<l form), incmiwil dw- 
Iinctn«Mof thercnlniJ 1i|;hl M.rcak, an unimuiilty IikIii color of 
Ihcinrtcry.iiiKl iilli.-ruIiuiiBiii Itn-cuursi! uniJcalitivroliru^vnm. 

(2) Palhoicno manic SIkd*. -<'hiuiffni in Mm and brcnillh 
ul ihv art^rJM. lun uf tnuivlMcenry. Itwion.* in the artvriul wulla 
coiwiBlinKofn'lutfKtriiiaiiii ibi? Sunn of ivriviiMulilin. indPti- 
iBtion of iho vtiiid by ihc uti/rcnnl artrnni. rniiiioiiHnws o( 

Vuiii* and while Mripu or i-aritomtie* nioiig their coure™, irdemn u( the irtiiiu iii ibe 
fortTi v( Kray opHcily nrmind tlic dink or following the coiirw of thi' vrawrli. hcniorrliaj[eK 
u tinmr cxInvniBiiiuiiB ur t(iti[idi(>h iiiritcralionK. Sometimes ver>' Kuddrii cli!tnjn« in 
the calibirr nf thci rctitiul arlvrio may tic aevn uccMtipiuiyiiiR t-uaomolur ctisw. 

X-ray Examination. — .\bfioInte proof of arteriosclerosis is also given 
by the X-ray, by which calcified i>!a<iue.-< along ihe course of dei-ply .■'ituated 
arteries (popliteals, femorala, abdominal aorta, etc.) may be discerned aa 
distinct shadows rangetl along the courae of the arler}'. These may be 
brought out more distinctly by using two »terco«;opic pictures' instead of 
one. Unfortuiialely, it has not been possible to discern sclerosis of the 
coronaiy sneries in this way. 

Sclerosis of Ihc Abdominal Aorta. — Arteriosclerosis of the abdominal 
aorta and splanchnic veswlH is very common, iw has been nhown by Haftcn* 
feld. Bond, Brookj*, Ortner, and tlilbiide. In fact , it may almost be diagnoxed 
with eertajnty when the bliiod-prewure is elevated. Occasionally the course 
of the ahdoininal aorta may be felt to be tortuou-s. Sclerosis of the abdom- 

Fra. 16?.— Toituoiu nuljal 
■MMT. (ASurfal.) Solid linis 
Ooonr of Ihc nAit\ urtvrT at 
300 uun. ill tiliul-tirnvurc. 
Brnktn 1i»*. aiiimii lit tbv ttr- 
((T>rBt S5 mm.hlnnil.pnwiir*. 
tttmriunti uiiriiF. 

l-'io. 1S8.— KcliiiBl fhlinit'- 'n imriin.i-lfnu.ii. A, Nuniial tun'lu". B 1" F. turpi-BBiie »liar.«« 
oerurtiim in »m>ritji.cliTi>«i». inrlwHinB pnllnl atiiTutu IBI, lan>r »»iiiiiiiiiit t mivi-t-itifTi uppwianc" (Ci; 
iD'IcDWil vHrin (H, <'i, ■(wrvmrrl nlmwiiin iiupullifcinn wiUfKPznBiiW (.fi, E): n-f kwrew »pilliiri™ U'. I*): 
(vrlufnv (rUrlc" in'l v»in" (i), Ki: (i«tiv««ulliii ftt, D); MleroMii ol vhmj* (K1; »d*<u of diik 
(B,C. D, E). bruiuiilmgc* (C F}.— D, (AfUr -It Sehwclulu.) 



ina) vesaelti li; not iDfrpquently ncoompftiiiiM] by crimes of severe nbdominul 
pain not unlik<> thone of tabea (abdominal vasomotor rrisns), but these nmy 
also be preiwiit from tiiinpic piiWtioii of the nbdoiiiiiiul nortii wht-n (ti^ng 
upon loose peritoneal moorings. Sclerosis of the pancre&tit artery is often 
acrompauicd by diabetes mellitU8. 


In arl^rioBclerosis the mpchaiiiciJ factors ufTecting blood-prejwiire 
tend to approach tho»e in a sj-stem of np<i tubes, — a high prf>Eii«m- thmugli- 
out Byslole, 8 low prPMurc in diastole. In such a synU-m we should have, 
as a rule, a greater difference between pressure in syst-ole and in diasl^le 
than when the nornml elastioity tends !o keep up the dia«tolic pressure, 
80 that the pulse-pressure is often more than 50 to 00 mm. rather than being 
nearer 30 or 40 mm. as in the normal individual. 




Fio. ISe.— Etfccl ol ■nsiiuMlrroaii opnn llu> circulalion, I. nomuL It, u-lenuKlnnvit. oilh 
hiit^ jrcTiplierpJ foiittjmrv iui<! 4D*vn>tie furmof pul*a vnvn. TTim ifcfn>tr poiiiU tu « htm in nuLvmiAl %nA 
nainimi^ l»r«Hrjf< and itirrvfta^l [rulH^pwiniiv. III. ArUntiAflvn^in wiUi U.w (vriphtraj nauUknw, 
■tiowiof low blcajd-pniaiurc »iid inorioni pvlM^M**'"* "ixl callkptlns puliw. 

Pulse.— The pnW insy a.s!«ume any form whatever, from rollapsing 
and almont waler-hammcr in character to an anacrotic plateau, or even 
in rare <^ai«e8 to a pulsus tanlui^. These depend upon I he n.-httion between 
strength and mjc of Wat and outllow through the iirtcriolea. Thus, if the 
peripheral arteries or any large areas of blood-channels are diluted and 
liLckiiig in elftsiicily, there will Ik- a monienlwry ri^- in pressure at the begin- 
ning until the pressure wave is transmitted from the aorta to the [icriphery. 
When it reaches this point there is a sudden ontllow through those vesseU 
and n sudden full or collapse, which i» greater tharf it would be in a more 
elastic system (see I'lg. 159). On the other hand, if the jienpheral outflow 
is small, the pressure in the m)ii-el<»."'lie »y.-«tcni quickly rises higher than 
in an elastic system and remains so throughout j^-st«Ie, forming a systolic 
plni«iftu (atiDcrolie pulte) u-ilh a large rapid rise and plateau reaching to 
the end of sysUjIe. then a gradual fall during diastole. The pulw form 
aeeordingty gives us the information in' as in other condi- 
tions (sec page 44), — namely, indii'ntcs low peripheral rewstaniT- when 
it is collapsing and iiigli peripheral resistance when it U anatrrotic or bus- 



tained. The pubw may either be quite large or very smalJ, depentlont upon 
the degife citln-r of vusoconHtriotioii or of endari«riiis. It* character may 
be ver>- variable; it may be quite quick und collapsing, corresponding to a 
gi.>iieral rigiiliiy of the whole vn^culnr syaiem, or the ve»i<(;I may fill rapidly, 
remain well sustained with long sysLolic plateau, and may then decline 
either rnpidly or .slowly. However, the lumen of the rjidiid arterj' may 
have decreased so much from an endarleritijt that llie fiUing of the artery 
is slow and thf iip-stroke on the pulse-trnoing very oblitpie, ju»l as would 
bo typical of aortic- stenoslH. Tiiia is not extremely common, and the very 
quick up-stn>ke is the form fi-pquently seen. On the ot.Iiit hand, in 
raivr rases when, »s Romberg and ai.-so HiuHi-nfcld have pointed out, the 
Hplanchnic vessels are not involved, the ma.\iinal blood-pressure may bo 
quite noniinl (I Irt-I'JO mm,) anrl the minimal also {HO mm.). 

Blood-prcssiirc. — The htood-prcssurc is often high. Thayer found 
in his studieji of pont-lyphoid arlerioscleraiis that the mnximal blood- 
prcMurc was uHually 20-30 mm. higher tlmn lor normal individuaia ol 
corresponding age. 

Rnmlicri; nml Siiwndn, on thn olhrr hnnd, found that this ocriirrcd in only 
IS.Ji per cent. uF nil urlvriiiifclerotics. while tirocdt^l tnund hyperteTidiuii in only 37 
per cent, of 4411 ciwm of ■rlcruMclcrcuiii Itvt Iruiii chrutiic ntphritit. DunJn fnunil 
Riniilar iwiiillf. tarael, however, fo'iiid liyprrlcnaion — over HH mm. Tin ff ISO cm. 
H,0 (v, Reckliiigliauneu Bpponiluji) — in 04 4 [>ec cent, of 45 cnrnu of urterioBclcrudi. The 
minininl pmuiuni khu aUo Jncrritwl. but less than the imuiiianl. isnwJ gtvM the 
follow! iii; uvuntee G^r«H: 

Normnl — 

cm. [1,0 

mm. Us- 

A rleriiwclf rosis — 

citi. H,0 

mm. Hg 

Avernjrc inppcnjH; — 

mm. Uj 





















InMl's fiiturSB seoQid frril wfih the writer's cxpcrioace (luins the tlrlaogvr ap- 
parotim). The bigh«Rt of ihew blowI-pmBurcM aro »ocn in cu«« with chmnic ncphrilia 
{[Bruel, Janowny. Ilomnr). Thn wrilvr ha« oflen rminil u mtutninl prvnuro ot 'i2(S tutu. 
Hg with a iiiiiiini&l of 160, tliouKh usiutlly in noHociation nith ni^hritU. 

As has been seen under cardiac overstrain, the presence of arterto- 
8clero^8 has a marked effect in impairing the bodily strength nnd the ability 
to withstand strain. The diminution in arterial bed increases the total 
work of Ihe heart, and the patches of artcriMl rdiroMM pii-vi-nt the arierifts 
from dilating under functional activity. On the other hand, the loss of 
arterial elasticity removes a factor which tend-t to propel the blood during 
diastole and thua to maintnin the blood (low at the least expenditure of 
encrgj' by the heart. As n result of this factor, the heart is compelled to 
increase its systolic output {increased ]>ul»e-preK«ure) under iiorniid i-undi- 



tions and hence has little ability for further increaee in reserve. Muttcular 
vffiirt thprcfiin' (eIvon risf to sijjns of grewk-r .■•tniin thiui in normal imlivid- 
iiuIh, greattT increase in blood-presaun?, and greater fatigue. 

The inK-nsity of vasomotor reactions variwt considerably iu ilifTereiit 
cases of arterio!icleroGi& In some cases, as Komberg has sliown, the vaso- 
motor reaelion of the arm vetc'x-l.t lo mid may entirely disAppear; while in 
othcrii (vaHumot^r crises) the nmctionK are so intense as to produce ischa;mia 
of the parts. 

The Second Aortic Sound. — Corresponding to the high blood-pressure 
there is also accentuation of the aeeond aortic ttonud, which on the one hand 
may be due to the heighlened blood-prcMure and the pnrwtcr lensiun of the 
aortic valves, or, on the other, lo the thirkeninR and partial calcification 
of the valves themselve.'t, which pve.>* rist> lo ii louder .sound than usual 
when the valves strike together, even under the usual pressure. A marked 
ftcrentuatinn of the aortic second sound theivfore alwaj's lends to the 
suspicion of arleritwclcrosis, even in the absence of thickening in the n-alls 
of the auperficial vessels. However, it ia not pathopiomonic. since it may 
often be hounl in cases where no six-eial sclerosis is present, especially at 
times when the heart is actJng strongly and probably giving forth a larger 
output into the aorta at each systole, as in typhoids with dicrotic puii** 
or in perfectly healthy young persons during attacks of palpitation. In 
such coiiea the accentuation of the second sound ia tranaitory. 


The blood count may vary considerably, first on account of the great 
variety of diseases jissociiited with arteriosclerosis, and secondly, because 
the latter ia aometimea accompanied by polyoythapmia or erythra'mia. 

There are no likiiid cliunges which in tlicnufclves can be said lo be defi- 
nitely associated with arterioscterosia. 


When the aortitis near the base of the aorta is marked, und especiaUy 
if calcified plaques are present, the first sound as well as the second may be 
changed and may l>c accompanied by a loud murmur which is usually trans- 
mitted lo the carotid and brachial arteries, resembling that heard in aortic 
Kteno«i.4 hut less intense. Since the condition is much mure common than 
the latter, this murmur is also more commonly due to this cause, hut in 
the absence of the churi«-teristic \ni]» il is quite indi.-'tingui.ilinble from 
that of aortic stenosis, for both arise at the same site at the same time and 
am transmitted in the same way. The murmur is often necompMnied by 
a marked thrill having the same distribution and is foUowed by a distinct 
dinatolie shock. 

As iv^iiida ■ or ihr narl* ntiMiP. Kitnff hoj foueil lliat it frequently occuni nl 
a^la^'enu{l> anc of fifl\-flv? (f'^'y-f""' '" •.vpiiilitics)«iis rmiilt of iSn iniial facMn; tome- 
liini-i a nnfrle Irauiim tu ibi- {'linnt iiiuy sFCfii lo br tlic ini|>urtant tiKniiciii iii tlii> ctiolncy. 
It t.i nprcially cninmon in syphililir* and fnt prrnoii*. aii>l m fm]Urnlly iu>ci>ci:ilrd «ilh 
fiuk-. unhy-in^)' mior, vfr>- hi||;h Moud-pmoiiire (170 <o I'JO mm.), occulonnlly Oilli-ictiCD 
tn >uc of the |>u|nls, poiiM over the chnt and down ttie nmia, <rdcnut over tlie ■b;miun. 



uiiiliit^ral ililiilalion ot voiiw in Becoiiii und Ihinl intcmiiawn, ringing nortic ncctinil noutul 
v,'ilht>iit (liiutolic munnur. hyjirrlrophy of the hoan, oftrn piit^iH oclpr, rarely pubnu 
tardiM or piilniix iDiruiloxiw. Cariiui?' ]>uiii may In! pnitwnt. oft«ii Telt just aller iwrvuH- 
Bioii, and dtvicrilieit cus aamrlhixti; liurtug through tlur klemuni, loiactimc* with n feciing of 
OorMtriction, Mimcitimra raili.iiiiiK to thr anns ami neck. OrcsnionAlly itpells of wtiaknen 
in Uie ivmiii iiiuy iic fi'lt nut Jiihko iiit^niiillriil claiidiputioii. 

The d J f f F r<'n t i n t diajcnonis from noitic AU^nmiw in niadc by the f:rfidual 
U^troke on Ihe puW Ir.iciiiK in the iultt'r cnat-, us cuiil.nmtvd with t\te xiiIileD ti|>-Htnike 
nnd plateau in tlii? funnier: frnm uortic iluntlKciiMicy by the diMtollc mitmiur hii<I ht)ch 
pula«>pfnanin!; Imm juiriirixm by the pprcuMlon nnti tluorodcopic linilin^. Nevenbelen, 
il cnuHt be admittHl thul iiuuiy doubtrul cuaen ariae. 


Primary wlcrosis of Ihc piilmonnn- artvry Ja not oxtreniely rare, but ia dlfllcult or 
iinpuHubli- to iliitKiiuw with certtiintyi but the preseno*? ot v(!ry loud suuiidn in thi! pill- 
mooic asm or of n r o u g b ■ y s t o I i c m n r ui li r licunl lotidist iit tlie pulmonic nnd 
traniiniittpd iipwiird ToniirdH the li'ft clni'iclc amitHw ihc »iit*pirion of a pulnioiuiry 
ncleroaiii, npeuially if ta^na ut cuii|Riiitul Icviun srr alHWiit and tlic niurniur in not hiianl 
over the cnioliii. HowcVT-r, sclerucii ot (he pulaiocnry nrtcty is ofton ivcondary lo 
milTuI «l«nn«is and oniphyiwmn. 

Cmk or PtuuARV Pi7LHONAitr Sci^exosm. 

Romberg reports tlie ciuw of a man. ui^ed 24. who hud luid no infceiioiui iliHMwe 
except meiiMlw nx » child and .1 irtM'nt iBli)(lit miincnlar rhRUmnriiim, thivc months xUet 
wliich lie b(.'f;an (u Imvi- i;riidu»lty inmaMinK ahurtneiis of breath, cpigiMtrie 
pn»«iirr. occnMioital bRndii«li« liail giddinisH. nnd tiis color Im-iunc vrry bliip. On tx- 
sininalioM he (thowpd marked cyanosis over the fsre. body, »nd limbn. 
There wnn a piiliiatton due to the right «-cn(riclR in th« fiiurib inlempnce 4 em. iiMi^e the 
nianiinillary line and Ihenoe inward 10 the slemnni, »U<i> a wnaller piiliiaTloti (lefl ventricle) 
in th«liftli interBjMice muinnulliiry line, cardiac duliieea 7 cm, to riyjlil. 15 cm. to left. Both 
pulmonic Hountb were louder than the nortir. {"uUn «muU, rr([tilnr, lit}. I4vrr enlarged: 
Hpieeii enlarged. No oHleniii; no HwelKni: of ve»*>lH of neck. 

Prohnlile diagnosix (('iimrhniunn), eongenitnl heart l«<iun. I'ntient gradually lierame 
nxitwt; diptalis wan williuut efTeel- Died one month after ailmiwion. 

A t] topiy »howcd enlurgiil lipiirt; riuhl ventriele byperlrophied and 
f orm H the entire apex, nnd the conns Artcrlflim and right nnriele are mpe- 
ciiilly hyper t roph ied . All The valve* intact and normid; aorta free from BclerocU, 
but unUKuaily email. Ductus urteriiMus closed. Tremcniluu* rcleroaii and 
ntberomu of Ihe pulmonary urtQrjr and all its bmncbm.' 

The murmur may Iw dintiiiKuishfid ovpr the nbilnininal iiorta »nil the 
femorftl artery, though the thrill i« rnrt-ly traiwmilU-d m far. There is no 
Duroxies douhlcf murmur unleea aortic ioatjfficiency U aUa present. 

Sanders han nscmtly t^oltectcd similar caws from the liu-ratuiv. 


The getieral trciitnient of arteriosclerowa is mainly prophylactic, 
hygienic, and dietetic, and actual specific treatment is of far 1cj« value. 

Diet. ^Carefully selected <i i e t is a most important factor, restriolJon 
being in liolh quality tind quantity. The general diet given in 
heart cases (ntc page t67) is of great benefit here, or equivalent diets with 

' NolM of a CMC of pulmoiiar>' «n«rio«ctcro«is (O. A. K.) •ecoDiiarjr to mittn] iitcuou 
are giwo on p. 354. 



this as a basiii. However, in lumple arterioHcLeroius the quantity taken At 
a timo need not bo fo grcutly rcstrit-Wtd; but the lulfll i]uniniiy in Iwpiity- 
fiiwr hours should not exceed twenty-five hundred palories, and ahould 
always be near ilic lower level for prot^^ids, and lus free tu* j)iit<!<ible uf purin 
hodieH {nitrogenous extractivea such as are found in meat), creatinin, et«., 
and niM> of salt. The more reeent .'^ludieet iiuoted »bove mmm to indicute 
that excess in Hah is almost as injurious aa are excemes in alcohol, and that 
the suit mackerel of Bonlon is iw dun^rouii ftfl the beer of Mihviiukoe. For 
the sclerotic danger probably lurk* m the Smitlifiold ham or the eold smoked 
tongue as well as in the Baltimore rye or the Martini cocktail (Beyer, Buri*-, 
lladficld). The pnlientV safely lien in milk, e^g:<, potatocit, bread, other 
carbohydrates, butter, and the simpler fruits. 

Restriction of Liquids. — On the other hand, tho liquid intoikc also 
should not be exoeasive, since drinking targe amounts either of water or 
of beer seems to fuvor srlem»iH (Krehll, but the amount ingested ifhould 
remain in the vicinity of fifteen hundred cubic centimetres a day, some 
peri'oii.'i thriving bettt at five hundred cubic centimetres above, aonui at 
five hundred cubic eenlinietrcs below this le%'el. 

Tobacco and alcohol should be dispensed with entirely if posaiblo; 
if the patient inmU on taking .fmall quixntitie^, one or two light dr}- cigan, 
afi thin aa possible (Lee), or "stogies," a day are perhaps the mildoiit that 
one may prvncrit>c. Cigarette sittokc is u.iually inhiileil and pipes are very 
heavy. Thick Havana cigars ishould be entirely prohibited. 

As to alcohol, if the patient insists upon lakinjc a small quantity^ 
this should be limited to an occasional glais of claret or white wine, or 
perhaps a single glass of beer at rare interval.-*. The latter in large quan- 
tities is espeeiidly undesirable, both on account of the large amounts of 
liquid taken and because it contains both alcohol and proteid and purin 
substances extracted from the ycn»t. Gin is perhaps more dangerous 
than whiskey. 

Coffee and tea sliouli) bo taken in only small quantities, since 
the vasoconstrictor action of tlie cufTeine favors the onset of spasmodic 
vasoconstriction (vasomotor crises), and, on the other hand, the increase of 
blood^ressure itself brought on by eaffeine U damaging to the arteries. 
However, it must be stated that, in contrast to nicoliru<, leaci, nclrenalin. 
etc., injections of caffeine into animaU have thus far failed to bring on 
arteriosclerosis and that perhajJS the ileleteriou« effect of caffeine may bo 
overesti mated. 

Hydrotherapy.— Systematic hydrotherapy .is of considerable value in 
biterioscleroKU, especially the use of warm baths, warm douches 
(Brieger), or alternating warm android douches (Kiley) applied both locnUj- 
and generally. They owe their elhcacy to the vasodilatation which they 
bring about, and hence must be cla-sscd in effect with the drugs of the nitrite 
group. In most cases the effect of a good warm douche or warm bath is 
more marked and more Wting ihiin that of any of these drugs, and it is 
further devoid of that certain residuum of deleterious effect which all 
drugs leave behind ihem. So that, while one cannot agree with Brieger 
that arteriosrlerosis can be entirely cured s)'mptomatically by proper 
hydrotherapy, ueverthetess warm baths and warm show era 



once or twico a day should be an indispeniiablc part 
of the treat nicnt of every nrlcriosclcrotic. Cold balhs 
ehoulcl be (ivoidcd, wnee tbey precipitate vasomotor ittaclion^, whi<h in 
the arterioBcleroUc nisy amount to viuw<.'on.slricior !*piwm. 

Drugs. — PoUMltim Iodide. — As to drugs, universal experienoe points 
to the efficacy of po*i u m iodide in dows ft.scending from 0,3 
Gm. (gr. v) t.i.d., p.c to as high as 4 (Im. f.jil: Home cliniciana favor- 
ing the smullcr. isoiiic \hf. larger doc>«H. In the writer's ex|Krricnec doses 
und«r 1 Cm. (rt. xv) seem to have somp effect in alleviating symptoms; 
and when there is a (tiispicion of Uies the doae shoidil be inoreawd stiJl 
further (The tliL-nipcutie lu-tion and its limitnltunK arc disrussed in 
Cliapler V.) 

It has been attempted to settle the ([ucstion cxprrinieutuUy by deter- 
mining the effect of potaesium iodide upon the course of adrenalin atheroma 
in rabbits, Koranyi, Boveri, and (.Vimmins and Stout, who wen* the first 
to undertake these inve»tigalioii«, all reported that potassium iodide or 
iiidipin, when injected durinR the lime that adrenalin was beinf; injected, 
inhibited the production of atheroma, However, it must be borne in mind 
that Hiland, Ixteb and Uithens, Adier and llensel fourid that lar^e doses 
of pot!is»iuni iodide seemed to inereui^e rather than inhibit the utheromatoux 
changes. It is at pre»ient impossible to tell exactly what quantity repre- 
sents the optimum dniw for human beiuKii, and whether ttierapeutic doses 
ever reach the stage of harmfulnoss. 

While aelerosis of the pulmonary artery secondary- to the pulmonary 
stasis of mitral stenosis is relatively common, primary strlerosis of this 
arterj- is rather rare. 

Nlirlica. — Next to the Iodides in general use is the group of nitrites,— 
amyl nitrite, nilroRlycerin, sodium nitrite, er>-tlu"ol tetranitrate. These 
drugs HIT' of vuhio for symptomatic treatment, to relieve pwn or discomfort 
for the time being, but they exercise no inhibitor^' influences upon the prog- 
tp.Hn of the arteriosclerosis, us has been shown for adi'enalin arterioseleroas. 
On the other hand, their effect upon the symptoms due to arierin sclerosis, 
the pain of intermittent claudiration, of angina pectoris, of the abdominal 
Olid peripheral vasrulnr crises, is most remarkable, and in thifi regard they 
are invaluable (Lauder Urunton). However, in their udndnistration it 
must Im* borne in intnd that pcrw»ns with arteriosclerows seem to have 
considerable tolerance for nitrites (page 188), and to bring about vii.'<odila- 
tation and fall in blood-pressure much larger doses must be given than is 
iiecesaar^' to produce the effect in normal individuals. Accordingly, as 
indicated in Chapter V, the drug should be administered in increasing 
doses until the physiological effect (flushing, ihrnbhin^ in head, ringing 
of the cant) is ubtaineil. and then continued tn a <l(>sc just n tittle smaller 
than this. One need not be surprised, however, to find that this dose for 
a person with arteriosclerosis, particularly a colored person, may lie ten 
or even twenty times the average dose for a normal individual. Wlien 
such is the case the blood-preiitsure is pruh.ibty a Ijenefieial eom]>ensalor>' 
phenomenon, and the nitrites should be discontinued. 

In the chronic hypertension of arterioseleroiiia venesection ia 
not onlv useless but often hamiful. 




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Sci., 1907, cxxxiv, 811. 
Rokitaiisky; Handbuch der pathotogischen Anatomie, 1344, ii. 
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Thoma, R.: Ueber die .^bh^n^gkeit der BendegewebeneubiMung in der Arterienintima 

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1S83, xciii, 443; 1884, xcv, 294; 1886, ciii, 209; 1886, cvi, 421. Ueber einige senile 

Verftnderungeii des menschlichen Kiirpeni, Leipz., 1334. 
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Gefasawandung und die Entztindung der Venen, Berl. klin. Wchnschr., 1375, xii, 533, 

Ueber die Entstehiing der spontanen Aneurysmen iind die chronische Mesarteriitis, 

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Jebrowsky and Lee. See p. 013. 



Joau^, 0.: Atherome aortIi|ue Hperiiuuutul pur iiijfclloiu rvpct^m d'ndniiuiliiu! dan* Im 

vttincii, Cpmin. rcnci. Soc , <ic Binl., I'ar,, IIMKI, Iv. la'-l. nad I'reetHr m^i , IWU, ii. 798. 
Fincher, B,; UptJe-r ArlMieMerkniiikuiij"i-i] iiuch AUtDRAliniiijcktioiifii, Vfrhnniil. li, Korijc. 

t, iiMiLTv MeJ.. Witwbwlcii, 190.1, xxli, 2M, 
Pic luul Itiiiui.'unoiir: Com riliii lion a ]'i^(iiil<! ijii dclViRiiiunnc tic I'alhrroni:! ]uirti(|Uo 

mperiinuQtalv, Cuiiipt. rvrid. Sue. dp Iliol.. I'ur.. IWi. Iviii. 219. 
.Adlcr, I., and Hiinirl. <>,: Siudiiw on 8o-calloil t^xpcrimcntal Artf^rioMlcnMiiii. Tntiui. 

Ama. Aim, PlijisiciHiis, I'liilu., 11M)7, xxii. AS^t, 
Eib. W.. Jr.: lvii]ifriiiicnicilc luiil hi»l(>lo|a>lC)ll^ Sliidicn iichcr ArUtriMiinknuikting Doch 

Adrcimlininjektiotieii, Arch. t. ex|i«r. I'athol. u. fliumittkal.. I^i|«., 1))(I5, liii. 173. 
Hur»t?y. W. H.: Studie* on Ihc liiflucnnp o( Tciwion in the Dcgoicmtimi of Kliwiic Kitirea 

a( Ilurird Anna, J. K»;r*r Mod.. X. York. 1906. viii. asS 
Pearcv, H M ,!LijdSl(Liilou. I;. Mi^P.: ICxpcrimenUil AncricMclcnsu, J. ExpiT. U.. N. YoriCi 

1906, viii, 7t. 
IlaMMifi^M. A.: Uglier die Herxhypenrnphic Iwi ArterioBklcruoe. DeuUch, Arch, t. klin. 

Med.. Leipi., lis, 193. 
Bond. ('. a.: (Tlinicnl Obmin'allotU) of ArlvriuHclcroaia rmni AllnaeDI&ry Toxiiui. Traaa. 

Amu. Ami. I'liyn.. I'hiiu., 190B, xxi. 7:(. 
Ortaer, N.: 2ur KJinik <\ct AnKiiMklora«v dor Duniinrurien, Volkroaiui'a Satiitnl. kliii. 

Vortr., I*ip«., .N. S. No. Ml. 
Gilbride. J, J.: (iuotruinlisliniil OiMurhancM due to Artcrioxlcronin, J. Ain. M. Aaao., 

Cltiiu^co, I90fl. lii, o.^n. 
llaniburKcr, W,; Beilrftgc lur AHiprwddcmw drr MuKMiaricrit, Deutuch. Arch. (, kljn. 

Ml-<].. LdpK,. 1009. xevii, 49 (with cxcclkiil tiililicvraphy)- 
Ilnitonffld. Qiiotc^l oil p. 213. 
Pal. J,: Die Gofamkrifleii. Ijfipt., I90S. 
Vaqiiri, Auhprtin, WicsrI. S<v p. 213, 
Bayer. R-r ITeber den HinHuati dwi KochimlMw aiif die urteiiwklttotlaehe Ilyperlonic, 

Arch, f, cxper. f>ntho1. u, Phnniiiikol., IMfut, 1907, Ivii. t<>2. 
Fr«monl-8i[ilih, V.: ArtcriosclenMis in Ihc Young, Am. J. M, Sc, PliiUi. aiid N- Y., IflOS, 

cxxxv. 199. 
HitKchbern: Ontralbl. f. prsiki. Auseiihtulk., 1882. vi, 329. Quoted from de Srhwmntta. 
Kaelilfiiaiiii: I'ebcr uphtlialiiiiiakopiiU'h aichtbarc Rrkrankunt; iln NelihuittfvrJMae bet 

nllttrm finer .^rtsriotklrnn'i', Zl*olir, f. Win. Med.. Berl . I1!*H!>, xvi. (HHi. 
Pricift-iiwnld. H.: Kepurl «o iho Uphlhulmo>fo|nR Kxnminnlioii uf Dr. PresTon'a OmM 

uf ArtcriaBclpri»ii>. J. Am, M, Amo., ChicnKO, 1891, xvi. 6'2X 
Dc SchwfrinilJi, (.!.: tnini-ucular Anxlowlerous. mid iln Profniuiitio and DiaKnoatJc Si(^ 

nifieaim. liilenuit. (1iiii», Phila.. 1007, 17lh 84-r., vol. i, 177. 
RontlicrfC and ItnjvnfclH. Qimiril on p. 313. 
Tlinyrr, W. 8-. On rtie Luie ERmtU tj Tvphoid Kc^'cr on the lleuri aud \'*«»elB, Am. 

J. M. M<-., Phila. and N Yoik. lOOt, cixvii, 391. 
Rombfrjt. K.; nohor Ar1ft^OBkle^J>*. Verh. d. Kiiiiii;. f. innere Med,, WjMi., IftCM, xxi. fiO. 
^wuda: BliiUtruukiiKwunx liot .\rl«rio«k1pniiu>, ]>ciit>ir)i, mod. Wchimchr.. UHH. xxx, V25. 
Grnndcl: t.'elicr dcii Wrrl dpr niiiidnii'kiiiwnuiiK filr iLe Elebandlunfc ijrr .\rt«ria«klera)io, 

Verhandl, d, Koiik, t. iim. Med . Wiculi., lom. xxj. 113. 
IsTvel, A.: Klininchf! Bcaiiachtimjccn iirber das Kvmplom drr nx-pcrtenaioii. Sumnil. 

klin, Vprtr, l*ipii,, liHir. fnner* MH.. So. 13i-I3l(. 
Janeway and Honier. Qiioled on p. 35. 
Bittorf. A,: Znt t^vai]tunnMo\og\e t\tT Aoriorii<klero»r, Deuiecli. Aich. f. k!in. Ued., 

LdpE., inot, ixixi, ay 

Rombeig. E-: Ueber Sklerui>e der I.ungrnart^rir. neilUcli. Artb. f. kUn. Med., Leips-i 

■aOl, xiriii. t»7. 
8ander». W, E : Primary' PiilTiiunuty AtlerioMlnncic with Uvpcilruphy of ihe Ri|[ht 

Veiilriclf. Arch. Inl, Mrd., Chirajio, IftOD, ii), ".JBT, 
Rogers. I..: Rulenftive .^tlieroina and Dilalatioii of tlie Pulmonary Arloric*, withouL 

markeil \'atvTiIar I^wjim*. iw it not verr Rare Cam* of C'ardiuc DiwuiBe in Beiiml. 

CJuart J. M«l,. Oifoni, mVi-9. ii, 1. 
BriCK«r. L.: Ctiiiieal Lectumi at tlie UydrothcrapeuliMche Anttolt <t«r Kgl. Poltklinik, 

Berlin, 1900. 


Riley; Bl&tl«r f. klio. Hydrotherap., 1888; cited from Buxbaum, B., Lehrbuch der Hydro- 

therapie, Leipz., 1903. 
Senator, H,: Ueber die Arterioakelerose und ihre Behandlung, Therap. d. Begenw., Berl., 

1907, xlviii, 97. 
Koranyi, V.: Ueber die Wirkung des lods auf die durch Adrenalin erzeugte Arterioae- 

kroee, Deutsch. med. Wclinschr., Leipz,, 1908, xxxit, 679. 
Boveri, P.: Contributo alio studio degli ateromi aortici eperimentali, Clin. med. ital., 

Milano, 1906, xlv, 41, 
Cummina, W. T., and Stout, P. S.: Experimental Arterioecleroais by Adrenalin Inocula- 
tions and the ERect of Potaasium Iodide, Univ. Penn. M. Bull., Phila., 1906-7, xix, 101. 
Biland, J. Ueber die durch Nebennierenpritparate gesetzten Gef&ss- und Or^aver&nder- 

ungen, Deutsch. Arch, f, klin. Med,, Leip«., 1906, Uxxvii, 413. 
Loeb, L.. and Githens, T. C: The Effect of Eiperiraental Conditions on the Vascular 

Lesions produced by Adrenalin, Am. J. M. He, Phila. and N. York, 1905, cxxx, 658. 
Loeb, L., and Fleisher. M. H.: Influence of Iodine Preparations on the ~Vas4ular Lesions 

Produced by Adrenalin, ibid., 1907, cxxxiii, OtW. 




The general clinical manifestationa of arterioaeleroaia boar fk close 
relation lo tho von<lition dcflcriltcd by Pnl aa ■'vasomotor crisPs." under 
which he inclutlcft all cotitlitions which arc as80ciat«d with moro or less 
aiitldon constriction or dilatation of the artcricii, and whose syinpUiin:* and 
signs disappear or niarki-dly diminish lut soon as thix paroxysmal change in 
the blood-vrsaels passes off. There are accordingly 

(1) Vasoeonetriclor crises, usually associated with hypenen»ion. 

(2) \^asodUator (hypotension) crises. 

The v**i>i!nnfit riRIor crini^' I'al ilividrdinto 

(1) Abdominal iy\». (J) Pm-IophI (.v|>p. (3) VvtvUral ly\». (4) Criwa in the es- 
ticmitieB. (5) Vntre in tlie lurgu «rkTif». 

The vAKoililalor crisr^ acrnnllnK to Pal incliidii * 

(I) Ordijittfy Bj'iirope. (2) Suniicitl ahiick. Ili) Collnpi* afltr infectious ttueoM 
or moft poisonings. (A) Llrylhmnii'laltliu nnd many nlhcr "irophic" akin duRnnr.' (*>) 
OoCMJontil ciutee of tubes with lancinating puliiB uml luu' blood-firMiiire. (0) Vnriu'iH 
attack! a! v^eakavsa in Addison's di«eue. 

Probably no unit cauae exists for the crises themaclvcs; the visceral 
eHscit and lancinating pain in tahes. the pninter'.i colic, the ura>niic con- 
vulsion, the delirium of the cerebrid sclerotic, the pain of angina pectoris, 
and the attack of cardiac asthma fleem to have little etiolof^ in common 
except their relation to the sympathetic nerves. Howrver, all manifest 
hifth re, and, accordinR lo Pal. all are relieved by artificial 
depression of blood-pres.turf. It is, therefore, not unlikely thai, however 
diverse the ultimate causes of the condition, the cause of the symptoms 
is hi|(h blood -preswi re with loealiiied vasoconstriction. The variation in 
the areas of constriction in regions whose arteries are already tielorolic 
aceoiintii for the occurrence of the different symptom complexes. 

As to treatment, the statements of Pal woidd lend one to believe that 
they are all relieved by vasodilators, especially nitro- 
glycerin and the nitrites, occasionally by sodium thiocyanate, 
and that marked improvement results while the blood-pressure is lowered. 
Th« symptoms return if the blood -preiiKU re again rises. (Pal, also Heits, 
and NorTpro.) However. Prof. Barker's experience at the Johns Hopkins 
Hospital does not warrant such sweeping conclunons. 

' Biu-Tger's MudiM iodicaie ibnt tb«R ai« organtc iMioits la »oin« uf ttiew caeca. 


Case op Abdomimal Vasomotom Ckubs. (QroTEs raou Pal.) 

P. v., uum^ mitlcor, nertl 07, had riieiimatium H yciin m^, anil for tJic pnsl yew 
pnlri nnH pmsun' iii ihe eitijcastriuin, wpecbiUy on lakiiiK a <le«p bivalh. Hm occa- 
aivu»l paroxytms nf cxtrcnx- ilynpnnen and pslpitulbn of ihv lieart, but 
alu-uji liHB Boiiw »liorlne<* of broath. He was (omiprly a heavy drinker, now driiilM two 
or ihtrc lilf«« of lx*r a day a» weQ lut a hnU Hire uf wine umJ BOiut whiskey! He alao 
aiauketi in motkratinn. 

Oil mlmiiiBiuii, April 7. 1!HM. he wna found Kibe a Hell-noiiriKhed man, Hliitbily cyanotic, 
l.iinm cloni- "^P'nttion It-l. Ilcnri. UiuiniuRi iinpulse iunistli inUinpacc two Gnf^n* 
brvudtli bcymiJ nisriiniillary line- DiJnts* extend* to third rib above and two finger*" 
briMult.h beyond Iht? right iimrgiii uf the stvntuiu. SouiidH iiuilc clenr at upes tuid base, 
a!coiul uortlc itoiind no! aecentiialcd. Piil«c 
liS; rsiiini wbIIh n-liSl; blood-i>nw<itro 'i'Jo. 
Liver «ntarf[r<(; ■pipcn nol [Kilfuibli-. Shgbt 
u.-dp[nu of fci't aril) It'jpi. L'nne 2<iUU c-c; »p. 
ICi. IHIOt allnirain 1.3 tJni. per Utre. 

I^tricnt waN iciven 0.6 (inn. t,gt. viii) ao- 
dltuii tliiiivyiumte t.i.d, todiriiiiiifth his bloorl- 

April 21, Patient delirioiw; blood-prra- 
lure 110, Tliioeyuiialu dlBfontiou^. whecr- 
upon delirium di«ip|>citni. The (hart in Kif. 
160 bIiowb the course of ihe blooii-prowiirc, 
pulnc-nitr, niid nspir»tion. The ptilienl niLs 
frw (njni olhrr exceptional HyinptomH from 
April 7 ui May 1. May 1. )«.00-ll :<0 a. m. 
FnrU hoi .iml cold. Il.:i0, Sudden stlock 
of Bev*re pain and great feeline of prvwuns 
in epiitaiilniim. l\.3R. Piiina in back and 
tliir\l 1o Mt'enlh verlebrse. (.'ried out aith 
puin. luul ahKi crim " I oni chukin)c." Lunip 
clear, Canllae diilnnw only to right iircniul 
niaiiciti i>nd (u luv fniKX-rs' br«i«dl.h wil hi u 
left manutiilhiry line. 1 1 .10. Syinpiuiiu 
dimininh hilt ]>rt«(iiire in epifcutrium Ktill 

prmeul. 11.41. ^tymplo^1H ivapiiear, 11,4'i. A t«con<l »c\-en.- attack an if^iittv. I1.0&. 
nimlnution of nympionw, piiins tea*. After a fei^ niiauivii imiieiii luui u third momentary 
attack with hlood-presmirc ov*f JOO n>in. II ft. which then *ubsideji. 12.10. 
Feebi belt«r. 12.55. Still lieiter. Frw from aitacki uiHj May 3. during uluoh lime he 
(nceii'ni 0.5 Cini. (kt- vii) ciiiirelin t.i.d. On May 18, lodinm tbioryanatc was 
Again given, tthieh lowered blood-prftsaurc but caused delirium. 

Prcro ibat time until diacbarsed frvquent ultacks u( pain and hypcrtenidon. 

Pal reporta similar hypcrtcnsivL' crises in asaociation with the colic of 
]«aA poisoning And alsn with Iht- vUct-ral (rrisf^ii of talK-o,' th<! pain bcin); 
always rclii-ved n-hc-n llio bluo(l-pn-»tun.' is bix>ught dowjt by aniyl nitrilc 
or mtroglyeeriD ; as, for example, in the following caae. 

^•81000 iwnswte— *wae amt — msrawnoM 

Fiu, too.— Riiit.i-nt<~u"rli»tluf P. V, Ty|)im) 

v»Kir»rrrnr Tirinlp. 

Cask or AaiK>ui.-(AL (^atais in Lbad I*oi»o»iko. 

N. J., p«intrr, iRerl :ll, hiu> had lead cnlje tvtee before. Wwi fr«e from it 
on chanice of ucciipation, but il returned when he n^u worked in lead. Drinkn little: 
denica lue*. He luu had abdominal piuu for thrvc wecka. During past few iluya h»d 

• The ehticn of I'ul tlml a uirailttr na«ociati«n of puiii with high blood-prini»ure exiila 
with the l.iDelnaling painn of Umlxi raunot t>e maintained, fince the pain* in hia own r* — 
ate noraetimeB nwocialed with hypot«niiiou. Donietimes with hypertniiiioii. 



bail ci>ii 1 1 nuciUH rrainpB. losn ol Hpp<.-tilc, anil no #lool. He is (uiic uiul tuifl u 
nuirkctl tc«d line IhipiU Tract mday. l.unjpt clenr. \limrt rioniut: pulsp ntthrr lianJ. 
Abdotnituil wall* ttniM, Unilpr on bolh mifes. Splwn jiul palpuiblr. 

July 23. S.:ia r.H. 
9.10 P.M. 
9.13 KM. 
9-I.S v.M. 
«.17 P.M. 
0.4i P.ii. 
n,48 P.M. 
13 H. 

4.20 «Ji. 

D. I'. 130. Slighl pHin. 

P. GS. B. P, 170, TiicreiwiHi ptun. 

AiDjrl njlrito inKalalJon. 
(t. P. 10.V \o imlo. 

K, P. t6J, Piiinugiiiii.liuiti(ij;thfnniTr nne-lnlf IioiirwilliuuneB.I*. 
U. P. 1)5, .\ftpr ainyl iiiirilo, nliicli u^nio gave rclinf. 
B. P. 140 Psiiw return. 

160. rtittlicr incnauv' of pain. 
B. P. 13.^. P.t i n » 4l i m 1 n i B li ii iicl f r a m y 1 n t r r i 1 1> , 
TLcy return ntfiin. bul 
fi.30A.u. B. P. S.V Pnin* rtiitnppeaf ii iidr r am yi nitritp. 
MUr July 23, bliXMJ-prcMun* ikm tlwaya unik-r 130 (durinx liul (our <iay» under 
110). tkie puiiciit ina fn« [ram )iiun, nail buivclii item rvKiilar. 


Thn fnlluwinK nac, illuslmtintt wlinl Pal t*miB lliy oercbml type of vnnciiliir eriBfa, 
wail tin<ler tlii> vriter*s mj« at the Joliiin Hupkinn Uonpltsl: 

J. M. C, ^Tovcr. ngiil 52. wlio had iiiff«n>d repeulvdly «-i[li myncnrd it In, 
hyp«vf t iophii?vd licari, irregular pulse, uml general unajwiva, rnT«r(^ llic Joliua 

|[»|kkiii>i Hoapital in Svplfnibrr. 1903. 

Ool. 24. Fkrtlen al night. IWc pupU 
iat^ift Ihaa rijtht: Imth re-itn ni>nnally. 
Nnv. 2. Very weiik. Pulw neuk mid irit^ru- 
lut. Liver Milurgrd, 

Xnv. tV M 12.30 P.M. Ixfuii to complitin 
■i( iro "prnl discomfort witli numbnrwi in lpjB»; 
c(i[ii|>1niiir'il tA ficrvniiiintwi and rmltowiiMti. 
Al 12.45 P.M. tlif rvsllnnnpsn [)«an«! 
v«ry marked; he bcsan lo iitri)a- mil with 
hii. hnnflu and to Iry iv ictl out of bpd. H'an 
at Ihin liiiit coiuvioUH luid able lo undrntarid 
qiirsiioD*. ( Blond- iimuniro curve shown In 
Fic. 101. j N'u aphaBia. PupilB equitl and 
rlilutiKl. Head and eym drawn to ri|:fal and 
rigid. Thviv wim oome twitcliinK of ruuBcIni 
of both ■niw and liandB. KHlexm of rifcht 
arm slightly PXajQirralM. Soon liwanie cya- 
imlic Hiiil vemeta of neck stood oul. Be- 
cntiip uneonrtcioim. Henpiraiion KtrrtoroitK. 
Blood-(ir*»iu r« 270 mm. I(k. Aflpr 
400 C.e. of blood hu) beea withdrawn from left snn. crnnonis slowly Bubsided. nsplra- 
tion bnoomins '"" Klciioniiu and blood-prvwin' fullintc to iSO mm. Itjc. 

BeooniN conaniouii after cathetiTixulioii al 7,30 P.M. ^lill picking al bedclotliM, 
which TODtiiiued tmlll next mominK. Iln wa* tlieti mcntnllr dear bj 11 a.m. ami pupila 
reacted to liRht. 

Nov. 6. 9 P.M. Remained elear and recalled lialluciUiitionB of •prei'iouii night, 
rraiixinK them ui hulluri nations. Bloo<l-pr«f«iin> 160. 

Had no further otinck* of llii* kind ami blood-[)ti»(ii\ir« ivmained below 190. 
Died March 2S, 1!H}4. Aulopny «hoB-ed chronic myocnriiiti« (licurl 1000 (!m.1, chronic 
adlwsivc pcricarditii, cvrunar>- •cleruiiB, V(Ui>ne|Aran», M>c) atono in rifcbt kidnay.' 

< It in jxMsilile tlial this attftrk may ha^'«' been due to Imtuitory cerebral <Klein« 
like that di»crit>cd by il. t^Ludiiiiii: and Jam«H Itordley (Subtemporal DeronipnTiwion in a 
Cam of Chronic Mc|>hrilii> nith I'm-mia; with EJipecittl Coimidnatioii of the Neurureliiial 
l«ak>n. .Km. i. M. Sc, 1908. cxxxvi. 484). 

Fio. Ifll. — HIcHMl-prnvurr cliart tfhifwtiign vn^ru- 
lar cftMt of 111* ccrelir»l 1>P*. 




This condition is always associated with eclcraste of the femora], 
popliteal, or one of tlu> other ftrt«ru>a of the leg whieh nrf> iiMially pipe-«t«m 
in character. Often thv atheromatous chanf^x arc readily demonstrable 
by th« X-ray. Owin^ to the narrowed lumen of the arter^', the ainouyt 
of biood that can flow through it ig Itmitod, 
but this i« Hufltci«nt to supply the niunrle whon 
nt rest. During slow walking thv CO, pro- 
duced by the muscle and the oxygen needed 
by it increase greatly. If lh« urt**riul flow in 
sufficient, no Hymptome appear; but when 
rai)iil walking or raiming It* l^fgun. there is a 
sudden increase in the oxidation in the muscle, 
anil, (unce the blood supply cannot keep pace 
with it, asphyxia of both the muscle and i(« 
nerve endings seta in. accompanied by paralysis 
of the limb and often iiiU-ni"*- pain nriKing from 
stimulation of the sensorj- fibres by the CO,. 
Th« patient i.s compelled to halt. During the 
rest the CO, produetion falls, and the slow cir- 
culation is able to carry off the excess and to supply freah oxygen to the 
tissues. With the renewed iM-ration, function reluni«. The patient is able 
to walk again until local asphyxia sets in; and. since this will bo brought 
about by tho same amount of CO, as before, his walking will be limited to 
the same distance. He must travel in stages. {V\g. 162.) 

(ill. 162. DlMinm lu iUiwlnta 
thn *UtmtiAtifm of Ci'h by th^ htttod 
■n normat utd fotprottc &rl«ha». 
SoUd lios ludiolOT <:x)i (uriiiBti&n 
Jurinc hklta kAd Hhilx mil king, 
Brekan l>n« tfpfi m mui iI,p n|»dil>- 
al COi eUtnlnallnn. * inditmua lb* 
dwra* c4 OOi aHuiauIatioD *1 Hhieli 
pain ••niflCimi* tot ia. 

Case or lNTK«ui-rrB.vr CLAvniCAnoK. 

B. E., carpenter, aged 71, eompliuiu of puin in riitlil foot, clrinlu bc«r and wtunkey 
in moderation, smolcM verj litiJe, and ha* alwny* ttnva healthy. In OctolKr (oe wim rad 
■Bdnebed. Fur Ibe pusl tea ut fifle«ii years imtieul has bveii »t> 
tBcked t>y iKivrre pains in both fr<^t, caunint; him ta Htop tn hia 
wntkx. KiiMH tiev»r gave «ii)-. Ttie Rltoclw camp on oftrnest ihiring exertiw. On 
examination, thorax ia nnphv-nenuitoiu; hcaii sliglilly eiiUtviyl to Wl. Bli>witi£ iiystolie 
IDUraair bfianl av«r the (ricukiiiii niva. 1>c«oiniiiK mtiuicnl nvrr l.lie ii[>ex, well heard io the 
Axillii. but (aiiiT n[i<l bluwiiije i[i ttie putiiiuiiary nnw. where Ihe tutiond aound i* accrriUiulMl. 
I^llMR iili^rhtly irrfciilHr. tti^ht nnMn\ nrntv (clrrolic than left. Blood-praeHiiiv 165 mm, 
Oiicral reildcciiiiK Irotn tarmni\vt»l»i*a\ joinis lo Ihe lom vl rurht font, whore p ii I n a - 
linn i>l dnrinli* peilin is not tcit. Both libiala .irr p.ilpnhlF, but piilsatlnn 
is wgU fell. Led loot itnrmnl. nrtiry pubuiting well, Both poplilOHls iire vny •clerotic. 

Given nitmKlyccrin nu;. I <gr. i^) t.i.d.. ttllernuliiiK wilb noiliuRi nitrite 0.2 Gtn. 
(tcr. jil) Lid. lie wiu (omcwhat imivoviKl by Irenlmenl. hut left Ihe hoepital » few 
JayM Inter. 

Prognosis. — Since the claudication is ximply part of the general arterio> 
ecleroMS, the prognosis is bad, for the coronary arteries, aorta, and cerebral 
arteries may be involved, Homeiimes, however, the arterial change is 
confined to the limbs, occurring finiply as <legeneration of tlw media with 
atheroma, exactly &» in found in expenmenta) adrvnalin arterioscleroais. 
In that case the prognosis as to life i?. of course, better. 




The flo-ralled " hypotensive" crieea seem to bear no relation to arterio- 
sclerosis, but rather to trauma, action of toxic substniiecs. iiiid perhaj)!* 
to cutaneous diaeasett. They are in the main a.-^ociateii with depression 
of the vasomotor system and have been diBcuKscd elsewhere. The one 
ciAidition with paroxysmal depreswon of the blood-pressure which may 
owe its origin to arterio^cleroMH is paroxysmal laehycardiu ($cc page 


Maurice Raynaud in 1S62 described many cases of this group, espe- 
cially of the condition which hears hi;* name. He cthowed that the three 
phenomena miniifestcd in these conditions are: 

1. Local liyncope, i.e., blanching from absenee or diminutJon 
of blood in the arteries of the part affected; — Raynaud's disease a spa.-*- 
modic vasoconstriction. This ta usually symmetrical in its distribution., 
affeeting the ends of the cxtinnities, i.e., toes', hands or feet, arms or legs. 
The trouble in one extremity is frequently more intense than in the other. 
Often it leads to fonnatioti of hulhe, ulcerutlon, and to synimetricat gangrene 
(Kaynaud's disease). 

2. Local asphyxia, i.e., presence of a venous blood, that is to 
say of a blood in-iuRiciently oxygenated, causing bluene.w of the part (now 
designated as acrocyanosis) with a distribution corresponding to that of 
Uayiiaud'^ diwase, 

3. Loral li y p e r a e m i a , giving rise to redness (as in the condi- 
tion termed eiyihi-omelitlgia by Weir Mitchell). 

Later investigations have enabled Cassircr as well as Barker and 
Sladen to epitomi7.e the symptoms of vasomotor disease as follows: 

Tlio vasomotor symptoms include (1) liyperivmiii. {'J) syncope, and (3) 
asphyxia; the sensor)-. (1) pain, (2) hypera^sthesia, (3) aQ:esthesia, (4) 
parajsthesia: the irojihic, (1) uleeration, (2) gangn^ne, (3) dystrophies 
of the skin (Barker and Sladen). They affect the fingers and particularly 
the toes. Tlie chief tyites of di.-tease are acrocyanosis (C'assirer), erj-thro- 
melalgia (Weir Mitchell), and Raynaud's disease. 

The symptoms may be arranged ait fallows in ascending scale (Uarker 
and Sladen); 

1. Acrocyunona. 

Viuoniciior cymplom* — vrdouh vinf^ation bbJ hjrpoiviBia ia finger* unci 
IOCS uith c.vaiiutir'; MOAory And iTophic iliiiuirbaaow abstnt. 

2. AcruiMiriKitheKin. 

.Xcrofyaaoatr—^cttaory Bympionw (pamslbesia), ntimbiicv. pniii. nrnl luigUng. 

3. EryUiTomelalfcfa. 

Vasonialor — hjrpMicnua (urtvnal). Seumiry — pain, 

4. Raynaud'* diwwie («JI (lif >ymp<oinM). 

VttMimoior — hj^pera-niiu. syiirope. and asphyxia. Sensory — pain. atimtlwMa, 
ponMtheiiiB. Trophic— gangicnc u>d iclerDdennn. 

As might be expected, there are many cases with symptoms inter- 
moiliutc between these groups and nkany transitions from one to the other 



PalholoRj. — Raynaud realiwd that tho guiigrcue in tlic ditwnso wlik-h 
^ihtAra his iiftiiic (liffen'<l from nrdinary ganjcrene and directed his first inves- 
tTgatioufi to the statti of the arteries. 1I« found that, though the 
pulse became very small or impalpable during the 
nttackfl of blltnching, it returned tn normal volume 
between attacks. He made very careful pathological etudies of 
the cxlromili*'!* in a number of rascH, and frndinfi; the aneries clear ron- 
eluded that the trouble was of vasomotor origin, a view which he supported 
by d« rating lraii.Mtory changcK of caliber in the radial, popliteal, 
and retinal arteries, associated with the attacks. In ucconlanoc with thcw 
fltiKiies of Raynaud the vasodihition of erythromelalgia corresponds to a 
period of panilvHis of the vjwocoiistrictor nerves (xynipathel ic paralysiit) 
quite similar to the active hypera-mia which Claude Bernard produced in 
the rabbit's ear by cutting the i-ervical sympathetic. Just such a local 
paralysis of the vasomotorH produced by the overheating of a hand or foot 
iiciuimbed by eohl gives rise to the eondiiton of "ehilblaiim." The latter 
condition is always associated with overheating after exposure to cold 
and often with formation of blebs, while attacks of erj'thromelalgia may 
occur spontaneously from slight emotional or nervous disturbances or from 
slight exposure to cold without overheating. There is rarely bleb forma- 
tion. An attack of clii!blfttn.-t induced by overheating may thus !>e con- 
tinued in apontaneouB attacks of erythromelalgia. 

Raynau<l's tiisease. on the other hand, corresponds 
to an extreme vasoeonst riet ion , like that produced 
in ergotism. Raynaud himself was so much impresse<l with this 
similarity that he made searching inquiries in all his eases regarding the 
character of r>-e bread taken, and conducted an extenave series of experi- 
ments upon ergotism in various nnimnls. He wasforeeil todi-tcard the ergot 
hypothesis by the absence of any obtainable evidence of ergot ingestion, 
but the parallelism between the two conditions remains. 

CutK OF Mild RAiXAtn'a DiacAai!. 

A. S.. a tmiticH nursr, njcril 3(t. una nlwny* hcnlttiy until ifac nfcr of ninMMin, wlicn 
during licr poriotl of IraiiiiiijE ehc ujui curii|H'l1<><l tti have a omall nvuriiin cyni ami one 
ormry renioveJ, For »oiuf .vi^iim >hv BUltcrcd cuiwidcmble (niii Iroin inllit-sioiM. no ttiiit 
thrci; ycnre nRii ihciw ivrrc Imikrn up by a hccoikI i>|>efalii>ii. Phc Imrr llic ri|>crn1iou 
««l), hut iluriiuc cuiivaltM-eiicc tlir«e «e«ks \alvt had a fiiintiiiK vi^W. tiucf ulieii she 
nulfi'nt Truni severe piU|iilat>i>n. Cur Ibc \ia*l Iwoj-winiHhofiiui fouml Uml in foM nvathrt 
bolh hrr hiuid* nnil (orcnnn* bcromr tibfoliilcli' ubitr. c«l<l, nml numb. Thin coniliiioti is 
soon rc>li«ved by rutibinit or by liiyiiuj iln'ni (ri a btutii of Humi naier. but in Biillicii-nily 
•even: to |>rrv«it brr Imni iiccppling a very dmirnlik- ii|>|ioiiit4»cnt in a cotilcr rliin-itc. 

nciwwiiHtinclinllie ["Slienr twrn* [icrffcily hcaUhy, ha» a ROod color. All itieurierieB 
arv Buh. 'tbey ofuMun li> br ut iiomial culllx^r uiid jiMlisiilv iiunnully. Thtr lirarl in iionnal 
in *uc Init movm 7 cjn. friHi) Irfl to ri^ht .ti the )Kilicnt. tiinw from oiu^ utile !■> ibc olbor. 
Thp rtvht ki'iiicy ic aW {iut|:>tibk- uikI veijr movable. The rtm of Ute abiJuni^'ii uii't ibe 
liinjc* iitv clear. The blaneliitiK of Ihe buoili oDcitra ksw frpqiieutly mid lou inteitsely whrn 
the patient'* health lo koihI, hul it ncciin miicb mote frnt<K^''y when the paiicnl iHCXCiTe'l. 

Nilritcs. bodiiduiiiia. dijEilnlix. bnnriiideH, Hml « larffe Dumtier of cardiuc slimulaiila 
have beai tried liy Ifac {lallcnt nitfaoul marked eOeci. 




In recent yearn Weisa antl v. WiniWRrt«r, and eapeoialiy L. Buerger, 
liavc <li»crjvcR-il it group of ctu^-a in which symptoms at timrv :amulatjng 
those of the vasomotor tiophoneorosea are i>roduee<i by complete occlu- 
sion of the srttfries or veins with ^pontaiivou.t throniboRis (throiiiboiui(iiti.s 
or thrombophle bills obliterans). In such easea the !arp;est arteiy" »"'' 
Mimi-tiincs both iirti^ry luni vein Iwcomc owlutk-il by a thi-omboiic proresw 
of considerable extent. After a short time the freah red thrombi within 
the veaseis undergo organtitntion, uaunlly with pennaiient obhleration of 
ttie lumDn by white fibrous tissue. There is no proliferation of new eliwtic 
fibres enrrcaphiiiK on the lumen as t* the enM- in u r t e r i o a r ! e r o a i s 
(Kg. 163), though a. few elastic hhrcs are found in the newly formed blood- 

A n 

Fio. IKl. — Tlir(iiiili>»i«ii4> •■l.lii.crana 'A^ and «ndiirtintl( ablilprani lUi. lAfirr Kuprcer.) Tti* 
#l]bili(i fitirmi LaijiinnI hliLcki ftrrutiHirit ffum ilm otji»uU«i1 tbrvuibui iu A but pr»«it lu }Atx^ imriibtir* in 
Ih( ■naiicvclr-nDUe Itnim K. 

Thia waa the rondilion first aouKht for by Raynaud lo explain the 
orii^n of aymnielrii-iil giuigrciie, and dcfcrilnnl by him under the head of 
aenile K^^iKrene. In Huerper's experienee of over 70 rases, however, it is 
most frctjucnt in Rus-iiati and ni:»lc Ht'bn.'w.-< Ix'twcen twenty and 
thirty-five or forty, and hence in usually a "presenile" gangrene. In 
ituch cnsvit the local aynco)>e and ulnerntton arp due to arterial occluaion. 
The red bluMh is due to coniiJcnsatory capillary dilatation (termed eryth- 
mmclia by Huerger. in contrast to erythromelalKia). Cyanoaia of the limb 
occurs when the venous circulation is ulowcd from any cause. 

The sensory disturbances found in the trophoneuroeea are aUo found 
in thromboBnii;iti.-< obliterana. 

The clinical picture produced by thromboan^tis obliterans is some- 
times Mt srmilar to that of Raynaud's ili.iease (sjmsmmlic vaanconstriction) 
that Buerger has found some undoubted cases of the former condition 
reported in the literature aa cases of the latter. 

Differ GFidniion bciwccn TfiromboniiKiil^ Obtli«rant and AoBcioncurow*. — Or. Itiicnicr 

has uifumiril IliL' wnlvr llmt lie timls the fulliiuitiir iniiiit? iiBcf ill Utr dtitirul itiirrrciilinliun: 
1. Tbrrt- in iiluDj-s ul Inul on t^ vomvl nliU-b ri-niain> {ir r in n n o n t I y 
pulselesH, wltile in Raynaud's di»caM ihe pubvAOoii ntliimn to itoraMl. 



S. I n I ormi tt«n t claudication i* pitM^nt in tnoat of the rima. 

',i. Unually oiiH limb JH uCrcctfrd & coti«ide»ble time before the other, and 
thn diNcnsc^ Ukiiiilly nttnck* Uic lunrr rxttcntjtiis. 

4. There itrv exucerliuiioiis, bill I hey cnni«' on ftnd Btihtiidc rather 
e Did 11 Ally luid uf« nol paroxyiowl like Itayuuud'a ditnu<F. 

A. limltfi whiclt nre k<«I (eryihromnlia) or blue in the dtipaulent poMlion lieconii> 
blanche it and inch acinic when «ievBt«<d. 

II. Uijpatiiw phlrbilio in not infrFf|Ucntl>- aJBucinlnl v-ii)i tlinmilK)uiixiti« oblllcniiv, 

r, He htu nei-ii over 70 cumw in Rtimian nnd i'i!li*li male iU-hivmi, but never Jn » 
female. ItaytiiiiKl's diicnoc occun mure uflrii in fciiiulen. 

N. Oii«et ill u«iially|[r»dual, while ii » oudden in [tn/naud't tlimue. 

0. The cireiilultiry plieiioaiMia nrv for Ihe nui'I part ni>l of "VMomolor" nri([in, 
but arc duo lo ocrluvion of vc>=*el». They llieicforc beiir the hIiuqii of pcrmuiicncy. 

NevertJieleRH, Dr. BiierRCr has fouml a number of rases in which the 
clinirnl <!ilTtfrenlinlion from Rftyii«ud'« diseaae was vory diflicult. Dr. 
Bemnrii Saclia, on the other band, believc« ihut tlw vjiKomolor ni>uitiH(!8 
■ iheniBt-lvcs in cli^ciiKod Iilood- vessels as well aa in healthy ones,.i 
and that the pathologira) diagnosis of rmiurtvntitf or titroniboangitis does] 
not exclude th« clinical diag- 
noNM of vr>' thro melalgia or 
Hayoaud'H disea-w. Indeed it 
19 r<'Bilily I'oticcivable that 
tliromboHiii should occur more 
readily in somewhat discaacil 
arteries than in normal ones. 
Kven Dr. Ilucrgt-r has found 
some intimal changes in hJa 
cases. Va-soconKlriclion may 
olao favor thromboEie. More- 
over vasoconstriction, nrleriul 
di.tcaw, and the formation of 
agglutinative thrombi may, as 
is seen in orfcoi poisoning, all 
be produced by the action of a 
single toxic agcat. 

Cask op THRouBOANOms 

The following Is Ihc history of 
a case which, ibuugh at (lie tinic 
din^ined oM Raynaud '■> di«-njw and 
manifettinx many bynipiuiiis of (he 
latter, ia the ligiiit of iluereer'ii in- 
vvatiKntionii apprani to be one of 
tbramboanjtitiii oblitenuui. 

U. t'.. tailor, nfccd 32, admitted April H, IOCS, complaining of tore toea and 
*ore flnKerH. Had Tbeuinulinm at 12 yrar*; athciwiMi ««ll. Smokaa l«n cijcatrttra 
daily. In DMcinber, lSd9. cold brsan (o cniiHC a burn in k Knaation in N|t t«« of 
right (not. tn Mnn-h, 1!>00. pus nillected under the buse of nail. The nail waa 
removed . and (our muiitlia bter the entire toe. Wound did not hcsl n-etl. Ader lhi«, 
liuglinK in olbnr tnnii when out r>f doora, nc^v-r when iodooni. In April, 
l!Kl?, Uie fing«r? and Ihuinb nt the riithl hiuul bcRun to (in^lo and become pain(ul, njirl a 
liKle Uler on tliaw o( the lc(t hand. In January, 190-1. the left bin t o o bo^n to beconM 

Pm, IIM.— II I rtriof 4 inusnl with l}ir«nb». 

■Dit'ii oblttenuii. iliuvmn (•ukiwiuiu ulrm aiul (he 
ftCUftrp* of aiuputaUal Uitm^ Th* nrrami p«Al ui ih^ ^vn- 
gnninu uloar*. 



Phyiticial fXAmioalion on entrance, nc^tivc rx(ippt for the cxintmitiM. Doth 
haiiilH urv [luHhuil. iiol blut<. nul (enil«'r, but there is sotiiH ik-funnutiou o( the 
Ncond jihnlanx of the nuildli; lingera. Kigbl l>ig toe niiwingi iilougtu Ix^tnvoii ihUd nml 
fourth digitH. Left g,K&t too nL«i«tic; t<iiul«muM and \iAin i>v»r lioth tinit tiietatnn^s. 

Fatieut caio|ikiiis uC {luruxyamB of iiitciuw puiii during l\\c night. liuitiDC 
fiv) to t^n miTiiit<v>. DlrvnlJun of tlin limb, wnrm drrwinKn, iiiamih^, vrrp a.l wiihoiit 
effect. Cuiiititlun became wuree in eF'ilv uf but HeCI, cuiiipriMBes, clc, luid ibi- Ipfl grvut 
toe knd to be removed. The ilumi) did not hcid for «ct-ernl monlhit. There 
was nevnr jiulfation in either popliteal; vary litile in either 
f euioral . Putieut diwharKiivl iti February. HMM, uiiiiutiruviil. 

During thin tiine blowi count: red bhrnd-coqiunoli* A. 000.000- .'i.AIXI.QOU. llirnio- 
globln 100 i*r cent. Urinp nomiiil- Itltiod-pre-Mun! 100 lo 130 nini. Hg. I'uba- 80. 

The fi»lIowiii)f hi.-ftorj' re[ire.seni.ii a mon> lypicjil caae of thrctmlioon- 

gilis obliterans (quoted from Buerger). 

M. K.. 14 yi'itrs, KuBHiuii Hebrow. futbtr of three liealtliy childn'n, wim udmitled to 
Mt, Sinai llosjiitiil on Drt^nmbnr .\ lEIOS. HU limlu nr^vci Iroiiblrd him until .ibout a ycnr 
a;{i), wbi'u he [fit th(^ preiic<iice uf under aputa on the iunvmldeuf the ri^bt foul. Houu ulh^r 
hard "luni|iB" nnd "curdfl" spjieurvd; (oiiie of ibcw iii the neighlmrbood of the aiikle, 
olhurs lusher ujiou ihe led. Aftr^r I wo nmntlw thiwdiMip|#aretl, only loieeuraftera very 
ehorl intcrvHl. Sinet- tlieu he had neier been iilisolultly fn* from peculiur "pninful ipota," 
Olid now, on admiwion. be xtill biw signs of some of iheni. About ihivc monOui after the 
OiiMt of theee ayniptoiiin be experienced pain in llie bi^ loe, eiipeciully on ualking. Tlu» 
has become t[n>'l'iall.V wonie. no that he hiiM liet'ti unable to net about properly for abiiMl 
two inontliB- Of lale be haa often hail eranj)*) in the calf and inslvp of the right leg after 
mdkiiiiE for n abort ilixtancv. His chief coniplitiiit, liowever, u the painful con<lition of the 
inner aide of hJa rij;ht lejc. 

Pbyxicnl exwniimtiuii showed evideuc«t of cirfululorj- dinturbunce in the riulil lower 
e:(trcmiiy. Both the dor8aIi»i |>e'lie artery and the posterior tibial were pukeleiu. nlibougb 
pulsation of tmlb the femonvl and [loaterior tibial «rtery could he eiwily delecte<i. 

Over the inner bor<ler of the riitht foot llicre is a i«»l ntrrak about one-balf inoh In 
length. This comwimnda lo u lender indurated ruuss which thiiw out niid in lout an it ia 
truireil upwtvril, A ahort dialnnee fielow [ho middle of the Ice 'he upjicr cml of a hard cord 
can t>c palpated- Thia extenilx down l>ehiriil the bonier of the libiu for niorv than two 
bichoa, in »dbcrr--nt to the akin, aoinewhal noihil.'itcd, and marks the centre of nn urea of 
by perse naitii-e. Bwolleti. turgid akin. There am no troj'liie diatiirbanees. Ohi^Turtis : 
Ihr-nmboanjUi'i an<l tkrombophMtitin of the inlernal »aphcjuj\u anri mime of ila tribiilariea. 

On necember I'>. lfK)S. a jxirlion of the thrombosed saphenous wa« remored for 
pathological ex umi tuition. 

On Ilcfiember 2il, IBOS. the jibynicnl cxnininntion wati recorded aa followa: In the 
horizontal position, the riuht foot ha« a lijjhl shade of red; this !» njo»t niarkeit o»-er the 
liijT toe nn<i fiidea olT townrdi the mikie. In the u-eb lieiweeii the thirtl and fourth tOM 
there tx a tileer. On the inner side of the foot almost tn'o inches from the InteiiMl 
mallcolua there in a hanJ, eonl'llke noibile uliich In adben'ot Co the skin. Itehinil the llbJA 
there is the Ncnr left aftitr mmovAl of u portion of the wiphenoiia I'vin. The sapbenotla can 
no longer be felt. 

On elet-ation of the foot blanelung setii tn rapidly and pain boconiea intntuw. The 
jiendcnt fool turns very red (marknl etiThmmelin)- 

Fim-rnKn Co uaaE.— February 15. 1009, the pain in tlie foot ha* been ^tettins atcadtly 
morae. and Ihe fourth toe ia beginning lo turn hlnek. On the 2:td of February itmptJation 
ai Um knee wna done, at tbf requeel of the patient, for early giuigrene of tlie fourth toe. 


In thtt light of Bii«rp>r's patholngit^al ntudic?. treatment should be 

direoled toward keepinR up a rapid circulation through the part and dimin- 

Jshing the tendoney to roaB;iiIate. To bring about the former the vasodilator 

lnig!4. especially the nitrites, should be freely used, but most of all the 



mechanicul mcthodn of inducing art«riAl hypenemia, — hot poultices, 
musLanl foot or hand baths, or the Bicr'fi hyperamia by suction in racuo 
(not Bier's Mtjigiuilioii liyix-ra-iiiia). ICxsnngui nation of the arm or leg 
with the Ksmarch baiidftgc. which has l>e(fn iidvocalcd by aome writers, 
has givKii but liitlo rlinicai encourageniejit ; and in the light of the recent 
pathological studies aeenis to be the worst po&iibU! procedure, WDoe it 
provukvit the fita^ation it intends to cure, at least long enough to induce 
further thrombosis. 

It i» poKiible that the adminiEtration of sodium citrate by mouth, in 
doses suffirivnt tu :<law the coagulation time of the blood, inifcht aid in 
diminishing the tendency to intravascular coagulation, but, since the fibrin- 
ferment i.s .-oipplied on the spot from the cells of the intima, it is probable 
that this would not be of much iivuil. 

To keep up arterial hypeia-nua until the thromboangitts has been 
repaired is the only hope in lhora|jy. 

From the time of Raynaud to the present excellent results have been 
reported from the use of warm (but not too hot) poultices. 


VabDuutoh (-'Hlau AND ANUIUKlCUIUMeS. 

Pal, J.: tNe Qefftwkruen, Lc\\:a., nm. 

Chnicot, J. M.; Sur In cluu<licjiUuii iiilvruiitli-ati^ ubst-rvfe iliuin iiii ens it'oblitcnttnn com- 

plHo dc luno dc« lutcrm jlioiiuc* primitive*, (.'nmpt. rrod. Sac. dr lliol., Pnris. 1857, 

3 f^riu, xii, 'i'ia. Sur la claudiraiion int(irDiil(«nI« par obUieratiun «tt«riellc, I'rugrte 

VM., Pniw, IS87. 
Ivrb. W,; U»ber ilua "lOtemTitliivnde lliiiliMi'' uiid sudors neivOne S[oruii|;co iofolp' voo 

Qt^t&ta rrknuikiiiigcn, DtMilach. Zlachr. f. Nervrobdlk., xiii, 1. Ucbnr Dyxbiisia an^Jo-^ 

nclpTOticji, Miiitncbc-n. moil. Wchnvchr, 190*, \i, flOfi. 
Barker. L. >'.. aiiJ Hidden, V. J.: Ou AnocyuJuniB Chronica Atuuilbetioa witb Cltuigrvnc, 

rtc, J. Ncr\-. and Meiit. 1«»., K. York, 1907. xxxiv, 7lfl- 
Ctusiivr, R.; Die Viwomolorinrhp Tn>phi>iieiini»«n, [Jcrl., 1001, 
MilcbeU, 8. Wdr: PliiU. SI. Tii.i™. ls:2: <iuoI«l fnan A»cli». MitcWI. S. W.. uul Hpiller, 

W. Q.: A CsMc t>l Hrr'thniniplnlKiu wilh Mlrrowopiral Ivxiuiii nation of tlii> Tiwue 

from Ml Attipmalod Tw, Am. J. M. Sc., PhUa., ISIKI, N. S. cxvii, I. 
Raytuiud, A. C. M.: IJp TuBphyxie Icicule pt de In goiigr^nc njniitriinu! dc« pxtnfinilte, ' 

Par., 186:^: nino. On Local j\iiphyxin and 8ytiunntrical GsnuTcac of iho Exlremitiiw, 

Tnod. by T, Biirlow, Loml., IWS, 
Biwrticr, I..: Tliromlio.inRiitiii Oblilrtiuiii; a Btudr of thr ^'nI^-lJl»r Iamohs Iniding 

Prwnile GaiuTrnc, Am. J. M. Sc,. Pliila. snd N, York, 190S. cjuiivi, 387. T\\e Vdivl 

in TiironibomiKiilia Ublitcmiw. willi I^l^^iculIlr Hpft-trncr to AncrioiTnoiw Aiias- 

lOiPOMH RA n Clin? fnr ihp rnnditinn. J. Am, M. Awo.. ChioHitn, I'.'O!), lii, 1319. 
8ac)i><. B.: liuynuiiit'N Diaeaiie. tIri'lliruiiicliitiKH. and ibe Allied Comlitioto. in their 

Rdntion lo VnMular l>israw of the ICxImmitic*. Am. J. M. He.. Philn. and X. Y'ork,' 

1906. cxxxii, Ml. 
jUao. Strausn. H.: L*Bl>er un^iutpui-tisi'he UauigiAii <Ra}itBuil'Mibe KnutkbMt), Areb. (. 

F»y«huil.. Berl., 1005, xutix. 109. 





The. ettrotmry aitorie* have utniAlIy b«)rn conniJcred to l><> lerminal mrt«HH in the 
MOM of r/>hnhplni; tlinl i», ihat Iheir l>nLnc)i«f> (ii<l nut anaaloinoMe with OQu anolber iiulli- 
cimtly to iiittiiitaiii nil ud(>iiuul« circiiliition. uii'l iiiFarctiuii fallows thnr occtusioo. "niU 
U CQRMit undtr inii'>t clinjciil oondilioni; and Porter hw. found tix peri men laJly that tho 
[iifan^tlon i« pmporlional lo ihosiipof thp litnili?il bmnch. Ill niaiiycnites lii^lIuDof scoru- 
imry givea Tine to GbitlUiry cuii tract ion i anil nuddeii iteuth (Porli-r. Ma({r»lii nnd KcnniHly, 
Krnncckcr); in olbent death may follow within a Sew miniilM (rohiihrim nnd v. ^hiilLhoM- 
R«chberK)i within an hour {P-Jiiium), or the animal niuy Live H-vctuJ utvlm or aiore 
(Baumgftrt«u) if the opctulian a doiw Mcjiticftitj. Ueuth t-vcu ibeii ofirn oocur* ■uddcniy. 


iif^WV^ /||/v.«%wih/yi ^v 

Fia. lU. — EKait o( lig«uan nf > l&ntp niraiiiiryutarTupoB the blonl-pmmrr. (Alter Cahnhnin kod V> 
liobulUieift-UsclibcfX.} Conmrniy krtcry Ucaud *( a. 

Olnribuilaii of the Coronafy Artcrlcx. — Walter Boumgnrtcn in Porter'* I&bormto^ 
waaabk lu Maatv l)u- \'ur>>>ii" coronary hrancbw ot cats and dojEs under aaeptic precau- 
tion* and produced iiifurctn in llit- t.'urrwt>ondiriic amu of tbe inyoctLhlitun. Ue found 
the follonint; cffiyiM by lijtaiiiiK the vnrioiw br.anchca: 

Kamuii desceiid«il8 : Anterior w.ill of left ventricle, an1«rior papillary iDlii^ 
ele, left half of tlio (Jiickneai of tliv inti^rr't utricular wptuiii. 

Rarnuk circ urn flex iin: Piwtpriar w.tll of left ventricle. iip>x, jioctcnor pofttl- 
tury mtuclH, a certain uxtcnt of Ihe ni-bt ventricle, potrlcrior wall of left atriutn, |NMt«vior 
third of the Hfplum. 

Ram UK Hcpli: Thin I* (civcn off in tha dofC ttnar the oriiiift of thn mmun dnitron- 
deiH or independently of il. LijcHlun) produow a trUugulAr infarotioD with the apex of the 
irianRip towAfib the Uitature. 

Kigtii coronary: (Jmalrr |iart of rtdht ventricle, po«t*rior porllon of tba 
appotidix atrii. (The sniaUur bnuicbm of tlM alriu ar« not catiifht in Ihe lipttiire.) 

PauniKartcn alw> excised the aoicmio area and pctfusd it vith <leSbriniite<I blood, 
Uid found tliit region vat able to reHume contraction* when the dr- 
culnlion «ai renewed nitliin dx to eleven liotln after the ar1«ry hml been lieulvd. Tbn 
reij^on of the e«nt^« '^ (he infarct Intt it* contractility before that nrar the periphery, 
indicating tlut ii certain ileKive of collateral circMUtiun, p«rhap« tluoiiith l)ie vewcbi of 
TbebMua, had taken plnciv "nii* mirk Fxplaim nhy it i* tliat a cerliun lime ctapnid 
between tlie otMlruclion of the art«ry and tbc tuddcn ocwation of beat in the cxp*<j- 


menu of Patium hikI of Cohnhoim anil v. Scliullhrw^-Itechlirric. The (rcaler nuinbef of 
BauinKnrUMrM doga uiul cats flurviv«tl (he «|iiTaliuii w^'ll iiiiil eIiowi-O no vliar^-v Lii Iwiirt 
action beyonit » (miwitAry ntrhytluni.i Iwiinf; tncnty-faur to thirty-aix hoiin-. Thfi 
M>ij[iil> were tiomml in ewri,' ivti(M>cl and [MHAfM^cl nn tiixluc valviiljir iiuullty. 
Only two iknimaLi jJiowiii idini" "f lutldi^i cunJiac ftulunt. one tlyiug in ihr niid«t 
of violent exertion »nd thr other ntxm >.hr:t i1, f^xsclly a« occur* in man i/ne 

Ilintch and Hpnlt^holx found thnt, thotifih infarcts nrm prnduivd tiy lixalinn of ihe 
ouronnr}' urlpr>'. the infarcls weru mnulkT than Itip urtu siipi'lit-il !tllaIumi(^:llty by the 
artory, and thnrc wn* a not inpiinniilc'riiblc? iimoiuil iif unn«lorin»i«. csjipcinliy l«(w<icn the 
bmnelMui nn«r the Hurfarr> of the heart./ Tn manChiari h»» Cnunil riirii|.]fiii.' ix'cIiiBwn vt 
the right p(Htinur>' attpry mthuiil infurctiou. aiid I'ujei'tistvthrT hun lijrnffd tJial arU-ry 
in on o|>erntion irjthoiil rvil miult. Thnip ant (hr main f:icl* rvganlini; (ho rfimnary cinui- 
lotjon wliich thniiv light upon the clinical coudittooc uLticrvnl. 

Prntl hs8 shon-n that the excised msmmalian heart can be nuunshoti 
through th<' veins of ThclK-sivis HuRieiently to rnrry o»t forcibli- conlnw- 
tions for a cotiaiilerabic tinic, though this probably k not the case in the 
Living nninml. 

It ban lonjc bpcn a matter of dnhaUt whether the heart mtmclo waa 
nouriahe<l with blood diirinit lht.< *y«rolic or during the dias- 
tolic period: the earliiwl conlfntion being that of Kcaruinucci ( I8.S9) that Ibe coro- 
nary veawla are sqiircxfid ompty hy thr contraction of the heart mukclc-libnw during iiy«lote 
and Gil from the liir^T and niur« superficial coronary vmacls during diaatole. After a long 
contmvcnir, during which Itabalnl rihowed thai the curve of coronary* btooiUpresKUrc nnd . 
apparently also ibe curve nf 1)]od<1 velocity wr^re exactly niinilnr lo ihc curve in the aurtaJ 
the nucatioii v-aa definitely settled upon the excised lieurt by Pbrtw luid lii» pupiki' 
in favor of the old view of Kcamniucci. They oiao found that the blood in the CoronatT 
vdna ih H|uec«Nl out in diastole. 

The existence of vajtomotor nerves for the coronaritvt has been proved 
by Mjias.*, who foiiml that the va^iis everted a vasoconstrictor, the accel- 
erator a vasodilator notion upon thcsir veawOs, 

Thia <tiui eunCirtned by O. LanfccndorfT and Wiici:er«, who fotind aUo that adtvnulin 
exnMd a vanndilalor action upun tlie coruniiry nrleri« of the exc-seU heart lti«trsd of it» 
lunial vaaiJOotuilrielor action, IVith Wigit^ni and fi, S. Bond havp found thai the outlkiw 
through the wirooary vein* of tlie dog'n beail in aitu is increaseil by I be ndniininl ration 
of udreiialin. Bond in^'^vtixatcd the nlTccts of a larf^ ntiuilxr of other ilriiKii aj> n>ell, and 
(oiuid that the corunury outflow always foliunr>l ihe curve of m-ncral blood-prmmre: •» 
that, under the expnrimenlal conditions, he iviw unable to <leTn(iD«lratc any »pcrilie action 
upon the coronary' vctucls. even from duiiea fiir lar)n>r than would l>e adnilniiitered in tlicrn- 
pcutict. Itowevrr. the operation if m itevcrc that the animal* are alivaya in jtrofound 

Ida Hyde in Porter'n loliorolory found that Ihe coniDary blood flow wan diauniahed 
by distention of the heart, a fact which may account for the wealccr contraction of ovor- 
dihilod bearU. 



While the stclerosis of the coronary arteries does not differ in it~i pathol- 
ogy from the iwIiTowis of arteries clecwhere, nevertheless the action upon 
the heart pves rise to clinical and to secondarj' pathological conditions 
which are quite difTereiii from those of general arteriosderosis, and which 
therefore deserve special consideration. 



Another important conililion which u vct^- common is nrteriuHrtc- 
rotic or atheromatous rhange arising in the mrta with or without asflociated 
involvement of the cDroimrit'!! lhcni!*Ivci«. but .-(iixT-nilin^ »o tis to involve 
the mouths of the coronaries as thpy arise from the aorta, and strangu- 
lating these vessels as they pass thrmigh the aortic wall (sec Vijc. 166). 
This hax tho same pffpct as a mt'ttil band coiiatricting an artery would have; 
namely, of diminishing the blood-prcHswre and the velocity of tinw in Ihe 
artorj' beyond it, of allowing the walls of the artery to contract down and 
hence of producing a further permanent secondary narrowing of the lumen, 
with progrewive diminution in the blood supply to the part (Haktett). 
The course of the artcr>' may show patches of hardening with indentations 
ntid widenings, collnr-iike constrictions, or uniform widi-ningsi; ur, on ihe 
other hand, the arteries may be couvcrled into uniform tubes whose walla 

may give the sensation of nihher 
tubes on the one hand (uniform 
fibrous scleratis), or of absolute 
pipe-BtemH (complete calcification) 
on the other. This condition is, of 
course, particularly common in 
arteriosclerosis afTeciing the base 
of Uie aortu and in tite arli-rio- 

IfMt ihc mtlrc (pwlmm . It, Tli» wUfirtip rammrj anvry, nni>tii hr<iu(l>t el{"»ii ■ wif» lam ti»»i> pnuxl 
Ihruuc^i tU* mouili uf ilie roriHiAry briery, 

sclerotic form of aortic inMufTicicncy, and may account for many of the 
symptoms to be discussed later (see page 2K4). 

Since the heart muscle reiiuires much more blood when it is beating 
forcibly and rapidly than when it iv beating slowly and quietly, it is easily 
«een that this collateral circulation may be sometimes ade<,]uate and some- 
times not. Also, since in diffcront individuals of the Rame species there are 
variations both in the structure and dispoaition of the minute arteries and 
in the needs of rhe muscle-fdm's for nouri-thmenl, it is but natural that the 
resultfl of coronaiy diaeuse should vary greatly. 


The clinical pictures associated «ith coronar\' .tclerosis are characl«r- 
ixed by eomc or all of the following features: p a i u over the precordiuni 
or down the arms, feelings of suffocation or of impending death, 



paroxyBma of most inteniw dyspnoea with palpiliition, enkrgement 
uud pulsutioii of the Uvfr. fEPiioral n-eakoetia, sudden death. 

A considerable gra<ie of art«rio8ckTOsi:t may be piVMeni in both young 
and old in<lividunl» without giving any 8>'mptom8 whatever, an shown in 
the case of J. L. (pafie 487). Another example of this waa a colored boy 
under ihp writer's care who nfti-r very vigorous Ufe died at the ajte of nine- 
teen in the fifth week of typhoid fever. Neither l>efore nor during the fever 
had he had any rardiae symptoms. However, liij corooory arterica wete^ 
found to be very sclerotic. 

Sudden Death. — Sudden death i^ frefpiently the Rrst manifesta- 
tion of the eondilioti, and cx!ini|)k-M are ahiiosi daily in the newspsju'r* of 
persons, usually men past middle life, who drop dead without warning and 
with no previous iUne.ts, due to .fuddeti thrunihosi» of the sclerotic eoro- 
n»Ty arteries, or perhaps merely to the fact that, though the sclerotic 
process has been going on gradually, the instant has pa.'irtwl at which the 
canlinc- nutrition iMi-ome.i in.iufTK-irnt and ischa-mia sets in with sudden 
functional insufHciency. just ae occurs in the leg in intermittent claudica- 
tion. This be the rase in many hearts in which no actual throuibosiii 
oremboUsm can be found post niortem. 

Parox)'sms of dyspncca such a» tho^ <lescril)ed on page I4S, the so- 
called cm-dine a.Hihtii!!, nrc aUi* extivmely common in coronary rtderosis, 
especially when combined with aortic insufficiency tvide page 3R0), in 
which ctt.-* they are no doubt tlue to the dilatation and weakening of the 
left heart and the consequent aceuniulalion of CX), in tlie blood. It has 
been suggested by I)rs, C. M. Toopcr and E. O. Jellinek of San Fnuici«ico 
that this waa always an accompaniment of sclerosis of the right coronary 
arteiy and dilatation of the right heart, hul in autup:<ie« of two casea umler 
the writer's care who had Mufferod from such attacks the right coronary 
waa absolutely free from scletY)aL9. 

Sensations of pain In the precordium, ami es|)eciully behind the stenium, 
as well as pains and temlernetw over various interspaces and radiating down 
the arms, are e.specially common in coi-omiry scleixwU. 

Paroxismal Tachycardia. — Attacks of tachycardia beginning with 
sudden doubling of the pulw-rate and ending in audden halving of the latter, 
just as is present in essential paroxysmal tachycardia, have been ilescribed 
by Romberg as manifestations of coronary sclerosis, and Krehl also cites 
similar findings. 

In Rorahcrc'i) raw the piil»>'nile rniv suddenly from 100 to '2W, irhilc the r«splru> 
lioD rvi]iAiiii.-(l Dl 20. Tli(< ultuck lusled Ih-o duVH and lluiii lliH pulne-rule dn>p|HHl s%id- 
ittnily lo ion. Ijiirr nii aortic nlcnuna developed gtikdusU}- and (tic [mlimit di«l of tioun 
Tailuiv. Ilie u>ii<>|wy showinit iiurtic Menuaift and Mlercwis anil marked ci>roniir> nclcroBiii. 
I>r. [liurkrr infornu the trric^i that he atso has iwen a oi>upl« of ottoea in which fiich 
attacks were tiwioridii^il with conmnrj- ncli-nwi*. 

(juit« rvcvnily Hinilur utiurks huve hven produced by T. Lenb upon Ugnliag (lie 
coranarj- ftrlcrini in cntu cvrn after Ihc canliuc tiem* bud bivii ttDCiiaocd. 

Painful sensations about the heart are particularly common in asso- 
ciation with coronary aclerosia, hut on the one hand they are by no means 
eoufined to this condition, and uei the other hand most extensive coronary 
aclerosia may be present without the occurrence of cardiac pain. The most 
marked form of c^trdiue pain, the so-called "angina pectoris" (pronotuiced 



an'glna, not angl'na} to be discussed below, U tn it« most typical fonn 
usually B^nociittcij with u L'urtuiti dvgroe of coronary nclcronitt. 


In I7CS both Ueberden and Rougnon described attacks of pain in the 
chest. Tnc forinvr recoj^nixc-d the t-onrlttion l\w more clearly and dcw-ribcd 
it in Uie foUowiog words: 

"Bui tlietr ui > disunli^r of llit- bn-iul iiiiirk«I wilb Btroiig und ja-culmr syinptouui, 
CotiHid«iniblr for thn ktnil of ilaiigrr liclnnKing ti> it, luid lot o-xtmnicly nur, which dovrws 
to be im-iJiiutied hu^^ at lengib. The te;i( of it, uid kouw oI •uaaKliuK tuid anxiety with 
which it i» uitniulcd. tuny inukc it uol imprupiTlj' be callisl ttoginn pectoris. 

" They who iiro atfliclrd with it lur mred whilt? they nrv n a 1 k i n k linon' <«j)c- 
cially it it bt. u|>-ti>II and muii aftrr valiii^ vkiili n puinful niid moat disn^nvable 
•eueal.ioii in l.>in brrai*t, which nrcins lu i{ it would nxtinjctiiHli life if it wnrc to incrcoM: or 
to tonliiiiw; liul lfi« inonicril tliey stand etill all this iinuasiiicw vatiiBhoB, 

"In all other itspt>cia the patiuDtB unr, at the bcginninf; of tlic liiicitibr, perfectly 
w«U. ajid Ln piirtirulor have no iihar i iitti^i' of hri^ath, from which It Is toldlly 
dilTemil. The pain ia doinc t inius situalvd in the upper part, some- 
liines ID tlic middle, Konictime'H at Ihr; bnttoro of tho or ntcrni, 
uiiJ often more inclined to tbo lofc Ihan lo th« right olde. It lilce- 
irise very fcx!qui-DtJy i-xii^iids froia the brviut U> the iiud<lle of ttw turn. The p u I h c ui, 
ttl leaat isoinctiinn', not distiirbi^d by Ihui pain, an I havp had op|Kirtitiutira of 
ob«erriag by fM-UiiE tlie pultie diirini; tho puiruiywii. Malen an' iiiuel liable lo this 
dieeaae, mpocially auch tv hu<.'e punscd their fiftieth your. After it hn« con- 
tinued & year or marc, it nil] not crane a* iiMtAiiiannou»ly ii|Kin slaniiinj; otill. and it will 
come on nut only wheti thi- persons atv walkiiii* l>ul nben they are lying 
fiouii. wpcriolly if they liir <in the left nidc, .ind olitiKc them lo nm out of their bpd». 
In wime iurelerule caaM it ha« been bruoebt on by Ibe routioli of a borne or a carriage 
and even by HWallowing, coughing, going to atool, apcnkinx, or 
Bny disturbance of mind. 

"Such is Ibe uHual appearance of this disease, but some varieties may be met with. 
Some liav(> liern Krixed wliile tliey wete (tnnilini; still or cittins, aUo iifion tint waJitnjc mil 
of sleep, and thr pain somotinie* renchosdown the ri^ht arm as well 
aa Iho left and even down to the hands, but this is uncommon; in a 
very few pw«ans the »rni ban nt the itame lime been niuiihcd and dwelled. In one or l«w 
porwms the pain liaa tssled Home houiB or «vpn days, but thiM has liuifpened wtien the com- 
pUint lus brrn of long slaoiJiiig and tliotoughly rooted in the conatitution; onec oiUy the 
very Itrsl attack conlinuod tho nhole n'lxht. 

"I have seen nearly a, hundred people luidtr tliis disorder, of which num- 
ber ihorf have Ixx-n three women and one boy two jntars old. All the rcM 
wn: men near or piut tin! lifliHh year of their age. 

" IVnons whi» iiav-e [lerHcverwl in milkiiig till the pain has relumed four or fii-c IJint* 

have then Buniftimc* %'ninited The Iimnlnation of aiiKina [•ecorii' ia remarkable. 

For if no accident intervene but the dlncaw ifo on to its height, the patients all 
suddenly fall down and pcriafa almost immediately. The an^na 
pectoris, as far as I hsTw been ahl« to inviwtiftale, bclongH lo the clae* of spasmodicfli not 
of fnflanunalory complaints. For. 

"In the flnt place, the neccin and the treewi of the fit is sudden. 

"Secondly, Iheiv are lonx Lnlorvals of t<erftrct health. 

"Thinily, wine and siiiriiuuiis liquorK and opium sflord considemble relief. 

" I-'ourtbly, it in inerea^rd by diittiirbancn of mind. 

"Fifthly, it conlinucH many j-ears withutil any other injury to the health, 

"Sixthly, in the IwKinninf; it is not bmuftht on by ridinf; on horscliu-k or in a car> 
tia<c. as is wuul in diteaoes nrlHini! from sdrrhus or inflaniinalion. 

"Seventhly, during Ihe 111 the pulse is not qiiickeneiL 

"Laatly, iU atlaeks are often nft«r the first sleep, which Is a eircumatanee common 
lo taaay apBitnioilic dlsordet«. 



"With mpMt to Ihp Irpatnipnl of thi* contplnini. I bavc little or notJung lo advnnce. 
. . . . Quiut, waruilb. mid Hpirituuiis lii|iiurB help to resloitt inlintttn 
who an> ncnrly cxhniwlrd anil Ui diiprl ihr cffivt* nf n Gt nliic^h (low not coon go off. 
0|>iuiD lakMi al bciJlinic will prevent Ihe aKacks lit ntehi." 

Hcborilcii's oonlcmporarj', the great John Hunti^r, siiRered from this 
<Ut<ea)!e, and d^Hcribed hU attacks most vividly. 

The niwdern attpeetH of the whole subject have heen diecuseed in a 
masterly way by Sir W. Oairdoi^r as well Olk in the nion> rerciil monographs 
of W. Usier and U. A. Gibson. 


In HelMTilcn'it description we have epilomixed almost all the elinieal 
featurpK. (1) The euddeii nltack^ of opjiR-ssion in ihc che«t, with a feeling 
of strangling, and, as Hunter putt) it, "aa though the aiemum was being 
drawn back to the !<pine." or, in the words of Matlht^w Arnold, iw "though 
there were a mountiiin upon my client," (2) The mental unguish (termed 
by (Iiiirdner iiiigfi' iiiiiiiii). with the fenr of impeiuling death, espt-cially pro- 
nounced in John iliiiiler. (;() The intense pain, situated sometimes in the 
lower sometimes in iipj)er pari, of the sternum, more fre(|uently to the left 
than tu the right (although occiutionally to the latter), and very often 
radiating to the ami, especially the left. {4) Some of the disturbaneea ' 
of i«ens«ti(in; even HelnTtien siH-ak.-t of nunihiK-K.4 of tlw nnii. {5} Changes 
in the pulse in some eases: intermissions; extrasyi-tolcs in some eases 
(Hunter}; alternating pube in others (Mackenzie), (d) The extreme pallor 
and constriction of peripheral arteries during the attack. (7) The sudden 
death. (S) The main factors in bringing on ftttark.t.— wtilking up-hill, 
flatulence and digrstive disuixlers. bending down in undressing, mental 
excitement or anxiety, and eh|iecially anger; but none of the more gentle 
emotions, «ueh »» pity, sorrow, etc. even when felt intensely. (The effect 
of exposure to cold does not seem to be mentioned by these writers.) (9) 
The anj^ociation of the condition with sclerosis of the cornnary arlerie.t. (10) 
Its frequent association with nbnormal fiitty deposits at>out ihe heart 
(ef. Jenner and also page 214). (1 1) The relief nf symplonis by means of 
opium, warm applications, hot drinkx (vit^odilutor mechanisnui), and 
eounter-irritation (Heberden). (12) Its incurability, owing to the seat of 
the trouble. 

To these poinUt clinicnl observations since Jenner have added: (1) 
The existence of anginoid attacks with several conditions other than those 
of L'oroiinry selerosis. part icuinrly with over-indulgence in tobacco, with 
hysteria, with hyperthyroidism, and with other purely vasomotor phe- 
nomena, aa well as with praciicaliy all the vtdvulnr tlisease.i^ of the lieurl, 
(2) The frequent association of angina pectoris with certain definite areas 
of tenderness which iieprefieni spinal .'•egments corresponding to the referred 
pain. (3} Tlie occurrence of rise In blood -pressure with each attaek. (4) 
The relief of the attacks by inhalations of amyl mtrile and other vasodilator 

Sir William Guirdner has called attention to the occurrence of certain 
eoseit n-sembling Helx-rcien's angina i>ei-tori.-' in every way except in the 
absence of |>nin us n symptom (angina sine dolore). 



Pa(hs Traversed by (he Pain Scnsaiions.— Thp afferent impulses from 
the heart have lx*n lrate<i by I.iniwiit nml Cy<«i through the tlopre.-wor 
fibfus of the vngus. Il has bci-ii ehowti by Eystcr lind Hooker that the 
afTerent impuli^s from the aorta aD<l coronary ftrKTief ilo not, lake this 
same puth but pass upwitnl in the iiiiiin bundle of the vaguif. There is no 
evidence from animal experiment that afferent impuli)e» paas in any other 
way; hut Henry Head. n.-t n re«ult of his most extensive studies upon pnin 
in visceral disease, Btat«« that this " produces impulses whieh pass into 
the Kpinal cord by lh« white rami. The scpnent on which they 
tnfriuf^ is excited and pain is produced. At the same time all potentially 
ptunful influences pastdng into this se^icnl from the nfferent nerves are 
oxugeeniUxl, and ultimately the body wnll may become tender." 

Time BniHUtiuiis of rpfprrc'J imiii rollov ihf nanii.- palli lu tius b«Mi dmrribiil by 
UayiiiB for the vnsodilnlnr fibres niili whieh prDinpiUhic iiciintli<>n wrrna (o hr clciwjf 
wMOCiatciil, us shann in lierpw s»B(«r, etc. Pcutopalliic »i-ti«ati<itui hk referred lixck lo the 
dintribulion of the corrcapooilitig nerve ■cgmcota nitliout dow rrfervncc Ui Ihn )iointii 
al which they anw. 

InMniibilli) of the Hc»r< lo Touch. — Thu heart itself H-eimi lo be devoid of UtciUc 
M^riMiiioii, [or llurvoy jnvcM llic followJnit ilnwripHon of ihe cnndilioii in ihp binetcim-yeiip- 
uUI sun uf \'iiK'uu[il Muiitt£OTiivr.v. ulio tijtii u fixliikiiis 0|i>-iiiii)( in (lie ehmt cull over th* 
hf.irt followinit fniclure of the rib ia enilj childlMioii. " I foucii n lorfii- i>|ieii iip*cc iii the 

chmt 11110 which I coitlil intro'ltiro ihm: of my 
Rngem niiU my thumb ... I Mkvi thut I was 
hnmiliiix the apex of llic tienrlt covered over with 
a. \aytT of furuiouii flrvli by way of external de- 
fence, 11* ccifiiniotily hii|>peiiii in old foul ulraiv. 
. . . Ttit' yuiitli iievtr knew when «e touched 
bis htwrt exrept by the sight nr ibe sensation ho 
had thn>ii|Kh the estcrnal tnicitnnient " 

Palpttalion and Ani:)nal Sensations 
Compared. — The Bonsations which may be 
felt from tiic heart itself may be either 
rhythmic and felt an a distinct sensation 
Hccompanyintc each systole of the heart, 
such as the fettling of palpitation, or tlic 
pain felt at each I»oat in some cases of 
pericarditis, e»)K>ciaUy thojie tt.-«40cJat4Nl 
with pneumonia. The sensation in th« 
hitter oon<iition tniiy, however, arise iji 
the parietal {>ericardium. and may hav« 
nothin)c to do with the heart itself. 

Sensations of palpitation may be 
wry distressing, partly on account of the 
feelings of nuffocalion which accompany 
them, partly on account of the mechan- 
ical shock of the heart beating forcibly against the cheni wall like a bird 
in a cage. But. however intcnae and distressing, the sensation of palpi- 
tation b always a prcssuiv sensation and ne\-er tnic of pain. On the other 
hand, the n-al cardiac pain is never intermittent, never felt as a distinct 
seiii^ation with each lx>at of the heart, hut, whether dttll and aching or 
sharp and stabbing, it has no throbbing quality about it. It is, then^fore, 

Pig. 107. — DtitribulionolpMU >ii>iui«k> 
ufaiM^tll lieeUiha- JScIihoaUc. &fTcr llffi'l 

ukI Mm-km ii», I ASCAO. irv± purrr«poii.l - 
111! tothi*>^of<i<iinjiii"ti»; Tfi.AfI, amtnit- 

Kr«a etinfipoiiillns lulrfl WHlriclitiuir4cl». 



not at all homologous with the Bensatton of palpitation and must belong 
to a quite different category. Hirschfelder has added some evidence for 
this view by observing that in some cases of palpitation the sensation 
was referred definitely to the root of the aorta, and was exactly similar 
in character to other sensations of throbbing in the radial artery alone, 
which were sharply localized along its course and not spreading like a pro- 
top athic sensation. 

Referred Pains in Angina Pectoris. — James Mackenzie and Henry 
Head have called attention to the commonness of referred pain and tender- 
ness in angina pectoris. Mackenzie showed that there is often tenderness 
in the areas supplied by the second 
and third cervical segments, whose 
fibres along with some from the 
spinal accessory run down to the 
heart through the vagus. This would 
account for the occipital headaches 
and tenderness of the sternocleido- 
mastoid and trapezius muscles which 
are frequently present. The muscu- 
lar tenderness is elicited by squeez- 
ing gently between the thumb and 

The distribution of the pain and 
hypera^sthesia, according to Head, 
bears a close relation to the chamber most afTected, and particularly to 
the somatic segment of the embryo to whicTi it corresponds. 

Fio. 166. — ^DutributioD of attacks of pain and 
Beaiory discurbanocB id a caae of aapDa peclono. 
(After Head, with pcimiuioiL of tbe publishcra of 

I Correspond embTyo- 
logLcaily tu 

Auricles 5, 6, 7, 8 thoracic 

Ventricles 2,.3,4,5,6thi>racic 

AscendLng aorta. . . 3 and 4 cervical . . 


TraTiBverse arch ... C. IV. 

N«rv« nupply 

5, 6, 7, S segmenla 

2-0 thoracic geg- 

3 and 4 eervicol 

AuDcistnl phenomena »nd 
paiD referred lo 

Descending aorta. . Thoracic secments . 2-12, cap. 4-12. 


2-12 I 

Ptilmonary artery. C. V-VIII.. , . 

Lower axilla and shoulder- 

Cheat wall from 2d-7th rib, 
ulnar surface of forearm 
to wrist, and inner aapecl 
of upper arm. 

These segmenta also to 3 and 4 
c. and 1 thor. Tenderness 
in neck of stemomastoid and 
trapeziuB muscles. Tender- 
ness and pain at back of 
neck. (Dilatation of pupil?) 

C. IV.. Laryngeal areas of neck (4th 

I branchial bar). 

Back or front of chest, espe- 
cially below nipple; abdo- 

Outer two-thirds of arm and 
hand; arm muscles. 

C. V. 

Thus, the auricles (atria), which are the hindmost in the development of the cardiac 
lube, receive their innervalion from and refer their pain to the fifth, sixth, seventh, and 
eighth thoracic segments. The ventricles, the next chambers headward, correspond to 



tlio Mcund to the Rixtli l.hnrncic; ih« nMcndinK aorta trom the WD^Iunar valfM to the 
oriKin of thi! <tuctu» aIt(^ril»UI cumspoaila to llip pririiitive nurtu uitli (he third and fMirth 
hntiichiul an.f^ry, .and ihr piajn m rafemd (o thntr wK"""^!!' (htir aa anniiriitni. etc.. Iiivolv- 
iiiK tills ill lulult lifv nil) nlflO invxilvc the n«iiic;hbi>riui: iit-rviui mid thu puiu wUI be refRmd 
tn thi! fint, itecond. nnd Ihird (horndc Kegnienla iu> wtrll). The fifth to thr eighth cvrdoal 
KOiniH-nU. curruMpondinK '" thn pulmonary arlcry, will not be involved, and pain amy not 
lie refetred over Ilienc sreas.' ITherv art iimiiy uolable exceptions to thin rule evni aniont: 
Ilfjiil'" cn««; bill lhe(T is ununlly ox-erlnpping of thi»e aroati-) 

Sudden Death and Motor Disturbances. — The ph«nonivnti thus far 
conndered un> purely twnsory; and the question arises, what are, if any, 
the motor disturbanr^es connpcted with angina pectoris? It i« evidciit that 
the ct'wation of the heart-boat in mnkien deiith that occasionally occurs 

may be due either to the occluson 
(if the itrHi-ry or to u suddrn onset 
of complete heart-block as in the 
Adanift-^tokcN syndronif. Tlw lat- 
t<f'r condition is Hometimes associ- 
ated with anKina pectoris and vcr>' 
frequently with coronary' scleroeid 
(spe page 472), thouRh this is rare, 
and more frequently the puh«e be- 
comoK regular aftvr a short time, or 
sudden death from heart-failure sets 
in ju*tasinlhccxi»oririK'nlsof Cohn- 
heim and v. Schuitheas-Kechber:g. 

Durini; the attacks of auKinK 
pqrtoiis the blood-pressure is often 
higli, though Mackrnzi<^^ ntuti's that in many cases there is no chantnc 
whatever. This seems to be due to a true pectoral va,-winotor crisda in the 
tettme of Pal, rising sharply with and falling sharply after the attack, u 
ehowu in Fig. IQ9. 

Fn. IMI, — Blood 'pmaurr curre ihowinc crin* of 
hrptfUnuanduriuflAllBcLtoFuiciiu pMlori*. 


The idea that selemsis of the coronary arteriea was the ledon vhicb 
caused an^nn jK-ctiiris seems to have oripnaled not with Hcberdcn but 
with i'^lward .Irnncr. th<? discoverer of vaccination, who was so certain of 
it« patliolo^' that before doing an autops)' upon a cai>e be made a bet 
with a friend that he would Gnd thickening of the corouar)- arteries. He 
won the bel. 

This indeed .-•reni.t to be correct for alnioett alt ««M4 of fatal an^na. 
since Ihirhanl found coronnrii' »e)ero«)« present in 12S out of 145 autopate 
recoixlcil in the literature, anil most of the others w^ere in cases of adherent 
|]cricanlitini or valvular lUseas*'. A few raM.^ of death h.i\'e occurred ia 
attacks of anpna due to tobacco or in poet-febrile contlitions wbere the 
coronat^' arti-riiM uvre clear, but in tbe«e ibe poicdbiliiy of obwiirv myo- 
cardi^ change must be borne in mind CO«lerj. 

' lltn own esMM do, a7, and as v wnl la cms cf luaa^ Qt«0 wtUcol, 
durii^ an-i aSwr allaelw thie lo aneuriMn invnhri^ ihr *w>mdu)| auna. 



Angina Pectoris without Coronary Sclerosis. — Howcv«r, la 1812, J. 
Latbum reporU'd a number of caee« which, in spite of the ocrurrenoe of 
intense anginal symplonw, <hd not run ibc uMuaJ counw onding in Eudden 
death, and to these be gave the name of "pseudo-angina" (angina 
notha) . 

B«an, Stokes, and (iravea also described reflex and toxic fornts of 
angina, but u much cknror light was thrown upon ibe subjv<-l by NolJi- 
nagel's article entitled "Angina pectoriB viugmotoria." He says, "We 
must interpnti ihia aymplom-coniplex to in(licati> thai we arc not dealing 
with a disease which ariK'it prinianly in the heart, but that the s>-mptoms 
of stenocardia are of secondani- origin and are brought on by a very general 
spasm of the arU'rics," 

The term "pseudo-angina" baa been severely critieised by Balfour 
and UitHwn. .-linvc "angina" i» a it>-mptom, not a diitease, and in all (.-ases it 
in a verj' real one. Nothnagel's term. "vjiBomolor angina," or Huchard'a 
"reflex angina," fvem.-* m the writer to l>e preferable. 

Theories as to Causation of Anginal Pain.—Maiiy theories have beon 
ndvaiKvd to explain the causation of pain in anginal attarkh. Thvso may 
be classified as follows: 

ill iKbtemU .om Conatry StcnodK. — The uru^nal view of JemiLTWji Inti^r stipple- 
mentci t>y Allan Uiimn. IhnC ^lIcHMIlckI□uy In- bniuglil oii b}-iijiphyxinof Ibc hrttn muxcle 
wtK-ii there wuh h diNpioporlioii Iwiwcen llic lunoiinl r4 blood tfuuiiiie to it »fid the lunounl 
of blootl which it iimled. Pulaiii, ill 1((7U. wus tlitr Gnl lo intnidun: itie theory that 
uiutirja |x<clx>riD in iliic to "ihr iolcntitlteiit clnuilirntinii of Ihp hcjin "; biil AIIhii Bumii 
had nlrc.'uly cooiplutdy deniobsl ruled this catuiJ /nclor iu IStKI aiirl bud ilntcribrd hin 
ulwervutiorM in Ilie fallAwiiif( word*: " If wit call Into vifconiuii aciimi a limb louiid wliicfa 
H-c liari> witli a iiii>i|prat« d(«r«« of liKhlDMi applieti h ItifitluK. v»> Tuid ihul the mmibrr 
can only support ii» action for a vrry Hhort liinp. formiw il«»upply otcnrrjty anil ile expen- 
diture (Iu iiul liulanei.' each other . . . nc uiCncM an Jndiicliun of un exIn^iiK! di-^mt 
of debility and wi; hnw llic pntifW cuiiipluiniag of au luiunuttl painful ftflin^j in the ticnb, 
but i^lill all i(>i muiieli>>i a^(^ in a male of jna<^tivit.y. . , If a fiemnn uith Ihe artfrim 

of th(.> hriirt iIim^iuhmJ in hucIi a nsy mi Iu inipwle tlie pm|civ« of the bioud olonf; thorn 
attempt Te> <Io ihe wimc (imcriid a ulecp or mount > pair of ataiif), he tiiida that the heart 
u ■ooiier f:i(ii;iiMl tliuii (he Other paruare," aad Uieaame pain rewults. 

C2) Ischicinia from VM*oeoniilrictor upwoti of the onronaiv nrlcricn, which rwliicM 
the fiuictioiuil (mriililioii lo the same Hlalo a* dewrihcd by AIImu IJunui (or the coruiiary 
Kclemiia. This «.-et!ia to apply lo the vanoiuolor and loxic ungiiiua mid oden ecinxli- 
tules a factor Kiiperim|H«cd upon the coronary ■clcroiuii in (he nnicina vern. Such an 
action of druKH opun llie coronary ttitseils haa bcca dcnioiwt rated on the excised liesrt by 
O. Ix)ch, Ijii^C'ndorff, !in<l \Mkbppi (sen pinte281). 

(Jl) Acute dllntatlon of I he heart, prorlurinic a pain Hlmllar to I hut i>f iii- 
tcstiaal oulic, Tliii theory particularly hiu Ihwii adhered toby many wriMrx. The 
(limllarily betwceo the anginal pain and lliat nf trtial. biliary, pnncrcntic. and inlctitliiHt 
colic HUtufexlM that it bclomics to thr common form by which (he viscerul nercea pve 
exprciuion lo otfnliiiti^ntton. Home dQatatioo uiually nccnnipnni«a Ihit ollarJc, aotl 
tieeinH to >ic n primary cauae of thi> pajn in cardiac ororalrain ajul in many caate oJF val- 
vular l»ion, 

/■I) M«urill».— It may at limni be due to ncuritii of the cardiac ncrvw, or, on 
tjie ulher liutid. lo a neiiriiia primary in the: brachial DertVM and r«ferre<l to the ketut. 
[.esionn of the oudiac ptextw have been described by Lunccrvniix. Groeoo. and Benennti. but 
Heran! and others have failed to find them. NVverlheleM it ia iiuil* poaalbic that buI)- 
■tniicn like tobacco (nicotine), which F<(imulate eeiUMMy nerv«a to the heart and which han- 
a specially loiie scdon upon (he Kanftlion celli. may [^oduoe tosie neuriti* of ihcee nerveH. 

<S) NeuratKta of tlie car<liac ncrt'M. 

<6) .Action of other coiwlilutiuaal diseaMW like gout, diabetes, and chronic nephritis. 


But it u ait»i proliable that the elTect« tkre duo to ttie other above-iuMitJoned faetoni wbicb 
accompany tlicac ilisciups. — aTtcriMclcruai ■nil (lie pr«tiGnce of v(uoc<HUitric(«r irubitinnors 
flitber an retention products or uil«nial cccroiions. 


The various conditions with which angina ia associated most conimonly 
might be clasu6ed a« follows: 

I. Organic LMiuo*. 

A. Sclcrcwi* of ctironary artcrin. | 

B. Auvunmi, e«|>Fciull.v of flnt part of anoeRdioc uoriu. 

C. Vnlvnlnr loduiu, H|>vciall)' aortic tiumllidi^ncy. (Thin coiwtitiitM a very 

common Kroup.) 

O. Aortic ancuriBiEi. npvdiUly of the BiiiUMB of Vnlwilva aud the oM-VDctitv 
^^_ nrrh. 

^B E. Adhvrviit |i(<ricuTiliuui. (Tlie tnwt fntqucnt form wliich U ae«o in 

^^^ Huldrcn.) 

I II. Vaaumotor anjunsB. 

A. Ilyttttn'cal typt. nicut common in uomm. luwociuiod with other vnw^ 
I motor <ii»1itrbiinrc' anil KtiKiniiln nf liysinrin. 

^^_ B. Toxic, due to the ucttoii ut vanuiiv puikT.<i^, n>|.<eciully (ol tob«coo. (A) 

^^B CatTpinc, tnlcrn nn Irn nn<l ui coffee. 

^^^ C. AMooiaicd with hy)>ortbyn:»li9iii and cxoplithnliiiic cuiirc. 

r in. Alraeka of inon- or l«wi luigindd puiii occur in tlie cnaca ol uciitc dtlulnlion of 

hullhy h^arli^, due In priiiiBTv rardi»c overstrain. 

Angina Pectoris in Valvular Diseases.— Th« attaclc!* of angina pvctom 
associated with coronarj- sckroeis, which represent the original form de- 
iscrilwd by Hplwrdcn, are usually designaU-il lis angiriu vera. Thvjic are 
very often associated with valvular lesions, especially with aortic insuffi- 
ciency in which the coronary legion.-* are usually continuous with those of 
the aorta, but they are also commoa in association with otiier valvular 
lesionR, since it is rare to find n ca»e of chronic valvular disease without 
some disease of the coronnry urter'M.'s. The ptesenoe of valvular disease, 
therefore, rather favors than excludes the diagnosis of coronarj- sclero^. 

In spile of the frequency with which thew two ciinchlions are asso- 
dated, occasionally one encounters cases of angina with valvular disease, 
especially aortic inmilTiciency, without any di.'tetuie of the loronary vessels 
whatever, as was well exemplified by a patient with a ruptured aortic valve 
who was for live years under obwrvation at the Johns Hopkins Hospital. 
During this time he suffered from very freipient atlncks of typical angina 
pectoris. He died suddenly while at stool. Autopsy showed rupture of 
Hortjc leaflet. The coroiiarj- arteries were soft and the walla were not 
thickened anywhere. 

.Angina Pectoris in Acute fXlatation. — It is possible: (t) that under 
these contUtions acute dilatations of the heart, due to momentary diminu- 
tion in lone of the heart muscle, might be the immediate cause of the pain, 
which would thus be of primary cardiac rather than vascular origin. (2) 
That in such dilatation, etc., centriix-tal stimuli may aiise in the heart 
which may cause a general vasoconstriclioii, (This is contrarj" to the usual 
depraaBor effect of stimuli arising in the heart, but it is nut at all certain 
that in the presence^ of such a pathological condition as angina pectoris 
the paths of least resistance in the centra) nervous s}'Btem may not be quite 



difTerent from what ihey «re in the normal individual.) (3) Mias Hyde ia 
Portor'H laborHlory has shown that dilatuiioii of the heart in itself caused 
diminution in the flow through the coronary arteriei*, and it in pos.«i)>lc 
that the circulMion niny thus be diminiifhcd to » point ut which relative 
iscbicmia of the heart may set in and cardiac pains result. 

Angina Pectoris in Aneurisni.— Allucks of nnj;iuu pectoris are ver>- 
common in csisea of aneurism Involving the ascending arch, and enpeciolly 
in early i<niall anouriNm^ near the ^nu^s of VaUalva. This has long been 
knon-n, but is the subject of an especially interesting article by Or. Osier 
upon "Angina pectoris as an early symptom of aneuristm." 

The aiiKinoiil pnliw in thin coiitlilinn arc probnbly Hmply n-flcx, not the rwiill of 
pritnnry ptripliifiu] vusocoiistrictioii. cunJiac iscliitrtniu. vie. but aiiiiply tlic occiitTRncc of 
pain MmMlioa «riiuiiK lu the aortic wulU from uvcntrvtchitig of thc^ aorta under pmeiira] 
mtKhUowd (ram any cauae «bal«ver, or from incn-tuKMl ricuniion of (he aortic udII u 
rMTllt of incrr««Kl nyilolic output, ttc.. iw U w> frequendy mMi iti tbe nbdunicui in no-rvous ' 
«oiiivii will) ettitCMlric fmn dar to a ihrotihlng of tbr abdoniinal nort». In the Inter uti^eii 
<if llic unciirinu, Ihf ayiuptoiiis niuy be Ipm iDt«fit«. <bie perliujJB lo the fact that by rrocicin, 
VIC. proMiure vipiMi lUieiiriEiii tins (liminiitbcd. jwrhnjis to ibi! fncl that after h liiiie 
ending of the oeiiBury iierM<« have lieeii iicnnanondy injured or ivtidered low *cniafii-r 
by iho proKtr«srivp chuigp ill the luirlif wull. 

Aflitlnal Altacki In ChlUren.— .\i>ginn pctTorin nWi occiire in cIiildrMi, Mipociidly iuy 
BMiociaiiuii with niitral Et«n<iniB, lu illuntraled by thr followiii|; nue: The paiirnt waal 
a boy nffcil S »bo bail hud rhiTUiciuliiiDi in the right liip Iwii yi^nra prcTioiuly, and siucti' 
lliMi "'liad Htlucka of |oiin over ihp liearl, wjircially after i>3ierci%e. The puiii n^ co 
ERVcrt! Ihiit it ccni|>t'll(xl hiin to stacKl [ivrfectl.v dtill unlil it |»u»hmI u(T: bin ch<«lu bocame 
blue and pair. Hit immrlinini frit iw though bdii in r vine, but iii^ver had nny feeligg of 
four. He alBo lutd ut (inim [luiu ou the r I k h t side over ulxiut the sixlb rib, whieh was 
somMimM prvornt with that on the left aide, but oflcji prwcnl uithoul ii, nxf<rti»e (i««nuMt 
to briiiK on both. Emnunalion «hoiiietl n very kliithtly pnlarfcrd heart nitli ■yatolicYnlrac* 
tinn nt-er Ihc fourth left in(«n>paic«, rione nboul urijciii of diuplirtipii <Brai(Ihrnl'a liicn 
ubMtnl], Arc-a of cardiac flalncNi chaiif^ with mipiniliim. The Untl nound al ihe apex 
niu inuppini: in eharuclcr and was prtioeded by a Dv^lbdefineil rumble, i^ecunc] nound was 
clfar. accentuated ovim' tlic puliDoniv area. Puliw ITi j«r niiauiv, of good VDliimc, retmlar 
ia force ond rtiyt.lini." 

Such attacka ace quflu definit* angifna v^m in the Mtnae of Helwrden. and inderd the 
latter incliidcn a mmilar cniw in lus lint. In chililrai Ibe UBwciution in, however, much 
niticv cinniiionly wllh valvular loeions than with coronary iK-lero<ii*>, and perlup* moat 
tmqiirnlly of utl with 

Adhercai Pericardium.— Thia ia an extrcoiely coctunon concomitant and eauie of 
anfcinal atlacks, npeeiiilly in children anil adolmcvnta. The pains are. prrfau|w, ttiiTiply 
reScx acbrw fmm the nrdicinry tufci upon the pericardiiuii, perliap* brought about by the 
atmtchiim; of the iwricardial fibre* which occur* when the heart becomes dilulcd. 


The second jtreat (trnup of rases with anginal symptoms are those in 
which the anginal ifymptomit are of purely vu.tuniutor origin (Kaynaud's 
disease of the heart) and are not associated with organic le.sionN.— the 
angina pectoris vasomotoria of Nothnagel (angina pectoris spuria of Lalham, 
angines de puitrinc rcllexes uf Huchard). The ciiaracU-riiitic pheniimenoal 
in thia group is the occurrence of general or local vasocon- 
striction ushering in the attack; that is, there are usually 
coldn«s:<, numbness, often tingling, weakness, and heaviness in the left 
arm. pallor of the latter, with marked (liminiitioii in size and caliber of 
the left radial, often abo of the right radial artery, ^metimea of the ve^ 



of the leg. trunk, und head. The patient may become pale and blue or the 
lips ashen, and the course of the iiu»i-k« may exactly aimulatv those of 
coronary sclerosis. Death in such attackd is, however, extremely rare. 
It has occurred in xeveral eai>e.i in which no porouary sclcroitiii nor other 
lesion was present to account for the death. However. Dr. Osier i^uRf^ta 
that in these citiva there may have Ivoen niyncHriliHl I'hauges demunsirahle 
only by the method of Krehl. 

Hysterical AnjtJna. — The most common form of va»onioinr »nf;ina Is 
the neurotic or hystericiil type, which is most tomtnou iu young women 
and is associated with the other siiimiata of hysteria, — exag:f;erated emo- 
tional rc.-^pon(*e with marked histrionic tcnrlencie*, trunsilon.' vusoniotor 
disturbances, ahiftioK areas of anieethema and hyperarsthesia, characteristio 
epileptiform wiitureM: and the existence of hysteriogcuic xoncs whcrt pres- 
sure? calls forth the above-mentioned symplomB. 

Ciinical Group* with Anginal Symptoms and their Charactfristu Feature* 

{modified from lluckard). 

Coronar>' Angina. — SUe of dUlurbance. — Stenosis or obliteration of the 
coronary arlerie.s. (In some ca!*c« valvulur lesion or only). Agf. 
—Age of nrteriosclcrosts after 40. Factors bringing on attack. — Effort of 
Bonie sort, mental or physical. Rarely itpontaneous, sometimes nocturnal. 
Not as!«ociated with any other form of neurosis. Salure of pain. — Ag- 
onizing; Aennation of prewture. Visually felt most acutely behind sternum. 
Keferrcd pain down arm, especially left arm. and over chest, neck. etc. 
Duration. — 2 to I'l minute.^, t<topping soon after standing still. AltitueU. 
—Silent, immobile. /"rojnoais.^Orave; almost always fatal. Treatment. 
— Vasodilators. 

Hvsterical Angina. — Site o/iJi«(urt(ancf.— Ccntnd nervous system acting 
through the vasomotor nerve and cardiac plexus. Age. — At all ages, even 
childhood: .foinoiimcs at menopause. Most frequent in women. Fartora 
bringing on aHacft. ^Usually spontaneous onset without effort, often recur- 
ring at fixed hours and ikKsueiatcd with other neurotic symptoms. NtUure 
of pam.^I'ain less agonizing, with feeling that the hear