3 1822 01159 8729 
 
 NCIPLES Of 
 
 DIAGNOSIS 3 TREATME 
 
 IN 
 
 HEART AFFECTIONS 
 
 SIR JAMES MACKENZIE 
 
 OXFORD MEDICAL 
 
 LIGATIONS
 
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 \N DIEGO J 
 
 
 Date Due | 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C5?J CAT. NO. 23 233 PRINTED IN U.S.A.
 
 WG 200 M156p 1916 
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 PRINCIPLES OF 
 
 DIAGNOSIS AND TREATMENT 
 
 IN HEART AFFECTIONS.
 
 Published by the Joint Committee of HENRY FROWDE and 
 
 HODDER &-> STOUGHTON, at the Oxford Press Warehouse, 
 
 Falcon Square, London, E. C.
 
 PRINCIPLES OF DIAGNOSIS 
 
 AND TREATMENT IN 
 
 HEART AFFECTIONS 
 
 BY 
 
 SIR JAMES MACKENZIE 
 
 M.D., F.R.S., F.R.C.P., LL.D. Ab. & Ed., F.R.C.P.I. (Hon.) 
 
 Physician to the London Hospital {in Charge of the Cardiac Department), Consulting 
 Physician to the Victoria Hospital, Burnley 
 
 LONDON 
 
 HENRY FROWDE HODDER & STOUGHTON 
 
 Oxford University Press Warwick Square, E.C. 
 
 1916
 
 printed in great britain by 
 
 Richard Clay and Sons, Limited 
 
 brunswick street, stamford street, s.e., 
 
 and bungay, suffolk.
 
 PREFACE 
 
 The contents of this book were prepared as lectures 
 to be delivered to the post-graduate students and 
 workers at the Cardiac Department of the London 
 Hospital. The outbreak of the war prevented their 
 delivery, and in publishing them I divide the matter 
 into chapters instead of lectures, while I retain the 
 colloquial form of expression. 
 
 A great deal of our recent knowledge of heart con- 
 ditions has been attained by the use of such mechanical 
 aids as the polygraph and the electrocardiograph. 
 These instruments are not available to the general prac- 
 titioner, so that if the recognition of diseased conditions 
 were to depend on their use, much of our recently 
 acquired knowledge would be of little practical value. 
 It has been a constant endeavoui on my part to recog- 
 nise the different conditions which these instruments 
 have revealed by employing the ordinary bedside 
 methods of examination, and I am concerned mainly 
 with them in this book. Those who wish for the 
 evidences which the mechanical aids have produced are 
 referred to my book on Diseases of the Heart. 
 
 As the main question in every examination of the 
 heart is concerned with heart failure — whether it is
 
 vi PREFACE 
 
 present or foreshadowed — one of the objects I have in 
 publishing this book is to present the essential matters 
 connected with heart failure in such a manner that the 
 general practitioner can appreciate them and apply them 
 in his practice. 
 
 Another object I have in view is to present this sub- 
 ject in such a form as to lead to a better conception 
 of what clinical medicine means and how clinical investi- 
 gations should be carried out, and, if possible, to 
 stimulate research on lines which are essential to 
 advance, but which have been wholly neglected. 
 
 I have to thank my friends Dr. George A. Suther- 
 land and Dr. R. M. Wilson for their kind assistance 
 and suggestions.
 
 CONTENTS. 
 
 CHAT. PAOB 
 
 I. Medical Research . 1 
 
 II. Heart Failure 37 
 
 III. The Patient's Sensations .... .48 
 
 IV. The Production of Symptoms 51 
 
 V. Breathlessness 55 
 
 VI. Syncope 60 
 
 VII. Objective Signs of Heart Failure .... 66 
 
 VIII. Angina Pectoris . 69 
 
 IX. The Hypersensitive Nervous System in Heart- 
 
 Disease 81 
 
 X. Breathlessness and Angina Pectoris .... 85 
 
 XI. Sense of Exhaustion 87 
 
 XII. The Examination of the Patient 92 
 
 XIII. The Heart from Youth to Old Age .... 97 
 
 XIV. Murmurs : Physiological, Functional, and Organic 99 
 
 XV. Murmurs {continued) : Diastolic Murmurs (Mitral 
 
 Stenosis and Aortic Regurgitation) . . . 108 
 
 XVI. Affections of the Myocardium 121 
 
 vii
 
 viii CONTENTS 
 
 CHAP. PAGE 
 
 XVII. Heart Irregularities 138 
 
 XVIII. Auricular Fibrillation 157 
 
 XIX. Auricular Flutter 172 
 
 XX. Heart Attacks 177 
 
 XXI. Acute Affections of the Heart . . 187 
 
 XXII. Blood-pressure . 200 
 
 XXIII. Prognosis 207 
 
 XXIV Principles of Treatment 220 
 
 XXV, Treatment (continued) : Rest, Diet, Exercise, Baths 226 
 
 XXVI Treatment (continued) : Digitalis, Strophanthus, 
 the Nitrites, Sedatives, Oxygen, Atropine, 
 
 Other Drugs 231
 
 PRINCIPLES OF 
 
 DIAGNOSIS AND TREATMENT 
 
 IN HEART AFFECTIONS 
 
 CHAPTER I 
 
 MEDICAL RESEARCH 
 
 The progress of medicine will be hampered and delayed till the 
 general practitioner becomes an investigator. 
 
 The time is approaching when, in the course of nature, 
 I must fall out of the ranks, and before doing so I wish 
 to look back upon my medical career to see what 
 light my experience may throw upon medical science. 
 The life of a general practitioner is not considered 
 one that can help much in the advance of medicine ; 
 it is, indeed, regarded so lightly that no steps are 
 ever taken to train one who intends to become a 
 general practitioner in any branch that would enable 
 him to undertake research work. You know well that 
 if a man aspires to research work it is to the laboratories 
 or to the hospital wards he is sent. As a result of my 
 experience, I take a very different view, and assert with 
 confidence that medicine will make but halting progress, 
 while whole fields essential to the progress of medicine 
 will remain unexplored, until the general practitioner 
 takes his place as an investigator. The reason for this 
 is that he has opportunities which no other worker pos- 
 sesses—opportunities which are necessary to the solution 
 
 B
 
 2 MEDICAL RESEARCH 
 
 of problems essential to the advance of medicine. But 
 before the part that the general practitioner alone can 
 play is understood, we must look upon the science of 
 medicine, its teaching, and its pursuit with new light 
 in our eyes. 
 
 A knowledge of disease and its effect on the human body being 
 required of the medical profession, it is useful to inquire if 
 this knowledge is being obtained. 
 
 I would ask you to realise for a moment what is the 
 highest object at which the profession should aim, and 
 then to consider how the object should be attained. The 
 highest duty, undoubtedly, is the prevention of disease. 
 We are, however, far from attaining this object in most 
 instances for the simple reason that the danger is upon 
 us before we are aware of it. Consequently a prelimi- 
 nary duty is laid upon us : that of recognising disease, 
 the manner in which it invades the body, the course it 
 pursues if left unchecked, and the measures we can 
 adopt to stay or mitigate its progress. 
 
 These are no doubt the objects consciously or un- 
 consciously pursued by every investigator in medicine, 
 but it is well to state them clearly and precisely, and 
 then to pause for a moment and reflect, in order to 
 satisfy ourselves whether the pursuit of these objects is 
 proceeding on lines that are likely to lead to successful 
 results. If we do this we shall surely realise that much 
 of our energy is spent on things that have little effect 
 on the furtherance of our aims, while fields that are 
 vital remain entirely neglected by us. 
 
 In order to discover whether present-day medical re- 
 search is being carried out in the best way, let us consider 
 how medical knowledge has been pursued in the past ; let 
 us try to realise the stage we have reached, and let us see 
 if there are not ways and means yet unutilised that may 
 help to expedite the progress of medicine. I will refer 
 to this part of my subject briefly, contenting myself 
 with bringing certain salient points to your notice.
 
 MEDICAL RESEARCH 3 
 
 The history of medical progress. 
 
 The practice of medicine is a gradual evolution from 
 a past state in which that practice was based upon tradi- 
 tion. Through the ages there have been periods when the 
 introduction of new ideas for a time directed medicine 
 towards a clearer and more scientific course. But such 
 phases have been temporary ; and medicine has ever 
 tended to slip back into the old groove of tradition. 
 Even at the present day the most enlightened among 
 us is hampered by these traditions. Although, indeed, 
 many notable advances had been made in many fields 
 before the middle of the last century, it was only about 
 that time, which was the period of the introduction of 
 systematic study, first of physiology and then of patho- 
 logy, that the study of medicine can be said to have 
 achieved a definite and scientific direction. 
 
 It must be apparent to you that no real advance 
 could be made until the systematic study of these 
 sciences gave us definite data regarding the physiologi- 
 cal processes and their modification by disease. 
 
 With the opening of laboratories for the study of 
 diseased organs, and the founding of professorial chairs 
 for the teaching of pathology, this branch received a 
 great impetus and has carried our knowledge of disease 
 a long way. The students of medicine by the bedside 
 were not slow to take advantage of the knowledge 
 which the pathologist gave ; and thus the study of the 
 lesions produced in the living were correlated with the 
 diseased conditions found on the post-mortem table. 
 In this manner physical diagnosis was gradually laid on 
 a sure foundation. The advance in this region has been 
 great, and physicians have been alert in seizing on 
 methods of examination which the advance of other 
 sciences have brought to light, as, for example, the use 
 of the microscope, the various electric methods, and the 
 X-rays. 
 
 The recognition of the microbic origin of disease 
 
 B 2
 
 4 MEDICAL RESEARCH 
 
 within recent years and the brilliant researches of the 
 bacteriologist have caused a great advance in medicine, 
 not only in the detection of disease, but in providing 
 new conceptions of treatment. 
 
 Clinical research at the present day deals with disease at an 
 
 advanced stage. 
 
 If we pause and look back at the advances made in 
 the last hundred years we may feel justified in rejoicing 
 that clinical medicine has made wonderful progress, but 
 if we look a little more closely we cannot but be struck 
 with the fact that " there remaineth yet very much land 
 to be possessed." Speaking broadly, the result so far is 
 that we know much of the diseases of which people die, 
 and we know a great deal of the signs and symptoms of 
 these diseases in the human body before they die. We 
 can, by our unaided senses and by mechanical aids, de- 
 tect disease processes when the disease has advanced 
 so far as to have done actual damage to the organs and 
 tissues. 
 
 But you will observe that the recognition of a disease 
 occurs for the most part when it has made such pro- 
 gress as to produce what we call a physical sign. Now, 
 a physical sign in a great many cases implies a disease 
 so advanced that destruction of tissue or permanent im- 
 pairment of the organ has been produced. At the best 
 treatment may arrest disease, leaving an impaired 
 organ; while frequently all we can do is to mitigate 
 the sufferings caused by a progressive disease. The 
 chief efforts of the profession have been spent in the 
 recognition of the more chronic diseases after they have 
 killed the individual or when they have gone beyond 
 the stage of cure. No doubt research into diseases in 
 the later stages was necessary as forming the foundation 
 on which further inquiries should be based, but it is now 
 full time that we should look beyond these stages and 
 see if we cannot get nearer to the goal which is our aim 
 by the detection of disease in its earliest stage.
 
 MEDICAL RESEARCH 5 
 
 The investigation of the early stages of disease has not yet been 
 
 seriously undertaken. 
 
 In order to obtain a fundamental conception which 
 shall be our guide in medical research, it is necessary 
 to keep clearly in our minds how disease invades the 
 system and the kind of evidence which reveals its pre- 
 sence. When this conception is grasped it will be clearly 
 understood why medical research, restricted to the lines 
 pursued in the past and in the present, has failed to 
 bring to light the knowledge essential to the recognition 
 of disease in its earliest and most curable stage. 
 
 Health may be described as the harmonious working 
 of all the organs of the body. The introduction of any 
 agent interfering with the function of an organ at once 
 destroys the harmonious activity. If we are to recog- 
 nise this agent we must appreciate the signs of its in- 
 terference with this harmony. The first sign of all will 
 be the consciousness of the individual that there is 
 something amiss — in other words, the first sign of the 
 invasion of the body by disease will be a subjective one. 
 At the early stages it may not materially interfere with 
 his functional capacity ; but, by-and-by, with the per- 
 sistence of some disagreeable sensation he will be brought 
 to seek medical advice. The advice may be sought at 
 a period when no physical sign is present, so that, in 
 the present state of medical knowledge, the nature of 
 the complaint will most probaby pass unrecognised. 
 
 This is no fancy picture, but represents the experience 
 of those affected by most of the chronic diseases, 
 whether of the lungs, the heart and blood vessels, the 
 digestive apparatus, or the kidneys. The diseases of 
 these organs often begin insidiously, and we fail to re- 
 cognise them until they have developed so far as to alter 
 the organ or its functions, and produce some " physical 
 sign." It is often assumed that diseases are now re- 
 cognised at the earliest moment at which it is possible, 
 humanly, to recognise them, and this idea has been 
 strengthened by the knowledge that we now possess
 
 6 MEDICAL RESEARCH 
 
 mechanical methods to supplement our senses. But it 
 cannot be too strongly insisted upon that these mechani- 
 cal methods only elicit evidence of damaged organs and 
 that we must learn to recognise disease before such 
 damage is done. Thus, the detection of consumption 
 by the X-rays in what is called the "early stages" 
 occurs in point of fact only after the tissues of the lung 
 have been damaged, and long after the actual invasion 
 of the body by the disease germs has taken place. 
 
 The patient's sensations give the first indication of the invasion 
 of the body by disease, but we are not capable of inter- 
 preting them aright. 
 
 Long before the physical signs became perceptible 
 the evidence of disease was there. The patient's sen- 
 sations give absolutely truthful evidence, but unfortu- 
 nately we are unable to interpret them, and too often 
 lack knowledge as to how to get the patient to describe 
 his sensations. There is nothing, perhaps, so striking 
 in the difference between a young physician and an old 
 one with experience, though the young man has just 
 received an education of the best and most modern kind 
 and has enjoyed all the advantages of laboratory and 
 hospital training, as the ability to recognise and ap- 
 preciate the patient's sensations. It is sometimes 
 wonderful how physicians with experience can recognise 
 the nature of a patient's complaint from the disjointed 
 remarks of the patient himself. This knowledge the 
 young physician has not acquired ; the older physician 
 has got the knowledge through past experience, and the 
 misfortune is that the knowledge is to a great extent 
 personal, and cannot be conveyed by its possessor to 
 others. 
 
 In a great measure this deficiency is due to the fact 
 that that precise training has never been inculcated 
 which would enable the physician to extract from the 
 patient a description of his sensations is such an intelli- 
 gible form that they could be appreciated. This, again,
 
 MEDICAL RESEARCH 7 
 
 is due to the fact that the physician himself does not 
 possess the knowledge which should enable him to in- 
 terpret these sensations and correlate them with definite 
 changes in the organism or with functional disturbances 
 of an organ. To remedy this it is necessary that the 
 patient's sensations should be as carefully studied as the 
 details of a laboratory experiment. Now, it is well 
 known that a physiologist can read aright the results 
 of an experiment only if he possesses some knowledge of 
 the functions of the organ with which he is dealing, 
 and that the success of his experiment will depend on 
 his being able to interpret aright the changes he detects. 
 The most successful experimenter will be he who has 
 the greatest knowledge, for the less experienced will fail 
 to detect many changes, and consequently will not 
 understand the results of his experiment. The same 
 reasoning applies to the physician. Before he can in- 
 terpret the patient's sensations he must have a know- 
 ledge of the functional disturbances that are capable 
 of producing these sensations. We must learn to re- 
 cognise that when we fail to detect a disease, in the 
 absence of physical signs, this failure in reality proves 
 only our own incompetence. The facts are there, but 
 we are not sufficiently well educated to make use of 
 the great source of information they constitute. As I 
 have said, the sensations of the patients should be as 
 carefully studied as the details of an experiment in a 
 laboratory, and that not only the sensations but all the 
 associated phenomena that may appear synchronously 
 with them, or at a later stage, should be carefully noted 
 and correlated. I know that physicians, generally, will 
 protest that they have all along pursued this line of 
 investigation and have exhausted it ; therefore, to im- 
 press upon you the point I am making, allow me to 
 give you two illustrations, the first drawn from the 
 sensations produced by abnormal action of the heart, 
 the second from the most common of all sensations — 
 pain.
 
 8 MEDICAL RESEARCH 
 
 The proper appreciation of the patient's sensations enables us 
 to understand many obscure complaints, as for example in 
 the recognition of abnormal heart action. 
 One of the most frequent phenomena present in 
 disease is a disturbance of the heart's action. In fact, 
 the sensation which often influences the patient towards 
 seeking medical advice is a consciousness of something 
 peculiar to his heart's action, and he may tell you that 
 he suffers from "palpitation." If you simply take this 
 statement without further inquiry you may miss facts 
 of the very first importance. Under the term " pal- 
 pitation " patients include a great variety of abnormal 
 heart actions; but, in response to intelligent questions 
 put to them, they will almost invariably convey to the 
 instructed physician very definite information. The 
 physician must himself, however, possess a knowledge 
 of the different ways in which a heart may act, and 
 he must be able to recognise the abnormal action in 
 two ways, viz., the behaviour of the heart as perceived 
 by the physician and the sensations experienced by the 
 patient as the result of the heart's peculiar action. This 
 knowledge can only be acquired by seeing patients dur- 
 ing an attack of abnormal heart action, by taking such 
 careful observations as will enable us to recognise the 
 nature of the attack, so as to differentiate it clearly, 
 and by inquiring from the patient himself what sen- 
 sations were perceptible to him. 
 
 By this means we are able to correlate the patient's 
 sensations with the peculiar action of the heart and 
 so become qualified to interpret the patient's sen- 
 sations. When you recollect that the patient's suf- 
 ferings may occur at intervals and for short periods, 
 and that it often happens that, when he consults us, 
 there is no sign of any disturbance, you come to realise 
 that the only data we can get concerning many a con- 
 dition are the patient's own description of them. Thus it 
 must be by questioning him that we find the essen- 
 tial knowledge. The questions put to him must
 
 MEDICAL RESEARCH 9 
 
 be direct and clear and must have a definite object. 
 For instance, we must learn what occasions or cir- 
 cumstances provoke the attacks ; whether the attacks 
 begin gradually or suddenly; the manner in which 
 they end — gradually or suddenly, with peculiar action 
 of the heart ; whether the rhythm of the heart is regular 
 or irregular during the attacks ; and, if irregular, what 
 is the character of the irregularity so far as his per- 
 ception has appreciated it ; and whether exertion during 
 the attack aggravates the heart's action. It may seem 
 to you an impossibility to get clear answers to these 
 questions ; the inexperienced will certainly fail to do so ; 
 nevertheless, with careful questioning and pains spent 
 in getting the patient to describe his sensations in his 
 own language, a great deal of useful information can 
 often be gleaned at a first examination. In some cases 
 it may be necessary to ask the patient to note particular 
 points in subsequent attacks, and frequently he will 
 bring such clear and definite answers that a safe diag- 
 nosis can be made forthwith. 
 
 Take the following illustration : A few weeks ago a 
 man consulted me, his complaint being palpitation of 
 the heart and, at times, attacks of giddiness. As in 
 the case of most patients, his description was blurred 
 and vague, but on putting questions to him, such as 
 how the attack began and how it ended, the behaviour 
 of the heart during the attack, the causes that seemed 
 to provoke the palpitation and the attack of giddiness, 
 I obtained this information. The palpitation started 
 quite suddenly without any known provoking cause ; 
 while it continued he felt weak and breathless on exer- 
 tion, and at times faint and giddy. He was conscious 
 all the time of the heart beating at a very rapid rate — 
 but quite regularly. Suddenly the heart would beat 
 slowly and irregularly for a few beats, the individual 
 beats being strong, and then he would lose all sensation 
 of distress, and the heart's action would be quite normal 
 in rate and rhythm. With these facts before me, I
 
 io MEDICAL RESEARCH 
 
 had little difficulty in recognising that he had that form 
 of paroxysmal tachycardia which is due to auricular 
 flutter. I was fortunate in catching him during an 
 attack and obtained polygraphic and electro-cardio- 
 graphic records which confirmed the diagnosis. 
 
 The observer himself must be trained before he can interpret 
 the sensations of abnormal heart action. 
 
 My object in giving this illustration is to draw atten- 
 tion to the manner in which this abnormal action was 
 recognised. In the first place, the observer had to be 
 trained. To obtain the knowledge necessary for elicit- 
 ing the information from the patient I had devoted over 
 twenty-five years to the study of abnormal actions of 
 the heart. I had to learn how to differentiate one 
 abnormal action from another. I have had opportuni- 
 ties of observing a number of people during these at- 
 tacks, and I have made a study of attendant circum- 
 stances, such as the behaviour of the heart when an 
 attack is in progress and when it has passed off. I 
 have inquired carefully into the sensations that were 
 provoked in the patient during the different phases of 
 the attack, so that now, after many years' study, I 
 am capable of eliciting from the patient the essential 
 facts which make it possible for me to recognise and 
 interpret his sensations. 
 
 You will gather from this that, before we are capable 
 of appreciating the patient's sensations, it is necessary 
 for us to have experience of a large number of indivi- 
 duals who have suffered, and to have made a careful 
 correlation of their sensations with the morbid con- 
 ditions which may be present. You will thus realise 
 what it is I am driving at when I say that the systematic 
 investigation of the patient's sensations would reveal 
 the early stages of disease ; but it is absolutely neces- 
 sary that the investigator shall have a long and careful 
 training if he is to be capable of eliciting and under- 
 standing the facts.
 
 MEDICAL RESEARCH n 
 
 This lack of appreciating the significance of the patient's 
 sensations is shown in the attitude of the profession 
 towards pain. 
 
 You may say that the illustration I have given is 
 rather of a particular kind and has little bearing on 
 the more common sensations. But if we inquire into 
 the more common sensations we will find that they are 
 as little understood, though equally informative. I will 
 give numerous illustrations of the importance of these 
 sensations and show repeatedly that their due appre- 
 ciation gives us the essential information as to the 
 heart's integrity when we are dealing with different 
 affections of the heart. But here let me emphasise the 
 neglect of subjective symptoms in diagnosis by a re- 
 ference to the most clamant and the most universal 
 of all sensations — pain. Although this sensation is one 
 that meets the practitioner every day, the information 
 that it is capable of yielding is rarely gleaned. One 
 would have thought that a subject of such vast im- 
 portance would be one of the first which the 
 different branches of medical research would have com- 
 bined to investigate ; yet the fringe of the subject has 
 only been touched upon even by those who, like Dr. 
 Head, have devoted much time and energy to its study. 
 As one who has given a good deal of time to this matter 
 and who has made some slight advance towards 
 understanding it, I confess that it is a subject the in- 
 vestigation of which is fraught with the greatest diffi- 
 culty, and this partly because we are still ignorant of 
 the mechanism by which pain is produced. On account 
 of this the everlasting tendency to theorise has involved 
 the subject in so much absurd and baseless speculation 
 that all theories are become suspect. Notwithstanding 
 these difficulties, however, the subject will repay investi- 
 gation, and if one is only careful to note the facts, to 
 avoid all speculation, and to exercise great patience in 
 following up cases, there will gradually be revealed, ever
 
 i2 MEDICAL RESEARCH 
 
 and anon, new facts which will explain much that has 
 been found obscure. But the investigation of this sub- 
 ject demands for its successful prosecution the shedding 
 of previous conceptions, and the keeping of the mind 
 free from bias. We know, for instance, that if a patient 
 refers a pain to some region of his body, and if we 
 recognise that somewhere within this region lies a par- 
 ticular organ, we are very ready to say that the pain 
 is actually in the organ. It is impossible to convince 
 the majority of physicians and surgeons of the fallacy 
 of this reasoning. 
 
 The study of pain, its site, radiation and accompanying 
 phenomena, reveals the mechanism by which it is produced. 
 
 It is impossible, with our present knowledge, to re- 
 cognise the seat of some of the most distressing pains. 
 Clinical medicine has not yet formulated definite ideas 
 as to how to start the inquiry upon this subject. I 
 have shown that before he can acquire the skill neces- 
 sary to obtain from patients such descriptions of their 
 sensations as will enable him to recognise the nature 
 of their complaints it is necessary for the physician to 
 undergo a long preliminary training. Much as it may 
 surprise you to hear it, the same training is necessary 
 before the physician is competent to investigate the 
 seat of the pain and to estimate the full meaning of 
 the sign. Many elementary facts which are essential 
 to the understanding of this sign — pain — are as yet un- 
 recognised. We have but the vaguest notion as to 
 which tissues are capable and which incapable, when 
 stimulated, of giving rise to pain. The fact that 
 a prick or a pinch or a burn which may give rise 
 to pain in the skin will give rise to no sensations 
 when applied to the peritoneum, or pleura, or any 
 viscus, is not recognised by the great bulk of the pro- 
 fession. The methods by which the various organs and 
 tissues should be explored have never been understood, 
 and we continually meet with statements by the learned
 
 MEDICAL RESEARCH 13 
 
 of the profession which testify to this fact. We hear, 
 for instance, the expressions " a tender liver," " a 
 tender colon," "a tender appendix." The very fact 
 that such expressions are made use of and accepted by 
 teachers and authors of text-books proves that the pro- 
 fession is not cognisant of the simplest elements of the 
 investigation to which I have referred. 
 
 So far as I have gone into the subject, I have learnt 
 what an extraordinary amount of precise information 
 may be acquired from even an imperfect knowledge of 
 the mechanism by which any given pain is produced. 
 The intelligent examination of the patient, revealing 
 the exact site of the pain, the occasion of its appear- 
 ance, the manner of its radiation, the way in which it 
 subsides, affords an insight into the constitution of the 
 nervous system, the extent of which even neurologists 
 little realise. The conditions that are often associated 
 with the occurrence of pain, such as the demonstrable 
 alteration in the sensation of certain structures in the 
 external body-wall, the coincident contraction in por- 
 tions of muscle and changes in the functions of other 
 organs, reveal so many illuminating facts that, if these 
 were systematically gleaned, a great stride forward in 
 the solution of many problems that baffle the physician 
 would be taken. When I deal with the pain arising 
 in affections of the heart I will show what a remarkable 
 distribution it follows. The radiation of the pain in 
 these cases indicates a path in the central nervous sys- 
 tem of which neurologists and physiologists have not 
 the slightest knowledge. An equally typical and in- 
 structive radiation is found as regards the pain of every 
 organ capable of producing pain ; yet we are incapable 
 of recognising the exact radiation, and we have not the 
 faintest conception of the origin of the pain in many 
 instances. 
 
 I cite the following experience to show by what long 
 and tedious means I was able to glean a little informa- 
 tion to guide me to a diagnosis in one simple case.
 
 14 MEDICAL RESEARCH 
 
 A man had suffered for several years from violent 
 attacks of pain in his abdomen. These came at inter- 
 vals every few weeks and caused him much suffering. 
 He had consulted a number of leading physicians and 
 surgeons, who were at a loss to account for the pain. 
 At last it was suggested that the pain was due to gall- 
 stone colic and he was operated upon. No gall-stones 
 were found and, after the operation, the pain returned 
 as violently as before. I was asked to see the patient, 
 and had considerable difficulty at first in eliciting the 
 facts from him, as he had not observed the position 
 of the pain with sufficient precision, while, on the other 
 hand, he was full of vague theories as to its origin and 
 nature. At last I obtained sufficient information to 
 enable me to decide where the pain started and into 
 which region it spread. I was thus able to state that 
 he had a partial obstruction of the bowel at the lower 
 end of the small intestine. An operation was per- 
 formed and this diagnosis was confirmed, a number of 
 adhesions from an old appendicitis, binding the bowel 
 down and narrowing its lumen, being found. With 
 the removal of these adhesions, the lumen of the gut 
 was restored and the patient ceased to have any further 
 trouble. Now the reason that led me to this conclusion 
 was that the pain was of that colic-like nature which 
 is characteristic of the violent contraction of a hollow 
 muscular organ. The pain started at the lower part 
 of the epigastric region, and, as it increased in severity, 
 it passed down the abdomen mainly in the middle, to 
 the lower part of the umbilical region. It did not 
 descend into the hypogastric region. The hollow mus- 
 cular organs capable of giving rise to such pain are 
 the gall-ducts, ureters, and bowel. The fact of the 
 spreading of the pain down the centre of the abdomen 
 excluded the first two hollow organs, so that the pain 
 was manifestly due to violent peristalsis of some portion 
 of the bowel. But a peristalsis never passes beyond 
 the point of obstruction. The region in which pain, due
 
 MEDICAL RESEARCH 15 
 
 to violent peristalsis of the small intestine, is felt is 
 the umbilical area. When the peristalsis passes into 
 the great intestine the pain is felt in the hypogastric 
 region. Here, as has been stated, the pain stopped 
 short of the hypogastric region ; therefore the probabi- 
 lity was that the obstruction would be in the lower 
 part of the small intestine. Now, in order to acquire 
 the information necessary to interpret this man's sen- 
 sations, I had seen a great many people suffering from 
 just such pain, and, after years of observation, I had 
 correlated their sensations with the morbid conditions 
 found at operations and on the post-mortem table. I 
 had seen a great number of people with obstruction of 
 the bowel at different sites ; I had seen cases with violent 
 peristalsis where the pain had started high up in the 
 abdomen and gradually descended until it reached a 
 point just above the pubes. At this point, it had been 
 noted, there arose an urgent desire to defecate, and 
 with the expulsion of the contents of the bowel sudden 
 cessation of all pain occurred. I had even had an 
 opportunity of watching, in the conscious individual, 
 the exposed bowel, had provoked peristaltic contraction 
 in it, and had noted the region in which the pain was 
 felt. I mention this just to show how much time and 
 labour had to be spent to acquire even the slight know- 
 ledge of pain which enabled me to recognise the nature 
 of this complaint, and to emphasise the fact that no 
 one is capable of appreciating the patient's sensations 
 or of getting the patient to describe his sensations until 
 he has spent much time and labour in acquiring the 
 necessary knowledge. 
 
 The patient's sensations must be studied while they are present, 
 and all associated phenomena carefully noted. 
 
 You will observe, further, that it is necessary for the 
 physician who would study these sensations to have 
 seen patients while the sensations were being experi- 
 enced, and to have noted all the circumstances present
 
 16 MEDICAL RESEARCH 
 
 at the time. For instance, what little knowledge I have 
 acquired of the meaning of the patient's sensations 
 during the abnormal action of the heart I have acquired 
 by seeing patients when the abnormal action was 
 present, by taking careful records by means of the poly- 
 graph, by auscultating the heart, and by noting the 
 changes in the heart, and also at the same time by 
 getting the patient to describe the sensations he was 
 experiencing. In a similar way, while studying the 
 subject of pain, I utilised those times when patients 
 were actually suffering to investigate the region in 
 which the pain was felt. If you undertake observations 
 similar to these you will soon recognise the necessity 
 for this procedure, for it is extraordinary how vague 
 is the recollection of the situation of pain of the most 
 agonising kind. Time and again I have had to ask 
 patients to note the situation of pain in angina pectoris 
 during future attacks and then have found their descrip- 
 tions to be at variance frequently with the situation 
 given from memory in the first instance. ^ 
 
 Bacterial invasion gives rise to sensations, and it is likely that 
 each organism gives rise to peculiar sensations. 
 
 I could occupy a long time illustrating the import- 
 ance of the accurate study of the patient's sensations 
 in different fields of medicine, but I will content myself 
 with giving one further illustration. We all recognise 
 the vast importance of the discovery of the microbic 
 origin of many diseases and the necessity for laboratory 
 workers to detect the specific microbes. But the 
 time must come, if we are to utilise these discoveries 
 to the full, when we must be able to recognise that the 
 body has been invaded by the microbe without having 
 had recourse to these laboratory methods ; for it is ap- 
 parent, on the surface, that only an infinitesimal number 
 of those who suffer can ever hope to have the benefit of 
 laboratory methods. It is therefore imperative that 
 physicians should strenuously seek for those symptoms
 
 MEDICAL RESEARCH 17 
 
 that arise on the entrance of microbes into the body. 
 Most of these symptoms will be subjective, and by the 
 careful correlation of these subjective sensations with 
 particular microbes, in course of time, the object will 
 be achieved, just as at the present time we can recog- 
 nise a great many abnormal actions of the heart without 
 the use of mechanical methods. 
 
 It is necessary to understand the changes effected by disease 
 
 in its progress. 
 
 Turning now from the early stages of disease, we may 
 consider an equally important subject. 
 
 It must at once be apparent to you that, before you 
 are capable of treating a patient with any prospect of 
 success, you must not only recognise the disease from 
 which he is suffering, but you must also know what is 
 likely to happen if the disease runs its course unmodi- 
 fied by any attempt to check its progress. If, in its 
 progress, it gives rise to signs or symptoms you must 
 be able to detect these, and thus to appreciate the 
 stages which the disease has reached. If there is danger 
 to be apprehended you must know wherein the danger 
 lies. You must also know whether you possess the 
 power of arresting the disease or of modifying its pro- 
 gress. 
 
 These are such self-evident propositions that you may 
 deem it a waste of time for me to recite them. But 
 it is necessary to recite them in order that the question 
 whether we possess this knowledge may be answered. 
 It is no doubt taken for granted that we do possess 
 this knowledge ; but if we inquire a little more closely 
 we will find that such knowledge as we possess is indeed 
 exceedingly imperfect ; and if further we inquire into the 
 manner in which this knowledge is to be acquired we will 
 speedily realise that, with the methods of investigation 
 hitherto pursued, it is impossible that it can have been 
 acquired. ^
 
 1 8 MEDICAL RESEARCH 
 
 To acquire a knowledge of the life-history of chronic diseases 
 it is necessary to be able to follow individual cases from 
 the start to the finish. 
 
 Realise first the only possible way of acquiring know- 
 ledge concerning the life-history of a chronic ailment. 
 Individuals with an ailment of that kind must be 
 observed, paradoxical as this may sound, before they 
 become affected. The invasion of disease must be per- 
 ceived. The slight varying symptoms of the earliest 
 invasion must be detected and, as the disease progresses, 
 the appearance of phenomena due to its presence or 
 provoked by it must be recognised. Thus, in a disease 
 which progresses through a period of years, the different 
 phases, passing into one another, must each be recog- 
 nised. Consider, now, the opportunities of the profes- 
 sion for acquiring this knowledge. It must at once be 
 apparent to you that this very necessary knowledge can- 
 not be acquired in laboratories. The other great field 
 of investigation — the hospital ward — cannot afford any- 
 thing like sufficient opportunities, although the world 
 has been taught to look in that direction for the 
 advancement of medical science. The early stages of 
 disease, before the appearance of physical signs, are 
 rarely observed, for patients in these early stages 
 seldom get beyond the out-patient department. 
 Individual cases are seen only intermittently and in- 
 frequently. It may be that a large number of indivi- 
 duals may be seen in different stages, but all the stages 
 are never seen in one individual, so that the merging 
 of one stage into another escapes detection. Hence it 
 is that our knowledge of any ailment which pursues 
 its course for months or years is patchy and imperfect 
 and does not afford a basis on which to lay a safe and 
 sound prognosis or to build up a rational treatment. 
 
 I am perfectly well aware that this view will be 
 strenuously contested, but I could illustrate my point 
 of view from almost any chronic illness. Take, for
 
 MEDICAL RESEARCH 19 
 
 example, the extremely common disease of the mitral 
 valves which results in stenosis. 
 
 Here is a disease that has been universally recog- 
 nised for over fifty years. It has been the subject of 
 investigation by numerous physicians, it has been lec- 
 tured upon and written about so much that I suppose 
 there is not a single physician who does not imagine that 
 all the information to be got from investigations has 
 been acquired. Nevertheless, there is not to be found 
 in medical literature the history of one single individual 
 carried on from the time of the attack of rheumatic 
 fever, which started the valve disease, up to the time 
 of death and containing a record and due appreciation 
 of the changes which took place. 
 
 I have endeavoured to obtain such records, but have 
 been only partially successful. It was not until I had 
 been engaged in research work for many years that the 
 importance of this kind of knowledge dawned on me, 
 and then it was too late for me to complete records with 
 sufficient fulness. This will be understood when you 
 reflect that to complete such a record may demand the 
 watching of individuals for twenty or thirty years ; and 
 as I only realised this after I had passed middle life, 
 the reason of the shortcoming of my observations will 
 be clear to you. Moreover, at the outset I had detected 
 many phenomena concerning which I had not at the 
 time the knowledge requisite to understand. As, 
 however, I had made it a rule when I had perceived 
 any manifestation with which I was unacquainted to 
 make a note not only of its appearance but of all atten- 
 dant circumstances and particularly of the associated 
 phenomena, the subsequent perusal of my notes, im- 
 perfect as they were, has revealed much of the greatest 
 importance. Had I been aware of the extraordinary 
 light which such a record would afford at a later date 
 I certainly would have observed my cases with greater 
 care. I have followed quite a number of cases from 
 the onset of rheumatic fever, and have seen the changes 
 
 c 2
 
 20 MEDICAL RESEARCH 
 
 I have referred to gradually supervene. There have 
 been revealed in the course of this work phenomena of 
 the greatest significance the existence of which was 
 never suspected, but which threw light upon the nature 
 of the disease and of its progress, and incidentally revealed 
 essential features in the production of heart failure 
 which demonstrated that the usual conception of heart 
 failure in these cases — by back pressure — was mislead- 
 ing and erroneous. Moreover, the behaviour of the 
 heart towards drugs of the digitalis group was shown 
 to vary in such a remarkable manner, according to the 
 associated condition of the heart muscle, that quite a 
 new light was thrown upon the nature of the actions 
 of this group of drugs; and this new light enabled us 
 to administer these drugs with a knowledge and pre- 
 cision never before attained. All these facts I will 
 clearly set before you in subsequent lectures ; here I 
 mention them to illustrate the great limitation imposed 
 on medical research by the imperfect opportunities of 
 those who have hitherto instructed us in medicine, and 
 their failure, in consequence, to obtain a thorough know- 
 ledge of the manifestations of a progressive chronic 
 disease. 
 
 The knowledge of the progress of disease reveals the meaning 
 of abnormal signs and constitutes the basis for an intelli- 
 gent prognosis. 
 
 Not only must we investigate the progress of disease, 
 but we must also be able to recognise the significance of 
 signs which we may assume to be abnormal. Hitherto 
 disease in the living has been mainly recognised by the 
 presence of abnormal signs. In a great many organs 
 deviations from the normal are apt to occur, and it is 
 necessary for us not only to understand the mechanism 
 of their production, but also their significance, so far 
 as the future of the individual presenting them is con- 
 cerned. The importance of this to you, as practitioners 
 of medicine, cannot be over-estimated.
 
 MEDICAL RESEARCH 21 
 
 In your practice one question will arise incessantly 
 and insistently, implied or expressly demanded of you 
 by every patient, and that question is, " What is to be 
 the outcome of my complaint?" This question will 
 meet you in most unexpected ways. Your diagnosis 
 may be brilliant, and yield you great satisfaction and 
 the applause of your colleagues, but your patient will 
 only be interested in it so far as it throws light upon 
 his future, and the problems thus presented are infinite. 
 
 Moreover, such knowledge is necessary if you would 
 treat your patient on rational lines. Your knowledge 
 of the condition you have so skilfully diagnosed must 
 be supplemented by the knowledge whether or not the 
 complaint is amenable to treatment, and even whether or 
 not it requires any treatment. 
 
 You will thus realise that what is called " prognosis " 
 is the coping-stone which completes the edifice of your 
 education. All your teaching and study should be but 
 a preliminary training to enable you to understand this 
 problem — the understanding of which, after all, is the 
 most essential part of your education. You can have 
 acquired only a mere fraction of your knowledge during 
 your hospital career ; the fuller knowledge must be ob- 
 tained from experience. It can be obtained in no other 
 way. 
 
 You might reason that a matter of such vital im- 
 portance as prognosis must have been the subject of 
 careful study, and that generations of physicians must, 
 by the time the twentieth century had been reached, 
 have so thoroughly investigated the subject that the 
 basis of a safe and sure prognosis must have been laid, 
 at all events for the more common diseases. You will 
 not be long in practice before you find that this is not so. 
 
 Let me illustrate the point. In your studies during 
 your student career you have seen the anatomical con- 
 struction of the heart, its chambers, and its valves. 
 In your physiology you have been taught the functions 
 of the different parts. In your clinical studies you have
 
 22 MEDICAL RESEARCH 
 
 had demonstrated to you the various sounds and their 
 modifications, and you have acquired great facility in 
 recognising the valve orifices at which different mur- 
 murs originate. You therefore flatter yourself that 
 you are in this respect qualified to enter practice. But 
 very soon after you enter practice you may detect in 
 some patients a murmur which your training has 
 enabled you to recognise as arising at the mitral orifice. 
 You may tell the patient that he or she has a murmur, 
 and that it originates at the mitral valves. This state- 
 ment may be incomprehensible to the patient, though 
 he may be greatly impressed by your skill, but what 
 he wants to know is what bearing has this condition 
 upon his future, and what treatment, if any, must be 
 undertaken. Suppose the patient is a youth ; he wants 
 to know if he is fit to play a strenuous game. Suppose 
 he is a man ; is he fit to pursue a laborious occupation ? 
 Suppose the patient is a woman ; should she be allowed 
 to become pregnant ? Suppose the individual is a life 
 insurance case ; how would you estimate the probabili- 
 ties of his life ? When such a concrete case as this is 
 presented to you, you will be at a loss. You can give 
 your diagnosis with precision, but when the essential 
 knowledge, from the patient's point of view, is re- 
 quired, you will be conscious of failure. But you will 
 say it is a hundred years since auscultation was intro- 
 duced, and the great physicians of the bygone century 
 must have solved this question ; let me turn to my 
 text-books. You may turn to your text-books ; nay, 
 you may ransack a whole library of books, in every 
 language under the sun, but you will get no definite 
 answer to this simple question, " How shall I estimate 
 the prognostic significance of this murmur ? " You may 
 inquire of authorities, men whose work it is to estimate 
 the value of such symptoms, such as examiners for life 
 insurance, and you will find some who would reject your 
 patient, and you will find others who will accept him, 
 and others again who will increase his premium on some
 
 MEDICAL RESEARCH 23 
 
 unknown scale ; but from none will you get a clear and 
 definite expression of the basis upon which the final 
 opinion has been founded. 
 
 Now, if you would really understand the inward mean- 
 ing of this diversity of opinion, you will find that it is 
 due simply to the fact that our methods of medical exa- 
 mination are developed on such lines that these experts 
 in prognosis do not know by what means prognosis 
 should be obtained. 
 
 You may well ask how it has come about that, with 
 all its advances, the profession should still be ignorant 
 of such an all-important subject. The reason is simply 
 this, that all sciences are gradually evolved out of a stage 
 of darkness and tradition, and medicine has not yet got 
 so far as to be free from tradition. Certain branches are 
 no doubt attaining the position of sciences, but such 
 branches as treatment and prognosis are still encum- 
 bered about with much tradition and even superstition. 
 The importance of prognosis is but imperfectly recog- 
 nised. We do indeed get eloquent discourses on this 
 subject by distinguished members of our profession ; but 
 the perusal of these discourses reveals the fact that 
 the profession has yet barely perceived the methods by 
 which the science of prognosis must be pursued, and 
 fails entirely to recognise the one individual who is 
 qualified to undertake its pursuit. 
 
 Investigation of prognosis can only be carried out by those 
 who have the opportunity of watching individuals during 
 the whole course of the disease. 
 
 To bring before you clearly what prognosis is and 
 how it should be pursued, I will cite my own experi- 
 ences and indicate how the meaning of prognosis gradu- 
 ally dawned upon me. I entered general practice in 
 1879, and for a number of years I was like a blind man 
 groping his way. Being convinced that the wisdom of 
 my teachers and of the authors of my text-books in-
 
 24 MEDICAL RESEARCH 
 
 eluded all that was to be known of disease, I felt acutely 
 my inability to recognise obscure diseases and to tell 
 the significance of many phenomena which presented 
 themselves to me. Time and again my prognostica- 
 tions were at fault, and although I strove to remedy 
 my ignorance by reading and visiting hospitals, I made 
 little advance. At last, after some years, I realised 
 that the wisdom of the teachers was not so profound 
 and all-embracing as I had supposed. I soon found 
 that there was a bewildering variety of subjects which 
 deserved attention. Amongst others, my attention was 
 directed to heart affections, because I found that this 
 class of disease and also diseases of the digestive organs 
 constituted the largest group of complaints among my 
 patients. Moreover, my attention had been arrested 
 early in my career by the death of a pregnant woman, 
 undelivered, after a long and painful labour, who suf- 
 fered from mitral stenosis. As I had ample opportu- 
 nities of studying the effects of pregnancy on the heart, 
 I first directed my attention to this matter, and, as a 
 preliminary, I studied the literature of the subject. I 
 was surprised to find how little was known of the source 
 of danger in patients with heart affections who became 
 pregnant, and I may remark that, even at this time of 
 day, our knowledge of this subject remains very meagre. 
 You will by-and-by discover this, for the problem of 
 pregnancy and heart disease is one that each one of you 
 will be called upon to face. The reason for the want of 
 knowledge was that the profession was ignorant of the 
 prognostic significance of almost every abnormal sign 
 which the heart manifested. Thus I found that amongst 
 pregnant women an irregularity in the heart's action 
 was very frequent, and so the question arose, What is 
 the significance — generally — of an irregular heart ? 
 When I proceeded to inquire into the matter I found 
 that there were different forms of irregularity, and so, 
 before I could make any advance, it was necessary to 
 recognise those different forms. At this time, over
 
 MEDICAL RESEARCH 25 
 
 twenty-five years ago, there was no differentiation of 
 the slightest value based upon any reliable foundation. 
 The first step, then — that of differentiation — had to be 
 undertaken. You will realise that before you can make 
 any advance in prognosis you must clearly define the 
 condition with which you are dealing. Well, at this 
 time the first step in making a prognosis on irregular 
 hearts had never been taken. Now I found, on the 
 careful examination of my patients, that irregular action 
 of the heart was the most common of all symptoms, 
 although, in my education, the subject had never been 
 alluded to, and in text-books on " Heart Affections ' : 
 it was barely mentioned. I had no difficulty in getting 
 plenty of material for observation. I need not tire you 
 describing the long and weary steps I had to take in 
 discovering methods for recording these irregularities 
 and the search for a real basis on which to found a sure 
 differentiation. Suffice it to say that, after some years, 
 I was able clearly to recognise the character of the 
 irregularity in the vast majority of cases and thus take 
 the first step essential to prognosis. After I was able 
 to differentiate the more common irregularities I put 
 this question to myself, " What happens to those people 
 who show these different forms of irregular action of the 
 heart?" At the time I put this question I had no 
 idea of the amount of labour and of the number of years 
 that would be spent in finding out the answer. To you 
 it may seem a very trivial and ordinary question and 
 one of no particular importance. But had the question 
 received its due recognition by the members of our pro- 
 fession, medicine to-day would be in a very different 
 position from what it is. I go further, and state that 
 very little progress will be made in medicine until those 
 who practise it put this question to themselves and 
 endeavour to answer it whenever they meet some sign 
 or symptom which they do not understand. I venture 
 to prophesy that when our physicians begin systemati- 
 cally to put that question in a short time the whole
 
 26 MEDICAL RESEARCH 
 
 attitude of the profession towards medicine will be 
 altered. 
 
 I will show you what was the result of attempting 
 to answer this question in only one of many instances, 
 and for this purpose I will take one of the most com- 
 mon forms of irregular action— that due to an extra 
 systole. This has been vaguely described as an inter- 
 mittent heart. My earliest researches showed that this 
 irregularity was, in many instances, due to a contraction 
 of the ventricle occurring prematurely. In order to 
 find out the bearing of the condition on the lives of my 
 patients, I collected notes of a large number of people 
 showing it. After a few years I had records of over 
 a thousand cases, and from these I gained information 
 concerning the age incidence. I found that the extra sys- 
 tole was relatively infrequent in the young, but became 
 more frequent after middle age, and that over sixty 
 years of age practically everyone showed it more or 
 less frequently. Then I had to watch many individuals 
 who showed it, in order to apprehend its effect gene- 
 rally in relation to the stress and strain of life. Thus, 
 pursuing my plan of investigation, I inquired what 
 effect it had when it was present in pregnant women. 
 I examined one hundred cases and found it present in 
 fifty — in most infrequently, in a very few very fre- 
 quently. I then watched many of these women during 
 their pregnancies. I took numerous observations when 
 they were pregnant and when they were not pregnant, 
 and during the period of labour when they were in pain, 
 and when they were free from pain. Further, I kept 
 in contact with men who pursued laborious occupations 
 and who showed this irregularity. I watched those who 
 were stricken down with some febrile complaint to see 
 what effect the fever and the disease producing the fever 
 had upon the irregular heart. I followed numbers who 
 only showed the irregularity at varying periods and 
 endeavoured to find out the conditions that provoked 
 it. In some, after years of observation, I found the
 
 MEDICAL RESEARCH 27 
 
 extra systoles became more frequent, and a few de- 
 veloped other irregularities — for example, that irregu- 
 larity due to auricular fibrillation. Some of those who 
 showed an extra systole drifted and died. In some it 
 appeared during an acute illness, and of these some 
 died. To find out its significance in such cases neces- 
 sitated an inquiry into all the other circumstances that 
 were present, so that a knowledge might be obtained 
 which would guide one in recognising it as a sign of 
 grave importance or not of grave importance. In these 
 and many other ways I attempted to find out the prog- 
 nostic significance of this irregularity. It took me years 
 of labour, and I had to make thousands of records to 
 get the facts on which to base a prognosis. When I 
 summarised the result of all this work I found that 
 I had not been able to work out the subject in all its 
 details. There are conditions (such as progressive 
 diseases of the heart and acute affections) in which I 
 have not been able to determine satisfactorily the sig- 
 nificance of this sign. Thus, for instance, after an 
 attack of rheumatic fever, extra-systoles may appear, 
 and I have not been able to watch a sufficient number 
 of cases for a long enough time to find out whether these 
 extra-systoles are in any way connected with those 
 fibrotic changes in the heart muscle which we find fre- 
 quently after rheumatic fever, and which probably are 
 the cause of auricular fibrillation. Nevertheless, I have 
 been able to draw certain deductions of value applicable 
 to the majority of cases. 
 
 A misconception of how a knowledge of prognosis can be 
 acquired has led to an inability to appreciate the results 
 obtained by the method described. 
 
 I have from time to time published these results, and 
 I have been interested in the manner in which they have 
 been received. Time and again physicians of standing 
 have stated that they were already conversant with the 
 matter and had long recognised the significance of irre-
 
 28 MEDICAL RESEARCH 
 
 gular heart action. When I have asked them why in 
 their writings they had given no hint of this know- 
 ledge, I have been answered that the matter is one of 
 common knowledge and needed no description. As a 
 matter of fact, many practise a form of self-deception 
 in this matter, for not only has the subject not been 
 solved, but even the necessity for such a method of in- 
 vestigation as I have indicated seems not to have been 
 realised. In text-books the prognosis of irregular action 
 is usually simply ignored or, if referred to, is referred 
 to in some oracular utterance that can be made to 
 bear any meaning you like. I was struck some years 
 ago by an experience which revealed the obliviousness 
 to this essential matter in clinical medicine. I came 
 across a clever American who spent every fifth year in 
 Europe studying some special subject in medicine. He 
 had just returned from Germany, where he had been 
 completing a period of study. I asked him where he 
 had been and what branch of medicine he had been 
 studying. He said he had been to a certain famous 
 clinic, the most renowned in Germany for heart work, 
 and that he had worked under a famous clinician on 
 the heart. When he told me how he had studied and 
 recognised the different irregularities I asked him how 
 he had investigated their prognostic significance. I 
 had some difficulty in getting him to understand what 
 I was driving at, so I said, " When you get home and 
 you come across a certain irregular action of the heart 
 in one of your patients, how are you going to estimate 
 the bearing of the cause of that irregularity on the 
 patient's future, and how are you going to employ it as 
 a guide in treatment ? ' He seemed surprised, and said 
 the idea had never occurred to him and that it formed 
 no part of his study. After I pointed it out he realised 
 its real importance to him as a general practitioner. 
 I invited him to visit Burnley, where I was practising 
 at that time, and he came for three or four days. 
 While he was there I showed him a great many patients
 
 MEDICAL RESEARCH 29 
 
 with irregular hearts, and also showed him my notes 
 of their past histories. Some of these patients were 
 leading strenuous lives, others led but a crippled exis- 
 tence, and I was able to show him the indications that 
 would guide one towards a prognosis and a rational 
 treatment. After his return to America he began to 
 apply his knowledge, and he wrote me to the effect that 
 he had now obtained an insight into the meaning of the 
 subject and to a knowledge which he could apply intel- 
 ligently in practice, and that, so far as this knowledge 
 was concerned, he had learnt more in the three days he 
 spent with me than he had learned during the whole 
 six months he spent in Germany. 
 
 Not very long ago I visited a famous Continental 
 clinic and was presented by a young physician, who was 
 in charge of the cardiac department, with a work he 
 had written on the extra-systole. In this work the 
 subject was dealt with after the conventional manner, 
 under different headings. The book wound up with the 
 prognosis. I said to the author, " I see you deal with 
 prognosis. Have you settled the matter?" "Oh, 
 yes," he replied. I then inquired during how long a 
 period he had been able to recognise an extra-systole, 
 and found that he had been able to recognise it during 
 two years. His observations had been confined to the 
 bounds of the hospital. So it would seem that this 
 young man thought himself capable of deciding in two 
 years a matter I had spent twenty-five years upon and 
 which I had not been able to complete. 
 
 I use this illustration not in any way to reflect upon 
 the eager young men who are to-day making the same 
 mistake — I have myself made many foolish mistakes of 
 the same sort — but to show that the profession has not 
 yet awakened to a realisation of what prognosis really 
 means. Every member of our profession is labouring 
 under the disadvantages inseparable from an imperfect 
 idea of what constitutes prognosis. How severely the 
 profession is handicapped by this lack of appreciating
 
 30 MEDICAL RESEARCH 
 
 the true method of investigation is seen in almost every 
 phase of clinical medicine. No sooner is a new method 
 introduced than its users begin to employ it as a means 
 of prognosis, long before the nature of the information 
 it reveals is understood. Take, as an illustration, the 
 attitude of the profession towards murmurs. Within a 
 few years of the discovery of auscultation as a method 
 of diagnosis — a hundred years ago — it was observed that 
 murmurs were found in patients with heart trouble, who 
 subsequently died of their disease, and the physician of 
 that day, before he even knew what was the cause of 
 the murmur, attached accordingly a grave significance 
 to its presence. To-day the whole profession is obsessed 
 by these early observations. No doubt, physicians who 
 are careful observers have been able to get a fair idea 
 of the significance of different murmurs, but even then 
 the knowledge is not so precise and definite as to enable 
 them to teach the reasons for their beliefs. We can see 
 to-day the same process at work in the case of blood- 
 pressure instruments as in the case of the stethoscope. 
 You will find many physicians solemnly writing of the 
 significance of blood-pressure, while as yet we are igno- 
 rant of what it is which they call blood-pressure, and 
 before they themselves have realised what the normal 
 pressure may be. If any of you care to test this state- 
 ment, look up the literature on this subject written 
 during the last ten or fifteen years. 
 
 In thus drawing attention to the imperfect knowledge 
 of what constitutes the science of prognosis, it must not 
 be thought that I am describing faults in my colleagues 
 of which I myself am free. Far from it. I was reared 
 and bound in the bonds of tradition. All these faults 
 and hasty conclusions I myself have indulged in. It 
 was only after weary years of study and after finding 
 myself so often at fault that I gradually realised the 
 significance of that question which I had put : " What 
 bearing has the cause of this abnormal sign on the 
 patient's future? "
 
 MEDICAL RESEARCH 31 
 
 The opportunity for investigation in hospitals is too restricted. 
 
 If one wishes to gain an idea of the reason why medi- 
 cal science advances so slowly and haltingly one has 
 but to look at those who are at present the investigators 
 and to consider their opportunities. To prevent or 
 combat disease it is necessary to know its origin and 
 its progress ; and one has but to ask what opportunities 
 our investigators have of seeing the disease invade the 
 body, and of observing its progress, in order to estimate 
 the amount of knowledge likely to be acquired by them. 
 Investigation is chiefly carried on in the laboratories and 
 in the wards of hospitals. No doubt in both places 
 observations of the utmost importance are made ; but 
 what opportunities have these investigators of seeing 
 disease in its early stages and during its progress ? In 
 the wards of the hospital, as you know, disease is not 
 presented in its early stages, and the opportunity of 
 watching its progress is limited to the short time the 
 patient spends in the hospital. It is true that in the 
 out-patient department many cases of disease in its 
 early stages may present themselves, but here again 
 the difficulty of following cases is well-nigh insuperable. 
 In addition, consider how the opportunities which do 
 present themselves have been missed. If you will re- 
 member what I said about the necessity of appreciating 
 the sensations of the patient, and also that I said it is 
 only after long years of study and preparation that the 
 knowledge as to how to elicit these sensations can be 
 acquired, you will be able to understand how useless 
 it is to expect any advance from the out-patient depart- 
 ment as it is at present administered. Some time ago 
 I called attention to the topsy-turvy way in which the 
 medical work in hospitals was conducted, pointing out 
 that, when disease was in the earliest and most curable 
 stage, and in a stage in which it was most difficult to 
 detect, and therefore required the most experienced 
 physicians to detect it, patients were sent to the out-
 
 32 MEDICAL RESEARCH 
 
 patient department and left to the least experienced 
 members of the hospital staff. On the other hand, when 
 the disease was most advanced and often actually incur- 
 able, and when the signs were easiest to perceive, the 
 patients were admitted to the wards and placed under 
 the care of the senior and most experienced physicians. 
 I have repeatedly seen patients whose symptoms were 
 purely subjective present themselves at the out-patient 
 department; and, when the nature of their complaints 
 was not recognised, I have seen them put off with a 
 bottle of medicine and told to return if no better. They 
 kept returning until the disease was so far developed 
 as to show some physical sign, after which, but not 
 before, they were considered fit for admission into the 
 hospital. Then they obtained all the resources of the 
 ward and laboratory investigators. 
 
 The general practitioner is the only investigator that has the 
 
 real opportunity. 
 
 But it is only a very small proportion of the sick 
 who visit a hospital. The vast majority of persons, 
 when they first perceive that there is something amiss, 
 turn to their family doctor and continue under his care. 
 It is the general practitioner, who sees disease in its 
 early stages, who has the opportunity of finding out 
 what conditions predisposed to the disease and of fol- 
 lowing it through all its stages. 
 
 If you but reflect what is the nature of the knowledge 
 that is essential to medical research as I have en- 
 deavoured to set it before you, and then consider 
 the opportunity of the men who devote their time to 
 research, you will be forced to the conclusion that this 
 opportunity is greatly restricted. And, further, you 
 will be forced to the conclusion that one, and only one, 
 class can carry out this particular, but essential, line of 
 research, the objects of which I have indicated — the 
 general practitioner class. I am not deprecating the
 
 MEDICAL RESEARCH 33 
 
 work of the hospital or of the laboratory — all are re- 
 quired. I am only pointing out why progress is so 
 halting and showing that it is bound to be fettered and 
 restricted until the man with the opportunities takes 
 his place as an investigator. If the signs of the past 
 had been read aright this would have been recognised 
 long ago. If any of you seek to inquire how the efficacy 
 of vaccination was discovered, you will at once be 
 brought to realise that Jenner might have spent his 
 lifetime in laboratories and hospital wards and yet 
 never have made his discovery, simply because he would 
 never have had the opportunity. 
 
 This need for the general practitioner as investigator, 
 which I am certain will, in time, become self-evident, 
 is, at the present day, not realised. We see money 
 poured out for the advance of medical research, but 
 whoever thinks of utilising the opportunities of the 
 general practitioner ? Some endowments are specially 
 guarded, indeed, as if to prevent the general practitioner 
 from participating in them. The domination of the 
 laboratory is so great that the whole tendency is now 
 to be ruled by the conception of the laboratory worker ; 
 so much so, indeed, that it is supposed to be a sign of 
 progress when a teacher of clinical medicine is appointed 
 who has received his training in a hospital or labora- 
 tory. If you will reflect, you will realise that a method 
 of selecting as teachers of medicine men who can have 
 no knowledge of the aspects in which disease will present 
 itself to the vast majority of their pupils in future life 
 is utterly indefensible. There is a vast difference be- 
 tween hospital practice and general practice. Such 
 teachers, with their limited training, are practically un- 
 conscious of the great opportunities for the advance- 
 ment of medicine which their pupils who go into general 
 practice will have. If you will but grasp these salient 
 facts you will realise that what is called progress in 
 teaching — i.e., leaving teaching exclusively in the hands 
 of laboratory-trained men — is but the forging of fetters 
 
 D
 
 34 MEDICAL RESEARCH 
 
 to bind the one class of men whose help is essential to 
 the progress of medicine. 
 
 A new spirit is essential to medical research. 
 
 If progress is to be made a new spirit must be in- 
 fused into teaching and into research. If the most 
 enlightened members of our profession were to in- 
 quire into the grounds of their beliefs, even those 
 most dearly cherished, how often would they be sur- 
 prised to find on what fallacies their beliefs are based. 
 Medicine is being evolved out of ages of tradition, and 
 the bonds of tradition are difficult to shake off. It is 
 not only the superstitious beliefs of bygone ages that 
 hamper us, but also the spirit of tradition, which is 
 ever present ; for the tendency to believe without reason 
 is ever recurring, while the reverence for authority 
 makes us accept statements without proof. 
 
 I could illustrate this in almost every field of medi- 
 cine, but the most notorious example is to be found in 
 our methods of treatment. Take the official pharma- 
 copoeia and inquire into the grounds on which the 
 various drugs have gained admission to its pages. You 
 will find that the vast bulk of these drugs has never 
 been subjected to any accurate observation, and that 
 many have gained admittance because the popular 
 belief attributed to them some supposed effect — evidence 
 that would equally have justified the inclusion in the 
 pharmacopoeia of the King's touch, amulets, and invo- 
 cations. Even the few drugs that are of value have 
 never been observed with that precision which would 
 enable the student to understand how to make the best 
 use of them. I trust it will not be long before the 
 most recent of pharmacopoeias will be regarded as no 
 more authoritative in therapeutics than would a 
 mediaeval work on alchemy be regarded as authoritative 
 as a text-book of modern chemistry. 
 
 The inquiring spirit, in seeking diligently for true 
 methods of acquiring knowledge and for obtaining sub-
 
 MEDICAL RESEARCH 35 
 
 jects for investigation, cannot follow a better way than 
 to ask, What is the basis of my belief ? No doubt, in 
 our early days, we must be content to be satisfied with 
 the statement of authority. But those whose duty it 
 is to teach should constantly be inquiring into the 
 reasons for the beliefs they seek to inculcate into their 
 students. If this were done systematically not only 
 would the teacher be surprised at the nature of his own 
 reasons, but the very recognition of the baselessness of 
 his beliefs would stimulate him to inquire. And once 
 the inquiring spirit was aroused the good it would ac- 
 complish and the lines it would pursue would not be 
 matters for anxiety. 
 
 My purpose in insisting in this lecture upon the 
 necessity for study of the patient's sensations, and for 
 the utilising of the opportunities of the general practi- 
 tioner, is to demonstrate that, in clinical medicine, 
 methods of research must be adopted that are peculiar 
 to this branch of science. I have heard it repeatedly 
 stated by leading members of our profession that the 
 limits of clinical medicine have been reached, and that 
 no further progress can be made until new methods 
 have been discovered. This belief is widespread, and 
 we see its effect in the sudden rush which is made after 
 any new mechanical device. Now I want to impress 
 upon you the fact that the means of investigation which 
 we possess in ourselves, without the use of mechanical 
 devices, have not yet even been begun to be employed 
 on a scientific basis. 
 
 Exact methods are now widely recognised as neces- 
 sary in investigations, and as their recognition is the 
 outcome of laboratory practice, laboratory methods 
 have at present a dominating influence in medical re- 
 search. But as yet we scarcely perceive the limitations 
 of laboratory methods. You can readily understand 
 that in the discovery of the mechanism of some obscure 
 process laboratory experiments are essential ; but to 
 find out what bearing that obscure process has upon 
 
 d 2
 
 36 MEDICAL RESEARCH 
 
 your patient's future life is quite another matter. Never- 
 theless, it is a matter essential for you to know. It fol- 
 lows, then, that research in clinical medicine must pur- 
 sue lines of its own ; these lines are not the loose, specu- 
 lative ones of bygone days, but the precise and accurate 
 observations on living individuals by means of which 
 alone knowledge of real value can be obtained.
 
 CHAPTER II 
 
 HEART FAILURE 
 
 The purpose of a patient in consulting a doctor is to find out 
 what bearing his complaint has on his future, and this 
 purpose gives the motive for all clinical research. 
 
 A patient consults a doctor because he is conscious 
 that there is something wrong with him. The doctor, 
 in his examination, may detect some sign or sensation 
 which he recognises as a departure from the normal. He 
 may recognise the mechanism by which the symptoms 
 are produced and be interested in it from the physio- 
 logical or pathological point of view ; but these are not 
 the points which are essential to a proper performance 
 of his duties, although they may be contributory to 
 that performance. It is from the patient's standpoint 
 he must view the matter, and, apart from the question 
 of immediate relief, the patient's standpoint is summed 
 up by the question, " What bearing has the cause of 
 this symptom upon my future?" 
 
 It is the necessity of answering this question which 
 should be the governing motive in all clinical investiga- 
 tions ; for this necessity, if we view it aright, gives to 
 clinical medicine an aim peculiar to itself and distinct 
 from scientific investigation in any other field. 
 
 When it happens that the abnormal manifestation 
 indicates that there is something wrong with the heart, 
 the question may be more clearly realised by asking 
 what it is the patient fears. The patient may not be 
 able to express it, and his ideas may be vague and con- 
 
 37
 
 38 HEART FAILURE 
 
 fused, but what in fact he is afraid of is that his heart 
 may fail. He demands of his physician that he shall 
 tell him whether or not his present symptoms indicate 
 heart failure or foreshadow its occurrence. This, then, 
 clearly, is the imperative question you have to answer 
 as regards every case with an affection of the heart. 
 
 When the patient thinks there is something amiss with his 
 heart, he fears it may fail. It is therefore necessary that 
 the doctor should understand what heart failure is, and 
 the signs by which it is made manifest. 
 
 To be able to answer this question it is necessary, in 
 the first instance, to understand what heart failure really 
 is. Heart failure may be defined as that condition 
 in which the heart is unable to maintain an efficient cir- 
 culation during the efforts necessary for the daily life of 
 the individual. This definition is purposely extended to 
 embrace cases of advanced failure as well as those in 
 which the heart failure is just beginning. It is needful 
 to insist upon this point, as the absence of a clear con- 
 ception of what heart failure means has led to the mag- 
 nifying of the significance of obvious signs, such as 
 murmurs or irregularities, and to the neglect of the 
 essential symptoms. I make no apology therefore for 
 calling attention, in this respect, to certain features of 
 the circulation, which are not usually considered with 
 sufficient care and understanding. 
 
 The main elements composing the circulatory system 
 are the blood, the heart, the blood vessels, and the 
 nerves supplying and controlling the heart and blood 
 vessels. The different parts of the circulatory system 
 are so constructed as to facilitate the flow of blood 
 and so to favour the work of the heart. The muscle 
 fibres of the heart supply the force which propels the 
 blood. So far, then, as the efficiency of the circulation 
 depends on the flow of the blood, the muscle force is the 
 only factor concerned, and the inability of the muscle 
 of the heart to supply an efficient force is the direct
 
 HEART FAILURE 39 
 
 cause of heart failure. The study of heart failure, there- 
 fore, practically resolves itself into an inquiry into the 
 circumstances which have impaired the functional 
 efficiency of the heart muscle. 
 
 Functional properties of the heart muscle are of importance 
 in the maintenance of an efficient circulation. 
 
 Before inquiring into the manner in which the heart 
 muscle may fail in its work, it is necessary to consider 
 certain features of the functions of the normal heart 
 muscle. Physiologists have shown that the heart muscle 
 possesses a number of separate functions which are exer- 
 cised during each beat of the heart. One feature com- 
 mon to all these functions is that exercise of them in- 
 duces exhaustion, and that, once exhaustion has been 
 produced, the maximum efficiency of function becomes 
 impossible until adequate rest has been obtained. If 
 the heart muscle is stimulated to action before a suffi- 
 cient rest-period has elapsed, the resultant contraction 
 is always less efficient than the normal. The reason for 
 this is that during the period of activity certain func- 
 tional changes occur which destroy the accumulated 
 nutritive material, the presence of which is necessary 
 to the exercise of the muscle functions. It takes some 
 time for these materials to be renewed, and the period 
 of what is called "rest " is actually taken up with the 
 restoration of this nutritive material. Hence we may 
 formulate one great law by deduction that " a period of 
 rest is necessary after every heart beat." The full sig- 
 nificance of this law and its bearing on heart failure will 
 be apparent if we look on the work of the heart as a 
 whole. 
 
 When the body is at rest the heart uses only a limited portion 
 of its power. When the body is active the heart calls on 
 its reserve force. 
 
 As the heart possesses the power not only of main- 
 taining an efficient circulation when the body is at rest,
 
 40 HEART FAILURE 
 
 but also of varying its activity according to the bodily 
 requirements, the force inherent in the heart muscle 
 may be considered, for practical purposes, to be com- 
 posed of two parts ; that is to say, a part which is em- 
 ployed in maintaining an efficient circulation when the 
 body is at rest, and which therefore may be called the 
 "rest force," and a part called into action when effort 
 is made, and which may be termed the " reserve force." 
 The " rest force " is the minimal force which the heart 
 must exert to maintain the circulation on a level con- 
 sistent with life; the impairment of this "rest force," 
 after exhaustion of the "reserve force," produces those 
 evidences of heart failure which persist when the body 
 is at rest. Continuance of the impairment of the " rest 
 force " leads, eventually, to a fatal issue. 
 
 Exhaustion of the reserve force may be physiological or 
 pathological, the latter being of the same kind as the 
 former, only occurring with greater facility. 
 
 The same principles of exhaustion by effort and 
 restoration by rest, upon which depend the proper func- 
 tioning of each individual beat of the heart, are applic- 
 able in respect of the reserve force. When a healthy 
 individual undertakes some form of severe bodily exer- 
 tion — for example, running at the " top of his speed " — 
 there comes a time, sooner or later, when he suffers a 
 temporary exhaustion of his reserve force. Ultimately, 
 on account of this temporary exhaustion, he is com- 
 pelled to desist. If he attempts to run again before a 
 space of time sufficient for complete rest has elapsed, he 
 will not be able to maintain his full speed during so 
 long a period as in the first instance. If he sys- 
 tematically denies himself a sufficient period of rest, his 
 powers of endurance will gradually become more and 
 more restricted. 
 
 Now it cannot be too strongly insisted upon that 
 that process, which we recognise as natural in a healthy 
 individual, is identical with the process occurring in an
 
 HEART FAILURE 41 
 
 individual having some defect, whether the defect is due 
 to disease of the heart itself or to other factors which 
 embarrass the heart in its work. The persistent forcing 
 of a heart which is being denied a sufficient period of 
 rest in which to recuperate itself is the real cause of 
 every form of heart failure, no matter what the actual 
 character of the disease may be. This, as I wish to 
 impress upon you, is the essential fact in the considera- 
 tion of heart failure. In advanced diseases the amount 
 of work of which the heart is capable may be very 
 limited ; nevertheless, danger will not arise unless, and 
 until, too much work is given the weakened heart to do. 
 The term "too much work" must, however, be under- 
 stood in its true significance. In those severe cases in 
 which the heart is unable to maintain an efficient cir- 
 culation when the body is at rest, " too much work " 
 will mean the mere effort of keeping " body and soul 
 together." In a case of this kind, as I have already 
 indicated, the life of the individual is necessarily in 
 peril. 
 
 It will be seen, therefore, that exhaustion of the 
 reserve force in individuals with enfeebled hearts is of 
 the same nature as exhaustion of the healthy heart ; and 
 that heart failure is simply the premature exhaustion 
 of the heart's force. No doubt exhaustion in diseased 
 hearts can be brought about in a greater variety of 
 ways than exhaustion in healthy hearts, but this con- 
 sideration is not germane to the point at issue. Whether 
 it be the action of the heart itself which tends to induce 
 the exhaustion, or the irregular action of the different 
 parts of the heart, or the too great frequency of the rate 
 of contraction, or a progressive lesion, the result is always 
 the same, and the principle governing the production 
 of the result is the same ; and by recognising this, we 
 get a clue as to the best way in which to prevent the 
 exhaustion or to restore the diminished energy. Not 
 only is the principle governing the exhaustion of the 
 " reserve force " fundamentally the same in health and
 
 42 HEART FAILURE 
 
 disease, but the symptoms of this exhaustion are also 
 the same in their manifestation and in the mechanism 
 of their production. When I deal with the symptoms 
 of heart failure I shall point out that the only difference 
 between a man in fair health and a man with an affec- 
 tion of the heart which limits his efforts is that, in 
 the case of the latter, certain disagreeable sensations 
 are provoked more readily than in the case of the 
 former. The sensations are identical in kind. Any 
 modifications they may show in different states of health 
 are quantitative only. The patient with a heart affec- 
 tion no doubt tends to suffer a greater degree of ex- 
 haustion than the man possessed of a healthy heart. 
 But the mechanism by which the sensations are pro- 
 duced is identical. 
 
 It will be clear from the foregoing that these sensa- 
 tions produced by exhaustion of the heart muscle, how- 
 ever easily provoked they may be, give no clue to the 
 underlying morbid condition. This fact must be borne 
 in mind. The actual morbid condition present must 
 be determined by the consideration of other evidence 
 revealed by the history and by the physical examina- 
 tion. The sensations, however much the degree of them 
 may vary, are common to all forms of heart impair- 
 ment. The well-known fact that certain sensations are 
 apt to occur more readily with some than with others, 
 as, for example, pain in aortic disease, in no sense alters 
 this fundamental truth. 
 
 When heart failure sets in the earliest manifestation is always 
 a subjective sensation of a disagreeable kind. 
 
 It is evident that if the "rest force" is intact the 
 individual, when at rest, will present no signs of heart 
 failure. It is also evident that in the early stages of 
 heart failure the signs of exhaustion will only be found 
 when an effort has been made, as it is only then that 
 the limitations can appear. That there is a limitation 
 can be known in the very early stages only to the in-
 
 HEART FAILURE 43 
 
 dividual affected. In other words, the evidence of heart 
 failure in the early stages is entirely subjective ; the 
 individual becomes conscious of certain sensations of 
 distress or discomfort on making an effort which, before 
 this time, he was able to make without experiencing 
 these sensations. As the heart failure advances, these 
 sensations are provoked by less effort, until finally the 
 " rest force " becomes encroached upon ; then we get 
 objective evidences such as dropsy and laboured breath- 
 ing while at rest. 
 
 To appreciate the meaning of heart failure, we must, 
 as has been indicated, bear in mind that the force main- 
 taining the circulation is the heart muscle. There is 
 a limit to the amount of work which a healthy heart 
 muscle can perform. It is the forcing of the heart to 
 work beyond this limit that produces heart failure. We 
 are justified, therefore, in looking upon heart failure as 
 the expression of an exhausted heart muscle. 
 
 Abnormal signs revealed by physical examination must always 
 be valued by considering what effect the cause of the signs 
 has upon the efficiency of the heart muscle. 
 
 The principles just enunciated afford a standard for 
 estimating the value of significance of all the signs, 
 normal and abnormal, which may be detected by physi- 
 cal examination. When we meet with an abnormal 
 sign, be it a murmur or a variation in rate or rhythm, 
 or an increase in the size of the heart, we must not, 
 upon the strength of that sign alone, jump to any con- 
 clusions. We must realise that that sign does not, of 
 itself, indicate heart failure. 
 
 As an outcome of the careful consideration of symp- 
 toms and their relation to heart failure, it can be stated 
 that the presence of a sign revealed by physical exami- 
 nation, no matter how abnormal it may seem, is of no 
 serious significance so long as it is the only sign present, 
 or so long as there is no limitation of the " reserve 
 force " of the heart. If this dictum be grasped, and the
 
 44 HEART FAILURE 
 
 full significance of the principles on which it is based 
 be understood, the practical study of heart affections 
 will be greatly simplified and much clearer and more 
 precise ideas as to the prognosis and treatment of heart 
 affections will be attained. When I come to deal with 
 some of the more common abnormalities, the importance 
 of this statement will be appreciated. 
 
 The early signs of the exhaustion of the reserve force are 
 certain sensations experienced by the Individual, and 
 produced in the first instance by exertion. 
 
 The symptoms of exhaustion are not necessarily in- 
 dications of a diseased or impaired heart muscle. They 
 may be found in healthy individuals, and they only in- 
 dicate exhaustion for the time being. Actual impair- 
 ment is, however, indicated when the symptoms are 
 produced with abnormal facility, as, for example, after 
 an effort that the individual was wont to perform in 
 the past without any sign of distress. The point that 
 I wish to emphasise here, then, is that it is the abnormal 
 facility with which the signs of exhaustion are produced, 
 and not the signs themselves, which is the earliest in- 
 dication of heart failure. 
 
 The standard for estimating the heart's strength is found by 
 ascertaining the response of the heart to effort. 
 
 The standard by which the heart's strength is to be 
 measured is not a fixed standard ; — it will vary 
 with each individual examined. The field of normal 
 response to effort varies widely in different healthy in- 
 dividuals. Every man knows the amount of effort he 
 can normally put forth without distress, and this amount 
 of effort is the only practical standard by comparison 
 with which it can be determined whether the field of 
 the heart's response to effort is restricted. It is the 
 appreciation of the fact that in cases of heart failure 
 distress is evoked prematurely that renders it possible 
 to appreciate the true character of any particular case.
 
 HEART FAILURE 45 
 
 When there is limitation in the range of effort it is 
 necessary, therefore, to inquire carefully into the history 
 of the case in order to find out when the limitation was 
 first noted, and the circumstances under which it first 
 occurred. 
 
 Exhaustion of the rest force is shown by the persistence of 
 certain signs, as dropsy or laboured breathing while the 
 heart is at rest. 
 
 The sensations which indicate exhaustion of the " re- 
 serve force " persist, and become more readily pro- 
 voked, as the exhaustion proceeds. By the time that 
 objective signs of heart failure have arisen — e.g., dropsy 
 and laboured breathing when at rest or after slight 
 exertion — the heart failure has proceeded a long way. 
 When such objective signs persist while the body is at 
 rest the "reserve force" is practically exhausted, and 
 the " rest force " is being encroached upon. 
 
 I may warn you here, however, since an exaggerated 
 importance is frequently attached to their absence as 
 well as to their presence, that the objective signs of 
 heart failure may never appear, even in people who die 
 from gradual and progressing failure of the heart. 
 Thus, I have known physicians give a good prognosis 
 in cases of extreme exhaustion, because, in their own 
 words, "compensation was good," and there was no 
 objective sign of heart failure. The subjective symp- 
 toms of heart failure, on the other hand, are never 
 absent when the heart's efficiency is in any way affected. 
 
 Methods of estimating the cardiac efficiency which do sot take 
 into consideration the sensations produced by effort fail to 
 bring out the information essential to a knowledge of the 
 heart's efficiency. 
 
 I am well aware that you will be surprised that I 
 emphasise so strongly knowledge of such a simple kind — 
 knowledge, indeed, with which the merest tyro is sup- 
 posed to be familiar. Had I shown you some records
 
 46 HEART FAILURE 
 
 obtained by a polygraph or an electrocardiograph, or 
 had I propounded some fanciful blood-pressure scheme, 
 by which you could estimate the heart's strength accord- 
 ing to some mathematical formula, you would not have 
 understood, but you would have been impressed. 
 
 We are accustomed to regard with amusement the 
 fear and respect with which the backward races treat 
 their idols, yet we are not free from the same tendency 
 ourselves, although the tendency may masquerade under 
 the guise of science. I frequently see eager young men 
 return from a Continental tour, carrying with them 
 some wonderful contrivance — it may be an ingenious 
 stethoscope or phonendoscope, or a curious blood-pres- 
 sure instrument. They carry the instrument home with 
 them in the firm belief that they possess a small idol 
 which will reveal the mysteries of nature. Some of you 
 may view with awe and reverence the small temple in 
 the cellar where you see Dr. Parkinson, as High Priest, 
 performing rites with that mysterious instrument, the 
 electrocardiograph. You see the victim sitting on a 
 chair, mute and impassive, like a statue of Buddha, 
 and you may fancy that the innermost secrets of his 
 heart are being wrested from him. Surrounding all 
 these instrumental methods of investigation there is an 
 element of mystery and a trustful expectation that the 
 fountains of knowledge are about to be unsealed. 
 
 I am not decrying the use of these instruments, for 
 they bring to light certain information which enables 
 us to understand better the action of the heart. But 
 if you reflect on what I have described as the essential 
 conditions that lead to heart failure you will at once 
 realise the limitations of all methods which depend on 
 the use of mechanical contrivances. You will realise 
 that the chief limitation is due to the fact that the 
 examination of the body, at rest, affords no opportunity 
 for estimating the reserve force of the heart. 
 
 Another method, that of studying the heart during 
 exercise, by counting the beats before and after some
 
 HEART FAILURE 47 
 
 exertion, has been advocated. But here there is a 
 fallacy so great as to render the method misleading. 
 It has been found that in some people with manifestly 
 damaged hearts the rate increases but slightly on exer- 
 tion, while, on the other hand, in healthy individuals 
 in good training, the heart's rate may reach 200 beats 
 per minute on exertion. Measurements have, further, 
 been made of the time which elapses before a heart's 
 rate falls to the normal after exertion, and calculations 
 have been based on certain variations in the blood pres- 
 sure ; but I have little hesitation in saying that none 
 of these methods brings to light the knowledge which 
 is essential.
 
 CHAPTER III 
 
 THE PATIENT'S SENSATIONS 
 
 The due appreciation of the patient's sensations is essential to 
 a knowledge of the condition of the heart. 
 
 As you go through life you will often find that the 
 simplest things are the most difficult to understand. So 
 it is here. If you could but comprehend the full sig- 
 nificance of these sensations of which the patients com- 
 plain, and which are so often put aside as immaterial, 
 you would indeed be getting to the root of things. I 
 think I have spent more time than most people in the 
 attempt to solve obscure problems connected with the 
 heart, and it may be that a measure of success has at- 
 tended my efforts ; but of all the problems I have 
 attempted to solve the most difficult have been, and 
 are, those connected with the sensations of the patient. 
 It is now more years than I care to remember since I 
 began this work, and yet, although I have obtained a 
 certain amount of knowledge, I am far from appreciat- 
 ing the full meaning of some of the most ordinary com- 
 plaints. Moreover, the deeper I have gone into the 
 subject the more impressed I have become with the great 
 usefulness of a due appreciation of the patient's sen- 
 sations in estimating the condition of his heart and circu- 
 latory system generally. Strange it is, surely, that, 
 although this investigation seems so simple, and does 
 
 not demand any record or instrument for its conduct, 
 
 48
 
 THE PATIENT'S SENSATIONS 49 
 
 it has never been seriously carried out, but has, on the 
 contrary, been regarded as a matter of little moment 
 as compared with the detection of some physical sign 
 by means of some mechanical device. I may say I am 
 continually seeing people who have been advised by 
 leading authorities in the profession to restrict their 
 energies and to alter their mode of life and business, 
 because of a murmur or an irregularity ; yet I find that 
 in these cases no inquiry has been made at any time 
 into the capacity of the heart for its work. Nor are 
 the text-books any more reliable than the specialists. 
 You will find, if you consult your text-books, that the 
 method of estimating the heart's capacity in terms of 
 its power of response is barely referred to, and that its 
 significance is never really grasped. 
 
 If further you wish to gain a full insight into the 
 matter and to understand how completely this aspect 
 of the heart's functions has been ignored by the profes- 
 sion, you have only to turn to the practice of those who 
 may be called the specialists in prognosis — I mean the 
 life insurance examiners. Look at the questions asked 
 in the medical form of an insurance society — which form, 
 remember, represents the accumulated wisdom of by- 
 gone generations of examiners — and you will see what 
 I mean. There are questions relating to the size of the 
 heart, its rate and rhythm, and the character of its 
 sounds, but there is not a single question directed to 
 the elucidation of the most important class of evidence, 
 the evidence which gives you the really essential infor- 
 mation on which to base a prognosis concerning the 
 patient's future. Some insurance companies have 
 special " heart forms," to be filled up when any abnor- 
 mal sign is perceived in connection with this organ. I 
 have seen those forms, yet I assure you that, though 
 each of them contained a long series of questions to be 
 answered, not one contained a question designed to 
 elicit what I think I have shown you is the essential 
 information.
 
 50 THE PATIENT'S SENSATIONS 
 
 It requires careful study and long training before we can 
 interpret the patient's sensations. 
 
 One reason for this neglect is the fact that the method 
 we have considered is surrounded by pitfalls into which 
 the unwary are continually falling. There is certainly 
 not one of these phenomena which indicates subjective 
 evidence of heart exhaustion which may not arise from 
 causes other than cardiac, or from conditions of the 
 heart widely dissimilar. Indeed, the confusion in 
 respect of these subjective symptoms is brought before 
 me nearly every day. It is a confusion resulting not 
 only from neglect, but also from misinterpretation. 
 Individuals who have shown some transient sign of 
 exhaustion, who have been breathless or who have 
 fainted, are treated as if they suffered from some 
 affection of the heart. On the other hand, I see, 
 repeatedly, individuals in the greatest danger whose 
 serious condition has never been suspected, because there 
 was present no physical sign indicating heart trouble. 
 In these latter cases, if the patient's reaction to effort, 
 as measured by his own sensations, had been investi- 
 gated and appreciated, the gravity of the condition 
 would have been recognised.
 
 CHAPTER IV 
 
 THE PRODUCTION OF SYMPTOMS 
 
 Symptoms are produced in three different ways, according as 
 they modify the structure of an organ, or its functions, or 
 call into play its protective meehanism. 
 
 Seeing that there is a great confusion as to the mean- 
 ing and significance of signs and symptoms, and seeing 
 also that we can only recognise disease and be guided in 
 our estimation of its importance by the detection of 
 signs and symptoms, it will, I think, be advisable, 
 before discussing the individual symptoms and their 
 bearing on the heart's efficiency, to consider for a 
 moment the fundamental principles involved in the pro- 
 duction of symptoms. 
 
 Each organ in the body has a definite position and 
 shape, and each organ has definite functions to perform. 
 Disease and impairment modify these characteristics, 
 and in truth the modifications constitute our signs and 
 symptoms. These signs and symptoms arise from three 
 definite and distinct sources : 
 
 (1) Structural : i.e., changes in the size, shape, or 
 position of the organ, or modification of its material 
 constitution. 
 
 (2) Functional : i.e., changes due to modification or 
 inefficiency of the function of an organ. 
 
 (3) Protective : i.e., the presence of sensations, always 
 disagreeable, produced by the intervention of the ner- 
 vous system for the protection and resting of the organ. 
 
 The full significance of this classification will be better 
 
 s 1 E 2
 
 52 THE PRODUCTION OF SYMPTOMS 
 
 understood when we analyse the individual phenomena. 
 For the present I desire that you shall grasp the pur- 
 pose of the classification, so that it may guide you, in 
 cases of doubt and obscurity, towards the proper answer 
 to the essential question which you must face when 
 dealing with heart-failure. 
 
 Structural symptoms. 
 
 Consider first the structural symptoms. We must in- 
 clude here not only the position, size, and shape of the 
 heart, but also the objective evidences of its activity, 
 such as alterations in rate, rhythm, and sounds. It 
 will be noted that the study of these structural symp- 
 toms, while illuminating as an indication of the cause 
 or nature of the impairment or disease, do not afford 
 the knowledge of the functional efficiency of the organ 
 which, I have insisted, is essential to the clear under- 
 standing of any individual case. 
 
 Functional symptoms. 
 
 The valuation of structural signs, therefore, must de- 
 pend on whether or not their cause impairs the efficiency 
 of the heart. For information on this latter point we 
 must study the second class of symptoms, those due to 
 functional inefficiency. I think I have made it clear 
 that such a study is impossible without an understand- 
 ing of the manner in which the heart responds to effort. 
 I repeat that we, as physicians, must recognise the sen- 
 sation or sensations which tell the patient that his 
 heart's power of response is, for the time being, ex- 
 hausted, and must never forget that these sensations 
 may not arise directly from the heart itself, but from 
 other organs whose supply of blood is meantime de- 
 ficient. In cases of extreme heart-failure we are, of 
 course, accustomed to recognise inefficiency by symp- 
 toms like dropsy and enlarged liver. That, however, is 
 not nearly enough. There is a period long antecedent 
 to the period of extreme failure in which due notice is
 
 THE PRODUCTION OF SYMPTOMS 53 
 
 given — most frequently by breathlessness. I shall de- 
 scribe later the exact relationship of these functional 
 symptoms to heart failure. 
 
 Protective symptoms. 
 
 The third class of symptoms is one that needs far 
 more careful consideration than has hitherto been given 
 to it. The functions of the different organs are much 
 more complicated than might appear at first sight. The 
 function, for instance, of the skeletal muscles is not to 
 be dismissed as "contraction." The skeletal muscles 
 are certainly contractile bands capable of exercising 
 force. But they perform other tasks. Many of them, 
 for example, are specially adapted for protective pur- 
 poses. When a lesion occurs in some viscus — e.g., an 
 ulcer in the stomach or an inflammation in an appendix 
 — a stimulus of a peculiar kind arises in the diseased 
 organ. This stimulus acts upon the sympathetic fibres 
 running from the diseased organ to certain regions in 
 the spinal cord, and sets up a disturbance which pro- 
 duces an irritable focus in the spinal cord. This irrit- 
 able focus communicates its irritability to the nerve 
 centres in its immediate neighbourhood, and these again 
 stimulate the motor and sensory nerves. Hence we 
 get contraction of the abdominal muscles, with an en- 
 hanced sensitiveness of the skin and deeper tissues of 
 the external body-wall. 
 
 Hollow muscular organs are endowed with a nervous 
 mechanism which is only called into play when they 
 are embarrassed. This mechanism is seen in the ex- 
 cruciating pains produced by strong peristalsis of the 
 bowel, by renal and biliary colic, and by uterine con- 
 tractions. While in these instances the violent contrac- 
 tion seems to be the agency producing the stimulus, it 
 is reasonable to infer that other conditions may also act 
 as an adequate stimulus. We know that the qualities 
 and properties of the heart muscle fibres resemble, in a 
 great many ways, those of the fibres of other hollow
 
 54 THE PRODUCTION OF SYMPTOMS 
 
 muscular organs. The heart muscle cannot, of course, 
 go into a peristalsis ; yet it seems reasonable to conclude 
 that it can send a stimulus into the central nervous 
 system capable of producing a severe pain, particularly 
 as this pain, in the majority of cases, is only called 
 forth when there is imperative need for diminution of 
 the heart's efforts. 
 
 To sum up. There are fundamental principles under- 
 lying the production of symptoms. Consideration of 
 these fundamental principles shows that symptoms due 
 to structural alterations (what are known as physical 
 signs) give no clue to the functional efficiency of the 
 heart. It is, on the contrary, by the consideration of 
 the other two kinds of symptoms that the essential in- 
 formation is to be acquired. Further, the presence of 
 a physical sign, however abnormal it may seem, should 
 never by itself be the basis of an estimate of the con- 
 dition of the heart. 
 
 I shall describe these three different kinds of symp- 
 toms under various headings ; the structural are de- 
 scribed in the chapter on an increased size of the heart, 
 murmurs, and abnormal rhythm ; the functional are de- 
 scribed under breathlessness, fainting, dropsy, &c. ; the 
 protective under angina pectoris.
 
 CHAPTER V 
 
 BREATHLESSNESS 
 
 Breathlessness is produced by stimulation of the respiratory 
 
 centre in the medulla. 
 
 The respiratory centre is in an ever-varying state of 
 activity. An excess of oxygen in the blood may dull it 
 or may suspend its action for a period ; a deficiency of 
 oxygen in the blood, or the accumulation of certain 
 waste products in the blood, may stimulate it to exces- 
 sive activity. Hence a weak heart that fails at any 
 time to send sufficient aerated blood to the respiratory 
 centre induces breathlessness. It may be that the heart 
 cannot do this when the body is at rest, giving rise then 
 to orthopncea. 
 
 Other factors may over-stimulate the respiratory 
 centre than the failing heart, as certain blood states, 
 the result of the anaemias, and diseased kidneys, and 
 mechanical conditions that interfere with the aeration 
 of the blood in the lungs, and disease of the lungs them- 
 selves. 
 
 Breathlessness on Exertion. 
 
 The most frequent complaint in heart affections is, 
 as we have seen, shortness of breath. This shortness of 
 breath limits its victim's response to effort. Limitation 
 of this kind is not, however, peculiar to cardiac suf- 
 ferers. Many healthy people are short-winded — that is, 
 they have so little reserve force that their store is 
 speedily exhausted. What is quite normal in them 
 
 5S
 
 56 BREATHLESSNESS 
 
 may, on the contrary, be due to some impairment in 
 others. Thus, an individual who has been accustomed 
 to take a considerable amount of exercise discovers sud- 
 denly a limitation of his powers. This may be very 
 slight and may not at first attract much notice. 
 Nevertheless, the limitation may indicate cardiac in- 
 efficiency. We have already seen that the amount of 
 reserve force available varies in healthy people. Bear- 
 ing this fact in mind, we shall not experience great diffi- 
 culty in discovering by means of a careful appreciation 
 of the patient's sensations whether the limitation is 
 normal or is due to impairment. 
 
 This breathlessness, which arises as the result of effort, 
 is a symptom common to all forms of heart exhaustion, 
 slight and temporary as well as serious. But it occurs 
 also in other conditions — e.g., lung affections and wast- 
 ing diseases — so that no conclusion as to its real nature 
 can be drawn until other phenomena have been investi- 
 gated. A weighing of the resulting evidence will reveal 
 which of the many provocative causes is at work in the 
 case of the particular individual under consideration. 
 
 Breathlessness at rest (orthopnoea). 
 
 When the breathing is laboured while the patient is 
 at rest, so that he is compelled to assume a sitting pos- 
 ture, the heart's impairment is so extreme that the 
 " reserve force " is soon exhausted. But before decid- 
 ing that the distressed breathing is cardiac in origin, we 
 must exclude the various forms of respiratory disease 
 which induce such extreme breathlessness — e.g., asthma, 
 pleurisy, pneumonia, emphysema, and intrathoracic 
 growth. When due to enfeeblement of the heart, the 
 distressed breathing is generally the outcome of a long 
 period of persistent over-exertion. The real cause of 
 the trouble is thus insufficient rest. In these cases the 
 history may reveal the fact that the onset was gradual 
 and extended over months or even years. Rest in bed 
 will often of itself restore a certain amount of strength
 
 BREATHLESSNESS 57 
 
 to the heart and cause the breathlessness to disappear 
 gradually. When the breathlessness occurs rather sud- 
 denly, the chances are that it has been caused by the 
 heart taking on an abnormal rhythm — for example, 
 auricular fibrillation — in which the ventricle is stimu- 
 lated to rapid and irregular action. Extreme breath- 
 lessness may set in within a few hours after the onset 
 of auricular fibrillation, though usually it does not 
 appear for a few days or weeks. Its onset in such cases 
 is precipitated by the individual attempting to do his 
 ordinary work while his heart is hampered by the abnor- 
 mal rhythm. The ease with which breathlessness is 
 induced and the response made by the heart to treat- 
 ment of the condition give us the data on which we can 
 estimate the functional efficiency of the heart. Per- 
 sistence of this form of dyspnoea (dyspnoea due to auri- 
 cular fibrillation) is often associated with dropsy, en- 
 largement of the liver, and a tendency to lividity of the 
 face and extremities. 
 
 Cheyne-Stokes breathing. 
 
 There is a type of respiration in which the breathing 
 ceases for a short period (10-40 seconds), and then gradu- 
 ally begins again ; from the period of cessation the 
 breathing increases in intensity till a maximum is 
 reached and then gradually subsides until it disappears. 
 Sometimes these phases are very marked ; at other times 
 they are so slight that they cannot be detected unless 
 the patient is watched during his sleep. This breathing 
 — known as Cheyne-Stokes — may occur when the patient 
 is sitting quietly in his chair; usually, however, it only 
 occurs when he is asleep or dropping off to sleep. 
 Sometimes the patient passes into sleep during the 
 apnceic period and may resume a conversation when 
 the breathing becomes re-established. Or he may con- 
 tinue to talk, but in a faint voice, during the apnceic 
 phase and return to his louder voice during the respira- 
 tory phase.
 
 58 BREATHLESSNESS 
 
 Although Cheyne-Stokes breathing is not usually dis- 
 covered as a subjective sensation, on account of the fact 
 that many of those affected by it are quite unconscious 
 of its presence, yet for convenience of description I 
 include it at this place. I should like you to rjote that 
 its presence may be suspected when the patient de- 
 scribes suffocating sensations, which keep recurring, or 
 states that he awakes feeling suffocated. This sense of 
 suffocation is usually due to the recurrence of the apnceic 
 phase; sometimes it is so distressing that the patient 
 will suddenly spring out of bed in an extremity of terror. 
 
 Cheyne-Stokes respiration has a varied clinical sig- 
 nificance. Many elderly people with no particular dis- 
 ablement, beyond the considerable enfeeblement so com- 
 mon in advanced years, show it. In people with high 
 blood-pressure, advanced sclerosis of the heart and 
 arteries, it is generally a sign of approaching disso- 
 lution. I have seen it in several cases of extreme 
 heart failure, with auricular fibrillation and auricular 
 flutter ; and in these cases it has quite disappeared when 
 the heart failure was relieved by digitalis. 
 
 Cardiac asthma. 
 
 There is a form of dyspnoea which comes on sud- 
 denly with great severity. It is so often associated 
 with marked changes in the heart that it has received 
 the name of "cardiac asthma." It occurs most fre- 
 quently in the night. The patient goes to bed and may 
 fall asleep for a few hours ; he is then awakened by a 
 sensation of suffocation, which forces him to sit up. 
 He breathes heavily and struggles to get into a position 
 which will allow him to breathe with freedom. This 
 dyspnoea may last for half an hour or longer, and may 
 then gradually subside, so that the patient is able to 
 go off to sleep again. Usually, however, the patient 
 remains propped up in bed, and if he sleeps his sleep is 
 troubled and disturbed, with a fear of the recurrence 
 of the distress. The attacks resemble ordinary asthma
 
 BREATHLESSNESS 59 
 
 and may be quickly relieved by a hypodermic injection 
 of morphia. 
 
 This condition occurs most frequently in elderly 
 people with degenerated heart muscle, high blood pres- 
 sure, and changes in the arteries. These conditions may 
 also, it should be noted, occur in middle life, and may 
 be associated with albuminuria. 
 
 Cardiac asthma is a very grave sign, especially when 
 it is associated with pulsus alternans and angina pec- 
 toris, and is usually a prelude of death, so that the 
 duration of the individual's life can be reckoned by 
 months ; in milder cases, on the other hand, where the 
 heart responds to treatment, life may be prolonged for 
 a few years. 
 
 For some years now I have been inquiring into the 
 relation of this condition to Cheyne-Stokes respiration, 
 and I find that the latter condition is present at times 
 with cardiac asthma. I find again that in most cases 
 the patient wakes in distress during the apnceic stage, 
 and the attack of severe breathlessness which then de- 
 velops is identical with what is called cardiac asthma. 
 I was in consequence disposed to look upon Cheyne- 
 Stokes respiration as the origin of the attacks of cardiac 
 asthma in all cases ; but Dr. Lewis tells me that, while 
 he was examining a patient, the latter suddenly de- 
 veloped an attack, with no preliminary Cheyne-Stokes 
 breathing.
 
 CHAPTER VI 
 
 SYNCOPE 
 
 Syncopal attacks or fainting, in which the patient becomes limp 
 and unconscious, are due to a deficient supply of blood to 
 the brain. 
 
 This cerebral anaemia may be due to the loss of blood, 
 to the failure of the heart to send a sufficient supply of 
 blood to the brain, the heart itself being the subject of 
 some abnormal action, or being depressed in its action 
 as the result of vagal stimulation, or it may be due to 
 the collecting of the blood into the large abdominal 
 veins and the veins of the periphery, with consequent 
 anaemia of the brain. 
 
 Syncope from venous stasis. 
 
 Taking the last condition first, we find it the most 
 common form of syncope. Many young people faint 
 when in a close atmosphere — e.g., schoolboys attending 
 chapel ; many women of anaemic, flabby habit faint under 
 similar circumstances ; soldiers on the march, especially 
 in hot weather, faint, probably because their heavy 
 clothing keeps their bodies so warm that the peripheral 
 vessels are dilated to such an extent that they deplete 
 the brain. In some people the tendency of the blood to 
 drain into the large abdominal veins is so marked that 
 the fainting attacks are easily produced. (See Chapter 
 
 XI.) 
 
 60
 
 SYNCOPE 6 1 
 
 Syncope from vagal stimulation. 
 
 When an impression is made by means of a violent 
 mental stimulus — for example, alarming information or 
 the sight of some harrowing scene — syncope may follow ; 
 again, violent intestinal peristalsis, or severe pain, as, 
 for example, that attending the opening of an abscess, 
 may produce syncope. The pulse in such cases may be- 
 come infrequent and of very low tension. The cause of 
 the depression here is no doubt vagal in origin. 
 
 There are two kinds of cardiac action which tend to induce 
 loss of consciousness — that in which the ventricles stand 
 still (e.g., heart-block), and that in which they beat at such 
 a fast rate that the output is greatly reduced (e.g., auricular 
 flutter). 
 
 Syncope from heart-block. 
 
 In heart-block the attack of unconsciousness occurs 
 so suddenly that it is seldom an opportunity is given 
 the physician for the recognition of all the features 
 present. In rare cases of heart-block, when the attacks 
 occur frequently, he may get an opportunity for the 
 detection of some of the more prominent features. The 
 condition called heart-block is, as you know, due to 
 the stimulus of contraction, which arises in the auricles, 
 failing to pass along the bundle of fibres that joins the 
 auricles to the ventricles. The result of this failure is 
 that the ventricles may beat at an infrequent rate. 
 You will readily understand that as disease is progres- 
 sive there are different effects produced according to 
 the stage reached by the disease. The first effect of 
 disease of the auriculo-ventricular bundle is a delay in 
 the transmission of the stimulus from auricle to ven- 
 tricle, due to the fact that the damaged fibres do not 
 speedily recover from exhaustion after being exercised. 
 
 This delay cannot be recognised without instrumental 
 aid, except in those rare instances where there is mitral 
 stenosis, and when a pause occurs between the pre- 
 systolic or auricular systolic murmur and the first sound,
 
 62 
 
 SYNCOPE 
 
 causing what is described as a mid-diastolic murmur. 
 When the auriculo-ventricular bundle of fibres becomes 
 more damaged, the recovery of the fibres, after being 
 
 Radial 
 
 Fig. 1. 
 
 Slow, irregular pulse due to partial heart-block after an attack of 
 influenza. The upper tracing is from the neck, and was taken 
 at the same time as the radial tracing. The waves a are 
 from the jugular vein and are due to the contraction of the 
 auricle, and the waves c are due to the carotid pulse, and 
 these c waves correspond exactly in time to the radial 
 beats. It will be noted that there are two auricular waves (a) to 
 one carotid (c) or radial beat, except in one instance, where the 
 c wave and the radial beat appear earlier. Note that the c wave 
 follows immediately on the a wave, except in the instance when 
 the c wave appears earlier, and there is a distinct interval between 
 a and c. The explanation is that there is an impairment of the 
 bundle connecting the auricles and ventricles, and after the passage 
 of the stimulus from the auricle to the ventricle the power of 
 conducting the stimulus is so exhausted that it fails to respond to 
 every second ventricular contraction, excepting in the one instance 
 where there is a response, and where the interval between a and c 
 is lengthened, showing a delay in the transmission of the stimulus. 
 (See Fig. 2.) 
 
 stimulated, is further delayed, and the ventricle at times 
 fails to respond to each auricular contraction, so that 
 
 As 
 
 s: 
 
 
 s 
 
 v«. 
 
 Fig. 2. 
 
 Diagram of Fig. 1. The downstrokes in the space A, represent 
 the contraction of the auricle, the downstrokes in the 
 space V s represent the contraction of the ventricle, the slanting 
 lines in the space a — c represent the passage of the stimulus from 
 auricle to ventricle (the a — c interval). The diagram shows that 
 the ventricle responds only to every second auricular beat, except in 
 one instance, when the increased length of the slanting line repre- 
 sents the prolonged a — c interval in Fig. 1. 
 
 ventricular beats drop out. This may happen at rare 
 intervals at first, but with advancing disease of the fibres 
 it gets more frequent (Figs. 1 and 2). A stage is at last
 
 SYNCOPE 63 
 
 reached when the fibres fail, for longer or shorter 
 periods, to convey a stimulus (Fig. 3). When the fibres 
 no longer convey a stimulus between auricle and ven- 
 tricle, the ventricle may take on an independent rhythm, 
 and may beat in a manner bearing no relation to the 
 auricular contractions. 
 
 In most cases where the ventricle takes up this in- 
 dependent action it will go on for an indefinite number 
 of years, beating regularly about thirty times 
 per minute. But, before it settles down to this 
 rate, there are periods alternating with the periods 
 of complete heart-block when the stimulus does 
 still pass from auricle to ventricle. It is at this 
 stage of the disease, when the stimulus first fails 
 
 
 Fig. 3. 
 
 The long pause in the radial tracing is due to partial heart-block with 
 a prolonged standstill of the ventricle. In the upper tracing the 
 waves a are due to the auricle. This tracing was taken two days 
 before the patient's first attack of loss of consciousness. 
 
 to pass from the auricle to the ventricle, that the pheno- 
 menon of Adams-Stokes syndrome is most common. 
 At this period there is often a little delay before the 
 ventricle takes up its independent rhythm, and, there- 
 fore, the ventricle may stand still for a longer or shorter 
 period. During this pause no blood reaches the brain 
 and the individual becomes unconscious ; and hence 
 there arises the train of phenomena described under the 
 name of Adams-Stokes syndrome — loss of consciousness 
 with convulsions. 
 
 In one case, from which I took continuous records ex- 
 tending over an hour, the patient had, in the hour, thirty 
 attacks of loss of consciousness. When conscious he
 
 64 SYNCOPE 
 
 would talk quietly and rationally, then his voice would 
 trail off to a mumble and he would become unconscious. 
 He would recover and resume the conversation where 
 he left off. The record showed that before he ceased to 
 talk the left ventricle had ceased to beat ; it was ten 
 seconds after the beating ceased that he completely lost 
 consciousness (Fig. 4). Usually the ventricle started 
 to beat after stopping fifteen to sixteen seconds. If it 
 stopped sixteen seconds the patient became convulsed 
 with slight twitching of the muscles of the face and 
 arms. If the stoppage was prolonged to twenty seconds 
 there was a strong convulsion of the whole body. In the 
 attack, accompanied by slight convulsions of the face, 
 he felt the twitching of the muscles as he recovered. I 
 cite this case because it gives a clear conception of the 
 
 Fig. 4. 
 
 The upper tracing is from the jugular vein, and shows small waves, a, 
 due to the auricle. The radial tracing after two beats shows a long 
 pause due to standstill of the ventricles, lasting 17 seconds. During 
 the pause the patient lost consciousness, which returned as soon as 
 the ventricles began to beat. It will be seen that the auricle con- 
 tracted at a rate of 100 per minute during the standstill of the 
 ventricles. 
 
 agency by which syncope and convulsions are produced, 
 and the time it takes for complete cessation of ventricu- 
 lar output to produce these phenomena. 
 
 Attacks of syncope are not infrequent in cases of auri- 
 cular fibrillation, due also to a peculiar form of heart- 
 block. There are rare cases where auricular fibrillation 
 occurs with complete heart-block, and syncopal and 
 epileptiform seizures may occur. 
 
 I shall not again refer to heart-block because, after 
 all, it is a rare condition, but before leaving the subject 
 I may say that, in treatment of this condition, we are 
 unable to influence the rate of the ventricle. We tried
 
 SYNCOPE 65 
 
 in the hospital all sorts of remedies without success. 
 Many patients recover spontaneously from the tendency 
 to attacks of unconsciousness, and these attacks disap- 
 pear when the independent ventricular rhythm becomes 
 established. The independent rate is usually about 
 thirty per minute. Other patients die in our presence 
 and we are incapable of giving them any help. 
 
 Syncope from extreme frequency of the heart rate. 
 
 The deficient supply of blood to the brain, which in- 
 duces syncope, may arise from the ventricle beating so 
 frequently that its output becomes greatly diminished. 
 There is a condition where the auricles beat at a rate 
 sometimes as high as 300 beats per minute and over. 
 To this condition MacWilliam has given the name of 
 
 5<4» £<* 
 
 Fig. 5. 
 
 Tracings taken during a short attack of auricular flutter, during which 
 the patient lost consciousness. From the character of the radial 
 tracing it can be inferred that the ventricle contracted at the rate 
 of 200, but the output was so small as barely to affect the radial 
 pulse. (Theodore Thompson.) 
 
 auricular flutter. In the majority of cases the ven- 
 tricle does not respond to every auricular beat. When, 
 however, the ventricle responds to every beat, the 
 patient is in great distress, and feels as if he is about 
 to fall and lose consciousness. Sometimes he does fall, 
 and the unconsciousness may last for a few minutes or 
 for a few hours, the pulse at the wrist being imper- 
 ceptible or barely perceptible (Fig. 5). In one of ray 
 cases unconsciousness lasted for four hours, the patient 
 scarcely breathing ; the doctor in charge thought several 
 times that the man was dead. The patient recovered 
 and lived for ten years, the attacks occasionally 
 
 recurring (see Chapter XIX). 
 
 F
 
 CHAPTER VII 
 
 OBJECTIVE SIGNS OF HEART-FAILURE 
 
 (Dropsy, enlargement of the liver, congestion of the kidneys, 
 
 oedema of the lungs.) 
 
 As the heart-failure advances, the force of the left 
 ventricle, which sends the blood onwards, shows signs 
 of weakening at the parts where the force of the heart is 
 normally least — for instance, in the feet and in such 
 organs as the liver and kidney. Hence we get dropsy, 
 enlargement of the liver, and albumen in the urine. 
 The facts concerning these signs are so well known, and 
 these signs indicate so extreme a type of heart failure, 
 that I do not wish to do more than allude to one or two 
 points. 
 
 (Edema about the ankles is common in many practi- 
 cally healthy people towards the end of the day, so 
 that, if the heart's efficiency in other respects is good, 
 and we can exclude other causes, such as an interference 
 with the venous flow or conditions such as anaemia, the 
 symptom is of little significance. 
 
 I have occasionally been misled as to the cause of 
 dropsy by the coincidental presence of some heart ab- 
 normality like a murmur, and have attributed the 
 dropsy to heart-failure when it was really due to some 
 other cause. I have seen enlargement of the liver and 
 dropsy treated for years as symptoms of cardiac origin, 
 when in fact the disease was in the liver. I have, there- 
 fore, sought for some method of differentiating causes 
 
 66
 
 OBJECTIVE SIGNS OF HEART-FAILURE 67 
 
 in these cases; so far, I am inclined to think that we 
 never get dropsy or enlargement of the liver without 
 at the same time distinct evidence of dilatation of the 
 heart. Such is the impression I have obtained, but I 
 have not tested the matter in a sufficient number of 
 cases to be dogmatic. 
 
 (Edema of the lungs. 
 
 In many cases, especially in those cases which are con- 
 fined to bed — e.g., in the fevers — the first sign of heart- 
 failure will be found on examination of the bases of 
 the lungs. The very first signs are the fine crepitations 
 perceived during the first deep inspiration. These crepi- 
 tations when the failure is beginning disappear with a 
 few deep inspirations, but as the failure proceeds they 
 persist, and by-and-by impairment of the percussion 
 note at the bases can be perceived ; this impairment 
 gradually develops into complete dullness, and at the 
 post-mortem the lungs may be found sodden and en- 
 gorged. 
 
 I have watched this gradual process in a great many 
 conditions, such as chronic heart-disease in the elderly 
 who are compelled to lie on their backs as the result 
 of some operation. I have noticed it in fevers, espe- 
 cially typhoid, and have used it as a guide to the extent 
 of the heart's weakness in these conditions. We know 
 that, apart from such an accident as perforation of the 
 bowel, heart-failure is the greatest danger in typhoid 
 fever. For many years I had used the absence of these 
 symptoms (i.e., crepitations and dullness of the bases of 
 the lungs) as a good prognostic significance, and their 
 presence and degree as a guide to the gravity of the 
 case. My usual routine method of examination was to 
 start by finding out upon which side the patient usually 
 lay ; I then got him to sit up and auscultated the lung 
 base of that side, while he took a deep inspiration. 
 When I detected crepitations I instructed that the 
 patient be raised, and at periods during the day be 
 
 f 2
 
 68 OBJECTIVE SIGNS OF HEART-FAILURE 
 
 asked to breathe deeply. I reasoned that this sign — 
 crepitation — was due to the failure of the right ventricle 
 to send the blood efficiently through the lungs, and that 
 lying in bed compressed the ribs and interfered with 
 free breathing, while sitting up, on the other hand, freed 
 the ribs. The deep breathing thus assisted the heart in 
 sending the blood through the lungs.
 
 CHAPTER VIII 
 
 ANGINA PECTORIS 
 
 As we are ignorant of the cause of angina pectoris, the pain 
 can best, for practical purposes, be considered as an expression 
 of exhaustion of the heart muscle, and as protective in 
 purpose. 
 
 In the previous chapters I dealt with the signs of 
 heart failure due to functional inefficiency. Here I pro- 
 pose to deal with the signs that are brought about by 
 the intervention of the central nervous system. Inas- 
 much as these are of a distressful nature — for example, 
 pain — and compel the sufferer to be careful and wary 
 in his efforts, or to cease from effort, they may be spoken 
 of as protective in purpose. What the nature of the 
 stimulus is we do not know, but, in the majority of 
 cases, it is associated with other evidences of cardiac 
 exhaustion, so that, for many years, I have given up 
 speculating upon its cause, and have diligently set myself 
 to collect as many facts as I could. A study of the 
 facts leads me to the following conclusions, and I put 
 them forward, not because they are supported entirely 
 by convincing evidence, but because they seem reason- 
 able, and present the matter in such a form as to be 
 of real use in estimating the symptomatic value of this 
 pain from the points of view of prognosis and treatment. 
 
 The peculiar regions in which the pain is felt indicate its 
 
 cardiac origin, while its distribution and accompanying 
 
 phenomena indicate that the stimulus passes into the central 
 
 nervous system. 
 
 I need not labour the facts that support the view that 
 
 the pain of angina pectoris is manifestly due to a stimu- 
 
 6 9
 
 70 ANGINA PECTORIS 
 
 lation of certain regions in the central nervous system. 
 The places where the pain is first felt, the areas into 
 which it radiates, and the appearance of areas of hyper- 
 algesia of the skin and deeper tissues, all point to a 
 central stimulation. The region affected in the majority 
 of cases is shown in the shaded area of Fig. 6. It will 
 be seen that the pain extends in a somewhat peculiar 
 manner over the left side of the chest into the inner side 
 of the left arm, forearm, and hand. The pain may start 
 in any part of this region, and may radiate to any other 
 part. Most frequently it appears within the shaded area 
 on the chest and radiates to the arm ; on the other hand, 
 it may, on rare occasions, start in the forearm and 
 remain there, displaying great severity ; again, it may 
 start in the forearm and radiate into the chest and be 
 severe there. It may also be found in similar regions 
 on the right side, and in the neck and along the jaw. 
 
 In addition to pain other signs may be discovered. 
 These include contraction of the intercostal muscles, 
 giving rise to a feeling of severe constriction of the chest 
 and increased flow of saliva and of urine ; they point, 
 all of them, to a stimulation of the central nervous 
 system. 
 
 The pain is frequently associated with effort. In 
 most cases the attacks of pain can be provoked by 
 effort or excitement. When provoked by effort, they 
 frequently cease immediately after the effort is stopped. 
 The pain may be slight at first and may pass off as soon 
 as the effort ceases, but if the effort be persisted in it 
 may increase rapidly and become so violent that the 
 patient is compelled to desist. In addition to the pain, 
 there may be a sense of constriction, as if the chest 
 were being held in a vice; this sensation corresponds 
 to that encountered in pleurodynia. There may also be 
 a sense of suffocation and a feeling of impending death. 
 
 While effort is the most common exciting cause 
 of the attack, and while the attack in the majority of 
 cases comes on while effort is being made, it happens
 
 ANGINA PECTORIS 
 
 7i 
 
 sometimes that the onset of pain is delayed. The attack 
 may not occur until some hours after the effort has been 
 
 Fig. 6. 
 
 The shaded area shows the characteristic distribution of pain of cardiac 
 origin. The skin of the area may be found in a state of hyper- 
 algesia after an attack of angina pectoris. The pain may not be 
 felt in the whole of this region, but only in portions — sometimes 
 limited to the chest, on rare occasions limited to some part in the 
 arm. The hyperalgesia also may have but a limited distribution. 
 
 made. Again, there are cases in which the pain appears 
 where the heart has been exposed to no particular effort, 

 
 72 ANGINA PECTORIS 
 
 but in which there is a history of a long period of over- 
 exertion preceding the onset of the angina. It is well to 
 bear in mind that pain may be produced by over- 
 exertion in healthy as well as in diseased hearts. 
 
 To appreciate this view of the symptoms produced by 
 exhaustion of the heart muscle, it is necessary to con- 
 sider the circumstances in which pain is most frequently 
 produced ; we can accomplish this by observing 
 what happens in the case of the healthy young when 
 over-exerted and by comparing their state with that of 
 men passing into old age who have also been over- 
 exerted. 
 
 If we take a number of healthy youths and get them 
 to run as far as they can, each of them will at last 
 slacken speed because of some sensation of distress. 
 The majority will suffer from dyspnoea, a few will suffer 
 from a disagreeable sense of constriction across some 
 part of the front of the chest, or over the sternum at its 
 upper part. 
 
 In the young recovering from an illness excessive 
 exertion will occasionally induce actual pain, which will 
 be referred to the left chest; while, in rare instances, 
 healthy young people suffer from this pain after violent 
 exertion. 
 
 I have come across a number of elderly individuals 
 who have had attacks of angina pectoris who have told 
 me that, before the pain appears, they experience a 
 sense of tightness across the chest. They describe this 
 sensation as being exactly like the feeling which stopped 
 them when running in boyhood. This sense of constric- 
 tion corresponds with the "vice-like grip" of which 
 patients complain during attacks of angina pectoris. 
 
 The most frequent physical conditions provoking angina pectoris 
 are the degenerative changes which accompany advancing 
 years. 
 
 Many men between fifty and sixty years of age, who 
 are actively engaged in business, are seized with all the
 
 ANGINA PECTORIS 73 
 
 typical signs of angina pectoris. Considering how 
 anxiously this condition is viewed, it is necessary for 
 the physician to form an opinion as to its gravity. 
 Let us, therefore, put aside all theoretical considera- 
 tions as to the manner of production of angina, and 
 approach the study of it from a practical and utilitarian 
 point of view. 
 
 In everyone, as the years pass, changes of a degene- 
 rative nature occur. Fibrotic changes in the heart 
 muscle render it less efficient, while changes in the car- 
 diac arteries interfere with the flow of blood to the 
 same structure. Exhaustion of the heart muscle gradu- 
 ally supervenes. Notwithstanding this, the individual 
 may lead a strenuous life till he is pulled up by pain. 
 Atheroma of the coronary artery is a condition fre- 
 quently met with in people who suffer from angina 
 pectoris ; and the part it plays seems to be two-fold ; 
 first, in many cases the smaller arteries are obliterated, 
 and, secondly, the changes in the artery wall interfere 
 with its power to dilate. Starling has calculated that 
 the supply of blood to the heart muscle increases three- 
 fold during the period of activity ; to meet the demand 
 for more blood the arteries dilate. The degenerated 
 arteries, on account of their rigid walls, are unable to 
 respond to the call for more blood, and, as a conse- 
 quence, exhaustion of the muscle is provoked. That 
 this is no fanciful idea you will speedily realise, if you 
 consider the effect of an atheromatous condition of the 
 arteries in the legs. Many elderly people who can walk 
 for miles at a slow rate are compelled to stop if they 
 attempt to hurry, or run, by the intense aching which 
 occurs in their feet and legs. 
 
 You can easily understand that hearts with rigid 
 arteries are bound to afford evidence of inefficiency. 
 If we pursue inquiries further we usually find this 
 evidence of inefficiency. If closely interrogated, patients 
 will invariably acknowledge that, some time previously, 
 it may be as much as five or ten years, they were con-
 
 74 ANGINA PECTORIS 
 
 scious on occasion of sensations of a disagreeable kind 
 on exertion, such as breathlessness and a sense of con- 
 striction across the chest. They ignored these sensations 
 and continued their work. These sensations indicated 
 that, at the time when they occurred, the periods of 
 rest were not sufficient to restore the exhausted muscle, 
 and so that, even then, some slight changes were going 
 on which impaired the efficiency of the muscle. In spite 
 of this impairment, the individual continued to work 
 as hard as when he was in the flush and vigour of 
 manhood. Exhaustion, being in the first instance 
 ignored, became finally so extreme that it culminated in 
 an attack of angina pectoris. 
 
 We are able to recognise, therefore, that pain and 
 distress result not merely from the degenerative changes 
 that accompany advancing years, but also from the 
 fact that too often an impaired heart is forced to work 
 as hard as it did before any changes occurred in it. 
 The presence of impairment and refusal to recognise 
 that it is present mean that the periods of rest ac- 
 corded to the heart are not sufficient to permit of 
 restoration of its reserve force. You will see now how 
 important it is to inquire into the life of your patient. 
 If the inquiry is conducted systematically, you may find 
 that the condition that provokes the exhaustion is over- 
 work — which is not necessarily excessive work, but 
 is always work of a more strenuous character than 
 the degenerated heart can undertake. We may 
 place in this category such troubles as worry and sleep- 
 lessness — in other words, circumstances which interfere 
 with the period of rest necessary to restore the ex- 
 hausted reserve force. In some cases the heart muscle 
 may be injuriously affected also by toxic agents, such 
 as tobacco, alcohol, and the toxins of infective 
 organisms.
 
 ANGINA PECTORIS 75 
 
 Angina pectoris affords an indication of the extent of 
 impairment of the heart muscle. 
 
 As the occurrence of angina pectoris indicates some 
 damage to the heart muscle, it is necessary, in each 
 case, to form an estimate of the extent of this damage. 
 This can be accomplished, to some extent, in two ways : 
 
 (1) By finding out the amount of effort the individual 
 can make under the most favourable circumstances. 
 
 (2) By noting the effect of treatment. 
 
 Many people afflicted with angina pectoris are unable, 
 starting from rest, to walk more than fifty or a hundred 
 yards without being distressed. This distress may 
 arise during several subsequent attempts, and then 
 the victims may be able to walk five or ten miles with- 
 out distress. This remarkable fact indicates that in 
 these hearts a good deal of healthy muscle is present 
 and that the attacks of distress are provoked by the 
 introduction into the picture of some factor which is 
 not myocardial weakness — for example, a full stomach. 
 (In many cases the pain is provoked only during exer- 
 tion indulged in after a meal.) The ability of indi- 
 viduals to undertake considerable effort at one time, 
 and their inability to undertake effort at another, afford 
 a very useful means of estimating the amount of efficient 
 heart muscle. It may, for example, be taken for granted 
 that when a man is able to undertake considerable effort 
 without discomfort he retains a good deal of healthy 
 muscle. The fact that occasionally slight effort pro- 
 vokes pain in his case does not alter this conclusion. 
 It will be found that, at the times when he is 
 restricted in his activity, some secondary influence 
 is at work the removal of which enables the heart to 
 regain a measure of strength. The limitations of effort 
 must therefore be ascribed to this secondary influence, 
 and not to the condition of the heart muscle. Again, 
 the extent of myocardial damage can be estimated by
 
 76 ANGINA PECTORIS 
 
 noting the effect of treatment. In all cases in which 
 effort is the provoking cause of angina pectoris, it may 
 be taken for granted that, during a long period of time, 
 the heart has been forced to work above the measure 
 of its efficient capacity, and that therefore the muscle 
 has been exhausted. A period of rest or of liberation 
 from the provoking causes will enable the heart to 
 regain some of its strength, and this added strength 
 will be recognised by an improved response to effort, 
 from which the extent of damage to the heart can be 
 estimated. 
 
 In people who suffer from angina pectoris the liability 
 to attacks varies markedly at different times. This is 
 a common experience. For example, during many 
 weeks or months the patient may be comparatively free 
 from his trouble, and may be able to undertake con- 
 siderable effort without distress, while at other times his 
 attacks are readily provoked. It is impossible to account 
 in every case for this variability. Periods of sleepless- 
 ness or of worry may be the provoking cause in some 
 instances, while in others digestive disturbances appear 
 to have an influence in inducing the liability to attack. 
 Systematic over-exertion may also provoke the tendency ; 
 and again it must be pointed out that this over-exer- 
 tion need not be great exertion ; over-exertion in this 
 sense is only exertion greater than the heart can 
 efficiently undertake. If you will consider the means, 
 referred to in books, by which relief or cure can be 
 brought about, you will find that a period of rest is 
 always included among them, and this in spite of the 
 fact that the physician may attribute his success to some 
 special treatment, such as a drug, a diet, or a bath. 
 
 The description just given applies to the vast majority 
 of cases of angina pectoris. It will be seen that, re- 
 garded from the point of view we have adopted, angina 
 pectoris is but the expression of exhaustion, and is not, 
 therefore, necessarily a serious condition in the usual 
 meaning of that term — i.e., that death is impending.
 
 ANGINA PECTORIS 77 
 
 The changes which it indicates, irremediable changes 
 which impair the heart's efficiency, and which are slowly 
 progressive, are, after all, only those changes which may 
 be expected to occur with advancing years. 
 
 Angina pectoris may indicate grave progressive disease. 
 
 There are cases in which angina pectoris develops with 
 great severity and ends speedily in death. On the 
 whole, these cases are rare. When they do occur, it will 
 be found that the changes inducing the exhaustion 
 (aortic disease, disease of the coronary artery or of the 
 myocardium) have advanced to an extreme extent before 
 the appearance of the pain. When the changes are of 
 the senile degenerative type, there is always a history of 
 cardiac inefficiency before the onset of pain— as revealed 
 by breathlessness on exertion. The attacks of pain are 
 easily provoked, and treatment avails little. When, 
 therefore, we find that slight exertion invariably pro- 
 vokes pain, and that little or no improvement takes 
 place on rest, we must look upon the condition as a 
 grave one. Another grave form of angina pectoris is 
 found in cases of syphilitic aortitis. This disease may 
 progress with great rapidity, and the earliest symptom 
 may be pain, sometimes of a severe kind, referred to 
 some part of the area shaded in Fig. 6, page 71. When 
 pain of this type occurs in the young or middle-aged, 
 inquiry should be directed to the determination of the 
 presence of syphilitic infection. If these syphilitic cases 
 be watched, an aortic diastolic murmur may be observed 
 to make its appearance. But even in cases in which no 
 murmur appears, the increasing ease by which the pain 
 is provoked should always raise the suspicion of syphilitic 
 aortitis. 
 
 In one of my cases in which we could detect no 
 physical abnormality the pain was provoked by the 
 slightest exertion, and the patient suddenly died a few 
 months after the first appearance of the pain. At the 
 post-mortem examination we found in the aorta, above
 
 78 ANGINA PECTORIS 
 
 the valves, a great thickening of the internal lining 
 membrane, which obstructed the mouth of the left 
 coronary artery ; in the wall of the left ventricle the 
 muscle fibres were breaking down because of the lack of 
 the blood supply. 
 
 In a few cases I have seen apparently good results 
 from energetic anti-syphilitic treatment, but in the 
 majority little benefit has resulted. 
 
 Attacks of angina pectoris when the patient is at rest imply 
 extreme exhaustion of, or active changes in or poisoning of, 
 the heart muscle. 
 
 In the vast majority of cases the pain comes on in 
 response to effort, at the time effort is made or shortly 
 after. When the degeneration which causes the exhaus- 
 tion of the heart is extreme, attacks of pain occur during 
 sleep or when the patient is at rest. In these cases the 
 pain is also provoked easily by exertion. There are, how- 
 ever, cases in which the pain does not appear in response 
 to effort, but only when the patient is at rest; these 
 people can sometimes undertake a fair amount of effort 
 without suffering pain. The majority of the cases of 
 this type depend upon some toxic condition which seems 
 to irritate the heart. This toxic condition may be of 
 intestinal origin or may be the result of infection or 
 excessive indulgence in tobacco. Further reference will 
 be made to these cases in the chapters on the hyper- 
 sensitive nervous system and on the poisoned heart. 
 In a few cases I have seen pain associated with subacute 
 rheumatism start in this way. The subacute rheuma- 
 tism is probably due to a condition resembling the fibro- 
 sitis of the skeletal muscles. These cases have all re- 
 covered. In one case in which pain came on only when 
 the patient was at rest, some obscure infection finally 
 supervened and caused pericarditis, which was followed 
 by death; I have been unable to account for the 
 condition.
 
 ANGINA PECTORIS 79 
 
 The view of angina pectoris as an expression of exhaustion of 
 the heart muscle affords a conception which gives a basis for 
 a sound prognosis. 
 
 In the descriptions I have given I have dealt with 
 those people who form the great majority of cases of 
 angina pectoris. From these descriptions it will be 
 gathered that angina pectoris is but a sign of the change 
 that accompanies advancing years. It follows, there- 
 fore, that the outlook is, in the majority of people, 
 favourable, particularly when there is present no com- 
 plicating affection, such as chronic Bright's disease, or 
 marked arterial degeneration. 
 
 If the significance of the anginous pain as an expres- 
 sion of exhaustion be recognised and the individual 
 affected by it be able to lead a life at a lower level, so 
 that attacks can, to a great extent, be avoided, the 
 individual may look forward to reaching an advanced 
 age, so far as his heart is concerned. I have watched 
 many people, who have had to lessen their efforts because 
 of angina pectoris, lead useful lives at a lower level 
 during ten, fifteen, and even twenty years. 
 
 When, in spite of an easing of the routine of the daily 
 life, the anginous pain is provoked by slight effort, or 
 occurs at times when the body is at rest, the outlook is 
 grave. This is the case especially in men. In women, 
 in whom generally the hypersensitive nervous system 
 plays an important part, the outlook is much less 
 grave (Chapter IX). In them less grave lesions of the 
 heart may cause long-continued suffering. In some 
 aortic cases, too, pain is easily induced, long before 
 there is any actual danger. 
 
 The view of angina pectoris as an expression of exhausted 
 heart muscle affords principles on which to construct a 
 rational treatment. 
 
 The heart must be relieved of its work by judicious 
 restriction of effort, or by complete rest, according to
 
 8o ANGINA PECTORIS 
 
 circumstances. The principle of rest is discussed on 
 page 226, and the suggestions there put forward are ap- 
 plicable specially to cases of angina pectoris. As there 
 are many circumstances incidental to the provocation 
 of attacks of pain in predisposed individuals — as, for 
 example, exercise after a full meal, sleeplessness, ex- 
 posure to cold air, gastric disturbances, and tobacco — 
 these must be sought for and, as far as possible, elimi- 
 nated. If the attacks tend to recur in spite of rest and 
 the removal of provocative causes, the more powerful 
 sedatives, such as chloral and opium, must be used. 
 
 In all cases, during the attacks of pain, speedily-acting 
 vaso-dilators, such as whisky and brandy, alone or in 
 hot water, and the nitrites (nitrite of amyl, nitro- 
 glycerin, trinitrin) should be given. In regard to the 
 use of the nitrites, a fear is sometimes expressed lest 
 they be used too often ; their effect, however, is so 
 very transient that there is no danger attending their 
 use, and the doses should be steadily increased till a 
 full effect has been obtained.
 
 CHAPTER IX 
 
 THE HYPERSENSITIVE NERVOUS SYSTEM IN HEART-DISEASE 
 
 Some people have a nervous system which is abnormally sensitive 
 
 to stimulation. 
 
 In the production of pain and other sensations de- 
 pendent upon heart trouble, there are two main factors 
 concerned — the heart and the central nervous system. 
 In describing angina pectoris I have referred chiefly to 
 the damaged heart. We know that many people with 
 damaged hearts suffer no pain, so that, to account for 
 the pain, we are bound to conclude that a partial 
 explanation is furnished by the variability in the sensi- 
 tiveness to stimulation of the central nervous system. 
 This system is not equally susceptible in all people. 
 There are people, however, with a nervous system so 
 sensitive that pain is produced with great facility. The 
 hypersensitive condition may be natural or it may be 
 acquired. Thus, abnormal sensory phenomena, such as 
 pain and hyperalgesia of the skin, are more frequently 
 met with in women than in men. This tendency to 
 abnormal sensory phenomena is greatly increased by any 
 form of illness of an exhausting nature, and by a life 
 of worry and overwork. Hence we find pain and tender- 
 ness in the left chest in patients affected by a great 
 diversity of conditions, ranging from grave disease of 
 the heart to slight functional weakness. 
 
 The hyperalgesia, as shown by tenderness on pressure 
 of the skin or muscles of the left chest and of the left 
 
 81 G
 
 82 HYPERSENSITIVE NERVOUS SYSTEM 
 
 breast, indicates a persistent irritability of certain 
 regions of the spinal cord. In certain circumstances, 
 a stimulus reaching this region, from sources other than 
 the heart, may produce a typical attack of angina 
 pectoris. In one patient, scratching of the skin under 
 the left breast, and even the pressure of the stethoscope, 
 produced an attack. Another patient, near unto death 
 and who died in an attack of angina pectoris, dared not 
 move his left arm because such movement often induced 
 an attack. In cases of slight functional weakness of 
 the heart, with an excessively sensitive nervous system, 
 we may get attacks of pain of the greatest severity, 
 [n order to determine whether or not the cardiac pain 
 is of a serious nature, it is necessary to review the whole 
 history of the case, to consider not only the state of 
 the heart, but also the state of the nervous system, and 
 particularly to find out whether or not the patient is 
 normally of a neurotic temperament. If it be deter- 
 mined that there is that indefinite condition, which I 
 can only describe as a hypersensitive nervous system, 
 but which is easy to recognise, then search must be 
 made for the cause which has induced this condition. 
 You will find the condition most typically shown in 
 people, especially women, who have had long periods 
 of anxiety and worry, with little and interrupted sleep 
 — for example, the mother of a family in which there 
 has been much sickness, or a daughter who has had to 
 work hard in the day and has to attend her ailing parent 
 at night. Again, diseases of various kinds, especially 
 those causing great exhaustion — e.g., loss of blood — may 
 be the provoking cause. Infection may also be an 
 important causative factor; the most severe case of 
 suffering of this kind I ever saw was a woman with a 
 pelvic abscess. An attack of pain of the most agonising 
 description was provoked by the slightest effort, and 
 recovery only took place when the abscess was 
 evacuated. 
 
 In these people there are often evident other pheno-
 
 HYPERSENSITIVE NERVOUS SYSTEM 83 
 
 mena, usually of a vaso-motor origin, such as a tendency 
 to flushing, and, at other periods, to coldness of the 
 hands. At times the attacks of pain are accompanied 
 by feelings of extreme cold and rigor-like shivering. The 
 shivering attacks may be independent of pain. The 
 patient to whom I have just referred, who suffered from 
 severe attacks of pain, again became ill a year after her 
 recovery, and had numerous attacks of a rigor-like kind 
 without pain. These attacks disappeared after a dis- 
 charge of pus into the bladder. 
 
 In milder cases there may be no attacks of pain, but 
 simply aching in the left chest and arm, or tenderness 
 on pressure of the left breast and surrounding tissue. 
 Such phenomena, often accompanied by no physical sign 
 pointing to disease or weakness of the heart, are never- 
 theless an expression of some exhaustion of the heart 
 muscle, and often you will find that they disappear with 
 the improvement in the patient's strength and return 
 with exhaustion. 
 
 Such terms as " pseudo-angina " or " mock angina " are misleading 
 
 and improper. 
 
 Lack of appreciation of the significance of pain and 
 other manifestations of a hypersensitive nervous system 
 has led to the employment of such terms as " pseudo- 
 angina pectoris" and "mock angina." It has followed 
 that, when cases have been diagnosed as belonging to 
 these groups, little consideration has been given to them. 
 Such terms should not be used, for there is no such 
 thing in nature as a false or an imitation disease. The 
 fact that there is a superficial resemblance between two 
 conditions gives us no right to call one a real disease 
 and the other a false disease. That attitude is illogical. 
 The symptoms provoked in either case have a real 
 foundation, and it is our duty to search for the real 
 causes and not to cloak our ignorance by a vain and 
 empiric nomenclature. 
 
 g 2
 
 84 HYPERSENSITIVE NERVOUS SYSTEM 
 
 Prognosis and treatment. 
 
 The prognosis of cases with a hypersensitive nervous 
 system is generally very good. The great majority of 
 these cases are women between thirty-five and fifty years 
 of age, and, after fifty, the tendency is for the painful 
 attacks to abate. In many instances a surprising 
 degree of strength is regained, and these patients may 
 reach a very old age. It is scarcely necessary to point 
 out that the removal of provoking causes renders the 
 outlook brighter. 
 
 In the treatment of these hypersensitive cases, pro- 
 voking causes should therefore always be searched for, 
 and, as far as possible, removed. A change of environ- 
 ment, a peaceful, restful holiday — not a rest cure — is 
 often of the greatest benefit. In the cases where it is 
 impossible to remove the cause mild sedatives are of 
 more avail than " cardiac tonics." Bromides, especially 
 the bromide of ammonium, pushed until a slight degree 
 of apathy with sleepiness is produced, is often of the 
 greatest benefit.
 
 CHAPTER X 
 
 BREATHLESSNESS AND ANGINA PECTORIS 
 
 It may be asked why most cases show heart exhaus- 
 tion by breathlessness and not by pain. The production 
 of pain in visceral disease requires a stimulus of a certain 
 elusive kind, which we are yet far from interpreting. 
 We know how extensive visceral disease may be, while 
 pain or other sensory phenomena may be absent, as in 
 ulceration of the lungs, stomach, and bowels. In other 
 cases a small gastric ulcer may give rise to great suffer- 
 ing. So in the heart, seemingly, like diseases may give 
 rise in one case to pain and in another to no pain. 
 
 But with diseases of the heart there is always 
 evidence of functional inefficiency, and this is prominently 
 brought out by breathlessness on exertion, or, in 
 advanced failure, at rest. 
 
 It has, however, been a matter of observation that 
 patients pulled up by pain on making exertion do not 
 always suffer from breathlessness. In studying a 
 great number of cases of angina pectoris, I find 
 that a certain proportion give a history of a 
 gradual limitation of the field of response to 
 effort by the early onset of breathlessness. Sub- 
 sequently those are seized with pain, and they are 
 then pulled up by the pain and not by the breathless- 
 ness. On inquiry, I have always found that the pain 
 came on after a less amount of effort than had pulled 
 them up before by the breathlessness. I would suggest 
 that in a measure the check to effort occurs according 
 
 8s
 
 86 BREATHLESSNESS, ETC. 
 
 to which mechanism is first brought into action. This 
 view is supported by watching certain cases of angina 
 pectoris. In some, as the disease progresses, the ten- 
 dency to breathlessness increases, so that the patient can 
 make but little effort without dyspnoea. In such cases, 
 Cheyne-Stokes respiration is apt to occur, while the 
 heart dilates and dropsy supervenes, and the attacks 
 of angina completely disappear. 
 
 This also seems to account for the infrequency of 
 angina pectoris with auricular fibrillation. When the 
 latter condition is present, breathlessness is very easily 
 provoked when the heart begins to fail. I have noted 
 in cases of angina pectoris the onset of auricular fibrilla- 
 tion, and when this occurred on making an effort they 
 were much sooner pulled up by breathlessness than they 
 used to be by pain, and the patient has great satis- 
 faction from his freedom from pain, though distressed by 
 breathlessness. Needless to say, their power of response 
 always remained extremely limited. 
 
 Thus a man, aged sixty-six, consulted me for angina 
 pectoris, which pulled him up on walking a short 
 distance. After treatment he improved and was able 
 to lead a fairly active life, though at times sharply 
 pulled up by the, pain when he was walking fast. When 
 seventy-three years of age the attacks of pain had 
 become more easily provoked, till suddenly he ceased 
 to have any more, but found instead that he was very 
 short of breath. Some months later he consulted me 
 and I found he had got auricular fibrillation. His state- 
 ment was very characteristic. A few months earlier he 
 was able to walk two or three hundred yards without 
 being pulled up by pain, but latterly he could not walk 
 a hundred yards without having to stop because of the 
 breathlessness. The heart was rapid and irregular, and 
 he improved under digitalis, till he was seized with a 
 cerebral embolism from which he died.
 
 CHAPTER XI 
 
 SENSE OF EXHAUSTION 
 
 The sense of exhaustion is produced by a vaso-motor mechanism, 
 and is not of cardiac origin, though it may be associated 
 with cardiac inefficiency. 
 
 There are three kinds of sensations that most fre- 
 quently indicate to the individual that his strength is 
 exhausted— breathlessness, pain, and exhaustion. I 
 have already described the first two and have indicated 
 their cardiac origin. 
 
 I deal now with the third sensation — the sense of 
 exhaustion. This is the most common of all sensa- 
 tions resulting from effort. Though often associated 
 with grave conditions, it is frequently produced when 
 there is no serious trouble. The sensation is one of 
 limpness, the legs feel as if they would not carry 
 the body, the brain feels fatigued, and the individual 
 may become dizzy and stagger, and, in extreme 
 cases, feel compelled to lie down to prevent an attack 
 of faintness, and syncope may occur. This sensation 
 varies greatly in degree, but it is so common that prob- 
 ably each of you has experienced it — as, for instance, 
 after first getting up after a more or less severe illness. 
 Where, however, it will come to your notice will be in 
 people engaged with their affairs. It will then present 
 itself to you in various guises, but most frequently as 
 something amiss with the circulatory system. As this 
 sensation may be associated with certain cardiac phe- 
 nomena, such as breathlessness on exertion, palpitation,
 
 88 SENSE OF EXHAUSTION 
 
 irregular action of the heart, murmurs, or increase in the 
 size of the heart, the tendency is to refer the sensation 
 to insufficient cardiac power. It will, therefore, be 
 worth your while to consider the nature of this com- 
 plaint. 
 
 To do this, you must find out the conditions under 
 which it is provoked, and recovered from. To begin 
 with, the sensation is usually not constant. If provoked 
 by exertion, it will be found to vary from day to day, 
 or there may be periods of weeks when the patient is 
 free from it, and then weeks when it is easily provoked. 
 Some days, if the patient walks a short distance, as on 
 a hot and close day, too heavily clad, the sensation is 
 readily provoked ; on other days, when the sun is bright, 
 the air cool, and the individual lightly clad, a wonderful 
 amount of exercise may be taken without discomfort. 
 Certain other states besides exertion may bring it on, as 
 standing in a warm room. Many women feel faint and 
 exhausted when having a dress fitted. 
 
 As the sensation is frequently present with cardiac 
 abnormalities, it leads to the supposition that the con- 
 dition is cardiac, but there are a few features which I 
 employ to show that it is not entirely cardiac in origin. 
 The first is the inconstancy of the sensation. The effort 
 that produces distress from a cardiac affection does so 
 in almost every case, and this you will understand 
 from what I have said when the response to effort is 
 taken as the standard of cardiac efficiency. This varia- 
 bility in the production of exhaustion renders the possi- 
 bility of a cardiac origin extremely unlikely. Another 
 point to bear in mind is, that the cause that produces 
 this exhaustion, may also affect the heart and produce, 
 secondarily, an abnormal sign. To appreciate the origin 
 of this complaint it is necessary to search for other signs. 
 In many of those people who suffer from periods of 
 exhaustion we find other abnormal signs referable to the 
 vaso-motor system. Thus, many will show changes in 
 the peripheral circulation, the hands and feet often
 
 SENSE OF EXHAUSTION 89 
 
 becoming cold, not only in cold weather, but in response 
 to some mental stimulus, such as the excitement of being 
 examined. Many shudder at the idea of a cold bath, 
 as the after-reaction is one, not of a warm congenial 
 glow, but of a shrivelled-up, cold feeling. In some the 
 fingers become pale and cold, and the sensibility of the 
 fingers will be so diminished that the fingers are numb. 
 At other times the hands and nose become red. Some, 
 in a warm atmosphere, become flushed and disagreeably 
 hot. Not infrequently, pressure, applied to the abdo- 
 men, will cause the jugular veins to become full. This 
 is an undoubted sign of the over-filling of the large 
 abdominal veins, as the pressure on them fills the right 
 heart, and the blood-flow in the jugular veins is impeded. 
 In healthy people one gets no such reaction, or only a 
 very slight one, while in those in whom the exhaustion 
 is easily provoked, the swelling of the jugular vein, on 
 pressure of the abdomen, is sometimes very great. The 
 blood-pressure in these cases is usually rather low, par- 
 ticularly during the attacks of exhaustion. It may rise 
 as soon as the patient lies down or after the exhaustion 
 passes off, and this accounts, probably, for the fact that 
 sitting or lying speedily dissipates the sense of ex- 
 haustion. 
 
 Exhaustion is brought about by a depletion of the higher 
 
 nervous centres. 
 
 Taking all these facts into consideration, I think we 
 are justified in referring the state of exhaustion to a 
 depletion of the higher nervous centres. The vaso- 
 motor system is over-susceptible to stimulation, in the 
 one case producing an over-action in response to cold, 
 in the other case, to a widening of the peripheral field 
 from warmth or exertion. In many cases the wearing 
 of an abdominal belt, that firmly grasps the abdomen, 
 will prevent the attacks of exhaustion and faintness. I 
 have seen one man in whom this tendency to exhaustion 
 and giddiness was so great that he could not follow his
 
 90 SENSE OF EXHAUSTION 
 
 work and was only comfortable when lying down. A 
 few minutes after standing up the heart raced off at a 
 great rate and he became giddy and faint. A firm, 
 abdominal belt at once produced such relief that, so 
 long as he wore it, he was able to work. Another man, 
 who consulted me, staggered and reeled and sometimes 
 fell on standing up. He had made a habit of bending 
 down and squeezing his belly before standing up. I 
 found that the pressure in the abdomen caused great 
 fullness of the jugular veins. 
 
 The provoking agent in the production of exhaustion is 
 frequently a toxin. 
 
 It is not always easy to find the real cause of this 
 condition, although I think there is now enough evidence 
 to show that, in many cases, it is due to some toxic 
 influence. A very considerable proportion of those who 
 suffer so readily from exhaustion have distinct evidence 
 of gastro-intestinal troubles. Many complain of different 
 signs of dyspepsia, and we can often detect evidence of 
 stasis in some portion of the intestinal tract, even when 
 there is no complaint made by the patient of indigestion. 
 Constipation is often present. Many years ago I was 
 struck by the disappearance of those characteristic vaso- 
 motor phenomena (cold hands and feet) in a man with 
 a chronic duodenal ulcer, on whom a gastro-enterostomy 
 had been performed. 
 
 The heart is often irritable and causes a good deal of 
 distress from attacks of palpitation, or from extra- 
 systoles. In some it may dilate, and even show signs 
 of insufficiency, in the sense that effort may readily 
 produce distress or discomfort from breathlessness or 
 palpitation. The mental condition may be affected; 
 irritability of temper and depression are not uncommon. 
 In many nutrition is impaired, and they become spare 
 and thin. The skin becomes dirty and yellow, especially 
 in the armpits and in the abdomen. 
 
 Although the absorption of the products of decom-
 
 SENSE OF EXHAUSTION 91 
 
 position from the intestines is probably the most common 
 cause, absorption from other centres of infection is 
 possible, as from the teeth and obscure inflammatory 
 conditions, like chronic appendicitis. A typical form is 
 seen after exhausting illnesses, such as typhoid fever or 
 influenza. In fact, any prolonged bacterial infection 
 may give rise to it. 
 
 In all cases, therefore, when exhaustion is the chief 
 complaint, causes other than the heart must be dili- 
 gently sought for. (See Chapter XXI.)
 
 CHAPTER XII 
 
 THE EXAMINATION OF THE PATIENT 
 
 The methods essential to the proper examination of a patient 
 have hitherto not been utilised. 
 
 Every physician of experience works out for himself 
 a method of examination, and though the methods of 
 different physicians may vary, yet the object is the same 
 in every case, namely, to get as much knowledge as 
 possible of the patient's complaint. Apart from slight 
 variations, there is a tendency for methods to become 
 stereotyped, especially in the examination for the 
 physical signs of disease. The methods of examination, 
 as commonly taught and pursued, are often assumed 
 to be so complete that no further progress can be made 
 unless by the employment of some new mechanical 
 means — so that it is asserted there can be no further 
 advance in the examination of the patient by the unaided 
 senses. The latter statement I have heard repeatedly 
 made by physicians of the greatest eminence. As 
 opposed to this view, I hope to demonstrate to you that 
 knowledge essential to the understanding of the patient's 
 complaint can be made out by our unaided senses, and 
 that artificial and mechanical aids can, in the nature of 
 things, only be accessory aids, and there is a great field 
 for observation scarcely yet touched. Many of you have 
 been under the impression that your education in the 
 methods of examination has been so exact and thorough 
 that it cannot be improved upon. A friend of mine, a 
 professor in one of our largest schools of medicine, told 
 
 92
 
 THE EXAMINATION OF THE PATIENT 93 
 
 me with great pride how marvellously thorough was the 
 teaching of the physical signs in his school. The students 
 were taught to inspect, to palpate, to percuss, and to 
 auscultate with the greatest precision, and steps were 
 taken by various means to prove their wonderful 
 accuracy. This view is one commonly held, but, as you 
 will have gathered, it leaves unexplored that which is 
 necessary to a due comprehension of the patient's con- 
 dition. 
 
 Having put before you the part that heart-failure 
 plays in the consideration of any given case, and having 
 indicated the nature of the symptoms by which 
 its presence can be revealed, you will realise how im- 
 portant the patient's sensations are in obtaining a know- 
 ledge of the heart's efficiency. Hitherto, in books on 
 diagnosis, nearly all the stress has been laid on the 
 physical examination, and little time given to the 
 elucidation of the patient's sensations. 
 
 To obtain the information you want, you must pro- 
 ceed by question and answer. Your questions must be 
 framed so that the patient recognises what it is you 
 ask, and it is, therefore, incumbent upon you to have 
 a clear conception, in your own mind, of the kind of 
 information you are seeking. Each question, therefore, 
 must have a definite object, and must be put so clearly 
 that the patient comprehends your meaning ; you must 
 also insist upon the answer being limited to the question, 
 and you must not pass away from the question until 
 you have got as full an answer as the patient is capable 
 of giving. Now, this implies, on your part, a knowledge 
 of the kind of information the patient is capable of 
 yielding, and, as I proceed with these lectures, you will 
 realise how much training on your part is necessary for 
 you to attain the skill of a competent examiner. 
 
 When the patient and physician come first together, 
 it oftens happens that there is an unconscious struggle 
 who is to be dominant. Many patients come to you 
 full of their own ideas about their complaints, with
 
 94 THE EXAMINATION OF THE PATIENT 
 
 theories as to the nature and cause of their sensations, 
 and eager to impart to you their own opinions. Or they 
 come with a bundle of notes which they insist upon 
 inflicting upon you. The first question you put to 
 them : " Of what do you complain ? " will immediately 
 give them an opening, and they will, if not checked, 
 proceed to give you an elaborate history of their troubles. 
 This you must quietly and firmly repress. Tell them 
 to reserve the story of their life until you have finished 
 questioning them, and insist upon them limiting their 
 replies to the sense of your question. If you do this, 
 in a few minutes you will have got from them all the 
 essential facts, and if then you say to them : "Is there 
 any other point you have not mentioned ? " you will 
 find that they will gaze helplessly at you and, in a 
 surprised tone, acknowledge that you have all the facts 
 in five minutes, which they thought would take half an 
 hour to tell. 
 
 When the patient presents himself for examination, 
 the physician naturally scrutinises him and makes a 
 mental note of his gait, his facial aspect, and how he 
 deports himself generally. The first question bearing 
 upon his condition should naturally be to ask of what 
 he complains. The reply to this question should be 
 limited to the sensations which immediately caused him 
 to consult you. Thus, if it is a heart trouble, he must 
 clearly specify the sensation he himself experiences, as 
 pain, breathlessness, or exhaustion. At first a note 
 should be made of all the sensations of distress or dis- 
 comfort of which he complains ; then take each sensa- 
 tion up by itself. Thus, if pain is complained of, find 
 out the situation in which the pain first appeared, 
 getting the patient to indicate this by placing his hand 
 over the region. Ask next to what part it radiates. 
 Inquire into the character of the pain, as to its intensity 
 and duration — whether continuous or intermittent ; the 
 circumstances provoking the pain, as whether it is 
 brought on by effort, mental excitement, or when the
 
 THE EXAMINATION OF THE PATIENT 95 
 
 body is at rest, and its relation to food. With these 
 facts clearly appreciated, next inquire into the first time 
 the pain, even in its mildest form, was felt, and the 
 occasion of its appearance. Exhaustive inquiries of this 
 sort should be directed to every other sensation, natur- 
 ally modifying the question according to the character 
 of the sensations. With the facts thus elicited, you will 
 have got a fair perception of the main facts relating to 
 his complaint, and the inquiry then follows as to ill- 
 nesses and habits of life that may have induced the 
 complaint. A brief inquiry into the functional efficiency 
 of other organs — as sleep, the state of the digestion, 
 menstrual functions, and frequency of micturition should 
 be made. 
 
 As distinct from these inquiries, an inquiry must be 
 made in all cases of heart trouble as to the efficiency 
 of the circulatory system, by getting from the patient 
 the amount of effort he is capable of undertaking with- 
 out distress, as how far he can walk, whether his work 
 entails bodily effort and, if so, how it affects him ; what 
 games he plays and how he bears the effort. Where 
 there are evidences of limitation, the nature of the 
 sensations provoked which induced the limitation — as 
 breathlessness, palpitation, pain, sense of exhaustion. 
 From the character of these sensations you will gather 
 whether the story of the patient is one of heart-failure 
 or due to vaso-motor disturbance. 
 
 In children some difficulty may be experienced in 
 getting out the facts, but, as a rule, I find it easy to 
 appreciate the heart's efficiency when they are old 
 enough to talk and run about. Unfortunately, there is 
 a mistaken idea in the minds of parents and physicians 
 that a suspicion of heart trouble demands that a child 
 should be kept at rest. No doubt, in rare instances of 
 acute or progressive lesion, rest is necessary, and the need 
 for it may be recognised by a physical examination. But 
 a great number of children, who are supposed to have 
 weak or impaired hearts and are able to run about, are
 
 96 THE EXAMINATION OF THE PATIENT 
 
 often needlessly restricted, because of some physical sign 
 — murmur or irregularity. While I shall deal with the 
 phenomena in detail, I wish to say that you will find that 
 children with a heart the efficiency of which is im- 
 paired will not injure it by over-exertion. Children are 
 very sensitive to distress provoked by cardiac inefficiency 
 and will themselves abstain without being told, and one 
 can usually recognise the degree of efficiency by getting 
 the child to state if he likes running about with a hoop 
 or running upstairs. When they tell you they like doing 
 it and it gives rise to no distress, you may take it that, 
 whatever the cause of the trouble, it has not impaired 
 the heart's strength. I cannot recall a single instance 
 where I could reasonably attribute heart-failure to a 
 child's voluntary exertions. 
 
 The same reasoning applies to the games of boys and 
 girls ; when they exert themselves and find pleasure in 
 doing so, it may be taken for granted that no harm 
 results.
 
 CHAPTER XIII 
 
 THE HEART FROM YOUTH TO OLD AGE 
 
 Sufficient attention has not been directed to finding 
 out what the manifestations of the heart may be in 
 health. Before dealing with the physical signs, I think it 
 is necessary to say a few words about the variations that 
 are to be found in healthy hearts at different periods 
 of life. Perhaps there is no fallacy so fondly cherished 
 by the profession as that a heart, to be normal and 
 healthy, must be of a certain size, have the rhythm of 
 its beat regular, and its sounds clearly struck and free 
 from any suspicion of modification. The presence of 
 a murmur is often considered to be inconsistent with 
 the idea of a healthy heart. True, there are some who 
 are willing to admit that this view is not justified in 
 every case ; but the great bulk of the profession, and 
 the teachers of the profession, do adhere to this view, 
 if not in theory, at least in practice. In healthy young 
 folks, from the time of birth, the rhythm of the heart 
 may show physiological variations. The young, healthy 
 heart is extremely sensitive to stimulation ; on account 
 of its peculiar, sensitive mechanism, we may have 
 marked variations in size, in rate, in rhythm, and in the 
 sounds of the heart. It behoves us, in any given case, 
 when we find a departure from that standard which has 
 hitherto, and foolishly, been taken as the. standard of a 
 healthy heart, to inquire if the unusual sign is not, 
 after all, a purely physiological expression of a healthy 
 heart. If ever you get so far as to ask that question 
 
 97 H
 
 98 THE HEART FROM YOUTH, ETC. 
 
 there is much hope for you, for then you will be spurred 
 on to seek for those signs which will decide the question. 
 
 This does not apply only to young subjects. In later 
 life, too, you will find many departures from the 
 standard which are in perfect accord with the idea of a 
 healthy organ. These departures are different from 
 those met with in early life, and therefore, here again, 
 the first question you should ask yourself is, " Is this 
 sign a manifestation of changes which do not indicate a 
 disease, nor embarrass the heart in its work, but which 
 are, in fact, the changes that accompany advancing 
 years ? " You are all aware that, as years go on, changes 
 occur in the outer man which are visible to the naked 
 eye, and you know that changes of a similar nature may 
 take place in the organs hidden from view. A slight 
 thickening of the edges of the fine texture of the valves 
 may modify the sounds of the heart without interfering 
 with its efficiency, so that you find that murmurs are 
 quite a common occurrence in people of middle age who 
 lead strenuous lives, yet never suffer from any form of 
 heart failure. 
 
 Changes of a slight nature may lead to disturbance in 
 the rhythm of the heart, and even to alterations in its 
 size ; yet the heart may not be impaired. There are thus 
 numerous changes, of a kind readily perceptible, which 
 are of no more significance than grey hairs. It behoves 
 you then, in valuing an unknown phenomenon, to pause 
 and ask whether or not it is but a physiological accom- 
 paniment of advancing years. If it is a physiological 
 accompaniment it cannot be taken as an indication of 
 disease. This truth will be kept in mind when I describe 
 the individual phenomena ; I mention it here to impress 
 upon you the necessity of asking such questions when 
 you are confronted with an abnormal sign.
 
 CHAPTER XIV 
 
 MURMURS : PHYSIOLOGICAL, FUNCTIONAL, AND ORGANIC 
 
 Murmurs were assumed to be of serious significance before their 
 real nature was understood. 
 
 About a hundred years ago auscultation began to be 
 systematically employed in the examination of the heart. 
 With that injudicious enthusiasm, which at all times has 
 heralded a new method of observation, fabulous qualities 
 were at first attributed to the stethoscope. People were 
 found to have murmurs before their death ; hence, at 
 a time before the cause of the murmurs was known, and 
 long before any single observer had watched individual 
 cases long enough to understand the significance of the 
 murmurs, the statement went forth with all the weight 
 of the highest authorities that these signs betokened 
 grievous heart trouble. To-day, notwithstanding the 
 enormous amount of attention which has been given to 
 the subject, the whole profession suffers from this un- 
 trustworthy observation. Perfectly healthy men are, 
 to-day, being rejected for the Army, or invalided out of 
 it, because a murmur has been detected in their hearts. 
 Others, who present themselves for life insurance, are 
 rejected or made to pay a higher premium for the same 
 reason, while innumerable individuals are subjected to 
 prolonged treatment and great restrictions in their mode 
 of life because these early superficial observations have 
 misled the profession. At times, physicians of experience 
 will admit that certain murmurs may not have a serious 
 
 99 H 2
 
 ioo MURMURS: PHYSIOLOGICAL, 
 
 significance; in saying this many of them appear to 
 imagine that they have made an important contribution 
 to the subject. But having failed to point out at the 
 same time how a murmur can be valued so as to discover 
 when it is of significance and when it is not, they have 
 really failed to carry forward our knowledge in any 
 respect. The result of this imperfect comprehension of 
 its meaning is that, at present, every graduate leaves 
 hospital with but the vaguest notion how to assess the 
 value of a murmur. In other words, teachers and 
 writers have hitherto shrunk from laying down clear 
 and definite lines for guidance, and I know that, in the 
 attempt I am about to make to do this, I undertake 
 a very hazardous enterprise. I do so, however, not with 
 the idea that I have finally settled the matter, but in 
 the hope that others, who follow me, may test my 
 observations, and so extend the knowledge of this very 
 important subject. 
 
 It must be more than twenty-five years since 
 Graham Steel startled me out of a deeply-cherished belief 
 by stating that " no one ever dies from mitral regurgita- 
 tion." By this he meant that, when the heart failed 
 and there was a mitral systolic murmur present, heart- 
 failure had occurred, not because of the regurgitation, 
 but because there were present other factors which pro- 
 voked it, such as some myocardial disease or impair- 
 ment. This was so opposed to the conception of heart- 
 failure by back pressure which I had been taught to 
 accept that I carefully observed my patients to see 
 whether or not it was true ; and now I can fully endorse 
 Graham Steel's dictum. I have kept records of great 
 numbers of people with murmurs and watched them for 
 years ; I have observed carefully and have noted that 
 some men have pursued laborious lives and have shown 
 no sign of heart-failure, while others have fallen ill and 
 died. From this long research I have drawn the con- 
 clusions which I now place before you.
 
 FUNCTIONAL, AND ORGANIC 101 
 
 Murmurs may be physiological as well as functional and organic 
 
 in origin. 
 
 I use the term physiological in the following sense : 
 Murmurs may be present in hearts which are perfectly 
 healthy in every respect. The conclusion that these 
 hearts are healthy is arrived at because the efficiency 
 of the heart is unimpaired, the individuals lead strenuous 
 lives and never show any sign of heart-failure, while, 
 if by accident or other cause they die, no disease or 
 damage can be detected in the heart on post-mortem 
 examination. If a large number of the healthy young 
 of both sexes, during the second and third decade of 
 life, be examined, a large percentage will be found to 
 possess murmurs. The assumption, then, that the sounds 
 of a healthy heart must be clearly struck and free from 
 murmurs is not based on accurate observation. 
 
 The term " functional murmurs " has passed into 
 common use, and is used to include all murmurs which 
 are not due to organic defects of the valves. The term 
 is often made to include physiological murmurs, and as 
 there is implied in it the idea of some derangement, it 
 is very apt to be assumed that the " functional " murmur 
 indicates impairment. In this way the physiological 
 murmur comes to be regarded as a pathological condi- 
 tion. Thus, in dilatation of the heart, a murmur may be 
 present ; it is assumed that the murmur is caused by 
 a modification of the muscle apparatus that regulates 
 the size of the orifice, and that, as a result of this modi- 
 fication, a leakage occurs. There is every reason to 
 suppose that this view of the cause of certain murmurs 
 is justified, and it may not always be possible to dis- 
 tinguish between the physiological and functional mur- 
 murs. Consideration of the functional efficiency of the 
 heart offers, undoubtedly, the best guide in these cases, 
 and we may fairly assume that when the heart is normal 
 in size and its efficiency is not impaired the murmur is 
 physiological. When, on the contrary, there is an
 
 102 MURMURS: PHYSIOLOGICAL, 
 
 increase in the size of the heart, with limitation of the 
 heart's response to effort, we may assume that the 
 murmur is functional. 
 
 During a febrile illness functional murmurs frequently 
 appear and they are never of much moment. It is 
 difficult, however, to distinguish them from murmurs 
 due to an actual lesion of the valves unless certain 
 characteristics peculiar to organic murmurs are present. 
 
 Functional murmurs may persist after the subsidence 
 of the fever, or physiological murmurs may then appear ; 
 and there may consequently be some doubt whether, 
 after all, the murmurs may not be due to a lesion of the 
 valves. The absence of other signs of cardiac disturb- 
 ance, such as increased rate and size, may in these cases 
 be taken as an assurance that the murmur is not organic, 
 while the appearance of the youthful type of irregularity, 
 especially if it is well marked, will set the matter at rest 
 by indicating that the heart has escaped damage. I 
 deal with this question of youthful irregularity very 
 fully in Chapter XVII. 
 
 How physiological and functional murmurs may be recognised. 
 
 These murmurs always occur during the systole of the 
 ventricle. In a large number of people they are un- 
 accompanied by any other sign of cardiac abnormality. 
 A great many people, especially young people, who have 
 this systolic murmur never afterwards show any sign of 
 cardiac inefficiency, though no treatment or care has 
 been undertaken. Post-mortem examination of such 
 hearts shows absolutely healthy valves. In some the 
 murmur is present when standing and disappears when 
 lying down. In others the contrary happens, the mur- 
 mur being present when lying down and disappearing 
 on standing. In some cases it may not be present when 
 the heart increases in rate during exertion or during 
 inspiration, but may appear as the rate decreases after 
 exertion and excitement or during expiration. In many 
 it is persistent under all circumstances. It would be
 
 FUNCTIONAL, AND ORGANIC 103 
 
 unprofitable, in our present state of knowledge, to 
 inquire into the reason for these variations. We are so 
 ignorant of the factors concerned in the production of 
 such murmurs that our conclusions would be but guess- 
 work. 
 
 What is essential to us as physicians is to recognise that a 
 systolic murmur, whether variable or persistent, may be of no 
 significance as far as the future of the patient is concerned, 
 and that when it is the only abnormal sign present, and 
 the response to effort is good, it implies neither cardiac 
 disease nor cardiac impairment. 
 
 If there be evidence of the dilatation of the heart, then 
 probably the murmur is functional, but, as I have said, 
 this point is of little significance ; our opinion has to be 
 based on the degree of heart-failure and the circum- 
 stances inducing the dilatation. In anaemia, and con- 
 ditions inducing exhaustion, functional systolic murmurs 
 are frequent, and here also it is manifest that the 
 murmur is of little significance. 
 
 How to estimate the value of systolic murmurs of organic 
 
 origin. 
 
 It is not always possible to tell whether or not a 
 systolic murmur is due to an actual disease of the, valves. 
 But when we are in doubt we can estimate its value 
 by consideration of the heart's efficiency and the pre- 
 sence of other signs ; for it must be borne in mind that 
 mitral regurgitation, even from a damaged valve, is 
 seldom, if ever, of much importance. It is not the regur- 
 gitation which is the serious matter, but the fact that 
 a damaged valve indicates that the heart has been 
 invaded by disease. The question arises, Has the disease 
 affected more vital parts ? Rough character in a mur- 
 mur, and especially a musical quality, may be taken 
 as an indication of a damaged valve. But it must be 
 remembered at the same time that organic murmurs 
 may be of a soft, blowing character, and thus be indis-
 
 io 4 MURMURS: PHYSIOLOGICAL, 
 
 tinguishable from those of functional origin. In order to 
 estimate its value the organic murmur should be con- 
 sidered from the following points of view : (1) Condition 
 of the orifice. The presence of the murmur may indicate 
 such narrowing of an orifice (as, for example, the aortic) 
 that it is clear that the ventricle is being embarrassed 
 in its work. If this has happened the response to effort 
 will be limited and the ventricle will be enlarged. It 
 is on these two factors that we must base our estimate 
 of the condition of the heart. As I have said, it is 
 doubtful whether mitral incompetence itself ever 
 constitutes a serious embarrassment to the heart. 
 (2) Condition of the myocardium. The presence of 
 this systolic murmur may indicate that the heart has 
 been invaded by a disease, and, as the disease is rarely 
 limited to one structure, it will be necessary, in all cases, 
 to consider whether any damage has been done to such 
 other structures as the myocardium and the pericardium. 
 In the absence of any increase in the size of the heart, 
 and of any abnormal action, and in the presence of a 
 good response to effort, it may be assumed that the 
 damage is so slight that it does not embarrass the heart 
 in its work. On the other hand, if impairment of the 
 heart's efficiency be present, and there are such other 
 signs as increased size and abnormal rate and rhythm, 
 our opinion must be based on those other signs as well as 
 on the murmurs. We must, in short, see the condition 
 as a whole. 
 
 The reasons for estimating the value of murmurs in this 
 
 manner. 
 
 The reason underlying this attitude becomes very plain 
 as soon as it is understood in what way heart-failure is 
 produced. If a murmur is caused by a lesion which 
 embarrasses a chamber in its work, then that chamber 
 will alter in form either by dilating or by becoming 
 hypertrophied. The absence, then, of any alteration in 
 the size of the heart is evidence that there is no embar-
 
 FUNCTIONAL, AND ORGANIC 105 
 
 rassment. Moreover, a lesion embarrassing the heart 
 in its work would also render the organ less efficient, 
 so that an inquiry into the cardiac efficiency and a 
 knowledge of its exact state furnish us with important 
 material upon which to base our opinion. 
 
 The meaning of systolic murmurs when these are accompani- 
 ments of heart failure. 
 
 When a systolic murmur is present along with heart 
 failure we find, almost invariably, other evidences of 
 cardiac trouble. These other evidences are important 
 guides ; they comprise an increased size of the heart, 
 the presence of an abnormal rhythm (for example, 
 auricular fibrillation), and changes in the manner in 
 which the circulation is maintained. 
 
 We may meet with signs of extreme heart failure in 
 which there is no increase in the size of the heart, but 
 in which a systolic murmur is present. As an instance 
 let me cite attacks of angina pectoris readily provoked. 
 It may be taken for granted that in these cases the 
 murmur is incidental and that its cause has little or 
 no part in the production of heart-failure, though its 
 presence may indicate that the same changes which may 
 have affected the valve are present in other structures 
 the impairment of which has induced the heart-failure. 
 It is not possible always to state definitely what is the 
 exact cause of a given systolic murmur. This should 
 be remembered. 
 
 In speaking of systolic murmurs I have not sought to 
 differentiate between the various orifices at which they 
 may arise. You have all been well instructed as to 
 how to recognise a mitral systolic murmur — the murmur 
 heard loudest at the apex and propagated towards the 
 axilla. Systolic murmurs heard at the base cannot be 
 identified with certainty, and much dispute continues 
 about the origin of many of these murmurs. When, in 
 the absence of the diastolic aortic murmur, there is a 
 possibility that the systolic murmur may be aortic
 
 106 MURMURS: PHYSIOLOGICAL, 
 
 in origin, the important question is whether or not there 
 are present signs pointing to a marked narrowing of 
 the aortic orifice. If these signs are absent little atten- 
 tion need be paid to the systolic murmur. If narrowing 
 of the aortic orifice be present the left ventricle will 
 be embarrassed, a state which will be revealed by 
 increase in its size accompanied by a diminution of 
 the heart's power of response to effort. Other signs 
 will be present also, as a thrill over the region of the 
 aortic valves, propagation of the murmur into the caro- 
 tid, and a small anacrotic radial pulse of low tension. 
 
 Extreme aortic stenosis without regurgitation is a rare 
 condition, and in the few people I have seen who showed 
 it, it has occurred towards the end of life, in mature 
 years ; the heart has been grievously exhausted — breath- 
 lessness or pain being easily induced. There is usually 
 a syphilitic history, except in the senile cases. 
 
 The meaning of a systolic murmur in acute febrile conditions. 
 
 It is in acute or febrile states that the greatest diffi- 
 culties of diagnosis arise. The elevation of temperature 
 or the toxins produced by a microbic invasion of some 
 other part of the body may readily alter the muscular 
 mechanism of the heart in various ways and so produce 
 a functional systolic murmur. On the other hand, the 
 microbic invasion may attack the heart itself and so 
 damage the valve directly and produce a systolic mur- 
 mur. It may be difficult to determine which of these 
 two conditions is present, and it is often necessary to 
 wait till the fever has subsided in order to arrive at 
 certainty. If the murmur changes its character from 
 day to day, tending to become more marked, and, 
 especially, if it takes on a musical quality, we may be 
 fairly sure that the disease has affected the valve. 
 Again, if, after the subsidence of the fever, the heart 
 remains persistently increased in rate, suspicion that 
 the valve is damaged is strengthened. The occurrence 
 of such other signs, as slight heart-block, will further
 
 FUNCTIONAL, AND ORGANIC 107 
 
 testify that the heart itself is the seat of invasion. On 
 the other hand, return of the rate to the normal after 
 the subsidence of the fever, especially when this is 
 accompanied by the appearance of the youthful type of 
 irregularity, will indicate, and this in spite of the sys- 
 tolic murmur, that the heart has escaped infection. It 
 is scarcely necessary to insist on the importance of this 
 view in regard to such diseases as rheumatic fever.
 
 CHAPTER XV 
 
 murmurs (continued) 
 
 DIASTOLIC MURMURS 
 
 (Mitral Stenosis and Aortic Regurgitation) 
 
 The murmurs which indicate lesions of valves embarrassing 
 the heart and leading to heart failure occur mainly during 
 the diastole of the left ventricle, and of these there are 
 two which include the great majority of serious valvular 
 affections, namely the murmurs due to stenosis of the mitral 
 valve, and the murmurs of aortic regurgitation. 
 
 Mitral Stenosis. 
 When the murmurs of mitral stenosis appear, and how they alter. 
 
 The most instructive murmurs are those produced by 
 stenosis of the mitral valve. Yet symptoms evoked by 
 this valvular affection, and its accompanying changes 
 in the heart muscle, are far from being properly appre- 
 ciated and understood at the present day. I would 
 therefore advise you, in your study of these cases, to 
 put behind you much of your teaching and approach 
 the subject with an open mind, and I would specially 
 urge you to recognise that there is here something far 
 beyond the mere presence of a particular murmur. 
 
 In a number of people whom I have attended for 
 rheumatic fever I have been able, during some ten, 
 fifteen, or twenty years, to observe and to note the 
 
 108
 
 DIASTOLIC MURMURS 109 
 
 changes that gradually arise in the heart as a result 
 of this affection. In none of these cases was there ever 
 any indication, during the causative illness or conva- 
 lescence, that mitral stenosis was present. Some 
 recovered with a seemingly intact heart, others 
 were left with a mitral systolic murmur. It was 
 not until years had elapsed that the first faint 
 signs of stenosis became apparent. In one woman 
 I perceived, as the earliest indication of the con- 
 dition, a short thrill preceding the first sound. Some 
 months later I detected a short presystolic murmur 
 which was not always present and which usually 
 appeared only when the heart was excited to violent 
 action. As time went on this murmur became constant 
 and gradually increased in length, starting in late dias- 
 tole of the ventricle and running up to the first sound 
 — the characteristic crescendo of the presystolic murmur 
 of mitral stenosis. Associated with this state of affairs 
 there was a doubling of the second sound, but I am 
 not certain as to the exact time of the first appearance 
 of that phenomenon. This is the stage at which we see 
 most cases of what is called early mitral stenosis, for 
 the patient has hitherto been leading the life of a healthy 
 person with a healthy heart, and only becomes alarmed 
 when subjective signs of heart-failure begin to show 
 themselves. The next change is the appearance of a 
 murmur immediately after the second sound, at the 
 beginning of ventricular diastole. As time goes on 
 this murmur lengthens, and we note that it begins with 
 a high pitch and decreases in loudness — the diminuendo 
 murmur of mitral stenosis. The diastolic murmur may 
 lengthen and run up to the presystolic murmur, with 
 the result that the whole diastolic period of the ventricle 
 is filled by it. It begins loudly after the second sound, 
 falls slightly, and then increases in loudness and ends 
 in the first sound. During all this time the heart is 
 usually perfectly regular in rhythm (Fig. 7). This stage 
 may last for many years.
 
 no 
 
 DIASTOLIC MURMURS 
 
 The sudden onset of persistent irregularity is accompanied by 
 disappearance of all signs of auricular contraction, the 
 auricle having passed into fibrillation. 
 
 In the majority of people the next change takes place 
 with dramatic suddenness, the presystolic element of 
 the murmur disappears suddenly and entirely, and only 
 the diastolic portion remains. At the same time the 
 heart becomes very irregular in its rhythm and frequently 
 there is severe heart-failure (Fig. 8). Now it is this 
 
 J 
 
 t\ 
 
 r 2 
 
 i 2 
 
 
 I 2 
 
 • 2 12 12 
 
 ll H&kllM.u 
 
 i a 
 
 I 2 
 
 Fig. 7. 
 
 Tracings of the radial and jugular pulse with diagrammatic representa- 
 tion of the changes in the murmurs of mitral stenosis. The down 
 strokes 1 and 2 represent the first and second sounds of the heart. 
 The first indication of stenosis is the appearance of the murmur 
 before the first sound, and on reference to the jugular tracing this 
 murmur will be found to coincide in time with the wave, «, due to 
 the systole of the auricle. With an increase in the stenosis, a short 
 diastolic murmur appears, immediately after the second sound, and 
 this is represented in the middle diagram. A further increase in 
 the stenosis, shown in the lowest diagram, leads to prolongation of 
 the diastolic murmur, which in combination with the presystolic 
 murmur fills up the whole interval between the second and first 
 sounds. (For the next change see Fig. 8.) 
 
 stage which is so instructive and which is of such great 
 importance in relation to a due appreciation of the cause 
 of heart-failure in many instances. It was in 1897 that 
 I was able to establish the relationships of a series of
 
 DIASTOLIC MURMURS in 
 
 phenomena which may be observed at this stage of the 
 condition. I attended a woman for rheumatic fever in 
 1880, and kept a watch over her till her death in 1898. 
 About ten years before her death she showed signs of 
 mitral and tricuspid stenosis, her heart being regular 
 in rhythm, with the exception of ventricular extra- 
 systoles on rare occasions. Suddenly she began to suffer 
 from extreme heart-failure, and I found that her heart 
 was irregular and that the presystolic mitral and tri- 
 cuspid murmurs had disappeared. The auricular waves 
 which had been present in jugular and liver tracings 
 had also disappeared. In fact, all evidence of auricular 
 
 Fig. 8. 
 
 After the changes described in Fig. 7 the next change is a sudden 
 alteration of the rhythm of the heart. In Fig. 7 the heart is quite 
 regular ; in Fig. 8 it is irregular. The wave, a, which is a marked 
 feature in the jugular tracing of Fig. 7, is absent in Fig. 8. The 
 presystolic portion of the murmur is also absent in Fig. 8, this 
 feature being best appreciated during the longer pauses of the 
 irregularity. The disappearance of these evidences of auricular 
 activity and the irregular action of the heart indicate the onset of 
 auricular fibrillation. The waves // are due to the fibrillating 
 auricle. 
 
 systole suddenly ceased. The irregular action of her 
 heart persisted till the time of her death, and there was 
 never a return of the presystolic murmur. (Compare 
 Figs. 7 and 8.) 
 
 How an appreciation of the nature of the changes in the 
 murmurs of mitral stenosis helps towards an accurate 
 diagnosis. 
 It is necessary, if you would deal faithfully with your 
 
 patient, that you should comprehend clearly the mean-
 
 ii2 DIASTOLIC MURMURS 
 
 ing of these changes. You will readily perceive that 
 mitral stenosis is almost invariably a progressive lesion 
 and that the impairment of the efficiency of the 
 heart is also progressive. The rate of stenosis varies — 
 sometimes it is relatively slow, sometimes rela- 
 tively fast — so that it is important for you to 
 gain information regarding the rate of this pro- 
 gress as well as regarding the extent of the stenosis 
 which may be present. This, therefore, is a point which 
 you must attempt to deal with in every case that pre- 
 sents itself to you. It is true we are unable to settle 
 these questions with great precision ; nevertheless we can 
 arrive at an idea, in a rough manner, which will help 
 us greatly in giving advice. 
 
 You will observe that I pointed out that the signs of 
 stenosis did not appear until a considerable period had 
 elapsed since the time when the heart was invaded by 
 the rheumatic disease. The explanation of this is that 
 the damaged mitral valve was not at first stenosed, but 
 was simply inflamed with, it may be, some destruction 
 of its fine margins. Inflammation, as you know, leads, 
 in the process of healing, to the formation of fibrous 
 tissue. As a usual consequence, the fibrous tissue, after 
 a time, tends to contract. Hence the valvular orifice 
 becomes increasingly narrowed. At first the narrowing 
 gives rise to a short murmur at the time of auricular 
 systole, which is evanescent, and appears only when the 
 auricle is stimulated to extra effort. With an increase 
 in the narrowing the murmur becomes permanent and 
 prolonged. There are two periods during ventricular 
 systole at which the blood is sent into the ventricle with 
 some degree of force. One of these, as we can easily 
 understand, is the time at which auricular contraction 
 takes place. The other period is not so widely recog- 
 nised. During ventricular systole the blood returning 
 from the lungs is stored up in the left auricle, and it fills 
 the auricle and raises the pressure in that chamber. At 
 the end of ventricular systole the sudden relaxation of
 
 DIASTOLIC MURMURS 113 
 
 the ventricular muscle causes a great fall in ventricular 
 pressure — a fall to a pressure lower than that in the 
 auricle ; consequently, at the end of diastole, there is 
 a rush of blood from the auricle to the ventricle. In 
 hearts free from mitral stenosis the blood passes quite 
 silently, but, as a result of the narrowing of the orifice, 
 the stream gradually becomes audible, at first giving 
 rise to a slight murmur, later to a murmur which 
 increases in volume and strength with the increase in 
 narrowing. The inrush of blood is, of course, greatest 
 immediately after ventricular systole and diminishes in 
 quantity as the auricle empties, so that the murmur 
 also diminishes in volume at this period and we get the 
 diminuendo murmur. 
 
 Recognition of these facts will enable you to under- 
 stand that, when we find the diastolic murmur, the 
 narrowing of the orifice has become so extreme as to 
 afford for the passage of the blood little more than the 
 characteristic slit with which you are all familiar in the 
 post-mortem appearance of advanced mitral stenosis. 
 
 When we inquire into the history of the case we can 
 usually get an account of the attack of rheumatic fever 
 which set up the valve mischief; the distance, in time, 
 from that attack and the nature of the murmur itself 
 will afford you materials for determining the degree of 
 stenosis present and the probable rate of progress. 
 
 This, I know, will be a very rough estimate ; in many 
 cases other factors will have to be taken into considera- 
 tion, and some of these I will mention later. I tried 
 myself to get more precise information, but I had not 
 realised the value and possibilities of this method when 
 my opportunities for more careful observation passed 
 away. This, therefore, I would suggest, is one of the 
 subjects that young practitioners might take up, for I 
 am certain that in the course of work extending over 
 fifteen or twenty years they should be able to add a 
 most valuable chapter to our knowledge and thus to 
 confer benefit upon our patients. 
 
 I
 
 n 4 DIASTOLIC MURMURS 
 
 Even this limited application of the method, however, 
 will help you in many cases. When you find mitral 
 stenosis in the very young, accompanied by presystolic 
 and diastolic murmurs, you know you have a grave 
 condition to deal with. When you find only a presystolic 
 murmur in a patient aged about forty, who has a history 
 of rheumatic fever in childhood, then you know that the 
 rate of stenosis is slow and that it may be stationary. 
 In one patient who came under my care with a very 
 slight mitral stenosis at the age of fifty, and who had 
 had rheumatic fever at eighteen, the murmur never 
 altered in character, though I watched him for twenty- 
 five years. He died at the age of eighty-two. 
 
 In most cases of mitral stenosis damage is done to the muscle 
 wall. This may produce heart-failure, auricular fibrillation 
 and heart-block. 
 
 I mentioned just now that there were other factors 
 present in addition to mitral stenosis which modified the 
 heart's action. In many cases the rheumatic infection 
 is not limited to the valves, but has invaded other 
 tissues. The muscle substance is not infrequently 
 damaged, and when this is the case heart-failure is 
 readily induced because of changes going on in, and 
 impairing the functional activity of, the muscle. Many 
 of the young who suffer severely from heart-failure dis- 
 play this condition, and in them the condition may lead 
 to death, though it is wonderful how good the recovery 
 from extreme heart-failure, with dropsy and extreme 
 dyspnoea, sometimes is in the young. I have repeatedly 
 observed in these patients periods of heart-failure, during 
 which recovery seemed hopeless ; yet, after a long 
 period, I have seen improvement set in, and the indi- 
 vidual sometimes recover so far as to be able to pursue 
 even a laborious occupation. One can but conclude that 
 some product of the rheumatic invasion has caused a 
 temporary weakening of the heart muscle. Many serious 
 cases of mitral stenosis in the young, however, never
 
 DIASTOLIC MURMURS 115 
 
 show heart-failure with dropsy. In these cases breath- 
 lessness and palpitation are the most troublesome symp- 
 toms, and haemorrhage from the lungs is not infrequent. 
 As a rule, this state is a dangerous one. Yet, although 
 increased pressure in the pulmonary blood-vessels may 
 be one mischievous factor, I must confess to being unable 
 to explain the manner of the heart-failure in these cases. 
 
 There is a stage in mitral stenosis which has long 
 been recognised, though the reasons for its occurrence 
 and its significance have not been understood till recent 
 years. This stage is that in which the "mitral pulse" 
 appears — a pulse frequently small and soft, with a very 
 irregular rhythm. This pulse we now recognise as being 
 due to auricular fibrillation. 
 
 I will defer the consideration of this subject till I deal 
 with auricular fibrillation as a whole, as the inception of 
 this new rhythm alters the whole aspect of the case, not 
 only in regard to the physiological change in the heart's 
 action, but in regard to the heart's power of maintaining 
 the circulation and in the peculiar response of the heart 
 to drugs of the digitalis group ; and besides, it appears 
 in many other conditions. In the meantime, I would 
 merely remark that there exists good ground for assum- 
 ing that the appearance of auricular fibrillation is not 
 due directly to the valve lesion, but to some damage in 
 the muscular tissue of the auricle. 
 
 Auricular fibrillation is not the only evidence we have 
 of muscular changes. There are, in addition, a number 
 of peculiar phenomena related to the bundle of tissue 
 which joins the auricles and the ventricles. The pheno- 
 mena are concerned with the changes giving rise to 
 heart-block. In heart-block we find the explanation of 
 the mid-diastolic murmur. This murmur occurs in 
 mitral stenosis, and is due to the systole of the auricle ; 
 in heart-block a pause takes place between the systole 
 of the auricle and that of the ventricle, the pause being 
 due to the slower passage of the stimulus from auricle 
 to ventricle along the damaged bundle. Sometimes we 
 
 1 2
 
 n6 DIASTOLIC MURMURS 
 
 get ventricular beats dropping out when the stimulus 
 fails — as it does occasionally — to pass along the bundle. 
 This is not infrequent after the administration of 
 digitalis, for digitalis acts very readily on a damaged 
 bundle (see pages 62 and 232). 
 
 In estimating the value of these peculiar phenomena 
 we must not attach too much weight to any single one 
 of them. With partial heart-block or with auricular 
 fibrillation the outlook may still be fairly good, and 
 individuals showing these signs may lead useful lives 
 for many years. 
 
 In estimating the value, then, of any phenomenon, 
 however peculiar, we must be guided mainly by the 
 functional efficiency of the organ as tested by its 
 response to effort. 
 
 Aortic Regurgitation. 
 
 Aortic regurgitation has a varied significance, and the manner 
 of estimating its significance is discussed. 
 
 Seeing the bad cases of aortic diseases in the hospitals, 
 I formed the opinion, which many of us must have 
 formed, that aortic regurgitation is a very dangerous 
 complaint. You know that the writers of our standard 
 text-books treat the subject with gravity. This view 
 was confirmed by my experience in a few cases shortly 
 after I entered general practice. It was, therefore, with 
 some surprise that, in those early days, I acci- 
 dentally came across a carter, who had a broken leg 
 and who had been leading a strenuous life, in whom I 
 detected double aortic murmurs. The man declared he 
 had never suffered from any inconvenience. I had occa- 
 sion, some twenty-five years ago, to examine a colleague 
 for life insurance, and I found that he, too, had double 
 aortic murmurs. Without hesitation I described him as 
 unfit for insurance. Since that time he has led a 
 busy life in his practice and played strenuous games 
 of tennis and cricket; the last I heard of him was a
 
 DIASTOLIC MURMURS 117 
 
 few months ago, when he called and informed me that 
 he had obtained a commission in the Army. Though 
 now over fifty years of age, he has never suffered from 
 the slightest symptoms of heart failure. In another 
 patient, a woman of fifty-two who had had rheumatic 
 fever at twenty, and who came under my care in 1892, 
 there was present a well-marked diastolic aortic murmur 
 and a typical collapsing pulse. She had lived an active 
 life, and she continued to do so, though in her later 
 years she had suffered at times from attacks of angina 
 pectoris. In 1906 she developed auricular fibrillation ; 
 she died in 1907 at the age of sixty-seven. 
 
 Being brought into contact with many cases such as 
 these, as well as other cases which speedily died, I asked 
 myself the question : Why are there these great dif- 
 ferences in the outlook in cases of aortic regurgitation, 
 and how can I find evidence that will guide me to a 
 rational prognosis in any given case ? 
 
 I admit at once that I have not been able to answer 
 this question satisfactorily, though I have obtained 
 several facts that have helped me in many cases. I 
 naturally thought at the beginning that the degree of 
 danger would depend on the extent of regurgitation, 
 and so I tried, by the study of the distribution of the 
 sounds and murmurs of the heart, to find a basis for 
 estimating the amount of regurgitation ; but I failed to 
 find any reliable facts. As far as I can judge from post- 
 mortem examination, the extent of the damage to the 
 valve does not necessarily correspond to the degree of 
 heart failure. Valves which have proved to be only 
 slightly damaged have, in my experience, been asso- 
 ciated during life with severe heart failure. 
 
 I found a better guide in the size of the heart. In 
 the cases I have mentioned, and in numerous others who 
 led vigorous lives free from any suggestion of heart 
 failure, the left ventricle was only slightly hypertrophied, 
 the apex-beat being slight and located only just 
 outside the nipple line. So that the important element
 
 n8 DIASTOLIC MURMURS 
 
 for the prognosis is the degree of enlargement of the left 
 ventricle. 
 
 But even when the ventricle is considerably hyper- 
 trophied, and a large, forcible apex-beat is found 
 situated well outside the nipple-line, a life of moderate 
 utility is often led by the patient, and this in spite of 
 the fact that the response to effort is impaired. In these 
 cases I found the rate of some value to me, and I was 
 able to conclude that those whose hearts were distinctly 
 enfeebled had a persistent increase in rate — about 90 
 when at rest, while the more vigorous had a rate approxi- 
 mating to the normal or under 80. Nevertheless, some 
 discretion is needed, for many sufferers from aortic 
 disease have extremely excitable hearts, the rate of 
 which increases greatly when they come into the doctor's 
 presence. They can tell you this themselves, for the 
 beat is very forcible and they are conscious of it. In 
 these cases, when you detect this violent action of the 
 heart, the patient's experience should be a guide to you. 
 But the most important factor in arriving at a prognosis 
 is the patient's response to effort. It may be taken for 
 granted that, if the patient is unconscious of any dis- 
 comfort or palpitation on severe effort, the outlook for 
 him is good. 
 
 The state of the pulse affords some help. When 
 an extremely collapsing pulse is felt, and when, on 
 using the blood-pressure instrument, the systolic pres- 
 sure is found to be very high and the diastolic pressure 
 very low (190-60), then the condition may be grave, and 
 will be found to be associated with evidence of heart 
 failure, A moderate difference between the systolic and 
 diastolic pressure (180-90) is quite consistent with an 
 efficient heart ; while in some of these cases the difference 
 is equal to the normal (140-85). Needless to say, in 
 these last instances the pulse has little of a collapsing 
 character. The high systolic pressure is, presumably, the 
 cause of bleeding from the nose, which is not infrequent 
 in aortic regurgitation.
 
 DIASTOLIC MURMURS 119 
 
 In aortic regurgitation we often find that the vaso- 
 motor system is in a state of great sensitiveness, and 
 sudden rises of arterial pressure may be associated with 
 severe attacks of angina pectoris. To this sensitive 
 vaso-motor system may be attributed the attacks of 
 syncope which are neither infrequent nor serious. 
 
 So far I have spoken of aortic regurgitation, which 
 has been established for some time, and in which the 
 disease of the valves is, presumably, stationary. These 
 cases are usually rheumatic in origin, or in the, young 
 arise from some obscure infection. The aortic disease 
 occurring in the middle-aged and elderly, which is due 
 to atheromatous changes, seldom leads to serious heart 
 failure. 
 
 Aortic disease due to syphilis is often progressive and of grave 
 
 significance. 
 
 In syphilitic disease the aortic condition is often a 
 very serious one. Once it has started, it often rapidly 
 destroys the valves, and in the aorta itself it may 
 seriously interfere with the blood supply of the heart by 
 blocking the coronary arteries. If taken in time and 
 treated energetically by anti-syphilitic drugs, the 
 disease may be stopped and a fair recovery may follow. 
 In some cases, however, the disease extends rapidly, and 
 death ensues within a year or two of its starting. 
 
 When heart failure sets in with aortic regurgitation it is 
 difficult to check its progress. 
 
 The heart failure of aortic regurgitation is in some 
 respects peculiar. It is rare to find dropsy; indeed, 
 when that is present, the disease may be regarded as a 
 complicated one, embracing, usually, among its mani- 
 festations an affection of the muscle wall. 
 
 Attacks of pain, often of the greatest severity, are a 
 very frequent evidence of exhaustion, as also is violent 
 beating of the heart ; attacks of extreme dyspnoea are
 
 120 DIASTOLIC MURMURS 
 
 not infrequent, and death sometimes occurs during the 
 first attack. 
 
 When I have looked at the enormous mass of muscle 
 which forms the ventricular walls in these cases, I have 
 often wondered whether those muscle fibres represent 
 a genuine hypertrophy or whether some disease condition 
 has taken part in the increase. The large muscle is so 
 very ineffective in maintaining the circulation, even when 
 the leakage through the aortic valve has not seemed 
 to be great. 
 
 When heart-failure sets in to any considerable degree 
 the condition is less susceptible to treatment, and 
 recovery is less frequent and less pronounced than in 
 heart-failure resulting from any other condition. One 
 frequently sees extraordinary recoveries from extreme 
 heart-failure — as, for example, in mitral stenosis — but 
 one does not meet with such recoveries in aortic disease. 
 Again, even when heart-failure is extreme in auricular 
 fibrillation with mitral stenosis, a good recovery can 
 often occur, but in auricular fibrillation with aortic 
 disease, when heart-failure sets in, the patient steadily 
 drifts, and we are seldom able to check the downward 
 progress.
 
 CHAPTER XVI 
 
 AFFECTIONS OF THE MYOCARDIUM 
 
 (Dilatation, Hypertrophy, Myocardial Degeneration) 
 
 The evidences of myocardial affection are revealed by alterations 
 in the size of the heart, irregular action, and inefficiency 
 of the heart muscle. Because the maintenance of an 
 efficient circulation depends on the activity of the muscle 
 wall, it will be realised that a knowledge of the state of 
 the myocardium is essential to a due appreciation of the 
 condition of any given heart. 
 
 Unfortunately, most of the changes that occur in 
 the myocardium show no sign or symptom by which we 
 can recognise them. Nevertheless, there are, a number 
 of manifestations which we can refer to the myocardium, 
 such as various irregularities of the heart's action, 
 changes in the size of the organ, and, it may be, in the 
 character of the sounds. While, therefore, we may fail 
 to have distinct evidence of the changes, we can obtain 
 indirect evidence by the study of the heart's efficiency. 
 In many cases this study gives us information of the 
 highest value, so much so, indeed, that we should never 
 conclude our examination of a patient till we have 
 arrived at a thorough understanding of the degree of 
 efficiency of his heart muscle. 
 
 In discussing the affections of the myocardium I will 
 deal first with dilatation and hypertrophy. Later I will 
 consider irregular action of the heart. The more pro-
 
 122 AFFECTIONS OF MYOCARDIUM 
 
 minent signs of inefficiency have been dealt with in 
 speaking of heart-failure. 
 
 Dilatation of the Heart. 
 
 The real meaning of dilatation of the heart has, so far, 
 
 eluded recognition. 
 
 The factors producing this condition are still obscure, 
 so that, unfortunately, there remains plenty of room 
 for speculation. As in the case of all obscurities in medi- 
 cine, the mystery surrounding dilatation provokes in the 
 mind a sense of fear. A more intimate knowledge of 
 the condition, however, though it has failed to afford 
 full understanding, has yet shown that its significance 
 varies greatly. The latest researches by Starling show 
 that a dilatation of any of the chambers of the heart 
 is produced when there is an increase in the, pressure 
 during diastole — the increase of pressure being due to a 
 larger influx of blood. Starling shows that, when the 
 heart is stimulated to greater effort, it dilates slightly, 
 because a slight increase in size gives the best condition 
 of the heart for increased effort. When the full effort 
 which the heart can make does not quite overcome the 
 resistance to the outflow, then the ventricle is not com- 
 pletely emptied, and so the residual blood added to the 
 inflow tends to produce further dilatation. In other 
 words, when failure of the heart sets in the chambers 
 do not completely get rid of their contents. These 
 leavings are added to the new blood, and so the trouble 
 goes on. 
 
 Clinical support for such a view can readily be found. 
 Healthy hearts exposed to severe bodily labour may 
 dilate without impairment of functional efficiency. 
 Chambers of the heart obstructed in their work — for 
 example, by narrowing of the exit — tend to dilate, as 
 in the case of the left auricle in mitral stenosis. Dilata- 
 tion is common in various conditions that produce heart- 
 failure of a moderate as well as of a serious kind.
 
 AFFECTIONS OF MYOCARDIUM 123 
 
 On the other hand, there are features which lead to 
 the conclusion that the whole truth is not contained in 
 this explanation. People suffer from heart-failure, and 
 even die from it, in whom there is no dilatation. A man 
 may suffer prolonged severe exertion and his heart may 
 be exhausted without any sign of dilatation manifest- 
 ing itself. In cases where the heart suddenly takes on 
 an abnormal rhythm with marked impairment of its 
 efficiency we may find that it dilates rapidly to a 
 remarkable extent, but, in other cases, we may find 
 no dilatation whatever. In certain febrile cases the 
 dilatation of the heart is extreme, in other similar cases, 
 with higher temperatures, there is no dilatation. 
 
 From such considerations as these we may conclude 
 that there are other factors than dilatation, the result 
 of increased pressure, which induce heart-failure. Here 
 indeed, as in all investigations dealing with vital func- 
 tions, we find that the mechanical factor is not the 
 only one. 
 
 A muscle fibre, when not in actual contraction, is not 
 relaxed to its fullest extent. It is not limp like a 
 cotton thread or other non-living structure. It still 
 maintains a degree of contraction which offers a resist- 
 ance — it may be a slight resistance — to extreme exten- 
 sion. This property of "tone" is capable of being 
 influenced by certain agents. Thus, Gaskell describes 
 a diminution of the degree of relaxation under the 
 influence of certain agents as antiarin, and an increase 
 in the degree of relaxation with other agents as musc- 
 arin. The possession of this property of tone by the 
 muscle and its susceptibility to various stimuli in a 
 positive and in a negative sense would account for some 
 of the variations in the size of the heart to which I 
 have referred. 
 
 Dilatation of the heart is recognised by an increase in 
 the size of the organ, the borders extending beyond that 
 area which we commonly assume a healthy heart will 
 occupy. The most common sign of dilatation is an ex-
 
 124 AFFECTIONS OF MYOCARDIUM 
 
 tension of the apex-beat or the left edge of cardiac 
 dullness to or beyond the nipple line. We may get, in 
 advanced cases, a descent of the apex-beat to the sixth 
 or seventh interspace and an extension of the dullness 
 to the right beyond the edge of the sternum with in- 
 creased epigastric pulsation. The extended area of dull- 
 ness to the left, which is so frequently an evidence of 
 dilatation, gives no clue to the chambers which are 
 affected. Post-mortem examination will often reveal the 
 fact of one or more chambers being much more dilated 
 than the others. During life we can rarely tell which 
 chambers are dilated. When there is extreme extension 
 of dullness to the right, we may assume that the right 
 auricle is greatly dilated, and when there is marked 
 pulsation in the epigastrium, with indrawing during 
 systole, we can assume that the right ventricle is dilated. 
 The difficulty in recognising the dilated chamber is due 
 partly to the fact that the pericardial sac on the right 
 side is more firmly fixed to the superior and inferior 
 cavae than the looser investment on the left, so that any 
 pressure tends to push the heart in the direction of least 
 resistance. In carefully following a number of cases I 
 have been able to observe a well-marked apex-beat, due 
 to the left ventricle — recognised by the systolic out- 
 thrust — replaced by a diffuse apex-beat, with a systolic 
 indrawing — -due to the great dilatation of the right 
 ventricle. With subsidence of the dilatation the out- 
 thrust of the left ventricle came back to its place. 
 
 Putting aside febrile cases and cases of severe heart- 
 failure, when we perceive that there is an increase in 
 the size of the heart in an individual going about in the 
 enjoyment of health, we must bear in mind that dilata- 
 tion of the heart may be a physiological process, and 
 that it may be due to causes which do not hamper the 
 heart in its work. It is mostly in the young that we will 
 find dilatation to be seemingly a physiological condition. 
 I remember being called, a great many years ago, to 
 see a boy of ten who had fainted. I found the heart
 
 AFFECTIONS OF MYOCARDIUM 125 
 
 dullness extending well to the right of the middle line 
 and half an inch beyond the left nipple line. At that 
 time I was beginning to doubt whether such signs were 
 evidences of a morbid condition, so I did nothing for 
 the heart, and I allowed the lad to run about and play 
 as if nothing had happened. I watched him and nothing 
 did happen, and he has grown up to manhood healthy 
 and vigorous with no sign of cardiac inefficiency. I have 
 since then taken particular note of the heart in the 
 healthy young, and have been struck by the frequency 
 with which variation in size occurs. The subsequent 
 histories of these cases of mine have shown that this 
 sign does not indicate any impairment. When, there- 
 fore, you have occasion to examine the young, do not 
 be scared by the bogey of dilatation of the heart and the 
 other, equally absurd, bogey of the over-strained heart 
 or the athletic heart. Inquire particularly into the 
 functional efficiency of the heart, and if that has been 
 good up to the time when some incident, such as syncope, 
 has occurred, take it for granted that the syncope was 
 not primarily cardiac and that the dilatation had no part 
 in the matter. 
 
 In people of middle life and later life changes of an 
 obscure kind often take place which lead to an increase 
 in the size of the heart. These are usually accompanied 
 by a slight limitation of the field of response ; but so 
 long as the limitation is confined to what common sense 
 tells you is in accord with the age of the individual, you 
 must attach no importance to it. I remember, in my 
 first years of practice, rejecting for life insurance a big, 
 stoutish man, sixty-two years of age, because his apex- 
 beat was one inch outside the left nipple line. He lived 
 an active life for many years and died at the age of 
 eighty-nine. As years went by I kept wondering at his 
 activity, and I kept note of other similar cases and found 
 that many middle-aged people had a distinct increase 
 in the size of their hearts and yet led active lives with 
 no sign of heart-failure.
 
 126 AFFECTIONS OF MYOCARDIUM 
 
 The causes of these increases I could never make out. 
 There was no kidney trouble. The patients were tem- 
 perate-living men, and the heart's efficiency was good. 
 So that I feel confident that an increase of the heart's 
 dullness to a little beyond the nipple line, even when 
 accompanied by murmurs and irregularities, such as the 
 extra systole, if at the same time there be a good response 
 to effort, need cause no worry, and that the patient's 
 outlook for the future is good. 
 
 Heart-failure, even to an extreme degree, may occur without 
 
 dilatation. 
 
 There is a widespread impression, prevalent even 
 among those who have devoted much time, clinically 
 and experimentally, to the study of the subject, that 
 when the heart begins to fail it dilates and that dilata- 
 tion is, even of itself, an evidence of heart-failure. 
 When, however, as I have already stated, the matter is 
 critically examined, plenty of evidence will be found to 
 show that heart-failure may end in death without there 
 having been perceptible any sign of dilatation and with- 
 out the smallest evidence of dilatation being forthcoming 
 on the post-mortem table. Moreover, many hearts, 
 markedly dilated, show an extraordinary degree of 
 efficiency. I have known a man with mitral stenosis 
 and a considerable dilatation of the heart pursue his 
 work as a mechanic, swing his forehammer and do all 
 the heavy labour of his calling, with comfort and ease 
 for over ten years. From such considerations we must, 
 I think, conclude that dilatation, of itself, is not neces- 
 sarily a phenomenon of heart-failure, and that, further, 
 it is by no means to be regarded as the only, the chief, or 
 even an invariable causative factor in heart-failure. 
 Where dilatation has occurred and proceeded pari passu 
 with heart-failure there were other factors at work than 
 dilatation. Thus I have seen cases of paroxysmal tachy- 
 cardia, due to auricular fibrillation, suffer greatly from 
 heart-failure. With the onset of the attack the patient
 
 AFFECTIONS OF MYOCARDIUM 127 
 
 would become very short of breath, his face, in a short 
 time, would become livid, his lips blue, while his liver 
 would enlarge and pulsate, and at the same time his 
 heart would rapidly dilate, so that in a few hours the 
 transverse cardiac dullness would have increased by over 
 two inches. With the sudden resumption of the normal 
 rhythm all these signs of cardiac failure would quickly 
 disappear, and in a few hours the heart's size would 
 markedly diminish. You will gather that in these cases 
 the heart-failure was not due entirely, if at all, to the 
 dilatation. In these cases the ventricular rate is so 
 rapid that exhaustion of the heart muscle ensues, while 
 the output of the ventricle is greatly diminished. The 
 heart-failure is thus independent of the dilatation. This 
 view is supported by the study of numerous cases of 
 permanent auricular fibrillation, and when dealing with 
 that subject I shall refer to the question of dilatation. 
 Here I will anticipate merely by pointing out that we 
 repeatedly meet with cases of extreme heart-failure and 
 great dilatation of the heart, in which, under suitable 
 treatment, a marked improvement takes place without 
 perceptible diminution of the size of the heart. 
 
 Dilatation is probably never produced by overstrain alone. 
 
 That dilatation can be produced in a healthy heart 
 as a result of over-strain, more particularly among the 
 young and athletic, is a belief widely held. I am con- 
 vinced that it is a view which is not justified. For more 
 than a quarter of a century I was engaged in general 
 practice and had large numbers of young people under 
 my care who played games strenuously and were em- 
 ployed in laborious occupations, and during that time I 
 never saw a single individual who suffered from heart 
 dilatation as the result of over-exertion. I think I may 
 fairly say that this was not due to inability on my own 
 part to recognise "overstrain." When one is a family 
 physician watching individuals for years, the results of 
 one's neglect are revealed in course of time.
 
 128 AFFECTIONS OF MYOCARDIUM 
 
 During the last eight years I have been in London 
 and I have had brought to me great numbers of the 
 young of both sexes with hearts said to have been 
 impaired by overstrain. I have not found a single case 
 of dilatation with heart-failure among them. In the vast 
 majority of instances the symptoms which were sup- 
 posed to be signs of overstrain were purely physiological 
 — for example, a slight increase in the size of the heart, 
 irregular action, and systolic murmurs. 
 
 I do not assert that in certain circumstances dilatation 
 may not be produced by over-exertion, but when this 
 does occur the circumstances are wholly exceptional and 
 very special. During the war I have had opportunities 
 of seeing a great number of cases of heart trouble which 
 were supposed to be due to overstrain, but in each case 
 there were present evidences of other causative agents 
 than overstrain. Thus, one officer, who was in the 
 retreat from Mons, complained of easily-produced ex- 
 haustion and breathlessness, and his heart's apex was one 
 inch outside the nipple line. His story was that, during 
 the fourteen days before the battle, he had had little 
 sleep, not more than two hours in the twenty-four, on 
 an average. In the retreat he was three days and 
 nights without sleep, and was nearly always on the run. 
 Finally he fell down unconscious. He was picked up, 
 and, staggering along, fell again unconscious. You will 
 see that an experience such as this is a different thing 
 from a game of football. 
 
 In other cases I get a history of some febrile illness 
 while the patient was in the trenches, and either he did 
 not go off duty or he stopped off only for a very short 
 period. With the resumption of his strenuous duties 
 he gradually became more and more exhausted until he 
 collapsed. In some of these soldiers there is a slight 
 dilatation of the heart. 
 
 The dilatation which occurs in healthy hearts exposed 
 to a strain is probably not due to " strain " alone, in 
 the sense that the heart is being forced to do an excessive
 
 AFFECTIONS OF MYOCARDIUM 129 
 
 amount of work, but to other agents which depress the 
 functions of the heart muscle, as, for example, the toxic 
 products resulting from an infection (see page 193). 
 When one meets with dilatation as the result of excessive 
 work one finds, on inquiry, that the heart had already 
 been damaged. This is seen in valvular disease (the 
 valve lesion offering an impediment to the contracting 
 chamber), or when there is some actual disease of the 
 myocardium itself; or, again, when the two conditions 
 are combined. 
 
 Dropsy due to heart weakness is probably never present without 
 
 dilatation. 
 
 The cardiac inefficiency that may accompany dilata- 
 tion of the heart is not necessarily produced by the 
 dilatation. In many cases, as in auricular fibrillation 
 and auricular flutter, the more urgent symptoms arise 
 in consequence of the increased rate which exhausts the 
 contractile force of the chambers and diminishes the 
 output. So that I am of opinion that there is no char- 
 acteristic and invariable sign by which we can assure 
 ourselves that any particular case of heart-failure is due 
 to dilatation. I have already called attention to the 
 fact that we do not get dropsy without dilatation of 
 the heart (see page 67). 
 
 Dilatation and digitalis and other forms of treatment. 
 
 With the cessation and removal of a provoking agent, 
 as an attack of paroxysmal tachycardia or an infection, 
 the dilated heart may return to normal limits as the 
 result of rest and cessation of effort, and a damaged 
 heart, dilated by overwork, may likewise diminish. But, 
 beyond this, there is a notion held by many people that 
 drugs, and other forms of treatment, can reduce the size 
 of the heart. Among drugs those of the digitalis group 
 have the greatest reputation. I must confess, however, 
 that, though I have seen marvellous improvement take
 
 130 AFFECTIONS OF MYOCARDIUM 
 
 place in a great number of cases from the use of this 
 drug, I have not been able to convince myself that it 
 has materially reduced the size of the heart. In many 
 cases, indeed, where there has been marked improvement 
 the size of the heart has not diminished, while, in a few 
 cases where the size has diminished, I could not be sure 
 whether the improvement was directly due to the drug 
 or to the fact that the slower and more efficient beats 
 emptied the heart more thoroughly. 
 
 In certain quarters, not famous for fullness of know- 
 ledge or for accuracy of observations, marvellous claims 
 are made on behalf of certain methods of treatment — 
 for example, exercises and baths. You will meet with 
 statements about the reduction of the size of the heart 
 as the result of some movements or baths which, if true, 
 would be nothing short of a miracle. These state- 
 ments are sometimes accompanied by outlines supposed 
 to represent the heart's size before and after treatment, 
 which outlines are, to the experienced physician, so 
 absurd as to deserve no notice. Nevertheless, one some- 
 times meets with them in the pages of books which have 
 a pretence to scientific accuracy. Personally, I look upon 
 these outlines and figures as nothing more or less than 
 fakes. I have repeatedly had patients brought to me 
 who were about to undergo one or other of these special 
 forms of treatment. A diagnosis of enormous dilata- 
 tion had usually been made ; but when I examined the 
 patient I found that the heart was perfectly normal in 
 size. I have repeatedly seen individuals with hearts of 
 normal size sent to places like Nauheim for treatment 
 and have seen them return afterwards to tell me that 
 the Nauheim doctor found the heart greatly dilated. 
 The dilatation, they were told, had been removed by the 
 baths and exercises employed. I mention this to put 
 you on your guard against these and all other forms of 
 cure over which there is a trail of commercialism.
 
 AFFECTIONS OF MYOCARDIUM 131 
 
 Dilatation must be valued along with other evidence. 
 
 To sum up — having detected the presence of dilatation, 
 you do not assume that there is necessarily much amiss, 
 nor that heart-failure, if present, is due to the dilatation. 
 In every case you must estimate the functional efficiency 
 of the heart ; if that is in accordance with the health and 
 age of the individual the dilatation may be ignored. If 
 there be distinct limitations of the heart's power, then 
 you must search for the cause that has induced the 
 weakness, and assume that there is some factor other 
 than the dilatation. Your view of the patient's future 
 should not depend upon the dilated heart, but upon 
 the possibility of the removal of this other factor. 
 If the cause cannot be removed, as, for instance, when 
 there is degenerative change in the heart muscle, then 
 you must be guided by the power of the heart to 
 maintain an efficient circulation. 
 
 Hypertrophy. 
 
 It is often impossible to recognise which chamber of the heart 
 
 is hypertrophied. 
 
 In describing an increase in the size of the heart I 
 have assumed that the increase is due to dilatation of 
 one or more chambers. We find, however, though this 
 is not generally the case, that certain chambers of the 
 heart may be hypertrophied as well as dilated, or one 
 chamber only may be hypertrophied while the others 
 are dilated without hypertrophy. This is so well known 
 that I need scarcely insist upon it; in mitral stenosis, 
 for instance, you may have hypertrophy of the left 
 auricle and right ventricle at first, followed later by 
 dilatation of these chambers ; later still great dilatation 
 of both auricles without hypertrophy may occur. 
 
 The signs of hypertrophy are often rather indefinite. 
 A powerful thrust of the apex-beat may be taken as 
 representing one of them, and as indicating a hyper- 
 
 k: 2
 
 132 AFFECTIONS OF MYOCARDIUM 
 
 trophied left ventricle. But milder degrees of hyper- 
 trophy are not easy to differentiate from an excited 
 heart action. Still, an apex-beat in, or just outside, 
 the nipple line with a forcible protrusion during systole 
 may be taken as evidence of moderate hypertrophy. A 
 powerful impact or shock inside the apex-beat and 
 forcible beating in the epigastrium may be taken as 
 suggestive of hypertrophy of the right ventricle. We 
 have no evidence of hypertrophy of the left auricle, 
 unless, indeed, the loudness and roughness of the pre- 
 systolic murmur in mitral stenosis be regarded as such 
 evidence. That it should be so regarded is, however, 
 not certain, because a slight force is capable of producing 
 a rough murmur, as is shown by the diastolic murmur 
 of mitral stenosis. We have no direct evidence of hyper- 
 trophy of the right auricle, though in rare cases it can 
 be inferred from the forcible waves of blood sent back 
 by the auricular systole into the jugular veins and the 
 liver. 
 
 When hypertrophy is physiological in origin it is very moderate 
 
 in extent. 
 
 The cause of hypertrophy is invariably an increased 
 opposition to the emptying of the chamber. The 
 systematic exercise of the heart's action keeps the organ 
 in a healthy condition. A cessation of systematic exer- 
 cise tends to diminish the vigour of the organ and even 
 to produce atrophy of its active tissues. An increase 
 in the exercise tends to produce an increase in vigour 
 and an increase in the active tissues, so that, within 
 certain limits, we may speak of a physiological hyper- 
 trophy, meaning thereby a state comparable to the large 
 muscles of a blacksmith's arm. In such cases bear in 
 mind that hypertrophy is moderate in degree and that 
 we can no more get an abnormal hypertrophy of the 
 heart than we can get an abnormal expansion of the 
 biceps as the result of exercise. I make this remark 
 because there are certain terms, often used, which are
 
 AFFECTIONS OF MYOCARDIUM 133 
 
 misleading, such as that of "athlete's heart." This 
 term, I understand, is intended to denote an abnormally 
 hypertrophied organ. Personally, I have never seen 
 such a thing ; and when my opportunities of observation 
 are considered, I think it will be allowed that I would 
 have seen it if it had really existed. I have, on the 
 other hand, seen many cases that were called " athlete's 
 heart," but a careful examination of them invariably 
 revealed other conditions which had been erroneously 
 attributed to the athletics. 
 
 Morbid Hypertrophy. 
 
 Setting aside, then, the hypertrophy which is physio- 
 logical, I am of opinion that all other forms of hyper- 
 trophy invariably occur as a consequence of some morbid 
 condition obstructing the work of a chamber of the 
 heart. The most extreme forms of hypertrophy are 
 found with aortic regurgitation and adherent peri- 
 cardium. There is something peculiar in the hyper- 
 trophy of aortic regurgitation, for though the muscle 
 wall undoubtedly increases greatly in thickness, I am 
 not quite clear in my mind that the hypertrophy is an 
 increase of healthy muscular tissue. In aortic regurgita- 
 tion, if my doubts are justified, it is not therefore the 
 obstruction to the output alone which causes the hyper- 
 trophy, for in aortic stenosis with no regurgitation, or 
 with only a slight amount of regurgitation, we never 
 see the same degree of hypertrophy. It is possible that 
 the dynamic effect of the regurgitating blood may par- 
 ticipate in the production of this hypertrophy, yet, so 
 far as I have looked into the subject, I have not found 
 any constant correspondence between the degree of 
 hypertrophy and the extent of the aortic leak. More- 
 over, the muscle itself is often so manifestly inefficient 
 that one cannot but suspect that the hypertrophy is not 
 genuine, even though the microscope reveals nothing but 
 apparently normal muscular fibre. On this point, 
 indeed, I cannot see a clear issue ; I merely direct your
 
 134 AFFECTIONS OF MYOCARDIUM 
 
 attention, therefore, to an obscure condition in heart 
 affairs. 
 
 The same unsatisfactory conclusion is reached in re- 
 gard to the hypertrophy of adherent pericardium. An 
 adherent pericardium does not necessarily cause hyper- 
 trophy, because one often finds an adherent pericardium 
 on the post-mortem table when there is little or no 
 increase in the size of the heart. On the other hand, if 
 the pericardium is more or less fixed to the chest wall, 
 in front to the ribs and behind to the spinal column — 
 e.g., in adhesive mediastinitis — then the hypertrophy 
 may be enormous. To a certain extent this hypertrophy 
 can be attributed to the fact that the muscle of the 
 ventricle has to drag in the ribs during systole ; but I 
 have found remarkable hypertrophy in cases of adherent 
 pericardium of rheumatic origin when there was no 
 attachment to the chest wall. In these cases, I fancy, 
 there has been some myocardial condition favouring an 
 increase in the muscle wall, but I have not been able to 
 demonstrate it. 
 
 Very big left ventricles are often found in kidney 
 disease and in cases with persistent high blood-pressure. 
 In these cases, no doubt, the arterial resistance is an 
 agent in the production of the hypertrophy; yet it is 
 not clear that it is the only agent. The conditions that 
 affect the peripheral blood vessels affect also those of 
 the heart itself, and thus, it may be, damage the muscle 
 fibres. At all events, I have been struck by the 
 post-mortem appearance of a number of my cases. These 
 hearts have shown, towards the apex, large areas con- 
 taining but few muscle fibres and a great amount of 
 fibrous tissue. The muscle must in these have been 
 seriously impaired years before the final breakdown. 
 
 Compensation and the significance of hypertrophy. 
 
 In dealing with the significance of special hyper- 
 trophies you must consider them along with the lesion 
 producing them as in valvular diseases. Here I want
 
 AFFECTIONS OF MYOCARDIUM 135 
 
 merely to point out that hypertrophy, due to any 
 morbid cause, invariably indicates an inefficient heart. 
 I want you to grasp this, as there has come into 
 use a term which is often used in a manner distinctly 
 misleading. I refer to the term " compensation." 
 The use of this term is characteristic of much that 
 is vague and unscientific in medicine. Even those 
 who use it never explain what they mean. Thus, 
 we will find an individual with a murmur described as 
 having a " mitral leak with good compensation," 
 although his heart is perfectly normal and physiological 
 in every respect. A patient with orthopncea and dropsy 
 from heart-failure is spoken of as being in a state of 
 " decompensation," and when the dropsy has dis- 
 appeared and the patient can lie down " compensation " 
 is said "to be restored." I have even known a dis- 
 tinguished professor of medicine rejoice the heart of a 
 man with aortic disease, who could not walk one hundred 
 yards without being pulled up by pain, by telling him 
 that his outlook was good as there was no dropsy, and, 
 therefore, compensation was good ! Yet this man died 
 shortly after from heart-failure, and no dropsy ever 
 appeared. 
 
 If a patient has hypertrophy which is not physiological 
 his power of response is limited ; if this fact be recog- 
 nised when there is, happily, a fair response to moderate 
 effort and the individual instructed as to his limitation 
 and told only to take such exercise as gives him no 
 distress, a fair prospect presents itself. The trouble is 
 that these patients think their limitations correspond 
 to those of healthy people, and so try to lead the lives 
 of healthy people, with the result that, instead of recog- 
 nising the sensations indicating their limitations, they 
 put them aside, too often with disagreeable results. 
 
 Myocardial Degeneration. 
 
 It is not necessary to point out that with advancing 
 years changes occur in the myocardium as in all other
 
 136 AFFECTIONS OF MYOCARDIUM 
 
 tissues, impairing the heart's efficiency. These changes 
 have probably been set up in early or middle life by 
 acute affections (as rheumatic fever) which have given 
 rise to no physical sign. It is possible that, as extra 
 systoles become more frequent in the later years of life, 
 they are produced by some obscure changes in the heart 
 muscle. It is also possible that these changes are 
 accountable for a large proportion of cases of new 
 rhythm — such as auricular fibrillation or auricular flutter 
 — which appears either at occasional periods (paroxysmal 
 tachycardia) or persistently. Apart from these pheno- 
 mena there is usually no physical sign of myocardial 
 change beyond an occasional increase in the size of 
 the heart; the most striking — often, indeed, the only — 
 evidence is the limited response to effort. 
 
 There is a group of cases — patients who begin to ex- 
 hibit their symptoms just before, at, or just after, sixty 
 years of age — in which the symptoms are so marked and 
 so manifestly the outcome of myocardial degeneration 
 that they deserve special attention. The most typical 
 cases of this group are those with chronic Bright 's disease 
 when heart-failure is the cause of the more prominent 
 symptoms. Dyspnoea, in these cases, is readily pro- 
 voked by effort, and Cheyne-Stokes respiration and 
 attacks of cardiac asthma are not infrequent. Pain is 
 sometimes provoked by exertion, and in the later stages 
 the attacks become typical of angina pectoris. 
 
 Myocardial exhaustion is accompanied by other signs. 
 The arteries are often thickened and the blood-pressure 
 high ; and the heart is enlarged — the apex being thrust- 
 ing and forcible and situated outside the left nipple line. 
 The heart's sounds are often muffled ; sometimes there is 
 a well-marked systolic murmur. The rhythm of the 
 sounds is frequently of that triple character — " the 
 gallop rhythm." The cause of this gallop rhythm 
 seems to be a lack of synchronism in the contractions 
 of the ventricles. In some of my cases Dr. Lewis has 
 taken electro-cardiographic records and has demon-
 
 AFFECTIONS OF MYOCARDIUM 137 
 
 strated that there is a slight delay in the contraction of 
 the right ventricle due to damage of the right branch 
 of the auriculo-ventricular bundle. There is also some- 
 times a delay in the transmission of the stimulus from 
 auricle to ventricle. The rhythm of the heart is often 
 quite regular, but frequently we meet with extra systoles 
 and the pulsus alternans. Dropsy gradually occurs and 
 may become very extensive. 
 
 This description, though typical of chronic Bright's 
 disease, is also characteristic of cases that have never 
 shown albuminuria — though albuminuria may appear at 
 their later stages. 
 
 These cases usually drift and die, treatment being of 
 little benefit. 
 
 The post-mortem examination of some of these cases 
 has revealed extensive fibrosis of the heart muscle.
 
 CHAPTER XVII 
 
 HEART IRREGULARITIES 
 
 The Meaning of Irregular Action of the Heart; The 
 Youthful Type of Irregularity ; The Adult Type of 
 Irregularity (Extra Systoles) ; The Pulsus Alternans 
 
 Irregular action of the heart is of very frequent occurrence and 
 throws a flood of light upon the mechanism of the heart- 
 beat. 
 
 In my early days in practice, while carrying out close 
 observations on many cases, I was struck with the fre- 
 quency of irregular action of the heart at all periods of 
 life. When I recollected what I had been taught con- 
 cerning this condition I found that, apart from some 
 vague incidental reference to it, I had never heard a 
 word spoken which might direct attention to the different 
 forms, their mode of production, and their significance. 
 Even the text-books of the day forbore mentioning the 
 matter, save for a passing reference to an " irregular " 
 heart. The writings of the greatest masters slurred over 
 the subject ; and to many, even at this day, the whole 
 accumulated knowledge possessed by the profession is 
 expressed in Broadbent's book on "The Pulse," pub- 
 lished in 1890. It might be worth your while to read 
 this book and compare the knowledge possessed by that 
 able and distinguished clinician with the knowledge con- 
 tained in some book written in recent years by a 
 physician familiar with the present-day aspects of the sub- 
 ject. I have little hesitation in saying that in no other 
 
 .38
 
 HEART IRREGULARITIES 139 
 
 department of medicine has advance in general know- 
 ledge of an important subject been characterised by such 
 wonderful strides. 
 
 The due appreciation of irregular action of the heart 
 has thrown a flood of light on the physiology of the 
 heart ; brought before us, with precision, diseases of the 
 heart the origin and manner of which had hitherto been 
 shrouded in impenetrable darkness ; given us a new 
 conception of how drugs affect the heart beneficially, 
 and enabled us to administer drugs with a scientific 
 precision undreamed of before. The differentiation of 
 irregular actions into groups, based on physiological 
 principles, has given us further the basis for a sound 
 prognosis. 
 
 The real significance of irregular heart action has not been 
 
 recognised. 
 
 Although so little has been said about irregularities 
 by teachers and writers, the subject itself has by no 
 means been ignored in practice. So ingrained had the 
 belief become that a heart to be normal must be regular, 
 that when an irregular heart was met with it was looked 
 upon with suspicion ; and many individuals, with per- 
 fectly sound hearts, have been rejected for life insurance 
 and for appointments in military and civil life because 
 of the presence of some innocuous irregularity, while 
 tens of thousands have had their lives restricted and 
 have been subjected to prolonged and useless treatment 
 for a condition that called for no treatment. On the 
 other hand, cases where the irregularity should have 
 revealed the necessity for treatment were never properly 
 understood and so were never properly dealt with. 
 
 You may think my language extravagant ; but if you 
 only consider how, at this moment, many a physician 
 of good standing would act towards an individual with 
 an irregular heart whom he was examining for life 
 insurance, you will scarcely, I think, blame me. Would 
 the physician accept, reject, or accept with an increase
 
 140 HEART IRREGULARITIES 
 
 of premium ? Strong statement as it may seem, I have 
 a shrewd suspicion that, no matter which course he took, 
 he could not give rational grounds for his action. Not 
 long ago an eminent physician stated that my investiga- 
 tions into the meaning of irregular action of the heart 
 revealed nothing new ; he and his colleagues understood 
 perfectly well all the essential matters concerned with 
 irregular action. Within a few weeks, as it happened, 
 my opinion was asked regarding the irregular heart of a 
 girl whom this physician had ordered to stay away from 
 school for three months. The order had been given 
 wholly on account of the irregular action. Yet, in my 
 view, this condition, far from being a sign of heart 
 trouble, was, in the girl's case, a sign that the heart 
 was free from trouble. A short time ago I took part 
 in a discussion on prognosis in heart affections at a 
 Society of Life Insurance physicians. I found the idea 
 prevalent that a man with an irregular heart should 
 either be rejected or have his premium increased. No 
 attempt was made to differentiate the types of irregu- 
 larity ; and the necessity of carrying out a differentiation, 
 when it was insisted upon by me, was regarded sceptic- 
 ally by some speakers. In other words, it became clear 
 that the element of pure guess-work was strongly pre- 
 valent. I put the matter in this way because I find 
 that it is impossible for the average physician to realise 
 how great an amount of information may be obtained 
 from a thorough appreciation of irregular action of the 
 heart. 
 
 To appreciate the meaning of heart irregularities, careful 
 differentiation had first to be made, followed by prolonged 
 observation of individuals. 
 
 As I wish you to perceive and understand what 
 research in medicine really means, or, at all events, 
 what is my conception of its meaning, I will cite to you 
 briefly the steps which led to my present knowledge 
 of the subject of irregular action of the heart, so that you
 
 HEART IRREGULARITIES 141 
 
 may appreciate the grounds on which I came to the 
 conclusions I put before you. 
 
 In my early attempts to understand the reasons for 
 my patients' complaints I endeavoured to unravel the 
 meaning of such phenomena as I did not understand. 
 Thus, one sign that I frequently met puzzled me, 
 namely, the movements in the jugular veins. I was 
 profoundly ignorant of the subject, but it was evident to 
 me that no advance could be made until the waves in 
 the vein were recorded in some manner or other. After 
 much labour I devised a method by which the move- 
 ments of the veins could be conveyed along a tube to a 
 tambour. By attaching the tambour to a Dudgeon 
 sphygmograph I was able to register the movements of 
 the jugular vein on the same paper and at the same time 
 as the sphygmograph lever recorded the radial pulse. In 
 this simple manner I was able, by comparing the beats 
 of the radial pulse with the movements of the vein, to 
 place all these movements in their appropriate places in 
 the cardiac cycle, and so distinguish the force that gave 
 rise to any particular wave or depression. I was then 
 able to detect the movements of the right side of the 
 heart on a tracing which also gave the movements of 
 the left ventricle (radial pulse). 
 
 While making the observations as to the nature of 
 the jugular pulse I frequently came upon people with 
 irregular hearts, and as these irregularities had for a 
 long time been a puzzle to me, it struck me one day 
 that I had better see what the nature of the movements 
 in the jugular vein were at the time the heart was acting 
 irregularly. I had no suspicion, when I did this, what 
 the outcome of the investigation would be, but I soon 
 found that it gave me a new and unexpected field for 
 observation. I found, very soon, that in some irregu- 
 larities all the chambers of the heart participated, that 
 in others the auricles beat regularly while the ventricles 
 acted irregularly, and that in others the auricles ceased 
 to act. Again, I found that the auricles might act more
 
 142 HEART IRREGULARITIES 
 
 frequently than the ventricles and that the time between 
 the contractions of the auricles and the contractions of 
 the ventricles might be increased. Although these 
 things are quite clear now, twenty-five years ago no one 
 suspected them to exist. I remember very well the first 
 occasion on which I detected an irregularity of the radial 
 pulse and apex-beat while the auricular systole was per- 
 fectly regular — the first occasion, that is to say, on 
 which the nature of a ventricular extra systole was 
 demonstrated in the human heart. Though now this 
 fact is merged into everyday knowledge and the manner 
 of its discovery has become of no importance whatever, 
 I mention it because of the glow of delight which I felt 
 on perceiving the nature of the irregularity ; for it is by 
 the lifting of the fringe of Nature's curtain that the 
 inquirer feels so bountifully rewarded for endless trouble 
 and toil. 
 
 Since that time many workers have laboured in this 
 field and other methods have been employed. Many 
 have found the irregular heart a fascinating and instruc- 
 tive study. But, notwithstanding its fascination, and 
 notwithstanding the profound knowledge of the heart's 
 action that has been acquired, the part of the work 
 which has revealed the mechanism of irregular heart 
 is but preliminary. The real work only begins after 
 the physiology has been worked out, and the guide to 
 the further research is found in the question : What 
 happens to the people who show these irregularities ? 
 
 The answering of this question necessitated a long 
 and weary pursuit, a pursuit brightened, nevertheless, 
 from time to time by the discovery of some new fact. 
 Great numbers of patients had to be followed during 
 many years, and close observations regarding the manner 
 in which they bore the stress and strain of life, in acute 
 illnesses and in laborious occupations, had to be made. 
 The changes, too, that occurred in the heart itself as 
 time went on had to be recognised. Large numbers of 
 cases were essential to the work, for by this means only
 
 HEART IRREGULARITIES 143 
 
 could one find the age incidence of the different forms 
 of irregularity and thus determine whether or not ante- 
 cedent illnesses, such as rheumatic fever, had any 
 bearing on the causation of any particular irregularity. 
 
 The great majority of irregular actions of the heart are of two 
 kinds, one which occurs in youth, and the other which 
 occurs in adult life 
 
 Proceeding on these lines, after I had collected over a 
 thousand cases I sought for some definite basis of classi- 
 fication. With the assistance of the jugular pulse I was 
 able to recognise different forms according to the 
 mechanism of their production. Two large groups, 
 which included, between them, about 90 per cent, of all 
 the cases, emerged distinctly. These two groups 
 differed. In one all the chambers of the heart partici- 
 pated in the irregularity, the contraction in each case 
 being normal, while, in the other, the ventricle con- 
 tracted prematurely while the auricle maintained its 
 rhythm, or both auricle and ventricle contracted pre- 
 maturely — the irregularity which is now called the ven- 
 tricular and auricular extra-systole. 
 
 I was also able to separate the two groups by a second 
 method, namely, the age incidence. I found that the 
 former group occurred predominantly in the young (" the 
 youthful type of irregularity ") and that the latter group 
 occurred predominantly in the later decades of life (" the 
 adult type of irregularity "). 
 
 This classification into youthful and adult types does 
 not find favour with the great majority of writers, who 
 prefer to recognise the groups by the names which indi- 
 cate their mechanism. As a rule, it is a matter of 
 indifference what name you use so long as the name 
 is understood ; the reason I am about to employ this 
 clinical nomenclature, instead of the physiological one, 
 is that the names — youthful type and adult type — carry 
 a meaning which will be of great value to you in your 
 practice.
 
 144 HEART IRREGULARITIES 
 
 The Youthful Type of Irregularity. 
 
 In the youthful type of irregularity all the chambers of the 
 heart participate, and it is present in perfectly healthy 
 hearts. 
 
 The individual showing it is never conscious of the 
 presence of this irregularity. You can recognise it best 
 by listening to the heart, as the ear can detect varia- 
 tions in the rhythm better than the ringer. As a rule 
 the heart will be found to vary in rate, a slight increase 
 occurring during inspiration and a slowing during ex- 
 piration (sometimes, therefore, called respiratory irregu- 
 larity). Sometimes it is not possible to make out the 
 
 ** n — r i ii i ■ 1 1 ii ii 1 1 ii» ii i ■ ii nn pi n im wui^w»ii » i ' 
 
 Ra.cCca.1. 
 
 Fig. 9. 
 
 Youthful type of irregularity showing respiratory variations. — diminished 
 rate during expiration and an increased rate during inspiration — ■ 
 more marked with deep breathing. (See Fig. 10.) 
 
 relation to the respiration very distinctly, but if you 
 ask the patient to breathe slowly and deeply, then it 
 becomes easy of recognition. I want you to bear this 
 in mind because, when you are puzzled as to the nature 
 of an irregularity in the young, this simple procedure 
 will at once set you right (Figs. 9 and 10). There are a 
 few cases in which the heart slows for short periods, 
 but in which its rhythm does not show this relation to 
 respiration. The immediate cause of this irregularity 
 is vagus stimulation — the act of breathing being suffi- 
 cient to stimulate the vagus which, acting on the sino- 
 auricular node, causes a transient slowing of the whole
 
 HEART IRREGULARITIES 145 
 
 heart (hence also sometimes called vagus or sinus 
 irregularity). 
 
 A slight form of this irregularity has been detected in 
 infants. It becomes most marked at the periods of life 
 when the heart-rate tends to fall from the rapid rate 
 associated with infancy, i.e., between the ages of five 
 and ten. It is often well marked about puberty and 
 may last until thirty years of age or after. I have not 
 followed cases with sufficient care to find out when it 
 disappears, but it becomes rare towards thirty. Certain 
 neurotic individuals may show it late in life. The period 
 when it is most marked is after the subsidence of some 
 febrile condition, and you can easily understand how an 
 imperfect knowledge of this irregularity causes many 
 
 A*d'*l- 
 
 Fig. 10. 
 
 Continuation of Fig. 9 when the patient breathed deeply and slowly. 
 The increase in rate during inspiration, and decrease during 
 expiration, is well marked. 
 
 physicians to imagine that it is a sign of gravity when 
 it occurs after rheumatic fever, measles, diphtheria, or 
 influenza. In some healthy young fellows it is very 
 marked when they are at rest, and especially after some 
 fatiguing exercise. 
 
 Considering its great frequency and the fact that it 
 may be very well marked it is astonishing that so little 
 attention has been paid to it by physicians. In large 
 text-books, even in those dealing with children's 
 diseases, it may never be mentioned. In fact, the only 
 article I have found dealing with it is one by Corrigan, 
 written more than fifty years ago; in this article it is 
 
 L
 
 146 HEART IRREGULARITIES 
 
 imperfectly described and looked upon as an evidence 
 of impairment of the heart, if not of disease. When I 
 have directed attention to this irregularity I have not 
 infrequently been told that everybody knows all about 
 it; but I find from experience that most people look 
 upon it as something wrong. The first consultation I 
 had in London was on a young girl who showed this 
 irregularity. She lived in the country, and one day 
 she fainted. A physician from London was summoned 
 to see her. He found her heart very irregular and he 
 had her conveyed to London with the greatest care. 
 She was put through a course of Nauheim baths and 
 some form of exercises, but still the heart remained 
 irregular. She was then put through another course, 
 with no better result. When I saw her she had been 
 three months in bed. Yet her heart was perfectly sound 
 and had only this well-marked youthful type of irregu- 
 larity. It was this irregularity which had frightened the 
 physician. Some six years ago a lad of sixteen was 
 brought to me because he was supposed to have an in- 
 curable affection of the heart. Two years before I saw 
 him he had had a febrile attack while at a public school, 
 and after the fever subsided his heart was found to be 
 irregular. He was treated at school for a period with 
 no success. He was then removed to London and again 
 treated for some months. He was next taken to Paris 
 to a reputed authority and treated by that authority, 
 but with no success. Finally he was taken to another 
 place on the Continent where was a physician famed for 
 his cures by injections of spartin and strychnine and 
 other drugs. Still no result followed, and the physician 
 informed the sorrowing parents that the heart was per- 
 manently and incurably affected and that the boy must 
 lead a very quiet life, play no games, and avoid all 
 violent exertion. He had been leading this miserable 
 existence for a year before I saw him, yet when he was 
 brought to me all that was present was a very well- 
 marked youthful irregularity. The boy was told at once
 
 HEART IRREGULARITIES 147 
 
 to begin leading the life of a healthy youth. He did 
 so, and is to-day a stalwart, vigorous, healthy young 
 man. 
 
 You will see from this that I look upon the youthful 
 irregularity as a physiological sign and not as evidence 
 of impairment of the heart. Far less do I look upon it 
 as evidence of disease of the heart. The observations 
 on which my view is based extended over a great number 
 of cases. Having detected the irregularity in young 
 men I have submitted them to no treatment. Yet they 
 indulged in vigorous games and afterwards led laborious 
 lives or engaged in occupations needing the exercise of 
 great muscular strength. I have seen girls, in whom 
 I detected the irregularity, grow up, marry, and have 
 children. In not one of these cases have I ever seen 
 the slightest sign of heart-failure. 
 
 The presence of the youthful type of irregularity after a febrile 
 illness may be taken as an indication that the heart has 
 escaped infection. 
 
 There is another aspect of this irregularity to which I 
 wish to direct your attention. It is one which raises a 
 question that I have been unable to answer definitely. 
 As I have said, the irregularity appears most markedly 
 after a febrile attack, while, on the other hand, any 
 circumstance which increases the rate of the heart causes 
 it to disappear. After an acute febrile attack, such as 
 rheumatic fever, there may be some doubt as to whether 
 the heart has escaped infection. It occurred to me over 
 a dozen years ago to inquire whether the presence of 
 this irregularity might not be taken as an evidence that 
 the heart had escaped infection. I had reasoned that 
 the young heart showed this irregularity because the 
 muscle was fresh and healthy and susceptible to the 
 slightest stimulation. The disappearance of the irregu- 
 larity, with increase in rate by fever, showed that the 
 weak stimulus from the vagus was ineffective during the 
 
 l 2
 
 148 HEART IRREGULARITIES 
 
 time that febrile irritation was present ; but the vagus 
 stimulation reasserted its sway when the irritation was 
 removed. I reasoned that the presence of an active pro- 
 cess in the heart, such as that occurring in acute 
 rheumatism, would prevent the appearance of this 
 irregularity by irritating the organ, and hence that the 
 reappearance of the irregularity must indicate that the 
 heart had become free from the irritating rheumatic poison 
 or infection. I have, as I have stated, been putting my 
 theory to the test, and so far I have not come across a 
 single exception. Bear in mind, however, that I only 
 put this theory forward in respect of cases where the 
 irregularity is well marked, and where, at the same time, 
 the pulse-rate has fallen below 70 or 80. Let me add 
 that even when there has been present a distinct systolic 
 murmur, which may have appeared during the febrile 
 attack, I have taken the irregularity as an evidence that 
 the heart has escaped. 
 
 A few years ago I was asked to see a lad who had just 
 recovered from a mild attack of rheumatic fever. While 
 the patient was still in bed his doctor recognised the 
 onset of a marked irregular action of the heart. There 
 was present also a soft systolic murmur. The doctor 
 feared that an endocarditis was present, and a consult- 
 ing physician, who was called in, concurred in this fear. 
 The lad was therefore ordered to be kept on his back 
 for from six weeks to two months. A week later I was 
 asked to see him and I found him feeling well. His 
 temperature was normal, his heart-rate about 70, the 
 rhythm showed a characteristic irregularity of the youth- 
 ful type ; the heart itself was normal in size, and a soft 
 systolic murmur was audible. I said that the heart 
 had escaped all damage and that there was no endo- 
 carditis. I advised that the patient should get up. 
 The event justified this view; the lad is now well, 
 strong, and fit. 
 
 The irregularity of the youthful type may be present 
 m old valvular affections and can then be accepted as
 
 HEART IRREGULARITIES 149 
 
 an indication that there is no active process going on 
 in the heart. I leave the matter there for the present, 
 trusting that some of you may remember this expression 
 of my opinion and may be able, after ten or twenty 
 years, either to support or disprove it, or to show its 
 limitations. 
 
 The Adult Type of Irregularity (the Extra-Systole). 
 
 The extra-systole is rare in the young, but increases in frequency 
 
 with advancing years. 
 
 Until I began to search systematically for it I had no 
 idea of the frequency of what is called the intermittent 
 pulse. I found, on taking tracings as opportunity 
 offered, that this irregularity was present in 50 per cent, 
 of perfectly healthy, pregnant women. I next con- 
 sidered the age incidence and found that the condition 
 was infrequent before puberty, more frequent between 
 thirty and forty, and that it occurred with increasing 
 frequency from the latter age until after sixty. Prac- 
 tically every healthy individual over sixty whom I had 
 the opportunity of examining at frequent intervals had 
 it. It was for this reason that I called it the adult 
 type of irregularity. 
 
 The recognition of this irregularity is very easy in 
 the majority of cases. There is a small premature beat 
 of the ventricle which is not always perceptible to the 
 finger and which thus gives rise to the impression that 
 the heart is intermittent (Fig. 11). If, however, the 
 heart be auscultated, two short, sharp sounds will be 
 heard during the early portion of the pause (Fig. 12). 
 These sounds are produced by the premature beat or 
 extra-systole. In some cases there can only be detected 
 one low muffled beat, and in a few cases no sound can 
 be detected at all. In these latter there may be some 
 difficulty in differentiating the extra-systole from the 
 dropped beat of heart-block, but the latter condition is
 
 150 HEART IRREGULARITIES 
 
 rare and is usually associated with manifest signs of 
 heart weakness. 
 
 The patient's sensations are important for the diagnosis. 
 
 The patient's sensations are often a very good guide 
 and they may vary very much. Some patients are quite 
 unaware of the irregular action, others are conscious of 
 the pause, while others are distressed by the big beat 
 that follows the pause. Some have a transient sensa- 
 tion of fullness in the region of the heart, while others 
 have a suffocating feeling in the throat and may give 
 a short cough. You should make yourselves familiar 
 with these sensations, because in many cases the irregu- 
 
 FlG. 11. 
 
 The smaller beats are premature and due to extra-systoles. 
 
 I » * 2 • 2 j IP I B 
 
 TrriTi.. "rri 
 
 Fig. 12. 
 
 Diagram representing the sounds of the heart with an occasional extra- 
 systole — two short, sharp sounds occurring prematurely and followed 
 by a pause longer than the normal interval between the second and 
 first sounds. The downstrokes 1, 2 represent the first and s«cond 
 sounds of the heart. 
 
 larity is not present when you examine the patient. 
 Moreover, the consciousness of the presence of the sen- 
 sations often fills the patient with fear, and therefore it 
 is necessary to understand the causes of these terrifying 
 feelings. The feelings may come on only at infrequent 
 intervals, as, for example, after a full meal; or they 
 may occur in the night, or they may be present at 
 irregular, short intervals. Often they occur regularly 
 after one (pulsus bi-geminus, Fig. 13), two, three or four
 
 HEART IRREGULARITIES 
 
 J 5i 
 
 normal beats. The peculiar sounds, while the pulsus 
 bi-geminus is present, are shown in Fig. 14. 
 
 Apart from the worry and fear which it occasions, the extra- 
 systole is of little significance. 
 
 The real matter which concerns us as clinicians is the 
 effect which this irregularity has on the patient's mind. 
 The peculiar sensations connected with it, such as con- 
 sciousness of the pause in the ventricular contraction, 
 give the victim the idea that his heart may stop 
 altogether, while the big beat worries him, especially 
 in the night. His anxiety may be added to by the 
 doctor's uncertainty and by his failure to cure the 
 trouble. A friend of mine, whose wife was being treated 
 at Nauheim, was once much upset at that place by 
 
 V 
 
 Fig. 13. 
 
 Pulsus bi-geminus due to an extra-systole occurring after each normal 
 
 beat. 
 
 1 2 
 
 2-?_ 
 
 1 2 
 
 LLL 
 
 i_2_ 
 
 ^H * * 12 
 
 1 s 
 
 II 
 
 li 
 
 Fig. 14. 
 
 Diagram representing the sounds of the heart in a case of pulsus 
 
 bi-geminus as in Fig. 13. 
 
 being told that his heart was " affected " when he had 
 casually suggested that he should have one of the baths 
 himself and had submitted to examination as a pre- 
 liminary. The doctor felt his pulse, assumed an air of 
 great gravity, declared that the heart was " bad," and 
 insisted on his taking a " cure." When my friend 
 returned home I had some little difficulty in restoring 
 his confidence in himself, for the treatment had had no
 
 152 HEART IRREGULARITIES 
 
 effect on the irregularity, and he kept feeling his pulse 
 for the intermission. That is over twelve years ago, 
 and he is quite well to-day, although the pulse still 
 shows these intermissions at times. Fear of this kind 
 will cause strong, healthy men to put themselves to 
 any amount of trouble in order to " get cured." A man 
 consulted me some six years ago because of an inter- 
 mittent heart. When he sat down I noticed that his 
 right hand instinctively sought his left wrist and that a 
 finger was kept on his pulse. I knew at once what I 
 had to deal with. His story was this : His doctor, in 
 one of the Western States of America, had found his 
 heart irregular, and, being unable to cure him, had 
 sent him to a celebrated physician who had treated him 
 for some weeks with no improvement. He next went 
 to New York and was again treated by a distinguished 
 physician without result ; then he was recommended to 
 go to Nauheim. On his way through London he con- 
 sulted me, and, on inquiry, I found that his whole 
 trouble was due to the consciousness of these extra- 
 systoles. I asked him when he could get a ship back 
 to America, and he said in four days. I told him to 
 take it, get back to his work, and never feel his pulse 
 again. This he did, and I heard from him lately to 
 the effect that he was in good health. When he had too 
 much office work he was still conscious of the inter- 
 missions, but when he took an active holiday in the 
 woods, hunting and shooting, the intermissions dis- 
 appeared. 
 
 While some people have these extra-systoles perman- 
 ently during many years, most people have them only 
 at intervals ; in some cases circumstances can be found 
 which provoke the extra-systoles— for example, indul- 
 gence in tobacco or alcohol. Certain articles of food, 
 such as tea and coffee, may provoke them, while mental 
 worry and sleeplessness have the same effect. On the 
 removal of these provoking causes the extra-systoles 
 may disappear, but they always tend to return, and in
 
 HEART IRREGULARITIES 153 
 
 the later years of life they become more and more 
 persistent. 
 
 In many people, in whom extra-systoles are constantly 
 present, they disappear during a febrile illness. 
 
 Prognosis. 
 
 Seeing that healthy men and women may present this 
 form of irregularity, it can be accepted that extra- 
 systoles, in themselves, are not indications of disease 
 or of impairment of the heart's efficiency. When there 
 are signs of heart-failure the prognosis should be based 
 upon the other symptoms present and not on the pre- 
 sence of the extra-systole. 
 
 It may therefore be stated that, when the extra- 
 systole is the only abnormal sign, the prognosis is good, 
 and when it is associated with other signs the prognosis 
 should be based on these other signs. 
 
 Where I have not yet been able to see my way clearly 
 is in regard to the meaning of extra-systoles in acute 
 affections. Thus, during an attack of rheumatic fever, 
 or shortly after the subsidence of the fever, extra- 
 systoles may appear. Whether they indicate that the 
 disease has invaded the muscle I do not know, as I 
 have not been able to follow up a sufficient rtumber of 
 cases to comprehend their relation clearly. In a few 
 cases their presence was coincidental with an affection of 
 the heart. Similarly, in acute affections, such as pneu- 
 monia, their sudden appearance has frequently been 
 heralded as indicating a very grave condition ; but John 
 Hay says he has noted their appearance in pneumonia 
 without any dangerous result. 
 
 The Pulsus Alternans. 
 
 Of the rarer forms of irregularity the pulsus alternans 
 stands out because of its prognostic significance. It is 
 rarely possible to detect it by the finger or by ausculta- 
 tion, but its presence is revealed by graphic records of 
 the radial pulse. The fact that the force of the larger
 
 154 HEART IRREGULARITIES 
 
 beats in the arteries is greater than the smaller beats 
 affords us an opportunity of detecting the presence of 
 the pulsus alternans by a simple method. On page 206 
 I describe how to take the blood-pressure by the 
 auscultatory method, where the armlet is distended 
 until the artery is obliterated. On listening with the 
 stethoscope at the bend of the elbow, when the pressure 
 in the bag is gradually released, the returning blood 
 wave in the artery under the stethoscope shows its 
 presence by a sound. When the pulsus alternans is 
 present this sound is only half the rate of the heart 
 at first, but when the pressure falls another five or 
 ten m.m. Hg., the weaker beat comes through, and one 
 can detect then a sound accompanying each beat of 
 the heart. At first the beats will be unequal in volume, 
 but as the pressure falls lower they become equal. 
 The distinction can also be made betwixt the pulsus bi- 
 geminus, where the smaller beat is due to extra-systoles, 
 by the fact that when all the beats are heard the sounds 
 are perfectly regular in the case of the pulsus alternans, 
 whereas there is always a delay after the weaker beat 
 in the pulsus bi-geminus, agreeing thus with the char- 
 acteristic features of Figs. 13 and 15. 
 
 As a rule, when the pulsus alternans is present, there 
 are no changes in the sounds of the heart, but occasion- 
 ally I have found, when there was a musical murmur 
 present at the aortic area, that this musical sound varied 
 in intensity with the large and small beats. 
 
 The pulse beats are usually perfectly regular in 
 rhythm, but the beats regularly vary in size — a big 
 beat and a small one alternating (Fig. 15). Some- 
 times the variation in size is very slight and only 
 brought out after an extra-systole. This appearance 
 after an extra-systole is a very instructive feature, for 
 in many cases there would be no evidence of this ten- 
 dency otherwise. 
 
 There are two conditions in which this arrhythmia 
 tends to appear : (1) during an attack of paroxysmal
 
 HEART IRREGULARITIES 155 
 
 tachycardia (as auricular flutter) ; and (2) when there 
 are degenerative changes in the heart muscle, producing 
 exhaustion. It is in this latter condition that it is an 
 evidence of gravity. There are always other evidences 
 present, the heart being generally increased in size, and 
 a great limitation of the reserve force, as shown by 
 dyspnoea on the slightest exertion, while there may be 
 attacks of angina pectoris and cardiac asthma. Asso- 
 ciated with these symptoms it invariably indicates an 
 incurable exhaustion, and not infrequently it heralds a 
 fatal termination within a short period. Occasionally 
 it is detected before the exhaustion is so extreme, and, 
 with rest, a certain degree of recovery may take place 
 
 Fig. 15. 
 
 Radial tracing showing the pulsus alternans. Each period is of exactly 
 the same duration (six-tenths of a second). Compare with Fig 13. 
 
 and the individual may lead a life, somewhat restricted, 
 for an indefinite period. 
 
 In paroxysmal tachycardia it is not of such grave 
 significance. It is probably due to the temporary 
 exhaustion of the ventricular muscle in consequence of 
 the long-continued increase in rate. 
 
 I have detected it in a few cases of pneumonia, 
 and all proved fatal, but the number has been too 
 few for me to say that it is always of such grave 
 import. 
 
 On rare occasions the alternating beats have been 
 noted during a temporary exhaustion of the heart, and 
 even when there has been only slight heart-failure, and 
 it did not seem to have a grave significance. It is there-
 
 156 HEART IRREGULARITIES 
 
 fore of grave significance only when it is associated with 
 other signs of exhaustion. 
 
 This abnormal rhythm must not be confused with the 
 pulsus bi-geminus — which owes its peculiar rhythm to 
 the alternation of a normal beat with an extra-systole 
 (compare Fig. 13 and Fig. 15).
 
 CHAPTER XVIII 
 
 AURICULAR FIBRILLATION 
 
 The recognition of auricular fibrillation opens up a new era in 
 the study of affections of the heart. 
 
 As years pass and my knowledge of affairs connected 
 with the heart increases, I am more arid more impressed 
 with the great importance of the condition which, of 
 late, has been termed auricular fibrillation. The value 
 of the work devoted to the study of this condition does 
 not consist merely in the ability we now possess to 
 recognise it, but rather in the light thrown upon the 
 heart's varied activity and upon its failure by the study 
 of the life-history of our patients. The recognition of all 
 the facts connected with auricular fibrillation brings into 
 prominence numerous problems which have hitherto 
 been ignored or only imperfectly recognised. Thus a 
 new era in the study of heart affections is opened up. 
 I state with firm conviction that no one can appreciate 
 the essentials in the recognition of heart-disease and 
 heart-failure until he has made himself familiar with the 
 varied phases of this condition. 
 
 For the due appreciation of auricular fibrillation the watching 
 of individual cases for many years is necessary. 
 
 Let me repeat what I have insisted on so frequently, 
 that complete knowledge can never be acquired by the 
 physician who limits his horizon to hospital practice 
 and the consulting-room. Although it is but a few years 
 
 '57
 
 158 AURICULAR FIBRILLATION 
 
 since physicians began to recognise this condition, 
 numerous articles have already been written on the 
 subject with that assumption of complete knowledge 
 which is so characteristic of much in medical writings. 
 
 This is to be deplored, because it is quite manifest 
 that a subject of this kind can only be understood by 
 means of the study of individual cases before the onset 
 of fibrillation and also for a long period of years after 
 its onset. Writers who have only been able to recognise 
 the condition within the last few years cannot have had 
 time to acquire more than an elementary and imperfect 
 knowledge of the subject. 
 
 I am not saying this to depreciate the work of these 
 writers, but to impress on you, and to exemplify the 
 fact that, in this most important subject, the methods of 
 research which are peculiar to clinical medicine demand 
 a totally different application than that usually em- 
 ployed by hospital and laboratory workers. 
 
 I want you, therefore, to study specially the cases of 
 auricular fibrillation that come under your notice. If 
 you examine them carefully in the first instance and 
 keep in touch with them, as time goes on you will get 
 an insight into what heart-failure means and how to 
 combat it that will give you a fuller knowledge of the 
 meaning of heart-disease and its treatment. 
 
 The onset of heart failure by " back pressure " is shown by 
 the recognition of auricular fibrillation to be misleading. 
 
 It is probable, indeed, that from no other condition 
 will you acquire such a true knowledge of what heart- 
 failure really means. This knowledge will speedily 
 reveal to you how false is the doctrine that heart-failure 
 results from "back pressure." This doctrine, with its 
 attendant verbiage of " compensation " and " decom- 
 pensation," has blinded the profession to the real facts 
 for the last sixty years. The usual explanation offered 
 by doctors regarding heart-failure is, as you all know, 
 that it works backward from the point of origin. Thus
 
 AURICULAR FIBRILLATION 159 
 
 a mitral or aortic leak embarrasses one chamber after 
 another by " back pressure," and when at last the right 
 auricle is embarrassed the heart takes that irregular 
 action which is so frequent in heart-failure with dropsy. 
 You will speedily discover that this view has not been 
 derived from patient observation of individual cases, 
 but has been evolved from speculation as to the cause 
 of certain imperfectly understood symptoms. 
 
 The recognition of how auricular fibrillation embarrasses the 
 heart in its work will bring before you the essentials in 
 prognosis and treatment. 
 
 You will be guided in the management of heart affec- 
 tions by the knowledge you acquire regarding the effect 
 of this condition. You will learn to differentiate 
 between what is of significance and what is non- 
 essential. You will recognise that the treatment of a 
 heart case does not mean merely the giving of a bottle 
 of physic as a palliative measure, but that it requires 
 careful study of the conditions present, so that changes, 
 which foreshadow heart-failure and which, if not 
 guarded against, may end in serious failure of the heart, 
 may be detected. The recognition of such changes will 
 enable you to plan out the patient's future, to base your 
 treatment on a scientific basis, and, while avoiding 
 unnecessary restrictions, to permit such liberty as shall 
 enable the individual to lead a useful life. 
 
 The reasons for the beneficial effects of the digitalis group of 
 drugs can now be explained. 
 
 An equally striking result which the recognition of 
 auricular fibrillation has produced is the revelation of 
 the effect of digitalis on the human heart. The light 
 thrown on this part of the subject is indeed revolu- 
 tionary, so much so, indeed, that the vast bulk of the 
 literature on digitalis will have to be scrapped. You 
 all know how authorities have hitherto differed in regard
 
 160 AURICULAR FIBRILLATION 
 
 to the dosage and the kind of preparation of the drug 
 which should be employed. The conditions that seemed 
 to call for administration were never clearly defined, 
 so that it may be said that anything which seemed 
 unusual in the heart, whether a physiological sign 
 or a pathological, was taken as a valid reason for 
 giving digitalis. The dangers attending the use of the 
 drug have never been clearly explained, but have been 
 hinted at in oracular phrases which, while they alarm, 
 do not instruct. 
 
 Now, the recognition of auricular fibrillation has 
 shown that the heart while in this condition is peculiarly 
 susceptible to digitalis, and that, in many cases in the 
 past, the drug has been given and has acted most bene- 
 ficially. But it was never realised that this peculiar 
 reaction to the drug was an attribute of the abnormal 
 heart action. Hitherto the reasoning has been that, as, 
 in certain cases, the rapid action speedily became slow 
 under the influence of digitalis, it might be inferred that 
 all rapid hearts would benefit by the administration of 
 digitalis. The recognition of auricular fibrillation has 
 enabled us, on the contrary, to indicate with precision 
 the hearts which will benefit by the drug and the hearts 
 upon which the drug will have no effect. 
 
 We may state broadly that while the susceptibility 
 of the heart to digitalis, in individuals with a normal 
 action of the organ, may be extremely slight, as soon as 
 auricular fibrillation occurs the susceptibility becomes 
 at once very marked. 
 
 This peculiar and striking reaction to digitalis, ex- 
 hibited by the heart when in a definitely marked patho- 
 logical state, necessarily suggests a new conception of 
 research in the matter of the action of drugs. It is mani- 
 fest, for instance, that experiments on animals can only 
 afford limited information in regard to this subject ; 
 for the reaction of a normally acting heart to this drug 
 has been found to be fundamentally different from the 
 reaction of a heart acting with an abnormal rhythm,
 
 AURICULAR FIBRILLATION 161 
 
 such as auricular fibrillation. This line of thought opens 
 up great possibilities. 
 
 The discovery of auricular fibrillation was the outcome of a 
 long and patient research. 
 
 Judging from the tone of recent articles it would seem 
 that some people imagine that auricular fibrillation has 
 only been recognised since the term " auricular fibrilla- 
 tion " was employed. Few appear to understand that 
 all the essential clinical features were described before 
 the actual name was applied, and that the recognition 
 of the fact that the auricles fibrillate has not added 
 anything to the clinical picture or assisted in its recog- 
 nition, prognosis, or treatment. 
 
 It is now more than twenty-five years since I was first 
 able to distinguish this condition as being one by 
 itself. I was able to do this chiefly because 
 cases of auricular fibrillation never show any waves 
 due to the auricle in the venous pulse. Noting 
 that the condition occurred most frequently in the 
 elderly and in those with rheumatic hearts, I Kept in 
 touch with a large number of people in whom I saw 
 reason to anticipate its occurrence. In 1897 a patient, 
 whom I had been watching for a great many years, 
 suddenly developed extreme heart-failure with a rapid, 
 irregular action of the heart. For years before this time 
 I had been taking records and tracings and had found 
 invariably, in tracings from the jugular and liver pulse 
 of this particular patient, waves produced by the con- 
 tracting auricle. Moreover, I had noticed that, in his 
 case, there was always a presystolic murmur. After the 
 irregular action appeared these auricular waves in the 
 jugular and liver pulses and the presystolic murmur 
 disappeared ! Thus, all the evidence of auricular activity 
 had ceased. From careful consideration of numerous 
 other cases I was able to confirm the observation, and 
 for many years I speculated on what the auricle was 
 doing after it ceased to appear in the tracings. Thus. 
 
 M
 
 162 AURICULAR FIBRILLATION 
 
 in a book I published in 1902, I described the condition 
 as "paralysis of the auricle," and later I described it 
 as "nodal rhythm." When experimental proof was 
 adduced, by Dr. Lewis, that the cessation of auricular 
 activity was due to the fibrillation of the auricle, in 1910, 
 I had no hesitation in accepting the term " auricular 
 fibrillation." During the intervening years I had been 
 collecting cases and following them up ; I was therefore 
 able to produce many facts on which to base the diag- 
 nosis, prognosis, and treatment of these cases, and this 
 in spite of the circumstance that the condition had been 
 called by another name than auricular fibrillation. 
 Seeing that some of my patients died shortly after the 
 inception of the new rhythm, while others lived for 
 months, and even for many years, it is clear that an 
 understanding of the effects of the fibrillation cannot be 
 acquired in a few months or even in a few years. 
 
 What is auricular fibrillation? 
 
 The term "fibrillation" is applied to a curious con- 
 dition of the muscle fibres of the heart, in which the 
 individual fibres, instead of contracting in an orderly 
 and simultaneous manner during systole, contract 
 rapidly and independently of one another. The auricle, 
 when in a state of fibrillation, presents an entirely 
 different aspect from that which it does during its 
 normal action. It stands still and systole never takes 
 place, and meanwhile the walls quiver with fibrillating 
 contractions. A normal acting auricle can be thrown 
 temporarily into auricular fibrillation by electrical 
 stimulation. 
 
 If the ventricles pass into fibrillation death is in- 
 stantaneous. 
 
 Auricular fibrillation is usually persistent, and the heart may act for 
 
 indefinite periods. 
 
 In the majority of cases, when auricular fibrillation 
 sets in, it persists for the remainder of the individual's
 
 AURICULAR FIBRILLATION 163 
 
 life. I have watched, during many years, patients in 
 whom it was present, and I have seen it persist in the 
 same patient during sixteen years. In some cases it 
 may appear, last for a few hours, disappear, and never 
 recur; in others it may recur at frequent intervals 
 for some weeks or months and then disappear. Many 
 cases of paroxysmal tachycardia owe the paroxysms 
 to auricular fibrillation, and in such cases auricular 
 fibrillation may last for a few seconds, a day or two, 
 a few weeks, or months. As a rule, however, when 
 the condition is intermittent in its appearance, the 
 tendency to recurrence becomes greater, till finally it 
 becomes permanently established. 
 
 In the great majority of cases with heart failure and dropsy 
 the onset of heart failure is due to auricular fibrillation. 
 
 Before setting out in detail the features characteristic 
 of auricular fibrillation I should like to familiarise you 
 with the kind of case in which the condition occurs. 
 Let me say at once that 60 or 70 per cent, of all cases 
 of serious heart-failure (with dropsy) met with in prac- 
 tice owe the failure directly to this condition or have the 
 failure aggravated by its presence. The most common 
 evidence of the condition is the presence of irregular 
 action of the heart of a very disorderly kind. It is that 
 form of irregularity so frequently met with in the elderly 
 and in patients with hearts damaged by previous rheu- 
 matic infection. In the latter class the association of 
 irregular heart action with mitral stenosis has long been 
 recognised, and, on account of this association, the 
 irregular pulse is sometimes described as the " mitral 
 pulse," with which all clinicians are familiar. 
 
 While senile and rheumatic hearts are most frequently 
 affected by auricular fibrillation, there are numerous 
 cases in which it occurs in patients with no history of 
 rheumatism, and of an age at which senile changes are 
 not usually present in a marked degree. Other cases 
 are found which have been labelled " delirium cordis." 
 
 m 2
 
 164 AURICULAR FIBRILLATION 
 
 Digitalis will produce auricular fibrillation in those pre- 
 disposed to it ; violent exertion also may induce it ; and 
 many of the recorded instances of heart-overstrain afford 
 excellent examples of this state and of the heart-failure 
 which accompanies it. 
 
 The patient is frequently conscious of the onset of auricular 
 fibrillation, and the sensation is usually characteristic. 
 
 Many people become conscious of the heart's action 
 when it departs from its normal rhythm. Thus, extra- 
 systoles are sometimes recognised by the patient, who 
 becomes conscious of the long pause following the big 
 beat which follows the extra-systole. Patients liable 
 to paroxysmal tachycardia recognise their attacks by 
 the feeling of a gentle fluttering sensation in the chest. 
 When the attacks of tachycardia are due to auricular 
 fibrillation this fluttering is also present, but usually 
 it is not a continuous fluttering, but is interrupted by 
 thumping sensations, due to the occasional occurrence 
 of bigger beats. When closely questioned these patients 
 will generally state that the heart is irregular in its 
 action. 
 
 The rhythm of the heart in auricular fibrillation is of a 
 
 disorderly kind. 
 
 The symptom by which the clinical observer can most 
 readily recognise auricular fibrillation is the character 
 of the pulse. The pulse rhythm is usually irregular, 
 and the irregularity is of a very disorderly kind. Irregu- 
 larities, other than those due to auricular fibrillation, 
 have usually a distinctive character, as, for example, 
 the irregularity in the heart of the young, in which 
 variations in rate coincide with phases of respiration, 
 or the intermittent pulse, due to extra-systoles, in which 
 the irregularity breaks in on an otherwise regular 
 rhythm. In auricular fibrillation the pauses between 
 the beats are, as a rule, continually changing, and two 
 succeeding beats are rarely of the same strength, or the
 
 AURICULAR FIBRILLATION 
 
 165 
 
 pauses between two succeeding beats of the same dura- 
 tion. The character of these irregularities will be made 
 clear by the radial tracings in Fig. 16. These tracings 
 were taken from five patients. It will be found that 
 
 , in umiMMM i - ppwrn m/ih iii iiiiiiiihim 
 
 Fig. 16. 
 
 Tracings of the radial pulse showing the disorderly irregularity char- 
 acteristic of auricular fibrillation, from five different patients. 
 
 the duration of the beats is always varying and that 
 the rhythm is quite disorderly. 
 
 When there are murmurs due to mitral or tricuspid stenosis, 
 the presystolic murmurs due to auricular systole disappear 
 with the onset of auricular fibrillation, while the diastolic 
 remain. 
 
 I have already said that, with the onset of auricular 
 fibrillation, all evidence of auricular systole disappears. 
 When the auricles fibrillate in a patient with mitral
 
 166 AURICULAR FIBRILLATION 
 
 stenosis, whose mitral stenosis has been revealed by the 
 presence of a presystolic murmur alone, or by a pre- 
 systolic accompanied by a diastolic murmur, the pre- 
 systolic murmur disappears, but the diastolic remains, 
 as already described. When the heart is beating 
 rapidly the diastolic murmur may fill up the interval 
 between the second and first sounds, and most physicians 
 would then be apt to assume that the murmur was pre- 
 systolic in origin. But if the heart be auscultated after 
 its rate has decreased— for example, under the influence 
 of digitalis — the murmur then will be found to follow the 
 second sound, and there will be an appreciable silence 
 before the first sound at the exact moment at which 
 the presystolic murmur was wont to be heard (see 
 Figs. 7 and 8). I would strongly advise you to verify 
 this point, for it is a striking feature. It is also, un- 
 happily, a feature which even experienced clinicians are 
 seldom able to appreciate. 
 
 The onset of auricular fibrillation is usually accompanied by 
 
 signs of heart failure. 
 
 While these are the signs by which we may detect the 
 presence of auricular fibrillation, it is necessary to 
 realise that it is the signs of heart failure itself which 
 usually first attract attention. These signs of heart- 
 failure, however, are not peculiar to, or characteristic 
 of, auricular fibrillation, but are common to heart-failure 
 induced by other conditions. They may range from a 
 slight breathlessness on exertion to dyspnoea of the most 
 severe kind, accompanied by dropsy and enlarged liver. 
 
 As a rule, the onset of symptoms of heart-failure is 
 slow and gradual. This is due, in a measure, to the 
 fact that the individual afflicted usually persists in 
 living in his ordinary manner, though his heart is 
 hampered by the abnormal action. On the other hand, 
 the onset of heart-failure may be very rapid. Within 
 a few hours of the occurrence of auricular fibrillation 
 the distress of the patient may be very severe, his coun-
 
 AURICULAR FIBRILLATION 167 
 
 tenance dusky, his heart dilated ; he may also suffer 
 from orthopncea and a feeling of distress. I have seen 
 these phenomena arise rapidly in cases where, the fibrilla- 
 tion occurred intermittently, and the relief experienced 
 by the patient when the heart resumed the normal 
 rhythm was as remarkable and striking as was the onset 
 of the suffering. At once the patient knows that the 
 heart's action has altered ; he breathes in an easier 
 manner and the feeling of distress disappears. Within 
 a few hours the heart and liver have become reduced 
 in size, the lividity of the face has passed away, and the 
 tenderness in the chest wall and over the region of the 
 liver has begun to disappear. 
 
 In many cases the onset of heart-failure is accom- 
 panied by wasting, the patient sometimes losing a good 
 deal of weight in a few months. There is usually, also, 
 a tendency to flushing of the cheeks ; the flushes are of 
 a dusky colour, and occasionally a slight sallow tinge 
 of jaundice may appear. 
 
 The prognosis in auricular fibrillation depends on the condition 
 of the heart muscle and its power to maintain an efficient 
 circulation. 
 
 We must bear in mind that auricular fibrillation is, 
 in reality, a symptom of some myocardial change. To 
 be logical, therefore, we should consider the condition 
 only from the point of view of a myocardial affection. 
 We are at present so ignorant about myocardial disease 
 that we are forced to put one symptom of it forward 
 as if that symptom were, in itself, a disease. Illogical 
 as this method seems, it has its use, for the occurrence 
 of auricular fibrillation induces such a profound change 
 in the heart's action, and so powerfully affects its 
 efficiency, by reacting on the ventricle and modifying 
 the behaviour of that chamber to drugs, that we are 
 compelled to look upon the condition as a state apart. 
 Considering the variety of circumstances that induce 
 auricular fibrillation, it is difficult to state briefly its
 
 1 68 AURICULAR FIBRILLATION 
 
 prognostic significance. In referring to the pathological 
 lesions associated with it I showed that they were of a 
 very diversified kind in nature and in degree. It is, 
 in all probability, the extent of those pathological 
 changes which determines the prognosis of auricular 
 fibrillation, and an attempt should be made to estimate 
 their extent. If we look upon the inception of a new 
 rhythm as, in itself, embarrassing the heart in its 
 work, then the maintenance of an efficient circulation 
 depends on whether or not the heart is able to do its 
 work when hampered by the new rhythm. The efficiency 
 of the heart muscle is the fundamental matter. The 
 question as to how efficient the heart muscle is 
 must therefore be answered before any other question. 
 Upon this answer everything really depends. We realise 
 this, I think, very clearly when we consider the effect 
 of fibrillation upon many of its victims, with what 
 extraordinary rapidity heart-failure sets in, how the 
 patient becomes breathless and has to sit up in bed, 
 how his face becomes livid, his heart dilated, and his 
 liver swollen, and all this within a few hours of the 
 onset of fibrillation. With the restoration of the normal 
 rhythm these symptoms, as has already been said, 
 quickly disappear. When fibrillation becomes per- 
 manent in such individuals the signs of heart-failure 
 persist sometimes in spite of all treatment, till death 
 supervenes in a few weeks or a few months. 
 
 On the other hand, I have repeatedly seen fibrillation 
 set in without the individual being in any way conscious 
 of its presence. These cases may go on for years with 
 little inconvenience ; the majority, however, after some 
 years, gradually show signs of a limitation of the field 
 of cardiac response, and their future then depends on 
 how they respond to treatment and on their ability to 
 diminish their amount of bodily work and to live within 
 the limits of the heart's strength. 
 
 Much more frequently there is a considerable limita- 
 tion of the heart's power of response to effort, and if
 
 AURICULAR FIBRILLATION 169 
 
 the usual life of the individual be pursued, without 
 appropriate treatment, there is a great tendency for the 
 heart to fail gradually. 
 
 There is no doubt, also, that the onset of fibrilla- 
 tion can lead directly to a fatal termination, or, rather, 
 that it can be associated with conditions which lead 
 to death. Thus, one of my patients died suddenly 
 forty-eight hours after the inception of auricular 
 fibrillation. Another one fell down dead six months 
 after its inception. I have seen a number of other 
 patients, who had auricular fibrillation, die suddenly, 
 but some of these suffered from a considerable degree 
 of heart-failure. It has appeared to me probable 
 that in these cases the ventricle has passed into 
 fibrillation, as MacWilliam suggested. This view 
 is supported also by the fact that the histological 
 changes found in the ventricle were similar to those in 
 the auricle in some of the cases of sudden death. 
 
 The usual approach to death in auricular fibrillation 
 is by way of a steady advance of the heart-failure, as 
 shown by the breathlessness on exertion, orthopnoea, 
 dropsy, and enlargement of the liver, etc., sometimes 
 with an absolute failure of response to all forms of treat- 
 ment. I have seen death ensue in this manner a few 
 weeks after the inception of fibrillation ; other cases 
 have drifted on for a few months, while some have led 
 a somewhat chequered career for a number of years, 
 during which they were seldom fit for much bodily 
 exercise. 
 
 In giving a prognosis in cases of auricular fibrillation 
 it is therefore necessary to appreciate a good many 
 factors over and above the mere presence of the fibrilla- 
 tion. It is necessary to form an opinion regarding the 
 extent of the changes that have led up to the fibrilla- 
 tion, and, in many cases, to find out how long these 
 changes have been going on. This survey would include 
 a knowledge of the date of any attack of rheumatic 
 fever the patient may have had, and also how he com-
 
 170 AURICULAR FIBRILLATION 
 
 ported himself before the onset of fibrillation, and 
 whether or not he was liable to attacks of heart-failure. 
 These attacks of heart-failure are important, because 
 they point to a tendency to exhaustion which may be 
 aggravated by the fibrillation. These questions are 
 answered by a study of the functional efficiency of the 
 heart and by the results of treatment. If aortic regur- 
 gitation is present with heart-failure the outlook is not 
 good, as such cases usually drift and respond but 
 slightly to treatment. The character of the murmurs 
 present in mitral stenosis will also, as stated above, 
 shed light upon the condition. 
 
 It is necessary, also, when auricular fibrillation sets 
 in, to observe the accompanying changes in the heart 
 and the manner in which it maintains the circulation. 
 Thus, an increase in the size of the heart, or a rate over 
 120 beats per minute, usually leads to a speedy ex- 
 haustion of the myocardial strength. I have occasion- 
 ally met with a patient having a heart-rate of 100 and 
 120 per minute, yet having no increase in the size of the 
 heart and suffering little inconvenience ; as a rule, how- 
 ever, any rate over 90 beats per minute tends to induce 
 dilatation and consequent exhaustion. When, on the 
 other hand, there is little increase in the rate, or when 
 the rate is somewhat slower than normal and the 
 response to effort good, the prognosis is usually very 
 favourable. 
 
 A most valuable aid to prognosis may be found in 
 observation of the manner in which the patient responds 
 to treatment. In sudden attacks of severe heart-failure, 
 when the heart's rate is over 120 per minute, it will 
 be well to suspend judgment until the reaction to digi- 
 talis is found out. Many such cases respond speedily 
 to digitalis, and, with the resultant decrease in the 
 heart's rate, a remarkable degree of recovery may ensue, 
 so that the patient may be able to undertake laborious 
 work so long as his heart's rate is kept down by digi- 
 talis. This would seem to imply that the exhaustion
 
 AURICULAR FIBRILLATION 171 
 
 is mainly brought about by over-stimulation of the 
 ventricle, and that the slowing, by enabling the ventricle 
 to get more rest, enables it to regain a measure of 
 strength. From this result we can also gather that the 
 ventricular muscle must be fairly healthy, and we can 
 estimate, within certain limits, the amount of healthy 
 muscle by the degree of recovery. (For treatment, see 
 Chapters XXV. and XXVI.)
 
 CHAPTER XIX 
 
 AURICULAR FLUTTER 
 
 A condition allied to auricular fibrillation, and some- 
 times alternating with it, is that when the auricular con- 
 tractions are extremely rapid, sometimes exceeding 300 
 per minute. These contractions are not normal con- 
 tractions but seem, like fibrillation, to be due to some 
 peculiar quality in the heart muscle which is not clearly 
 understood. Although the auricles beat at the rapid 
 rate, it is only on rare occasions that the ventricles 
 respond to every auricular beat. In most cases the 
 ventricle responds to every second auricular beat, so that 
 the pulse-rate is one-half the auricular rate, the rhythm 
 being quite regular. In rare cases the ventricle responds 
 to every fourth auricular beat, and the rhythm is still 
 regular. In a good many cases the response of the 
 ventricle to the auricular beats is continually varying, 
 with the result that the radial pulse is irregular, in some 
 cases rapid and irregular (Fig. 17), in other cases slow 
 and irregular (Fig. 18). 
 
 The morbid conditions provoking auricular flutter are 
 unknown. It occurs in some who have had rheumatic 
 fever, sometimes during convalescence, usually not till 
 many years after. It occurs in the final stage of heart 
 failure in cases with long-standing disease of the heart — 
 myocardial and valvular. It occurs in acute infections 
 of the heart, and in those with senile changes, and not 
 infrequently it occurs in people in whom we can detect 
 no history indicating a provoking cause. 
 
 The course auricular flutter pursues is variable. It 
 
 172
 
 AURICULAR FLUTTER 
 
 173 
 
 may be present intermittently, the attack lasting a few 
 seconds, a few minutes, a few hours, a few days, a few 
 weeks, or even a few months. Under these circum- 
 
 HftdT^jj 
 
 Fig. 17. 
 
 Auricular nutter. The upper tracing from the neck shows a series of 
 waves, a, in the jugular vein at the rate of 220 per minute. The 
 waves c are due to the carotid pulse and correspond with the 
 radial pulse-beats (lower tracing). The radial pulse is slow and 
 irregular, 35-40 beats per minute. In the intercalated diagram 
 the downstrokes in the space A, represent the auricular beats, and 
 the downstrokes in the space V, the ventricular beats which corre- 
 spond to the radial pulse, and it shows that only a few of the 
 auricular beats get through to the ventricle at irregular intervals. 
 
 R&dioi k 
 
 Tracings of the jugular and radial pulses with auricular flutter. The 
 radial pulse is irregular, and the jugular pulse is of the ventricular 
 type and gives no indication of auricular activity, whose nature is 
 shown in Fig. 19. 
 
 stances it is recognised as paroxysmal tachycardia (see 
 page 180). In others it is persistent and may go on for 
 years. 
 
 The effect on the heart's efficiency is also extremely 
 variable. Some are not conscious of any limitations, 
 while all degrees of inefficiency up to extreme heart 
 failure may speedily arise after the occurrence of flutter.
 
 r 74 
 
 AURICULAR FLUTTER 
 
 The degree of inefficiency depends chiefly on two things, 
 the rapidity of the ventricular contraction, and the state 
 of the ventricular muscle. With great rapidity of the 
 heart's action the output is so slight that the brain is 
 insufficiently supplied with blood, and unconsciousness 
 may result (Fig. 5), or the heart may dilate, followed 
 by all the objective signs of heart failure. If the ven- 
 tricles are diseased they may be unable to cope with the 
 embarrassment of this abnormal rhythm, and grave 
 failure of the heart may speedily arise. 
 
 It is often impossible to be certain of the nature of the 
 condition by any method of examination, except by the 
 
 
 
 
 R 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 : 
 
 
 ~ 
 
 \ 
 
 
 l 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i • 
 
 
 
 ■-■■■• i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ii- 
 
 ■h 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^4-rV-r- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Fig. 19. 
 
 Electro-cardiogram taken from the same patient as in Fig. 18. The 
 auricular movements (P) are regular and 310 per minute. The 
 ventricular movements (R) are 120 and irregular. 
 
 electrocardiograph. It is chiefly to this instrument that 
 we owe the recognition of this condition (Fig. 19). 
 
 It will thus be seen that the signs by which we recog- 
 nise auricular flutter, the circumstances under which 
 it arises, and the effects upon the heart's efficiency are 
 extremely variable, so that, altogether, in auricular 
 flutter, we have to do with one of the most elusive con- 
 ditions in cardiac symptomatology. 
 
 Symptoms. 
 
 We can sometimes detect the condition by the rapid 
 beating of the jugular veins in the neck (Fig. 17), but 
 in many cases there is no jugular pulse, or it is of a kind 
 that does not show these waves, as in Fig. 18. This is 
 due to the fact that the rapid auricular contractions
 
 AURICULAR FLUTTER 175 
 
 vary in force, sometimes sending distinct waves in the 
 jugular veins, sometimes not doing so, and then the 
 waves in the jugular may be due to the ventricular 
 systole. 
 
 A persistent rapid radial pulse of 150 or over, when the 
 patient is at rest, and not increased by effort, usually 
 indicates the presence of auricular flutter. This absence 
 of response to effort is also typical when the rate is 120 
 or over, though effort in these cases may produce a 
 sudden doubling of the pulse-rate. A rapid pulse-rate 
 over 120 with the normal rhythm of the heart invariably 
 varies with rest and effort. 
 
 Prognosis. 
 
 From the description given of auricular flutter it will 
 be seen that it may impair the functional efficiency of 
 the heart, but is not in itself a dangerous condition. 
 When danger arises, it is in a heart which is already the 
 seat of somewhat extensive disease, especially when 
 affecting the ventricle or valvular disease with impaired 
 ventricles. Hence, the already weakened heart is unable 
 to cope with the burden thrown upon it by the abnormal 
 rhythm. In giving a prognosis, each case must be care- 
 fully studied by itself, and the condition of the ventricle 
 and the valve defects estimated, particularly the manner 
 in which the efficiency of the circulation is maintained, 
 before and after the inception of the abnormal rhythm, 
 and the response to digitalis. There is danger when 
 attacks of loss of consciousness arise, due to the rapid 
 and inefficient action of the ventricle, with grave signs 
 of heart failure. One patient whom I saw had an attack 
 with congestion of the lungs, and died 24 hours later 
 during a second attack. In many cases the flutter 
 passes into permanent auricular fibrillation. 
 
 Treatment. 
 
 The treatment of the transient attacks is discussed 
 under the heading of paroxysmal tachycardia.
 
 176 AURICULAR FLUTTER 
 
 When the condition is permanently established or per- 
 sists for a long time, a course of digitalis should be tried, 
 the digitalis to be given in the manner described in 
 Chapter XXVI. Digitalis is often beneficial and may 
 cause the auricles to revert to the normal rhythm. In 
 other cases it may only slow the heart. The slowing of 
 the heart may be due to an increase of the heart-block, 
 and with the stoppage of the digitalis the rate may 
 gradually increase. If it is possible, the dose which will 
 keep the ventricular contractions at a moderate rate (70 
 to 90 beats per minute) should be found, and the drug 
 given as required. If this line of treatment be pursued, 
 not only may it keep the heart in good condition, but it 
 may lead to auricular fibrillation, and the restoration 
 of a normal rhythm (Figs. 22-24) ; while if there be 
 extreme heart-failure, it may restore a more efficient 
 circulation. 
 
 When auricular flutter is present and there is a 
 tendency for the ventricle to follow each auricular con- 
 traction, the quieter the patient can be kept the better, 
 and sedatives such as the bromides should be given to 
 ensure sleep and to prevent mental disturbances, 
 dreams, excitement, etc. As in auricular fibrillation, 
 we know of no remedy which will with certainty stop 
 this abnormal rhythm in all cases.
 
 CHAPTER XX 
 
 HEART ATTACKS 
 
 Palpitation, paroxysmal tachycardia, sudden failure of the heart, 
 
 overstrain of the heart. 
 
 A great many people complain of "heart attacks." 
 Since the attack may not be in progress when we see 
 these people it is always necessary to ask them to explain 
 what they mean by the expression. Some will describe 
 as heart attacks periods when they feel faint, or when 
 they actually do faint. We can estimate the significance 
 of these periods by means of what has already been 
 said on exhaustion and syncope. Others again com- 
 plain of heart attacks to which they give the name 
 "palpitation." As employed by patients, this term 
 will be found to include many divers actions. Thus, if 
 extra-systoles occur rather frequently for a short period, 
 the patient is quite likely to say he has palpitation. 
 Patients will be encountered who will describe how 
 their hearts beat at a moderate rate but very forcibly, 
 and how the force gradually subsides. At other times 
 the hearts may beat rapidly, the rhythm being regular or 
 irregular. If you ask these patients to indicate the nature 
 of the action of the heart, for example, by tapping with 
 the ringer, they will often give you a fair indication so 
 that you can recognise the nature of their troubles. 
 
 The sensations peculiar to extra-systoles have already 
 been described. Where the heart is increased in rate 
 the increase is due in most cases to one of two conditions 
 — the condition in which the rhythm of the heart is 
 
 177 N
 
 178 HEART ATTACKS 
 
 normal and the condition in which it is abnormal. In 
 order to differentiate between them I will call the first 
 of these "palpitation," and the second "paroxysmal 
 tachycardia." The distinction between these two (over 
 and above the nature of the rhythm which you cannot 
 determine without instrumental aids) is that while in 
 palpitation the onset is often gradual, but occasionally 
 sudden, and the offset always gradual (the heart imper- 
 ceptibly falling to the normal — sometimes quickly — 
 sometimes slowly), in paroxysmal tachycardia both onset 
 and offset are always sudden. In palpitation the slow- 
 ing heart at offset can be increased in rate by exertion ; 
 paroxysmal tachycardia, on the other hand, terminates 
 with one or more strong beats with prolonged intervals 
 between them, and effort seldom has any effect on the 
 rate, though on rare occasions it may double it. 
 
 Palpitation occurs with a normal rhythm of the heart, and is 
 generally due to some cause irritating the heart. 
 
 Palpitation may occur in relation to a great variety 
 of complaints. The patient is usually conscious of the 
 change in the heart's action; he feels the rapid beats 
 and sometimes describes them as "gentle," sometimes 
 as "hard and hammering." This latter sensation may 
 occur with little or no increase in frequency. In cases 
 of valvular disease, where there is a limitation of reserve 
 force, slight physical effort or mental excitement may 
 readily induce an attack. Even in the healthy certain 
 mental states may have the same effect. When the 
 system is weakened from disease the liability to attack 
 is naturally much increased. It is in certain neurotic 
 subjects, particularly females, that one sees the com- 
 plaint attain its most distinctive features. There may 
 be no organic affection of the heart; and, though fre- 
 quent attacks may ultimately induce exhaustion of the 
 reserve force, yet, as a rule, they do not appreciably 
 shorten life. Anything that startles the patient, whether 
 it be a sudden noise, or mental perturbation, or uncom-
 
 HEART ATTACKS 179 
 
 fortable dreams, readily induces an attack. But an 
 attack may supervene as the result of more obscure 
 causes, amongst which may be included reflexes from 
 organs more or less remotely situated (stomach, uterus) ; 
 the sources of the trouble may, in other cases, be indis- 
 cernible. When a severe attack comes on the patients 
 may become painfully aware of the violent action of 
 their heart. They prefer to sit upright ; they draw deep 
 inspirations and move uneasily from side to side, with 
 the hand pressed over the heart. The attack is accom- 
 panied by sensations of a distressing nature, such as a 
 sense of suffocation and a fear of impending dissolution. 
 When it subsides it leaves the patient exhausted. 
 
 During the attack the pulse is usually increased in 
 frequency. The artery may be of fair size ; sometimes, 
 however, it is very small. The impact of the pulse- 
 wave on the ringer is sudden, and sharp, and of ex- 
 tremely brief duration. 
 
 We occasionally meet with patients in whom the pulse 
 is extremely rapid for a period, sometimes for a few 
 minutes, sometimes for a few hours, but who experience 
 no sensation other than exhaustion, and the attack 
 quietly subsides. The causes of these attacks are so 
 obscure that it would be mere guess-work, in the 
 majority of cases, to discuss them. 
 
 The opinion given about the case should be based, in 
 every instance, on careful consideration of the cause of 
 the irritation of the heart ; an inquiry must therefore 
 be made into the patient's state of health and into the 
 condition of other organs, particularly the digestive 
 organs. The treatment is directed to the removal of 
 any exciting cause or to the improvement of the patient's 
 health as a whole. Where the patient is of a nervous 
 temperament the judicious use of the bromides will help 
 in diminishing the frequency and severity of the attacks, 
 especially of those attacks which occur in the night. 
 During the attacks relief is often obtained by drinking 
 a cup of strong hot coffee or tea. 
 
 N 2
 
 180 HEART ATTACKS 
 
 Paroxysmal tachycardia is due to the sudden inception by the 
 
 heart of a new rhythm. 
 
 As we get a clearer insight into the mechanism of the 
 heart's action we are able to identify more clearly the 
 exact nature of cases which we were wont, in the past, to 
 include under some general term. Paroxysmal tachy- 
 cardia is a term used here to indicate the starting of 
 the heart's contraction, at an abnormal place, with co- 
 incidentally a sudden increase in the rate of the heart, 
 and finally a sudden cessation of the rapidity on resump- 
 tion of the normal rhythm. Analysis of a great many 
 cases shows that the cause of the attacks, in most in- 
 stances, is a transient fibrillation of the auricle when the 
 rhythm is irregular, or they are due to auricular con- 
 tractions arising at an abnormal source and occurring 
 at a great rate (from 150 to 300 per minute) when the 
 rhythm is regular (" auricular flutter "). In rare cases 
 the new rhythm may start in the ventricle. 
 
 Symptoms. — The heart suddenly takes on a rapid 
 action ; this may last for a few beats or it may go on 
 for minutes, hours, days, or weeks. When the attack 
 stops it does so suddenly, not gradually, as in palpita- 
 tion. The rate is usually increased, sometimes greatly. 
 A patient may have but one attack, or his attacks may 
 come on at infrequent intervals in the course of ten or 
 twenty years ; or, again, they may be of great frequency 
 and occur every few weeks or days ; or there may be 
 several attacks on one day. After one or two attacks 
 the heart may settle down permanently to a fibrilla- 
 tion of the auricle or to auricular flutter. 
 
 The sensation felt by the patient when the rhythm 
 is first started may be so slight as to pass unnoticed 
 by him. Usually he is conscious of a curious fluttering 
 sensation inside the left chest. This sensation is very 
 characteristic and almost pathognomonic. It may be 
 described in various ways according to the vocabulary 
 nf the sufferer, but the essential feature is the soft and
 
 HEART ATTACKS 181 
 
 gentle movements, which are not rhythmical, but which 
 vary softly in intensity. This is in striking contrast 
 to the sensations that may arise from stimulation of the 
 heart during a normal rhythm — for example, in palpi- 
 tation. Frequently the sensation is so disquieting that 
 the patient rests or walks about cautiously and quietly. 
 While the attack is in progress there may be but slight 
 limitation in the field of cardiac response. In other 
 cases the patient finds that the exertion he was wont to 
 undertake with comfort now induces breathlessness. In 
 rare instances the sense of prostration and of weak- 
 ness is extreme and is accompanied by a profound fear 
 of dissolution ; sometimes loss of consciousness for hours 
 may occur. In these instances the heart beats at a very 
 rapid rate — up to 300 per minute — and the pulse is 
 scarcely perceptible. Again, there are cases in which 
 the associated heart-failure may be so extreme that in 
 a few days, or even a few hours, evidences of imminent 
 peril are shown. The patient has to keep in bed ; the 
 dyspnoea is so great that he cannot lie on his back, but 
 must be propped up. If he survives, oedema of the legs 
 quickly supervenes, his lips become livid, and his face 
 swollen. The pulse is small, rapid, and sometimes 
 irregular, the beats varying remarkably in strength. 
 The veins of the neck are often full and pulsate with 
 great rapidity. The heart dilates in a few hours, some- 
 times extending two inches in the transverse direction. 
 The sounds alter, becoming short and sharp, and if the 
 heart's action is rapid, often no murmur can be detected. 
 The liver becomes enlarged and may be found pulsating 
 two or three inches below the ribs. The tissues covering 
 the heart and the liver often become extremely tender 
 on pressure. 
 
 With the sudden reversion of the rhythm to the 
 normal the change in the patient's condition is even 
 more remarkable than that attending the rapid onset of 
 the symptoms of heart-failure. At once the patient 
 heaves a great sigh of relief, and in a very short time,
 
 182 HEART ATTACKS 
 
 within half an hour, all abnormal signs in the lips, face, 
 and enlarged liver disappear, while in a few hours the 
 heart may be beating within its normal limits. 
 
 In some the paroxysmal tachycardia may be accom- 
 panied by no marked change in the size of the heart. 
 In these cases the patient is generally conscious of the 
 heart's abnormal action, and instinctively avoids active 
 exertion, either by keeping in bed or by resting in a 
 chair, or by walking about very quietly. The attack 
 usually lasts for a few hours, but may occasionally last 
 for many hours, or even one or two days. At the end 
 of this time there may be no increase in the size of the 
 heart and no sign of dropsy or enlarged liver. 
 
 Attacks of paroxysmal tachycardia may occur at all 
 ages ; but they occur more frequently in the later years 
 of life. It is impossible to tell what predisposes to 
 these attacks ; a good number of patients give a history 
 of rheumatic fever. The attacks may occur during 
 convalescence from the fever or many years afterwards ; 
 senile changes in the heart also predispose to attacks. 
 In a few cases disease in other parts of the body seems 
 to provoke attacks. 
 
 Prognosis. — The prognosis in these cases is fraught 
 with considerable difficulty. The symptoms during an 
 attack may be so alarming that the inexperienced are 
 apt to look upon a patient as hopelessly stricken. I 
 remember being called one night to see a woman eighty 
 years of age. I found her heart extremely rapid and 
 irregular, her face swollen and livid, and she was gasp- 
 ing for breath. I told the friends the end was approach- 
 ing; but, on calling to see her next morning, I found 
 her walking out in the street. After that she had 
 several attacks, and finally died during one of them. 
 I have watched other patients for years, when the symp- 
 toms have not been so extreme and have given rise 
 merely to a slight uneasiness in the chest. In these the 
 heart has not dilated, though the rate may on occasion 
 have reached nearly 200 per minute. Again, I have
 
 HEART ATTACKS 183 
 
 watched patients for over twenty years who had only 
 one attack, and can testify that they have had no other. 
 
 In some the change, from being transient, becomes 
 permanent ; and here lies the danger. For if the ex- 
 treme form of heart-failure which arises persists, in 
 spite of treatment, the patient drifts to death. 
 
 The prognosis depends also on the degree of dilata- 
 tion present. If the heart does not increase in size and 
 the attacks are transient, then, on the whole, the prog- 
 nosis is good, though in many cases the patient's life 
 is greatly crippled, because of the fact that the attacks 
 recur in spite of treatment. When, on the other hand, 
 there is dilatation, with the accompanying symptoms 
 of dropsy and enlarged liver, the outlook is bad. 
 
 Another element in the prognosis is the associated 
 disease. In many cases there is a history of rheumatic 
 fever, and valve lesions, the result of the fever, may ham- 
 per the heart. We have, therefore, when there is present 
 mitral stenosis and aortic regurgitation, to consider the 
 extent of the damage and the degree of impairment. 
 The frequent occurrence of attacks of paroxysmal tachy- 
 cardia adds to the gravity of the condition. Senile 
 changes in the heart also are associated with it ; the 
 extent of these must be gauged by the manner in which 
 the heart responds to effort. When the response is good 
 and the heart suffers little during the attack the prog- 
 nosis is quite favourable. 
 
 Treatment. — Absolute quiet is essential during the 
 attack. This suggestion is, indeed, scarcely necessary, 
 for the patient usually seeks rest or moves about very 
 quietly. In some cases, as I have said, quiet move- 
 ment may occasion little distress. A great many recom- 
 mendations as to means of arresting these attacks may 
 be found scattered through medical literature. Because 
 the attacks are commonly transient in duration, some 
 remedy, employed opportunely, seems to the inexperi- 
 enced onlooker to restore the heart to its normal action. 
 Many patients themselves have a knack of doing some-
 
 1 84 HEART ATTACKS 
 
 thing which seems to change the rhythm. Sometimes 
 the attacks can be stopped by the patient by simply 
 taking a series of deep breaths, by slapping the chest, 
 by the sudden application of cold water, or by vomiting. 
 
 Drugs of the most diverse character have been de- 
 scribed as active agents in stopping attacks ; in this 
 category are nitroglycerin and adrenalin. In my 
 early days I, too, thought I knew how to stop attacks ; 
 but more extended experience has shown me that, when 
 they stopped, it was from some cause unknown to me, 
 and which was independent of any means I employed. 
 I have tried intravenous injections of strophanthin, with 
 no satisfactory result. 
 
 Many people who suffer from these attacks notice 
 that, when there is digestive discomfort, the attacks 
 are more readily provoked ; undoubtedly the clearing out 
 of the bowels and careful dieting diminish the frequency. 
 In one case of chronic appendicitis the attacks dis- 
 appeared after the removal of the appendix. Some- 
 times the bromides, pushed till apathy is for the time 
 being produced, diminish the frequency of the attacks. 
 
 When signs of heart-failure appear and the abnormal 
 rhythm becomes permanent and is found to be of the 
 nature of auricular fibrillation, or flutter, then the treat- 
 ment described in connection with these conditions 
 should be employed. 
 
 Sudden failure of the heart. 
 
 On rare occasions an individual with some organic 
 lesion but otherwise in fair health is suddenly seized 
 with intense breathlessness and may die within the 
 course of a few hours. This phenomenon is seen as an 
 end picture in some cases of aortic regurgitation. We 
 also see the same fatal state in cases of acute oedema 
 of the lungs, where frothy, blood-stained expectoration 
 wells up out of the lungs. In some of these cases mitral 
 stenosis is present ; in others there is no valvular lesion. 
 I am unable to account for the attacks.
 
 HEART ATTACKS 185 
 
 The most frequent cause of sudden attacks of heart- 
 failure is the inception by the heart of a new rhythm. 
 In auricular flutter and fibrillation the rate of the ven- 
 tricle may be so rapid and the output may become so 
 reduced that an insufficient quantity of blood is sent 
 to the brain. From this cause syncope results (page 
 65). In other cases there is no loss of consciousness, 
 but there is much breathlessness, with great accumu- 
 lation of blood in the venous system, as shown by 
 lividity of the face, enlargement of the liver, and fullness 
 of the jugular veins. Congestion of the lungs may be 
 so extreme that in a few hours crepitations appear at 
 the bases, and dullness of the organs themselves can 
 be detected. On several occasions I have seen such 
 attacks mistaken for pneumonia by skilled physicians. 
 
 Overstrain of the heart. 
 
 There is a belief, widely cherished by the profession, 
 that overstrain of the healthy heart is a frequent occur- 
 rence. Some fifteen or twenty years ago quite a scare 
 occurred among doctors about the danger of overstrain 
 from athletics and school games. I have, for a number 
 of years, had brought to me great numbers of boys, 
 girls, and young men with " strained " hearts ; in nearly 
 every case the symptoms on which this expression of 
 opinion was based could be referred to one or more of 
 these signs (systolic murmurs, youthful type of irregu- 
 larity, physiological dilatation of the heart) which I have 
 already described and characterised as manifestations of 
 a healthy young heart. 
 
 In a number of cases when grievous heart-failure has 
 suddenly set in after a severe effort, it will be found that 
 the onset of heart-failure was due to fibrillation of the 
 auricle. The literature of the subject, when cases are 
 described with sufficient clearness, reveals the fact that 
 nearly every one of these patients had auricular fibrilla- 
 tion. Most of them are elderly people, or people with 
 some old rheumatic history. I have, however, seen
 
 1 86 HEART ATTACKS 
 
 auricular fibrillation occur in a few young people after 
 effort, in whose hearts I could detect no other fault. 
 
 I have described on page 195 the case of a youth in 
 training who collapsed suddenly, and have pointed out, 
 in connection with that case, that the trouble arose, not 
 alone nor even chiefly from exertion, but from the 
 presence of some infection. It is believed that during 
 war the severe tests of endurance, which are a common- 
 place of campaigning, provoke heart overstrain ; an 
 examination of a large number of cases shows that an 
 infection or other predisposing influence — for example, 
 want of sleep and worry — combines with the overstrain 
 to produce the exhaustion, and that in no case are the 
 symptoms purely cardiac in origin (page 194). When, 
 therefore, we encounter exhaustion in a hitherto healthy 
 individual, it is our duty always to search for some 
 cause other than mere overstrain. 
 
 I do not say that exertion alone may not damage the 
 heart, but I do assert that such an event is extremely 
 rare. In a few cases, in which I could find no provoca- 
 tive cause other than prolonged violent effort, the chief 
 complaint was pain or distress in the chest ; there was 
 no abnormal action of the heart and no increase in its 
 size.
 
 CHAPTER XXI 
 
 ACUTE AFFECTIONS OF THE HEART 
 
 There is a great similarity between the symptoms of an acute 
 affection of the heart and those due to fever and the 
 toxins of organisms in other parts of the body. 
 
 It is well known that, when the temperature is raised, 
 certain alterations take place in the circulatory system. 
 The rate of the heart, for instance, increases and the 
 peripheral vessels dilate. These phenomena may arise 
 simply from the effect of heat ; and, indeed, we get the 
 same results from a hot bath. It is often assumed that 
 the temperature alone is the cause, and attempts have 
 been made to associate a definite increase in heart-rate 
 with each degree of raised temperature. This view, 
 however, is fallacious, for, while, no doubt, increase of 
 the temperature does modify the heart's rate, the in- 
 fluence of the agent causing the rise of temperature 
 has other effects. I have kept notes of individual 
 patients, and I have found that, during febrile attacks 
 of different kinds, the rate of the pulse did not corre- 
 spond with the degree of fever, but varied, seemingly, 
 with the nature of the infection causing the fever. An 
 attack of ague furnishes striking support of this view. 
 In ague, during the phases of the hot and cold stages, 
 marked variations are found in the heart and peripheral 
 vessels, yet the rise in temperature is constant. Again, 
 in typhoid fever the pulse-rate may actually fall while 
 the fever is maintained. 
 
 The combined reaction of temperature and infection 
 
 i8 7
 
 1 88 ACUTE AFFECTIONS OF THE HEART 
 
 on the heart and blood-vessels is extremely varied. In 
 many cases, beyond increase in cardiac rate, no change 
 can be detected ; while, in other cases, marked changes 
 are found in the heart — for example, dilatation, some- 
 times to a considerable extent, and the appearance of 
 systolic murmurs at the apex and the base. 
 
 These phenomena may only be the physiological 
 response of the heart to certain stimuli, such as the 
 toxins of disease organisms in other parts of the body. 
 On the other hand, these signs may be evidences of the 
 invasion of the heart by the disease agents, and the 
 production by these agents of destructive lesions of the 
 tissues of the heart. It is often a matter of difficulty 
 to decide the nature of these phenomena during the 
 fever, and it may be necessary, in many cases, to suspend 
 judgment till the cause of the illness has been ascertained 
 and more clear evidence gained. I mention the matter 
 in order to direct your attention to the fact that these 
 phenomena may arise in cases in which serious mischief 
 has not occurred ; you should bear this in mind in every 
 case. It not infrequently happens that their appear- 
 ance in the course of a febrile attack, such as rheumatic 
 fever, is taken as an indubitable sign of endocarditis, 
 when, as a matter of fact, it has no such significance. 
 I repeat that it may not be possible to decide the matter 
 until after the subsidence of the fever, when the heart's 
 rate has fallen and its size diminished ; in the young 
 the youthful type of irregularity may appear during con- 
 valescence, and by its appearance testify to the escape 
 of the heart. On the other hand, a persistent increase 
 in the rate of the heart may occur, pointing to the 
 presence of some active mischief in the organ. 
 
 From such considerations we gather that there are 
 two conditions of the heart which may supervene upon 
 infection : (1) That in which the heart itself is invaded 
 by some organism whose presence produces certain 
 signs and causes actual damage to the cardiac tissues ; 
 (2) That in which an organism present in other organs
 
 ACUTE AFFECTIONS OF THE HEART 189 
 
 and tissues affects the heart, not directly, but by the 
 toxins it has produced. The distinction is of the very 
 highest importance, because the latter condition, which 
 I shall call the "'poisoned heart," is of frequent occur- 
 rence ; its symptoms are often misunderstood. 
 
 The heart in rheumatic fever. 
 
 Acute affections of the heart are seen most frequently 
 during an attack of rheumatic fever. In rheumatic 
 fever the pain in the joints and the illness produced by 
 the fever first call attention to the condition. I need 
 not dwell on these phenomena, as they are well known 
 to you. The frequency of heart-disease in rheumatic 
 fever leads us to study the heart carefully even in the 
 mildest forms of the complaint, among which must be 
 classed the "growing pains " of the young. The symp- 
 toms of the invasion of the heart are varied. There is 
 often an increase in size ; sometimes this increase is 
 slight, sometimes it is of very great extent. This latter 
 state of affairs is found particularly when the myo- 
 cardium is invaded. Invasion of the myocardium is, 
 of course, of frequent occurrence ; nevertheless, there is 
 nothing to distinguish the enlargement caused by it 
 from the dilatation of the poisoned heart to which I 
 have referred, except in those rare instances when an 
 irregularity of the heart's action, due to partial heart- 
 block, demonstrates that the auriculo-ventricular bundle 
 has been invaded. It is probable that the frequent 
 occurrence in later life of auricular fibrillation or flutter 
 is the result of an unsuspected invasion of the auricular 
 muscle during an attack of rheumatic fever. 
 
 The appearance of a soft systolic murmur warns us 
 that the endocardium may be invaded. With changes 
 in the character of the murmur this warning becomes 
 confirmed. The appearance of a diastolic murmur 
 causes us to recognise that the aortic valves have been 
 invaded and damaged. I may remark here that the
 
 190 ACUTE AFFECTIONS OF THE HEART 
 
 presystolic murmur of mitral stenosis never can appear 
 during the first attack, as it is the outcome of a slow 
 cicatrising process which develops after the acute in- 
 flammation has subsided. Invasion of the pericardium 
 is recognised by the peculiar pericardial friction sound, 
 or by the characteristic signs of effusion into the peri- 
 cardial sac. 
 
 On rare occasions similar phenomena arise in connec- 
 tion with other acute diseases — for example, septic joint 
 affections, influenza, erysipelas, pneumonia. 
 
 The treatment of acute affections of the heart. 
 
 As soon as we recognise that we have to deal with 
 rheumatic fever we must, as a matter of routine, place 
 the patient in the most favourable condition for 
 recovery; we must also employ appropriate remedies 
 for his relief and attempt so far as we can to stay the 
 progress of the disease (e.g., by the use of the 
 salicylates). 
 
 In all cases it is a good rule strictly to keep the 
 patient in bed until there is assurance that the condi- 
 tion is quite abated. In spite of this measure, however, 
 difficulty will often arise. The presence of a murmur 
 and of irregularity of the heart is so often associated 
 with rheumatic fever that, when these occur in the 
 course of this condition, or of other febrile states, it 
 often happens that they are taken as signs of disease. 
 The signs are, in fact, perfectly innocent. I have already 
 dealt with this matter and I would refer you to what 
 I have said. (Page 106.) 
 
 On the other hand, so long as there is positive evi- 
 dence of mischief — for example, a persistent increase of 
 rate, a changing murmur, or a diastolic murmur which 
 has arisen during the illness — the patient should be kept 
 at rest, and this should be enjoined until the rate is 
 quite normal, even although six months may elapse 
 before that result is brought about.
 
 ACUTE AFFECTIONS OF THE HEART 191 
 
 During an attack of acute rheumatism and in the sub- 
 sequent convalescent stage, treatment of the heart by 
 drugs is not indicated, and the indiscriminate use of 
 the so-called cardiac tonics (digitalis, etc.) is more likely 
 to do harm than good. 
 
 Septic Endocarditis. 
 
 There are a great many septic infections which injure the 
 heart, the specific organism invading the organ. 
 
 The endocardium is frequently attacked, and the 
 disease is then described as septic endocarditis. In these 
 cases there may be an invasion of the myocardium; it 
 is the resulting profound depression of the heart muscle 
 which is often the grave element. 
 
 The illness in these cases usually begins insidiously, 
 and at first may be mistaken for some trivial febrile 
 complaint or for influenza. Soon, however, the extreme 
 prostration of the patient, the recurrence of rigors, and 
 the patient's own sensation of illness show that the con- 
 dition is of a more serious nature. Usually, also, there 
 is an excessive perspiration. If the heart be watched 
 it will be found to dilate ; a systolic murmur appears. 
 The true nature of the condition may not be revealed 
 until the detachment of a vegetation produces hemi- 
 plegia, or an infarct in the spleen or kidney ; death may 
 speedily supervene (malignant endocarditis). 
 
 Other cases may linger on with indefinite febrile 
 attacks ; the patient is sick, pale, and ill, and the real 
 nature of the illness remains a mystery. In some of 
 these cases very little change takes place in the heart. 
 I have seen a woman, after confinement, have slight 
 fever for nine weeks without resulting change in the 
 size of the heart ; her heart-rate was generally about 80 
 per minute, and a rough systolic mitral murmur was 
 the only abnormal sign present. An attack of hemi- 
 plegia led to the recognition that the rough mitral
 
 192 ACUTE AFFECTIONS OF THE HEART 
 
 murmur was due to vegetations on the valves. Osier 
 has recently published an account of ten cases of chronic 
 infectious endocarditis. In addition to the irregular 
 fever he gives the following as the most suggestive 
 features which help to identify the nature of the disease : 
 
 (1) A knowledge of the existence of an old valve trouble ; 
 
 (2) the occurrence of embolic features, sudden swelling 
 of the spleen, sudden attack of haematuria, embolism 
 of the retinal arteries, hemiplegia, or the blocking of a 
 vessel in one of the limbs ; (3) the onset of special skin 
 symptoms, purpura, and more particularly the painful 
 erythematous nodules, in all probability due to minute 
 emboli ; (4) the progressive cardiac changes, the gradual 
 increase in the dilatation of the heart, the marked 
 change in the character of the mitral murmur, the onset 
 of a loud, rasping, tricuspid murmur, or the develop- 
 ment, under observation, of an aortic diastolic bruit. 
 
 In pyaemia and puerperal septicaemia we encounter 
 conditions of profound gravity which are caused by 
 certain organisms. The pulse in these cases gives the 
 most trustworthy information. It is small, soft, and 
 easily compressed, not necessarily very rapid ; the 
 temperature need not be high (101-2° F.). The heart 
 shows little change except that its sounds are feeble ; 
 the patient is lethargic, the face is slightly sallow or 
 pale and sunken. The aspect of the patient, taken with 
 the rate of the pulse, affords assistance in recognising 
 the condition. I dwell upon this point because, happily, 
 some of the younger members of the profession have 
 little experience of dangerous forms of puerperal fever, 
 but, having heard of the terrors surrounding them, are 
 not infrequently unnecessarily frightened at the occur- 
 rence of a post-partum rise of temperature of trivial 
 significance ; others, again, do not recognise the signi- 
 ficance of the heart symptoms when danger actually 
 arises. 
 
 The outlook in these cases is bad, and all attempts 
 at treatment have hitherto proved of no avail.
 
 ACUTE AFFECTIONS OF THE HEART 193 
 
 The Poisoned Heart 
 
 The toxins produced by germs invading the body may affect the 
 circulatory as well as other systems. 
 
 When an individual suffers from the invasion of his 
 body by some microbic infection he falls into a state 
 of ill-health. The symptoms are at first subjective and 
 give rise to a vague feeling of being " out of sorts." If 
 the infection be severe and belong to some of the well- 
 recognised groups of infection (e.g., typhoid fever, pneu- 
 monia, scarlet fever, or measles) the symptoms charac- 
 teristic of these diseases manifest themselves, and all 
 the symptoms of ill-health are naturally attributed to 
 the specific infection. But there are a great number of 
 obscure illnesses which never develop symptoms that, 
 in our present state of knowledge, we can recognise as 
 belonging to a specific disease. These illnesses may be 
 of a mild type and may give rise only to ill-defined 
 sensations. Some of the sensations may be referable 
 to the circulatory system — for example, palpitation, 
 breathlessness, or exhaustion easily provoked ; while 
 abnormal signs — for example, increased rate, systolic 
 murmurs, or dilatation — may appear in the heart. In 
 the absence of absolutely definite signs of infection the 
 patients are often regarded as the victims of an affec- 
 tion of the heart. 
 
 One feature which distinguishes these cases from cases 
 suffering from primary cardiac failure is a feeling of 
 tiredness always present and a sense of exhaustion easily 
 induced. If these people be asked what is the sensation 
 which they, on making a mild effort, first recognise as 
 indicating distress, they will invariably reply, " a feeling 
 of exhaustion." It may require a violent effort — for 
 example, running up stairs — to induce palpitation or 
 breathlessness, and therefore the onset of these symp- 
 toms is often attributed to such an effort. The sensa- 
 tion of exhaustion is, however, the predominant feeling ; 
 
 o
 
 i 9 4 ACUTE AFFECTIONS OF THE HEART 
 
 it comes on, too, at unexpected times, as well as during 
 effort. (See Chapter XI.) 
 
 The peculiar condition described as the irritable heart of soldiers 
 illustrates the effects of toxins with conditions producing 
 exhaustion. 
 
 The importance of recognising the nature of the source 
 of exhaustion and of differentiating between the ex- 
 hausted state and the state of cardiac inefficiency has 
 been brought prominently before me in an investigation 
 which I, along with others, have been conducting on 
 soldiers who have been invalided because of a heart 
 affection. Since the American Civil War it has been 
 understood that many soldiers break down in a peculiar 
 way ; they show no organic lesion, and as, in a consider- 
 able number, the heart is liable to periods of rapid 
 action, their condition has been described as the 
 " irritable heart " of soldiers. The well- written accounts 
 of these cases show that they correspond to the cases 
 we have been meeting with in our present investigation. 
 In an analysis of 400 cases we found that 90 per cent, 
 did not suffer from organic disease of the heart, and that, 
 although increased rate, dilatation, and other abnormal 
 signs were sometimes present, those signs were only part 
 of a general condition. In nearly all we could trace the 
 onset of illness to some infection (as shown by fever or 
 diarrhoea). These men led strenuous lives while they 
 were suffering from the infection ; after a time, however, 
 they got weaker, and finally they collapsed, and were 
 diagnosed as " heart " cases. In every one of these 
 cases the chief symptom was a feeling of weakness — 
 " rotten " was an expression commonly used by the men 
 to describe their sensations. I asked many of them 
 what pulled them up when they were walking on the 
 level, and everyone said it was the sense of exhaustion ; 
 if they ran or went uphill they would feel short of 
 breath and suffer from palpitation. 
 
 It is manifest that this class of patient does not suffer
 
 ACUTE AFFECTIONS OF THE HEART 195 
 
 primarily from a heart affection, but rather from some 
 toxic condition affecting the central nervous as well as 
 the circulatory system. 
 
 Case illustrating the effects of exertion during a mild febrile 
 
 attack. 
 
 In order to make clear the nature of this sudden ex- 
 haustion from infection I cite the following experience. 
 A youth training for a race had been spending some 
 time each day running round the track. One day while 
 so engaged he felt ill and giddy ; he stumbled and fell 
 and was picked up partly unconscious. His doctor at 
 once said that he was suffering from heart overstrain; 
 and a slight dilatation of the organ confirmed him in 
 this view. I was asked to see the young man. His 
 account of himself was that he had been perfectly fit 
 until the morning of his seizure. When he awoke on 
 that morning he " felt rather seedy." Notwithstanding 
 this, he started on his usual training exercise, with the 
 result just described. Now, no sound heart gives out in 
 this way from overwork, as you will readily agree if 
 you have understood the account I have given of what 
 constitutes heart-failure. When such sudden attacks of 
 weakness occur in presumably healthy people we have 
 to look for some other cause — in the elderly the onset 
 of a new rhythm, such as auricular fibrillation; in the 
 young some complaint other than heart-failure. As in 
 the case I have mentioned the training up to the day 
 of the breakdown testified to the health and vigour of 
 the patient's heart, I expected to discover an infection. 
 I took the temperature and found it 100° F. It was thus 
 evident that the weakness was the outcome of some 
 slight febrile attack. After a few days' rest the patient 
 was quite well, and shortly after he resumed his training. 
 In the end he ran his race with no sign of weakness. 
 
 Such is the account of a typical instance. In cases 
 where a sense of exhaustion is easily provoked, and is 
 accompanied bv palpitation and breathlessness on 
 
 o 2
 
 196 ACUTE AFFECTIONS OF THE HEART 
 
 exertion, the physician should always inquire how long 
 it is since the individual was in robust health, and 
 particularly in what circumstances he first recognised 
 his weakness. Frequently he will find that the onset 
 of the ill-health dates from some illness, it may be of a 
 trivial nature — such as influenza, a mild attack of 
 diarrhoea, or some indefinite condition with a little fever. 
 
 A great variety of conditions may induce exhaustion and affect 
 
 the circulatory system. 
 
 There are other patients from whom we cannot get a 
 definite history as to the beginning of the trouble. In 
 these cases we must exercise care to examine the con- 
 dition of the other organs. It may be laid down that 
 the intestines furnish the most common provoking cause. 
 Many different morbid conditions of the gut are closely 
 associated with the circulatory system — for example, dila- 
 tation of the stomach, with and without pyloric stenosis, 
 stasis in some portion of the intestinal tract, constipa- 
 tion, and so forth. It is not, of course, the organic 
 mischief present which directly causes the patient's 
 complaint ; but the organic change interferes with the 
 healthy action of the digestive tube, and so, by retaining 
 the contents of the tube, permits decomposition to set 
 up. The products of this decomposition are absorbed 
 and act as the poisoning agent. Other sources of 
 poisoning are found in chronic local inflammation — 
 e.g., a chronic appendicitis, or abscesses in different 
 regions of the body. External agents also produce 
 these effects upon the circulatory system as may be seen 
 in persons who over-indulge in alcohol and tobacco ; it 
 is scarcely necessary to insist that unhealthy occupation 
 or surroundings, with insufficient food, are predisposing 
 factors. 
 
 Symptoms. 
 
 The symptoms of the condition in the milder cases 
 are not those of a poisoned heart alone, but are also
 
 ACUTE AFFECTIONS OF THE HEART 197 
 
 those of disturbance of other systems. This applies 
 especially to the nervous system. Thus, the most 
 frequent symptom of all is absence of the sense of well- 
 being : the patients are conscious that something is 
 amiss, and many of them, as I have stated, express 
 this feeling colloquially by the word "rotten." There 
 is often an irritability of temper which is at times un- 
 accountable ; frequently, also, there is great mental 
 depression. Signs of vaso-motor irritability are com- 
 monly met with. The appetite is fickle and frequently 
 poor; and nausea may be provoked. The response to 
 effort is limited, the limitation being shown in the 
 majority of cases by a sense of exhaustion. Breath- 
 lessness on exertion is usually present also, though it 
 is not so much complained of as is exhaustion. The 
 peculiarity about the limitation of the strength is that 
 it is so very variable. In favourable circumstances, the 
 individual at times can do a surprising amount of 
 work, while at other times his strength is speedily ex- 
 hausted. Also, the sense of exhaustion is quickly 
 recovered from ; when the patient sits or lies down it 
 passes away in a few minutes, and he may later under- 
 take much effort without suffering. In extreme cases 
 the cardiac inefficiency may be very marked and may 
 lead to great breathlessness and to extreme heart-failure 
 with dropsy and enlarged liver. Such extreme cases 
 rarely arise as the result of microbe invasion, but are 
 frequently met with in alcoholics, especially in cases 
 where the alcohol consumed has been contaminated with 
 arsenic. Pain is a very frequent symptom. It is 
 referred to the chest, over and internal, to the left breast. 
 It is usually not severe, and is commonly rather a sense 
 of dull aching than a pain. Occasionally, however, it 
 may be of intense severity and may assume all the 
 characters of a violent attack of angina pectoris. One 
 feature, however, distinguishes it from the pain due to 
 over-exhaustion of the heart as a result of actual 
 disease, and that is its tendency to occur when the
 
 198 ACUTE AFFECTIONS OF THE HEART 
 
 individual is at rest. So striking is this tendency that 
 I have laid it down for many years that, when pain in 
 the characteristic cardiac regions occurs only while the 
 patient is at rest, the graver conditions of disease should 
 be excluded and search instituted for some provoking 
 cause, especially for some source of poisoning. In many 
 cases of poisoning the individuals suffer no pain, even 
 when making a considerable effort. Effort, on the con- 
 trary, may, in other cases, provoke the pain. In these 
 latter cases the fact that the pain also comes on when 
 no effort is being made suggests that there is some toxic 
 influence at work. In rare cases of tobacco poisoning 
 the pain is provoked during the act of smoking. This 
 is seen typically in elderly men who are actually suffer- 
 ing from disease of the heart; occasionally, however, 
 we find it also in the young who have no cardiac disease 
 of any kind. 
 
 Physical signs. 
 
 The patient may present no physical signs. In the 
 majority of patients, however, there are evidences of 
 an unstable vaso-motor system — for example, a ten- 
 dency to flush and grow pale. The least excitement in 
 these cases causes the face to become red, while the 
 hands and fingers remain pale and cold. Sometimes 
 the pallor of one or more fingers is extreme, they 
 become numb and "dead." 
 
 The heart's rate may be persistently increased, or 
 may be easily provoked to an increased rate; attacks 
 of palpitation are also easily provoked. Mental excite- 
 ment or effort are the usual stimulating factors, but 
 the increased action of the heart may occur without the 
 presence of any ascertainable cause. The heart's size 
 may be unaffected ; on the other hand, a slight increase 
 in size is not infrequent. It is only in the extreme 
 cases, which are rare, that we get dilatation of the 
 heart ; and then we may also get large pulsation in the 
 veins of the neck, dropsy, and enlargement of the liver.
 
 ACUTE AFFECTIONS OF THE HEART 199 
 
 Murmurs are frequent ; they are usually of indefinite 
 origin, though some seem distinctly to arise at the 
 mitral orifice. They are always systolic in time. 
 
 Prognosis. 
 
 The outlook in most cases is distinctly favourable. I 
 have never seen a single case of the milder form of 
 the condition develop any grave sign of heart-failure. 
 Many gradually get rid of the poison and recover; on 
 the other hand, some are crippled for years. The one 
 danger resides in the fact that, being in a state of im- 
 paired health, these patients are less resistant to other 
 infections, and so are apt to fall a prey to them. I 
 have seen a few cases, in which the source of infection 
 was originally intestinal, develop consumption. 
 
 Treatment of the poisoned heart. 
 
 It is scarcely necessary to dilate on the principles of 
 treatment. The recognition of the condition compels 
 a search for the source of the poisoning and the adop- 
 tion of measures for its removal, whether it be a focus 
 of infection, such as an abscess, intestinal absorption, 
 or alcohol. In cases which are the result of a past 
 infection, the placing of the patient under hygienic con- 
 ditions best calculated to restore his general health is 
 indicated, rather than attempts to treat the heart alone.
 
 CHAPTER XXII 
 
 BLOOD-PRESSURE 
 
 Blood-pressure records are used for purposes they cannot fulfil. 
 
 In discussing murmurs I pointed out that the un- 
 reasoning way in which the profession took up the 
 stethoscope had hindered the advance of medical science 
 and had done grave injury to many individuals, although 
 no doubt a good deal of useful knowledge had also been 
 acquired. We can see the same influence at work in 
 the attitude of the profession to almost every new 
 method, and at present the profession is much exercised 
 over blood-pressure instruments. Although it is only 
 a few years since instruments approximately accurate 
 have been in use, important and far-reaching conclusions 
 are drawn which are quite unjustified, and are in 
 the main misleading, for we are actually ignorant of 
 some essential factors concerned in the production of 
 the blood-pressure, and do not yet realise what are the 
 normal variations in health, let alone the variations 
 that occur in ill-health. We find the sphygmomano- 
 meter used as a basis for diagnosis, as a guide in treat- 
 ment, and as providing grounds for a prognosis, even in 
 life insurance. 
 
 We find it used to estimate the efficiency of the heart 
 muscle — sometimes by estimating the relation of the 
 systolic to the diastolic pressure, sometimes by the 
 variations in blood-pressure by change of posture or by 
 effort. Such calculations as these are based on a mis- 
 conception of what heart-failure is and what part the 
 heart muscle plays in the production of blood-pressure.
 
 BLOOD-PRESSURE 201 
 
 The research into the significance of blood-pressure has not 
 been undertaken by the observers who have the appropriate 
 opportunity. 
 
 It is possible that when we have sufficient knowledge 
 of the blood-pressure we shall find it of considerable help 
 in our work, but there is no prospect of our acquiring 
 that knowledge in the near future. It has never yet 
 dawned on the great majority of writers on this sub- 
 ject how this knowledge is to be acquired. While many 
 of the factors concerned in its production may be dis- 
 covered by investigation in the laboratory and the 
 hospital ward, other equally essential data cannot be 
 acquired in these places. I have endeavoured to watch 
 the variations in blood-pressure, as estimated mechanic- 
 ally, in people for a great number of years and have been 
 struck by the great variations that may occur even in 
 healthy individuals. The earliest complaints which 
 caused some patients to consult me were accompanied 
 by a high blood-pressure, and the progress of their ill- 
 health has been rapid. In a few patients death has 
 followed in a few years in spite of all kinds of treat- 
 ment. Others with the same high blood-pressure have 
 not gone so rapidly bad, but have lived for long years 
 with a very gradual deterioration in health, while 
 others have pursued a normal life with no signs more 
 remarkable than would accompany advancing years. 
 
 But I have no knowledge of the antecedents of these 
 cases, and I am unable to say what value should be 
 attached to the blood-pressure records. Some slight 
 advance I have made, in that I never take the blood- 
 pressure alone as a guide to an opinion, but consider 
 also the state of the arteries, the size and efficiency of 
 the heart, and the state of the kidneys. With the data 
 thus obtained I venture upon an opinion, but even then 
 it is by no means a very certain one. 
 
 The study I have given to this subject leads me only 
 so far as to indicate on what line the subject should
 
 202 BLOOD-PRESSURE 
 
 be pursued. The observers who alone are capable of 
 undertaking this quest are young practitioners in general 
 practice, because they have the two great essentials — 
 the opportunity for watching individuals for many years 
 and the prospect of living long enough to complete 
 their observations. It is manifest before we can recog- 
 nise the significance of an abnormal state we must know 
 the normal and the limits within which variations may 
 occur in health. Many writers on blood-pressure are 
 teachers of medicine, and if they would but train their 
 students how to observe, and impress upon them the 
 fact that it is to them, and to them alone, that we must 
 look for acquiring the knowledge essential to the under- 
 standing of this subject, these teachers would do far 
 more for the advancement of knowledge than they will 
 ever do by their crude speculations and hasty deduc- 
 tions. 
 
 Up to the present blood-pressure observations have yielded but 
 little information of real value. 
 
 It must be admitted that when we attempt to review 
 the subject, very little of practical value has come out 
 of the great amount of time and labour that has been 
 spent on this subject. In place of the statement of the 
 old physicians that the pulse was firm and hard we get 
 now a definite and precise figure which most people 
 imagine to be more scientific, as it is supposed to repre- 
 sent the systolic blood-pressure. Now it does nothing 
 of the sort, for the figure obtained by the use of the 
 armlet differs from that obtained from the pressure 
 taken directly from the artery. There is no doubt that 
 it has some relation to the actual blood-pressure, and we 
 can safely say that when we get a high figure or a low 
 figure it represents a high or low blood-pressure. 
 
 One of the most curious features seen in the writings 
 of those who use blood-pressure instruments is their 
 trust in the figures they employ. They often take them 
 as if they were a constant standard. Now the blood-
 
 BLOOD-PRESSURE 203 
 
 pressure may vary just as the heart's rate with exciting 
 causes, and too often temporary and incidental varia- 
 tion are not appreciated. 
 
 Perhaps the most striking instance of a lack of careful 
 observation is seen in the reckoning of the blood-pressure 
 in irregular action of the heart. I have never come 
 across a writer who recognised that in the irregular heart 
 of auricular fibrillation, for instance, it is, as a rule, 
 utterly impossible to get a correct instrumental reading. 
 Each beat varies in its strength, sometimes remarkably 
 so, but writers will ignore this and give a precise figure, 
 which under any circumstances can bear no relation to 
 the actual condition. Even if they take the strongest 
 or the weakest beat, or if they strike an average, the 
 observation is absolutely untrustworthy. 
 
 Claims are now being made that the differences be- 
 tween the so-called systolic and so-called diastolic pres- 
 sure afford important information. While no doubt 
 there are considerable variations found, yet here again 
 we are at a loss to account for the variations ; and to 
 attribute this or that to the condition of the heart 
 muscle, as is sometimes done, is to fail to appreciate 
 the part that the heart muscle plays in the production 
 of the blood-pressure, for it only provides the force for 
 maintaining the blood-pressure, the variations being de- 
 pendent on the other factors of the circulation. 
 
 High blood-pressure is looked upon as in itself an object for 
 treatment, and as the cause of high blood-pressure is 
 unknown the treatment can only be haphazard. 
 
 It is as a guide to treatment that the blood-pressure 
 is supposed to be of especial value. Happily, here 
 we are prevented doing any harm, for we are prac- 
 tically powerless to affect the blood-pressure. Hot 
 baths or some drugs, as the nitrites, may reduce the 
 blood-pressure, but the effect lasts only a few seconds 
 or a few minutes. By starvation and purging the blood- 
 pressure may be temporarily reduced, but it soon returns
 
 204 BLOOD-PRESSURE 
 
 to the old height. It has been a matter of interest to 
 me for many years to note the attitude of spa physicians 
 towards blood-pressure. Each physician advocates the 
 claims of his particular spa for the reduction of the 
 blood-pressure. A few years ago the virtue was claimed 
 for many spas that their waters produced a strong and 
 firm pulse, and now, when a low blood-pressure is the 
 fashion, these same waters have the contrary virtue and 
 reduce a strong pulse to a weak one. It has been a 
 habit of mine for many years to take the blood-pressure 
 of a patient who was about to proceed to a spa for 
 treatment. When he returned he generally brought a 
 letter from the spa physician stating that the patient 
 had received great benefit, and that in particular the 
 high blood-pressure had been greatly reduced. In every 
 case where I took the blood-pressure on the patient's 
 return it showed no difference. A short time since I was 
 consulted by a man on his way to a watering-place. 
 His blood-pressure was 190 mm. Hg. He returned two 
 months later, very cheerful because his spa physician 
 had reduced his blood-pressure to 130 mm. Hg. I again 
 took the blood-pressure and found it 195. I did not 
 undeceive him as the delusion made him very happy. 
 
 I have been consulted by a great many people because 
 of their high blood-pressure. Most of them have been 
 told of the height their blood-pressure has reached, and 
 they have willingly submitted themselves to treatment, 
 many of them going from one authority to another, and 
 with each change undergoing a new treatment. It has 
 been a matter of wonder to me to see the extraordinary 
 resourcefulness of those who treat blood-pressure and 
 the numerous theories that guide them. The drugs that 
 have been employed are legion in number, diets of the 
 most contrary descriptions — all-flesh diet, vegetarian 
 diet, purin-free diet, and various other modifications ; 
 baths and waters and exercises of all kinds ; high fre- 
 quency current and other electrical devices. Notwith- 
 standing this the blood-pressure has remained high.
 
 BLOOD-PRESSURE 205 
 
 Blood-pressure should never of itself form the basis of an 
 
 opinion. 
 
 You will therefore understand that I am not capable 
 of throwing much light upon the subject. When I find 
 a systolic blood-pressure approaching 200 mm. Hg., I 
 seek for evidence of damage in the blood-vessels and 
 in the heart and in the kidneys, and it is upon the results 
 found there that I base both my prognosis and treat- 
 ment. In fact, under all circumstances, the blood- 
 pressure, like murmurs, should not form the basis of 
 an opinion, but should be one factor and that not 
 the essential. 
 
 How blood-pressure research should be prosecuted. 
 
 In treating the subject in a somewhat disparaging 
 manner, it is not my intention to discourage the use of 
 blood-pressure observations. Far from it. My inten- 
 tion is to impress upon you the importance of investi- 
 gating the matter on the lines that will be productive 
 of useful information, and I write this so that you may 
 avoid some of the fallacies and short cuts that at present 
 are hindering the pursuit of a very important subject. 
 
 I would suggest that those of you who are general 
 practitioners should take note of the blood-pressure in 
 a number of your patients, particularly those you will 
 be able to keep under observation. Take these observa- 
 tions in the young as well as in the elderly. These 
 observations need not at first be taken frequently, but 
 as circumstances permit. By and bye you will discover 
 certain cases that need more careful observation and 
 these you should persistently follow. In every case 
 note attendant circumstances, particularly the state of 
 the arteries, heart, and kidneys. I am confident, if the 
 quest be undertaken, you will discover for yourselves 
 lines to follow and problems to solve, and you will need 
 no further guidance.
 
 2o6 BLOOD-PRESSURE 
 
 Blood-pressure instruments. 
 
 There are numerous instruments to be had. A very 
 useful one is Martin's modification of the Riva Rocci. 
 The observation should be made by the auscultation 
 method. This is done by listening with a binaural 
 stethoscope at the bend of the elbow over the artery. 
 Air is pumped into the armlet, which surrounds the 
 upper arm, till the pressure stops the flow of blood 
 in the artery below. The air is then slowly allowed 
 to escape and the eye watches the fall of the mercury 
 in the manometer. As soon as a little blood escapes 
 beyond the armlet a soft sound will be heard in 
 the artery, and usually at the same time a faint 
 oscillation with each beat of the heart will be seen in 
 the mercurial column. The height of the mercurial 
 column is called the systolic pressure. As the air 
 escapes and the pressure falls the sound in the artery 
 becomes clear and distinct. This clear sound is heard 
 till the pressure gets very low, when it ceases. Before 
 it ceases the sound becomes muffled, and it is the height 
 of the mercurial column at this stage McWilliam sug- 
 gests should be taken as representing the diastolic 
 pressure.
 
 CHAPTER XXIII 
 
 PROGNOSIS 
 
 I have set out my views on prognosis so fully in deal- 
 ing with the different symptoms that here I need only 
 call attention to some general principles, and indicate, 
 by a few instances, how they may be applied. 
 
 The guiding principle on which a prognosis should be based is 
 an appreciation of the functional efficiency of the heart 
 muscle, and its ability to overcome any embarrassment to 
 its work. 
 
 It is from this standpoint that every form of disease 
 — valvular, myocardial, and arterial — has to be gauged. 
 The data necessary for the forming of an opinion are 
 present in each individual, so that, when we fail to 
 appreciate them, the fault lies only in our ignorance. 
 It is for this reason that I have insisted, all through 
 the present work, on the imperative necessity of a due 
 appreciation of the relation of every sign and symptom 
 to the efficiency of the heart. Moreover, it is to be 
 clearly recognised that each case requires special study. 
 The fact that the physical signs and the patient's sensa- 
 tions in any particular instance might seem to indicate 
 that the case belongs to a common type is no excuse 
 for want of special study. The personal element and 
 the patient's daily routine enter largely into the com- 
 position of the disease-picture. It is manifest, for ex- 
 ample, that an impaired heart in a man who can lead 
 
 a life of leisure has a significance different from that 
 
 207
 
 208 PROGNOSIS 
 
 of an impaired heart in a man compelled to lead a 
 strenuous and fatiguing life. 
 
 Not infrequently we may detect signs regarding the 
 nature of which we are ignorant. Nevertheless we have 
 to estimate the bearing of these signs on the patient's 
 future. We may find, on testing the functional efficiency 
 of the heart, that the organ is impaired. The question we 
 have to answer then presents itself to us in this way. 
 Is the heart muscle capable of maintaining an efficient 
 circulation, even though its field of response is limited ? 
 It is well known that many people with damaged hearts 
 and a limited field of response reach an old age and 
 show no signs of heart-failure. This fact leads us to a 
 consideration of the question whether the limitation is 
 stationary or progressive. If it is stationary we may 
 say that the outlook is favourable, so long as the indi- 
 vidual is capable of living within his limitations. If, 
 however, the field of response is gradually becoming 
 more restricted, then we must have regard to the rate 
 of progression of the limitation, the possibility that rest 
 may restore the heart weakness, and finally the ability 
 of the individual to live a more restricted life. The 
 results of our study of these factors must be our guides 
 in giving a prognosis. 
 
 This applies to those cases in which the rest force is 
 not encroached upon and in which the heart weakness 
 is shown only by a limitation of the reserve force. 
 When there are objective signs of heart-failure, such 
 as dropsy, enlarged liver, and orthopncea, and when 
 these signs cannot be removed, the patient's future 
 may be reckoned in months. 
 
 When symptoms of heart-failure are present prognosis should 
 be delayed until the effects of treatment are recognised. 
 
 In most cases exhaustion of the heart, with its varied 
 symptoms of inefficiency, arises because the patient is 
 unaware of the existence of impairment and so forces 
 a damaged organ to do the work which is expected of
 
 PROGNOSIS 209 
 
 a healthy one. This is the reason why we see so often 
 a gradual exhaustion of the reserve force, with the 
 appearance of the characteristic symptoms which I have 
 already set forth. The process of exhaustion may have 
 been going on for years before the case is met with, the 
 early signs of inefficiency having been ignored until 
 some sign has compelled attention. This is particularly 
 the case with patients whose hearts have become im- 
 paired by the changes associated with advancing years 
 — those patients, for instance, who ultimately exhibit 
 signs of angina pectoris. As I have pointed out in the 
 chapter on angina pectoris, it may not be possible in 
 the first instance to say whether the exhaustion which 
 produces the pain is due to a heart already slightly 
 impaired and now exhausted by prolonged over-exer- 
 tion, or to an advancing disease. A period of judicious 
 treatment clears the matter up ; for while, in the former 
 case, a remarkable degree of recovery may follow rest, 
 in the latter, and in spite of all forms of treatment, 
 recovery is slight. The same principles guide us in 
 regard to other evidences of heart-failure — e.g., dropsy. 
 It happens not infrequently that a slightly damaged 
 heart in the young (e.g., as a result of rheumatic fever) 
 is not recognised until heart-failure occurs. With rest and 
 appropriate treatment recovery may, in this type of case, 
 be so complete that the patient may be able afterwards 
 to follow a strenuous occupation. It may be put down 
 as an axiom that all hearts with a normal rhythm, in 
 which there are present slowly advancing changes, re- 
 cover from their first attack of failure if rested. The 
 recovery may, however, be limited in degree where 
 severe damage is present. The reason is easily grasped 
 when the manner of heart-failure is appreciated. Heart- 
 failure being due to a forcing of the organ to perform 
 more work than it is fit for, reduction of effort and rest 
 allow a measure of the lost strength to be regained. 
 
 The factors which have to be weighed, then, in form- 
 ing a prognosis are the extent of recovery after treat- 
 
 p
 
 210 PROGNOSIS 
 
 ment, the prospect of the patient being able to lead 
 a useful life within the limits of his strength, and finally 
 the progressive or stationary nature of the disease. 
 
 I have already dwelt on the importance of treatment 
 as a factor in prognosis in auricular fibrillation. 
 
 No attempt should be made to base the prognosis on the 
 presence of only one abnormal sign. 
 
 It may be thought that insistence on such a statement 
 is not necessary, but experience has shown that in prac- 
 tice no obvious rule is so persistently neglected. It would 
 not be too much to say that the vast majority of mem- 
 bers of the profession have failed to grasp the true 
 inwardness of what is conveyed in this statement. 
 Every day I see individuals rejected for the Army and 
 for life insurance and subjected to prolonged restraint 
 and utterly unnecessary treatment because of the 
 failure of their medical advisers to comprehend this 
 statement. I have, in dealing with the more common 
 physical signs, such as murmurs and irregularities, 
 endeavoured to lay down the principles which should 
 be a guide in estimating their value. These views I 
 have repeatedly expressed ; and over and over again I 
 have been met with the assertion that they were per- 
 fectly understood. Nevertheless, among all classes of 
 the profession, the old and experienced as well as the 
 young fresh from the schools, and even the very teachers, 
 I find that, although the truth of the statement is 
 admitted in theory, in practice it is ignored. I have 
 already illustrated the foolishness of this procedure 
 when speaking of the extra-systole, and vague fears are 
 often aroused in the patient's mind when the doctor 
 hints at an irregular action of the heart. 
 
 In like manner the presence of a murmur is frequently 
 taken as a sign that persistent treatment is necessary. 
 All these futile attempts are made because, in practice, 
 the prognostic significance of simple phenomena has 
 never been understood.
 
 PROGNOSIS 211 
 
 We see, therefore, that the formation of a prognosis 
 is of great importance in the everyday life of the general 
 practitioner as an adjunct to treatment. I insist that 
 no serious view of a case, far less a grave prognosis, 
 should be based on the presence of one physical sign. 
 It follows, then, that in any given case which comes 
 before you for treatment, you must closely study the 
 nature of the patient's sensations, and must be able 
 to apprehend the significance of any abnormal sign you 
 detect. I deal with this matter in speaking of treat- 
 ment, but there are occasions other than mere thera- 
 peutic ones when it will be necessary for you to have 
 a clear idea regarding the future of your patient. The 
 mode of life a patient should follow and the occupation 
 he may engage in will often have to be determined 
 by you. As it is impossible to lay down special rules 
 for every case, a full comprehension of the manner 
 in which heart-failure is brought about becomes very 
 essential, since from this comprehension you will obtain 
 a principle which will suffice as a guide. There are a few 
 special points which I have endeavoured to elucidate, 
 with, I confess, only partial success, which may help you 
 when in doubt or in a difficult situation. 
 
 Prognosis and pregnancy. 
 
 To every general practitioner at one time or another 
 the question will be put whether a woman with a heart 
 affection should be allowed to run the risk of child- 
 bearing. He will have to decide the question. For 
 many years I directed much time to finding out the 
 changes in the maternal circulation in the healthy and 
 in those with diseased hearts. I found that many 
 women, who nevertheless attended to their household 
 duties and came through their confinements unscathed, 
 became exceedingly short of breath and had dropsy 
 during the later months of pregnancy. Many even with 
 organic heart troubles were little the worse for their 
 pregnancy. Those in whom the pregnancy caused serious 
 
 p 2
 
 212 PROGNOSIS 
 
 heart-failure were chiefly cases with mitral stenosis. As 
 this condition is frequent in women it requires special 
 consideration in relation to pregnancy. I have had a few 
 cases of women with mitral stenosis who suffered little 
 or no discomfort during child-bearing. These were old- 
 standing cases, however, and the disease was either 
 stationary or was advancing so slowly that for years I 
 could detect no change in the character of the murmurs. 
 There was present, moreover, only a presystolic mur- 
 mur ; the size of the heart was not enlarged, or was but 
 very slightly enlarged, and the response to effort was 
 good. In those patients who suffered from heart-failure 
 during the pregnancy the disease was either of more 
 recent origin — i.e., a shorter period had elapsed since the 
 causative attack of rheumatic fever — or it had pro- 
 gressed till a diastolic murmur was audible as well as 
 a presystolic, and the heart response to effort had 
 become distinctly impaired. The heart-failure in these 
 cases became extreme before full time, or an extreme 
 condition of heart-failure occurred within ten days of 
 the confinement. Some of the women died ; others re- 
 covered, but showed permanent impairment of the heart. 
 In some of these women, who came through their con- 
 finements fairly well, the heart regained but a limited 
 amount of strength. In cases of auricular fibrillation 
 the same experience was met with. Even when the 
 pregnancy and confinement were well borne the patient's 
 strength was permanently weakened ; in other instances 
 the result was actually disastrous. There is no difficulty 
 in understanding this state of matters when we consider 
 that in most, if not in all, of these hearts mitral stenosis 
 was present and was adding to the embarrassment of 
 the organ. 
 
 I have only met with two cases of pregnancy in which 
 there was aortic regurgitation. Both women became 
 very weak and ill towards the end of the pregnancy; 
 both bore their confinements well ; yet both gradually 
 got weaker and died some months after.
 
 PROGNOSIS 213 
 
 My experience would therefore suggest that pregnancy 
 should be forbidden in young subjects with progressive 
 mitral stenosis (see Chapter XV), with auricular 
 fibrillation or with aortic regurgitation, unless the leak- 
 age is slight and the left ventricle not enlarged. 
 
 Prognosis and anaesthesia 
 
 Another question that will frequently arise is whether 
 a patient with some form of heart trouble will be able 
 to stand an anaesthetic. I am one of those old-fashioned 
 people whose experience is limited to the use of chloro- 
 form, which I used freely in practice for over a quarter 
 of a century. In the administration of the anaesthetic 
 I was guided by the physiological effect on the con- 
 sciousness of the patient. Thanks to careful watching 
 I had few misadventures, and I am disposed to think 
 that the changes that have been made in the methods 
 of inducing anaesthesia are not all for the better. The 
 fact that chloroform is falling into disuse confirms me 
 in this view. It is a curious thing, is it not, that, while 
 in some hospitals there are no deaths in 20,000 cases of 
 chloroform anaesthesia, in others there is a death in 
 every two or three thousand ? This would seem to 
 suggest some fault in the administration rather than in 
 the drug administered ; an example of the same kind 
 of fault is furnished by the frequent misuse of digitalis. 
 
 The data which guide me in replying to the question 
 whether or not a patient should have an anaesthetic are 
 obtained exclusively by consideration of the manner in 
 which the heart maintains the circulation. If there is 
 a good or fair response to effort I unhesitatingly give 
 consent to the use of the anaesthetic, no matter what 
 the organic lesion may be. In cases of extreme exhaus- 
 tion of the heart through long-standing disease, as, for 
 example, when angina pectoris is easily provoked ; when 
 there is marked limitation of the field of response — e.g., 
 with auricular fibrillation ; when the patients are fat, 
 wheezy people with liability to bronchitis, the anaesthetic
 
 214 PROGNOSIS 
 
 should be given only if absolutely necessary, and then 
 with the greatest care. 
 
 I have successfully given chloroform in cases with 
 very marked heart-disease (complete heart-block, auri- 
 cular fibrillation, and all forms of cardiac disease), and 
 I am disposed to believe that the guide should always 
 be the state of the heart muscle and its efficiency as 
 found out by its response to effort. 
 
 The cause of sudden death was stated by MacWilliam 
 long ago to be, in all probability, fibrillation of the 
 ventricles. MacWilliam and Levy have since then, as 
 the result of experiment, found that fibrillation of the 
 ventricles is also the cause of sudden death under chloro- 
 form anaesthesia, and the latter observer has stated that 
 sudden death is more likely to occur with insufficient 
 anaesthesia than with full anaesthesia — a conclusion cer- 
 tainly in agreement with the teaching Lister gave us. 
 
 Prognosis and congenital heart-disease. 
 
 I have rarely been able to satisfy myself as to the 
 real defect in congenital affections of the heart. And 
 though I have seen a good many cases and watched 
 individuals for years I have never been able to correlate 
 the symptoms present during life with those found on 
 the post-mortem table. As, however, my opinion is often 
 asked, I give a prognosis upon the principles already laid 
 down — i.e., I consider the response to effort and the size 
 of the heart. Many of the cases have lesions, such as 
 a patent ductus arteriosus, or a loud, rough, systolic 
 murmur, with no increase in the size of the heart. In 
 those the outlook is good. But when the heart is much 
 enlarged and its efficiency markedly impaired, when 
 cyanosis is readily provoked by crying or by effort, the 
 outlook is not good. A crippled existence for a few 
 years, ended by some intercurrent disease, is all that 
 can be anticipated. 
 
 In some cases murmurs heard at birth may disappear
 
 PROGNOSIS 215 
 
 entirely as the child grows ; in these cases the heart 
 appears to be normal in all respects. 
 
 In other cases, which have no marked changes in the 
 heart, the body development is poor. It is probable 
 that the congenital condition here is the narrowing of 
 an orifice ; instead of this orifice becoming increased in 
 size as the body develops, it remains unwidened, and so 
 limits the distribution of the blood to the body. The 
 body is thereby weakened and so becomes liable to the 
 invasion of disease, especially of tubercle. 
 
 Nevertheless, there may occur a wonderful modifica- 
 tion of other structures to make good the defect. This 
 is seen in that remarkable condition in which the aorta 
 becomes obliterated (coarctation of the aorta). I have 
 only seen one case — a middle-aged woman ; in this case 
 the peripheral arteries had all become greatly enlarged, 
 so that the nourishment of the trunk and limb was quite 
 normal. 
 
 The personal element in prognosis. 
 
 There is one factor which must be taken into account 
 in estimating the value of a prognosis — the personality 
 of the observer. 
 
 I have two friends — both very distinguished physicians 
 — who illustrate in their own persons, in their tempera- 
 ments, and in their attitudes towards their patients two 
 great extremes. The one is buoyant and hopeful, and 
 he confided to me that when in doubt he always gives 
 weight to the most cheerful outlook. Even when there 
 is a strong suspicion of malignant disease the patient 
 leaves him buoyed up with hope. The other takes a 
 gloomy view of everything that he does not understand. 
 A sign of obscure origin is to him filled with the most 
 appalling possibilities, and though he may say nothing 
 to the patient, yet his doleful countenance and the 
 solemn shakes of his head convey far more despair than 
 would the utterance of the most hopeless prognosis. 
 Modifications of these two types you will meet with
 
 216 PROGNOSIS 
 
 everywhere, and the prognosis is invariably biassed by 
 their temperaments. 
 
 Mystery and prognosis. 
 
 If, then, we would guard against many errors in our 
 pursuit of a sound prognosis, we must realise and appre- 
 ciate certain human characteristics which modify the 
 interpretation of observations, and we must remember 
 that in drawing conclusions with a view to what, after 
 all, is a form of prophecy, the prophet includes a good 
 deal of his own personality. Again, there is one factor 
 which influences all humanity, and that is mystery. 
 Mystery not only influences the mind, it influences it in 
 a definite manner, by engendering fear. That which is 
 mysterious is, unconsciously, assumed to be evil; the 
 gloom which so often surrounds the prognosis in heart 
 affections may be traced to this human peculiarity. If 
 a metaphysician took the trouble to study the psy- 
 chology of the educated and scientific man he would find 
 in that man a subject at once curious and interesting, 
 and this more particularly when the scientific man 
 happened to be exercised about his own inside. We are 
 so accustomed to associate superstition with ignorance 
 that it startles us to find evidence of the subjection of 
 reason to faith in the educated. A highly-trained 
 chemist will accept no statement about chemicals un- 
 less and until he has put that statement to the test. 
 Let him, however, put some chemicals into his own 
 stomach, by way of producing an effect upon disease, 
 and at once he seems to become capable of believing 
 that they are endowed with the most fabulous properties. 
 
 The heart is an organ so essential to life, and the 
 mystery of death is so often associated with some of its 
 disease manifestations, that any abnormal phenomenon 
 is apt to cause apprehension in the minds both of the 
 doctor and the patient, that this may be evidence of 
 the thing that slays. I have frequently been called to
 
 PROGNOSIS 217 
 
 see learned colleagues who have betaken themselves to 
 bed because they have perceived an abnormal action 
 of the heart — the same having no prognostic significance. 
 A prognosis based upon an intelligent perception of 
 the meaning of signs or symptoms is the only means 
 at our disposal for dispelling the depression produced 
 by mystery. Some years ago a distinguished author 
 consulted me ; he was oppressed by the fear that he had 
 got angina pectoris. As in the case of many intelligent 
 people, the name angina pectoris was surrounded in 
 his mind by grave associations. His description of his 
 sufferings, too, embellished by a very wide and artistic 
 vocabulary, gave a tragic appearance to his complaint. 
 A little time before he consulted me I had read one of 
 his short tales in which supernatural elements were 
 described so graphically as to produce the most terror- 
 inspiring effect. After examining him I referred to this 
 tale of his and said that he had not given his readers 
 any clue to the nature of the supernatural events. He 
 then discoursed to me on the art of mystery and, among 
 other things, said that so long as the real cause of fear 
 was unknown, the human mind unconsciously assumed 
 that what it could not understand must be fearsome. 
 To draw aside the curtain was to banish the sense of 
 terror. After he had finished I told him that in his 
 own case this fear of the unknown was the source of his 
 trouble. It was the mystery associated with the idea 
 of angina pectoris that was making him ill. I then 
 explained to him in simple language the nature of his 
 trouble and sent him away much comforted and much 
 happier ; and, as years passed, he found that my prog- 
 nosis was justified. 
 
 The guarded prognosis. 
 
 There are many conditions regarding which our know- 
 ledge is so limited that we are at a loss what to say 
 and do in connection with them. There is, for-
 
 218 PROGNOSIS 
 
 tunately for us, a wonderful bridge by which we can 
 escape from this difficulty, and that bridge is the 
 guarded prognosis. When a patient presents an ab- 
 normal sign the significance of which the doctor has no 
 idea, the latter says, as a rule, that the condition is an 
 obscure one ; that the patient must be careful that no 
 injury results from an aggravation of the condition; 
 as to the future, he must "play for safety." In the 
 meantime he may employ some treatment in the hope 
 that it may prevent something worse from happening. 
 By this means the physician frequently acquires the 
 reputation of being a very safe man; but we may be 
 forgiven for asking: What of the patient? The ab- 
 normal sign may be, often is, of no significance, yet the 
 patient goes away carrying in his mind an ill-defined 
 fear that something within him is amiss and that dread- 
 ful things may happen. Not infrequently his mode of 
 life has to be altered, so that his business affairs are 
 interfered with, and even his future career modified. 
 
 We must realise that a guarded prognosis is really 
 a confession of ignorance, and that the real state of 
 affairs is, that there is present a sign of which the 
 physician is ignorant. As he will not admit his ignor- 
 ance his poor patient is made to suffer. 
 
 I admit that our ignorance of so many complaints 
 is so complete that there is nothing left for us but to 
 give a guarded prognosis. But we should realise that 
 it is our ignorance that is at fault, and it should be 
 our daily endeavour to find out the real significance of 
 that of which we are ignorant. If we come across some 
 phenomenon of disease of which we have no experience 
 we can, of course, do no better than give our guarded 
 prognosis; but when a physician is constantly coming 
 across the same phenomena for twenty or thirty years, 
 and at the end of that time is still giving a guarded 
 prognosis, it is evident that the real conception 
 of what clinical medicine is has not entered into 
 that man.
 
 PROGNOSIS 219 
 
 Statistical methods in prognosis. 
 
 Attempts are made at times to estimate the prob- 
 abilities of life by rinding out at what age a great number 
 of people die who, during life, have shown some sign, 
 such as a murmur or an irregular action of the heart. 
 It is curious that the fallacy of this view is not recog- 
 nised. If I were to note the age of death in a great 
 number of people with soft corns and were then to lay 
 it down that the average period of life in these persons 
 represented the probable duration of life in all people 
 with soft corns, the absurdity of this method of reason- 
 ing would be perceived at once. Why is it absurd ? 
 Because a soft corn is not a fatal disease. Now the vast 
 majority of signs on which the insurance examiner bases 
 his statistics are as free from risk to life as are soft 
 corns, so that when the examiner takes a murmur as 
 a criterion he is taking a sign the cause of which may 
 have no bearing whatever on the individual's health. 
 Those who have appreciated what I have said about 
 heart-failure will appreciate the truth of this criticism.
 
 CHAPTER XXIV 
 
 PRINCIPLES OF TREATMENT 
 
 In the past lines of treatment have too often been adopted 
 before guiding principles were understood. 
 
 There is a widely-established and very ancient belief 
 that for every form of complaint an appropriate remedy 
 exists. In accordance with this belief remedies have 
 been suggested during untold ages, so that we find 
 records of energetic and resourceful treatment from the 
 most ancient times to the present day, and among the 
 most backward races as well as among the most ad- 
 vanced in civilisation. As treatment was employed in 
 primitive times, when neither the nature of the disease 
 causing the complaint nor the principles on which this 
 disease should be treated were understood, much of the 
 therapy was based on empiric methods. The faith in 
 certain of these old remedies has been handed down 
 from generation to generation, and though no doubt 
 faith has been modified from time to time and new 
 beliefs added by each new generation, yet the empiric 
 methods have not been displaced. If one looks back 
 on the literature of the last hundred years one finds 
 this process of addition in operation. Some drugs and 
 methods have been employed for varying periods, and 
 some have fallen into disuse, while others have been 
 adopted in their place. Throughout all these changes 
 no fundamental principles guided physicians in the 
 adoption or rejection of a drug. The circumstance which 
 has determined the adoption of a new method has been
 
 PRINCIPLES OF TREATMENT 221 
 
 the apparent improvement of the individual in response 
 to its application, backed by the authority of the 
 physician who applied it. With the fading of the 
 physician's reputation the method has, as a rule, fallen 
 into disuse, unless there has arisen in the meanwhile a 
 financial interest in its continuation, in which case 
 brazen advertisement may have kept it going for a 
 time. 
 
 There is a great need for the intelligent study of methods of 
 
 treatment. 
 
 This advocacy of remedial measures based on no 
 definite principle is as marked at the present day as at 
 any, even the most benighted, period. I have been 
 struck by the criticisms passed on my suggestions with 
 regard to treatment in my book on the heart. The 
 burden of these criticisms is that I recommend so few 
 remedies. As you all know, a great many drugs, baths, 
 exercises, and other methods, the vast majority of which 
 are entirely without effect, are recommended by writers. 
 It is so easy for a writer to mention this or that treat- 
 ment ; but critically to test a line of treatment requires 
 such careful observation that few writers, even those 
 who puff their own particular lines, ever attempt it. 
 It has therefore always been my aim in writing to give 
 the results only of my own experiences. In employing 
 methods of treatment I naturally have followed, in the 
 first place, the injunctions of authorities who have pre- 
 scribed a certain line. But I always followed my treat- 
 ment critically and endeavoured to find out whether the 
 line recommended had the result which had been de- 
 scribed. This work has entailed an enormous number 
 of observations and long periods of investigation ; the 
 result of it has been a growing conviction that the great 
 bulk of the remedies and methods tested are without 
 any real benefit. Latterly I have refused to test new 
 methods and drugs which have been recommended, and 
 this for two reasons : first, I have acquired a certain
 
 222 PRINCIPLES OF TREATMENT 
 
 amount of knowledge which enables me to perceive 
 clearly the object to be aimed at in any given line of 
 treatment. If the advocates of any new method cannot 
 show some reason why their method will attain this 
 object, but base their recommendation on a fanciful 
 concept, or on imperfect observation, I, beforehand, 
 know it will be a waste of time to investigate the matter 
 further; secondly, so many recommendations are made 
 by people who have not acquired the knowledge of what 
 the object of treatment really is and who do not know 
 what is the significance of many manifestations which 
 the heart can exhibit. 
 
 The essential object in treatment is to anticipate and prevent 
 heart-failure, or to restore the heart if it has failed. 
 
 Before dealing with the matters essential to the treat- 
 ment of heart affections it is necessary that we should 
 hold clearly before us what it is that we attempt in our 
 treatment. In order to emphasise this necessity I would 
 refer again to the essential question which the doctor 
 must put to himself when he detects something amiss 
 with his patient's heart. The question he must ask 
 himself is : "Is this sign an evidence of heart-failure, or 
 does its presence foreshadow the occurrence of that 
 state ? " It is always heart-failure that is to be feared, 
 that if present has to be cured, and that if foreshadowed 
 must be anticipated and prevented. If the doctor can 
 satisfy himself that the sign present indicates neither 
 the one state nor the other, then the fear of heart-failure 
 may be put on one side so far as treatment is con- 
 cerned. 
 
 Another matter we must endeavour to recognise, 
 namely, our own limitations. If we detect a lesion which 
 is stationary, but which hampers the heart in its work, 
 we know that heart-failure may supervene, and our treat- 
 ment will follow the lines I will shortly indicate. But 
 having recognised the lesion we must also recognise how 
 helpless we are in removing it. If, for instance, there is
 
 PRINCIPLES OF TREATMENT 223 
 
 evidence of a valve defect, mitral or aortic, we must en- 
 deavour to find out whether or not the defect is a pro- 
 gressive one. We know that a mitral defect may exist for 
 long years and never embarrass the heart muscle nor show 
 any sign of becoming worse. Damage to an aortic valve, 
 again, may become stationary ; the regurgitation em- 
 barrasses the left ventricle, but, this fact having been 
 recognised, the ventricle may be spared exhaustion if 
 the patient lives at a lower level in regard to exertion. 
 This, however, is not cure, and we know only too well 
 that attempts to cure the valve lesion would be vain. 
 In like manner, when we are face to face with a pro- 
 gressive lesion, our power of checking its progress is 
 extremely limited. Thus, mitral stenosis is seldom a 
 stationary disease ; the stenosis slowly but steadily 
 increases. The rate of increase varies and may be 
 measured in a rough manner in the way already de- 
 scribed. What we have to recognise is that we cannot 
 stay the progress of the disease. In myocardial disease 
 too often the changes are progressive and we are equally 
 helpless. We observe how in some elderly people 
 arterial and cardiac degeneration proceeds rapidly, 
 while in others it is very slight and proceeds slowly ; yet 
 we are powerless to stay its progress. I know that this 
 view is strongly resented by some, and that it is main- 
 tained that by dietetic, medicinal, and other means 
 these changes may be stayed and even removed. As, 
 however, these changes are fundamentally the same as 
 those which produce the grey hairs and the attenuated 
 skin of the elderly, we might as well — while using the 
 various nostrums and treatments — expect signs of the 
 staying of those senile changes as signs of the staying 
 of the heart condition. 
 
 I mention this, not to discourage the doctor in his 
 work, but in order that he may clearly distinguish 
 between what is remediable and what is irremediable ; 
 when he is face to face with the irremediable he should 
 recognise the fact, and thus make it possible to give
 
 224 PRINCIPLES OF TREATMENT 
 
 such advice as will lead the patient to make the best 
 of his condition and to avoid the impending danger of 
 premature heart-failure. 
 
 Before attempting treatment be assured that the symptoms are 
 produced by an impaired heart. 
 
 I repeat that it must be clearly appreciated that the 
 danger in all cases of heart affection is the occurrence 
 of heart-failure, and that treatment must be directed 
 to preventing the occurrence of that condition, or to the 
 restoration of the heart if it has already failed. 
 
 Before attempting treatment you should assure your- 
 self that the symptoms of which the patient complains 
 — for example, weakness, breathlessness, and so forth — 
 are primarily cardiac in origin, and not due to some 
 general cause, like infections, anaemia, and diseases of 
 other organs. Also you must clearly comprehend the 
 distinction I have drawn between such symptoms as 
 exhaustion and syncope and those which are indicative 
 of cardiac failure. 
 
 The essential principle in treatment is the care of the heart 
 
 muscle. 
 
 When the evidence is conclusive that the symptoms 
 are due to cardiac failure you may take it for granted 
 that the failure has been brought about by the heart 
 being forced to do more than it was fit for. The first 
 indication, therefore, is to remove all conditions that 
 prevent the heart from getting sufficient rest; among 
 these conditions are overwork, sleeplessness, worry, and 
 digestive troubles. Where it is necessary for your 
 patient to pursue his occupation, you must enter fully 
 into the consideration of his daily routine and order him 
 to eliminate all forms of effort except those which are 
 necessary for his occupation. There are innumerable 
 little ways in which this lightening of effort can be 
 carried out, and the careful discussion of these, when
 
 PRINCIPLES OF TREATMENT 225 
 
 the patient understands the cause of his weakness, will 
 often be of the greatest value. This is a point on which 
 I lay the greatest stress, for frequently I see business 
 and also working men rendered more ill and made 
 miserable by enforced rest, when a mere easing of the 
 daily work would have proved — and in the end did prove 
 — amply sufficient. 
 
 When the necessary daily work is so strenuous that 
 the relief obtained by restriction of effort is but tem- 
 porary, it is better to advise the patient to change his 
 occupation. This applies especially in the case of the 
 young. Indeed, in the case of young people with 
 damaged hearts the selection of an occupation which 
 does not entail severe bodily labour may be the means 
 of prolonging life and enabling the cripple to pursue a 
 useful existence. But again I warn you that you must 
 be sure that the damage is of the kind which really 
 demands such restriction, for very often I find the young 
 restricted in their activities on account of signs and 
 phenomena which indicate no impairment of the heart.
 
 CHAPTER XXV 
 
 treatment (continued) 
 
 REST, DIET, EXERCISE, BATHS 
 
 Rest. 
 
 When exhaustion has gone so far that breathlessness 
 or pain is easily induced, and subjective signs, such as 
 dropsy, are present, rest is imperative. While other 
 remedies may be necessary, rest is the most potent 
 remedy of all. 
 
 In these extreme cases it is not always easy to decide 
 what position the body should occupy so that the 
 greatest benefit may be secured. As a rule, the patient's 
 sensations are a very good guide. It may be that lying 
 in bed causes such distress that the patient is not at 
 ease. In these cases he assumes some position which 
 he finds removes the discomfort, such as sitting in a 
 chair or leaning forward on a support. These indi- 
 viduals should be permitted to assume the position in 
 which they find the most comfort, or, at least, the least 
 discomfort, as that position favours the circulation in 
 regions which induce the distress — i.e., in the lungs and 
 brain — though it may militate against the circulation 
 in other regions — e.g., the legs. When dropsy tends 
 to increase in these cases, careful change of position, 
 raising the legs as high as possible, or deft bandaging 
 and massage, may do much to diminish the swelling, 
 other treatment being, at the same time, directed to 
 
 226
 
 PRINCIPLES OF TREATMENT 227 
 
 the dropsy and heart condition. When the failure is 
 not so extreme, and particularly if there is dropsy, com- 
 plete rest in bed is of the greatest service, and many 
 cases recover without other treatment. If necessary, 
 the shoulders may be raised, by means of pillows or a 
 bed-rest, to such a height as may prevent attacks of 
 dyspnoea from coming on during sleep. In all cases, 
 mild or severe, every source of discomfort arising in 
 other parts of the body should be attended to — e.g., an 
 irritating skin affection, piles, and frequent micturition. 
 
 Diet. 
 
 Digestive disturbances often disturb a damaged heart 
 and provoke abnormal action in fairly sound hearts. 
 This disturbance is often due to flatulence or fermenta- 
 tion in the stomach and bowels. The best treatment 
 of the condition in my experience is the giving of the 
 patient's food in a very dry state. Butter on bread or 
 toast should be forbidden, and the mouthfuls of dry bread 
 should be small and should be so thoroughly masticated 
 that the food is moistened to the consistency of cream 
 by the saliva alone. The meals in all cases should be 
 small, but should be taken at frequent intervals ; only 
 small quarlities of fluid (tea or coffee) should be per- 
 mitted after the meal, though between meals more fluid 
 can be permitted if needed. I do not restrict my 
 patients to any one kind of food, but prefer to leave 
 the selection to the patient's intelligence, advising him 
 merely to avoid what does not agree with him. I find 
 that there are few articles which do disagree with these 
 people if this plan of thorough mastication is followed, 
 and all moist and sloppy foods are avoided (thick soups, 
 milk puddings, porridge and milk, Benger's food, etc.). 
 Even in extreme cases this method of dieting is of the 
 greatest value, as in those confined to bed abdominal 
 distension from flatulence, aggravated by the ingestion 
 of fluids, is often a distressing complication. 
 
 Q 2
 
 228 PRINCIPLES OF TREATMENT 
 
 Exercise. 
 
 When the patient is fit to go about he should be 
 encouraged to take exercise in the fresh air. The 
 amount of exercise he may take will depend upon his 
 strength, and this strength can be gauged by his sen- 
 sations. So long as a man who is taking exercise 
 remains free from distress or discomfort, then the exer- 
 cise is doing him good. The principles underlying this 
 statement will be realised if you have grasped what 
 heart-failure is. We get, indeed, in this statement a 
 guide which will serve us in all cases, and we may lay 
 it down that the patient should diminish or cease his 
 efforts on the first appearance of a distressful sensation. 
 
 It is far better that the patient should take his exer- 
 cise in the fresh air, in some form congenial to his 
 temperament and suitable to his strength, than that he 
 should take it by making systematised movements, or 
 undergoing what is called graduated exercise. To every 
 case of heart affection there is a mental side ; mechanical 
 exercises tend to remind the patient that he is an 
 invalid, whereas a game, or an exercise in the fresh air 
 with an object beyond the consideration of health, 
 has a beneficial mental effect. In stating that the 
 patient should take that amount of exercise which gives 
 pleasure and does not give rise to sensations of distress 
 or discomfort, I am enunciating a principle of the 
 highest importance. If you will bear in mind what 
 I have said about the onset of heart-failure and 
 the symptoms by which it is produced, you will at 
 once grasp the significance of this principle; for I 
 pointed out that exhaustion of the heart muscle showed 
 itself, in the first instance, by producing sensations of 
 distress. 
 
 Moreover, as all organs benefit by the judicious exer- 
 cise of their functions, so likewise the heart is kept in 
 good condition by the exercise of its functions, so long
 
 PRINCIPLES OF TREATMENT 229 
 
 as the exercise does not produce exhaustion. This truth 
 has been clearly perceived, and a great many forms of 
 exercise have been evolved. On behalf of some of these 
 — the resistance exercises of Schott, for example — fan- 
 tastic claims have been made. Other methods, such 
 as the graduated exercises of Oertel, have been found 
 useful ; but these exercises are not based on a proper 
 recognition of the object to be aimed at. The object 
 to be aimed at is the strengthening of the heart muscle ; 
 by summarily laying down that so many yards should 
 be walked one day and so many another day, the 
 physician shows that he has failed to take into account 
 the peculiar nature of the heart functions. Thus the 
 power of response of the heart to effort varies greatly in 
 the same individual from time to time — one day a 
 patient with an impaired heart can undertake a good 
 deal of effort with comfort, whereas on other days the 
 same amount of effort causes him distress. This is due 
 to the fact that the heart may be embarrassed by a 
 variety of conditions, such as gastric and intestinal dis- 
 turbances, want of sleep, and the state of the weather. 
 The patient's sensations are therefore a valuable guide 
 and indicate the amount of effort which can be under- 
 taken by him with safety in all circumstances. 
 
 Baths. 
 
 The immersion of the body in water at different tem- 
 peratures has a great effect upon the peripheral circula- 
 tion and also modifies the rate of the heart. Where the 
 temperature of the bath is above that of the body 
 the peripheral vessels dilate and the heart's rate in- 
 creases ; when it is beneath that of the body the peri- 
 pheral vessels contract and the heart's rate diminishes. 
 It is doubtful whether these varied reactions have any 
 permanent effect on the heart. That a warm bath may 
 afford temporary relief in special circumstances may, 
 however, be quite true. 
 
 Great claims have been advanced on behalf of the
 
 230 PRINCIPLES OF TREATMENT 
 
 " magical effect " of the carbonic acid baths of Nauheim. 
 Anyone with an elementary knowledge of physiology 
 must, one would suppose, recognise that the immersing 
 of the body in water containing carbonic acid is not 
 likely to produce an effect on the heart. The carbonic 
 acid simply cannot reach the heart. A body is immersed 
 in the waters of Nauheim when these waters are at a 
 lower temperature than the body. The heart's rate 
 naturally becomes slower; yet the slowing is described 
 as a remarkable effect of the Nauheim waters. If any- 
 one will test the effect of a bath of ordinary tap water, 
 taken at a lower temperature than the body temperature, 
 he will discover that these effects are identical with the 
 effects produced by Nauheim baths. When the warm 
 body lies in cooler water saturated with carbonic acid 
 small globules of the gas are liberated which adhere to 
 the skin and the skin becomes red. This simple phe- 
 nomenon is taken as representing a remarkable effect 
 on the peripheral vessels, and is supposed to affect the 
 heart in some mysterious way. Contact with many 
 patients who visit Nauheim soon reveals the truth that 
 what benefits do arise from this bath treatment come, 
 not from a specific virtue residing in the waters, but 
 from the restful, peaceful atmosphere of the place and 
 from the stimulation of great faith in the efficacy of 
 the cure. The absurdity of the claims advanced on 
 behalf of Nauheim is at once apparent when it is 
 realised that all varieties of cardiac symptoms are 
 treated there indiscriminately and upon the same lines. 
 The reputation of Nauheim baths and of the artificial 
 imitations of them depends, it becomes quite evident, 
 more on brazen advertisements, financial interests, and 
 the slavish tributes of other spas than on an intelligent 
 appreciation and application of the principles of treat- 
 ment.
 
 CHAPTER XXVI 
 
 treatment (continued) 
 
 DIGITALIS, STROPHANTHUS, THE NITRITES, SEDATIVES, 
 OXYGEN, ATROPINE, OTHER DRUGS 
 
 Digitalis. 
 
 Since Withering published his book on Digitalis in 
 1745, this drug has been recognised as a valuable 
 remedy. Originally it was prized as a diuretic, after- 
 wards it became better known still on account of its 
 effect upon the heart. Yet, enormous as has been the 
 amount of research in laboratory and hospital ward 
 directed to elucidating the properties of the drug, we are 
 still, at this day, far from appreciating its effects and 
 in recognising its proper sphere in treatment. In the 
 following remarks on the subject I give the results of 
 my own experiences, and I acknowledge that these are, 
 of necessity, limited ; for this is a subject which no one 
 individual can hope effectually to elucidate. My reasons 
 for limiting myself mainly to my own experiences are 
 that the subject has hitherto been so confused and 
 muddled that no clear principle has ever been laid down 
 to guide the practitioner in the employment of this 
 valuable remedy. This has been due, in the past, to 
 the fact that the mechanism of the peculiar rhythms of 
 the heart and the signs of disease of the organ have 
 not been clearly recognised. At the present day we are 
 in a better position, though there is still much to be 
 learnt. Moreover, the experimental pharmacologist, to 
 whom we have looked for guidance, has been at a dis- 
 advantage which he has never appreciated, in that his 
 experiments have been made with large doses in order
 
 232 PRINCIPLES OF TREATMENT 
 
 to get rapid results — doses that are quite different from 
 the medicinal doses we give to our patients. Further, 
 the animals experimented on by the pharmacologist have 
 healthy hearts and blood vessels, whereas in our patients 
 these organs are diseased ; one of the most striking 
 results that have come out of my investigations is that 
 the action of digitalis on the human heart depends in a 
 great measure on the nature of the disease present in 
 the heart, and this is true especially of the cases in 
 which digitalis is most beneficial. It follows, therefore, 
 that the laboratory worker is shut off from the study of 
 the drug in these very fields of therapy where it is most 
 needed. 
 
 When I was engaged in general practice I kept fairly 
 careful records of the cases to whom I gave digitalis. 
 After ten years I gathered all my notes together and 
 analysed them, and there came to light a remarkable 
 variety of effects. In a large number of cases no effect 
 on the heart could be detected, even when the drug had 
 been persevered with so far as to produce sickness and 
 vomiting. In other cases remarkable effects were 
 shown on the rate and rhythm of the heart, and 
 in some there were the most beneficial effects on 
 the patient's condition. At that time I was engaged 
 in the study of abnormal rhythms of the heart, 
 and I found that digitalis in some cases produced 
 extra-systoles, heart-block, the pulsus alternans, 
 and even auricular fibrillation, besides other peculiar 
 effects which even to-day I do not fully under- 
 stand. The most striking effects occurred in hearts 
 which were manifestly much damaged by disease. 
 
 Digitalis in auricular fibrillation. 
 
 When I came to classify the cases which had benefited 
 greatly I found that the vast majority of them fell into 
 one group. This group consisted for the most part of 
 persons with advanced heart-failure and an increased 
 rate of contraction sometimes as rapid as 140 or 150
 
 PRINCIPLES OF TREATMENT 233 
 
 beats per minute. In addition to the manifest relief 
 of the patient obtained by the use of the drug there 
 was a remarkable slowing of the pulse. With the 
 fall of the pulse-rate to 70 or under the objective signs 
 of heart-failure, enlargement of the liver, dropsy, and 
 orthopncea usually disappeared. In every one of these 
 cases the heart, before treatment, was irregular in its 
 action, and showed that peculiar form of irregularity 
 which I had first associated with paralysis of the auricle, 
 and then, later, called the " nodal rhythm," but which 
 we now recognise as " auricular fibrillation." I made 
 a patient search through the literature to determine the 
 kind of cases which had been found by other observers 
 to benefit from digitalis. In most instances no notes 
 of individual cases were given by writers ; the vast 
 majority of writers, indeed, stated their opinions so 
 vaguely that no clear conceptions could be obtained. 
 In several cases, however, references to the heart's rate 
 and rhythm made it clear that the patients who obtained 
 marked benefit were, in fact, the victims of auricular 
 fibrillation. 
 
 During the time I have had charge of the cardiac 
 wards in the Mount Vernon and London Hospitals the 
 effect of digitalis on the human heart has been one of 
 the subjects of research. My fellow- workers in these 
 hospitals and I have been able to add a good deal of 
 more precise knowledge, yet the results we have obtained 
 have been, on the whole, but confirmatory of those results 
 which I myself obtained in general practice. I mention 
 this to impress upon you how great a power of adding 
 to our knowledge, even in therapeutics, the general prac- 
 titioner possesses. I may go farther and say that in 
 this field of therapeutics his services are absolutely 
 essential, chiefly for the reason that when treatment has 
 to be continued uninterruptedly for years, he is the only 
 person who can follow treatment intelligently. 
 
 One of the results of my observations was the ability, 
 not only to restore hearts when the failure was extreme,
 
 234 PRINCIPLES OF TREATMENT 
 
 but to prevent the onset of heart-failure. I was thus 
 able, by the intelligent use of digitalis, to secure for 
 many of my cardiac cases the comfortable and secure 
 pursuit of their work. 
 
 Extreme heart-failure is so frequently associated 
 with, and induced by, auricular fibrillation, that 
 the efficacy of digitalis is best shown in this condition. 
 When it is understood that auricular fibrillation is 
 present in about 60 to 70 per cent, of cases which 
 suffer from heart-failure with dropsy, and that the 
 heart-failure is induced or aggravated by its presence, 
 the importance of appropriate treatment becomes at 
 once evident. Every practitioner should, therefore, be 
 familiar with the method and principles of the treatment 
 
 Fig. 20. 
 
 Rapid, irregular pulse, 140-150 per minute, due to auricular fibrillation 
 
 with extreme heart failure. 
 
 of auricular fibrillation. When a great number of cases 
 of auricular fibrillation are studied it will be found that,, 
 in the earlier days of the presence of this condition, the 
 heart's efficiency varies considerably. In some cases 
 there is but the slightest impairment with no objective 
 sign, in others the limitation is considerable, while in 
 others the failure may be extreme with dropsy, enlarged 
 liver, and orthopncea. In nearly all the cases with 
 moderate or extreme failure the heart's rate will be 
 found to be greatly increased, even up to 140 or 150 
 beats per minute. Frequently the beats are so weak 
 that many of them are not perceptible at the wrist 
 (Fig. 20). 
 
 I am disposed to think that the heart-failure is due 
 to exhaustion of the heart muscle induced by the rapid 
 rate at which beat follows beat. There is not, in fact,
 
 PRINCIPLES OF TREATMENT 235 
 
 sufficient time for recovery between the beats. The out- 
 put is diminished and the surplus blood increases the 
 embarrassment of the ventricle. 
 
 There may be other factors at work in producing the 
 heart-failure, but it remains true that any method which 
 diminishes the rate at once improves the condition and 
 enables the heart to recover. Digitalis effects this pur- 
 pose, and we need but note how the fall in rate is at 
 once accompanied by a surprising recovery to perceive 
 the relationship existing between these two circum- 
 stances. This, of course, applies to the earlier stage 
 of the trouble. It is manifest that in time the best of 
 hearts gives way and that, in the end, all remedies 
 necessarily fail. In the vast majority of cases many 
 
 Fig. 21. 
 
 Slow, irregular pulse, 55-60 per minute. From the same patient as 
 gave figure 20, 10 days later, after treatment by digitalis. In 
 addition to the slowing of the pulse there was marked improvement 
 in the patient's condition, though the irregularity shows that the 
 auricular fibrillation persisted. 
 
 years of careful life free from heart-failure can, however, 
 be led when digitalis is properly administered. 
 
 When the rate is moderate — 70 to 90 beats per minute 
 — and the heart's efficiency is good no treatment is 
 necessary, and the patient should merely be cautioned 
 against prolonged physical effort. 
 
 When there is marked breathlessness on exertion, or 
 dropsy with an increased rate, the digitalis should be 
 persevered with till distinct evidence of its effect is pro- 
 duced. This evidence may be shown first by a marked 
 decrease in the rate (Fig. 21). In some cases, at the 
 same time, nausea or vomiting occurs, while others suffer 
 from a disagreeable oppression across the chest. 
 Diarrhoea and headache occur in a few cases.
 
 236 PRINCIPLES OF TREATMENT 
 
 As soon as any of these signs appear the drug should 
 be stopped, and should not be resumed until they have 
 disappeared. This disappearance generally takes place 
 in a couple of days after the first sign of a sufficiency, 
 and then the patient usually feels extremely well. If 
 the pulse-rate begins to increase again the drug should 
 be given in half doses, and increased or diminished 
 according to the reaction. In the majority of cases the 
 smaller dose does not induce the disagreeable effect, but 
 keeps the rate of the heart in check, so that often we 
 can increase or diminish the rate by withholding the 
 drug or by increasing the dose. In some cases five 
 minims of the tincture, once a day, will keep up this 
 control, in others it may be necessary to use double or 
 treble this amount, and in all cases it is incumbent on 
 the doctor, in collaboration with the patient, to find the 
 exact quantity of the drug that will keep the heart's 
 rate in the condition which the patient finds most con- 
 ducive to exertion, and this quantity continued while 
 the patient lives. 
 
 Any preparation of the drug can be used, for no 
 advantage appears to attend the use of special forms. 
 I have never found the B.P. tincture fail me, and it is 
 this form which I have used most frequently, because it 
 is the cheapest, and therefore is within reach of the 
 poorest. I begin usually by giving the patient one 
 drachm per day — twenty minims taken three times a 
 day — and I commonly get the result on the fourth to 
 the seventh day. Sometimes the result is delayed a few 
 days longer. An elegant and effective preparation is 
 Nativelle's granules of digitalin — the white kind con- 
 taining o-^o °f a grain. I have repeatedly compared 
 the effect of these granules with that of the tincture and 
 I find that one of the granules has the same effect as 
 fifteen minims of the tincture ; I therefore, when I am 
 using the granules, recommend that four of them be 
 taken per day at the beginning of treatment. If any 
 of the other numerous preparations are used, the drug
 
 PRINCIPLES OF TREATMENT 237 
 
 should be given in sufficient doses to produce an effect, 
 and the practitioner should be guided by the principles 
 I have enunciated. 
 
 Digitalis in auricular flutter. 
 
 In the condition allied to auricular fibrillation — auri- 
 cular flutter — the action of digitalis is sometimes won- 
 derfully beneficial. As I have already pointed out, the 
 manifestations of this rhythm of the heart are varied 
 and confusing ; the majority of the cases, however, have 
 a regular pulse-rate of from 120 to 160 beats per minute, 
 while the auricles beat at double this rate. This rapid 
 rate affects different hearts differently. In some it 
 speedily exhausts the ventricles, and dilatation and ex- 
 treme heart-failure appear ; in others, no sign of failure, 
 except a slight limitation of the heart's response to 
 effort is noticed. 
 
 The treatment of auricular flutter consists of rest and 
 the administration of digitalis in the manner described as 
 being necessary in auricular fibrillation. The drug must 
 be given in full doses at first, and then, with the decrease 
 in the pulse-rate, or on the appearance of nausea, it must 
 be stopped. In some cases the digitalis causes the 
 flutter to pass into fibrillation with a coincident great 
 slowing of the pulse ; when the drug is stopped the heart 
 may resume its normal rhythm (see Figs. 22, 23, 24). In 
 many cases, however, all that can be done is to increase 
 the block between the auricles and ventricles, so that 
 the ventricular rate decreases. By watching the effect 
 of the drug closely we may do a good deal to help the 
 patient, even when the drug has only this temporary 
 effect. I must confess, however, that the treatment of 
 many of these cases has proved very unsatisfactory. 
 
 Other conditions in which digitalis is beneficial. 
 
 While it is in auricular flutter and fibrillation that the 
 most dramatic effects of digitalis are perceived, there 
 is a widespread belief that the drug is of use in every
 
 238 PRINCIPLES OF TREATMENT 
 
 Radiol. 
 
 Fig. 22. 
 
 Tracing of radial and jugular pulses during a period of continuous 
 tachycardia due to auricular flutter. An electro-cardiogram showed 
 that the auricle was beating at the rate of 280 beats per minute, 
 while the ventricular rate was 140. 
 
 Jugula' 
 
 Fig. 23. 
 
 From the same patient as Fig. 22, after digitalis, which had changed 
 the auricular flutter into auricular fibrillation. The slow, irregular 
 pulse and the characteristic jugular pulse indicate the presence of 
 auricular fibrillation. 
 
 ^J^v^A^J^^^KK^A^' 
 
 Fig. 24. 
 
 From the same patient as Figs. 22 and 23. After the digitalis was 
 stopped the heart-beat resumed the normal rhythm as shown in 
 this tracing.
 
 PRINCIPLES OF TREATMENT 239 
 
 form of heart trouble, or in any form of illness in which 
 the heart is supposed to be weak. A careful inquiry 
 reveals the fact that there are but few other conditions 
 which are improved by digitalis. In all cases of heart- 
 failure with dropsy digitalis should be tried. It is 
 probable that the beneficial effect produced by the drug 
 is due to its diuretic effect rather than to its action on 
 the heart. In many cases with a normal rhythm the 
 improvement in the patient's condition with the dis- 
 appearance of the dropsy is accompanied by no appreci- 
 able change in the heart. In working out the relation 
 of the action of digitalis to the heart and kidney, we 
 have not reached a satisfactory conclusion. In some of 
 our cases of auricular fibrillation the diuresis occurred 
 within forty-eight hours of the administration of the 
 drug, whereas no effect on the heart was perceptible until 
 several days later. Moreover, the kidney functions, 
 when there is dropsy, are peculiarly unstable, and at 
 times some very slight cause may produce abundant 
 diuresis. Thus many doctors will dilate upon the mar- 
 vellous character of some " gunshot prescription " (or 
 purveyors of drugs will tell of the wonderful diuretic 
 effects of some special preparation), because in one or 
 two instances abundant diuresis has followed the admin- 
 istration of the nostrum. I remember on one occasion 
 prescribing the well-known pill of digitalis, squills, and 
 mercury to a dropsical woman ; when I called to see 
 her next day she produced with great pride a bucket 
 full of urine which she had passed in the night. The 
 effective remedy in dropsy cases need not, however, be 
 a drug at all. A patient of mine with cardio-sclerosis 
 and a regular rhythm was unable to lie down, and so 
 sat in a chair for three weeks. Extensive dropsy super- 
 vened which resisted all my efforts at treatment. Finally 
 I put the patient back to bed, and the following day he 
 began to micturate and never ceased till every sign of 
 dropsy had disappeared. 
 
 A great many cases of heart-failure with a normal
 
 240 PRINCIPLES OF TREATMENT 
 
 rhythm have also chronic kidney trouble; these cases 
 are, as a rule, very resistant to treatment. Although 
 digitalis acts here as a diuretic I rarely find any coin- 
 cident effect on the heart. Still, I do not deny that 
 there may be cases, where some special features which 
 I have failed to note are present, in which digitalis may 
 affect the heart. During the last year I have seen, on 
 several occasions, a man of forty-six with chronic 
 Bright 's disease and a failing heart benefit greatly by 
 digitalis. When I saw him a year ago he had dropsy, a 
 very rapid heart, and Cheyne-Stokes respiration, and 
 he had had a retinal haemorrhage ; much care and treat- 
 ment had been spent on him. I suggested digitalis in 
 the manner described and it acted in a very striking 
 manner. He was relieved of his dropsy ; when the digi- 
 talis was stopped the dropsy returned. Resumption of 
 the drug always caused the dropsy to disappear. The 
 doctor in attendance on this patient says that the rate 
 of the heart always went up when the digitalis was 
 stopped and fell during its administration. I have not 
 been able to watch the patient myself with that pre- 
 cision which is necessary to a clear differentiation of 
 symptoms, and I mention his case only to show that 
 the field for the employment of digitalis is at present far 
 from being exhausted. 
 
 In some cases where there is marked muscle failure 
 digitalis acts for a time beneficially, but it is not easy 
 to specify the particular case. As, however, when heart- 
 failure of a severe kind occurs we are forced to try all 
 sorts of remedies, and as drugs of the digitalis group 
 offer the best prospects, when these drugs are used they 
 should be pushed until a definite reaction occurs, either 
 on the heart or the digestive tract. 
 
 These drugs are often used in acute affections, as 
 pneumonia, but in my hands I have never perceived any 
 effect, nor have I seen the record of any positive result 
 in the writings of others beyond the usual statement that 
 as the patients in some cases seemed to improve after its
 
 PRINCIPLES OF TREATMENT 241 
 
 administration, it was therefore the digitalis that caused 
 the improvement. 
 
 Danger in the administration of digitalis. 
 
 For a long time I was at a loss to understand the 
 warning of authorities regarding the danger of sudden 
 death during the administration of digitalis. Of recent 
 years, however, I have obtained an inkling into the 
 
 Radtat 
 
 Fig. 25. 
 
 Simultaneous tracings of the jugular and radial pulses. The jugular 
 pulse is of the ventricular type, and the tracing shows complete 
 agreement in rhythm between the right and left ventricles. From 
 an old rheumatic heart, in which, at the post-mortem examination, 
 there was found great stenosis of the mitral orifice. Before digi- 
 talis. Fig. 26 was taken from the same patient. 
 
 Fig. 26. 
 
 Simultaneous tracings of the apex beat and the radial pulse from the 
 same case as Fig. 25. The coupled beats are well marked in the 
 apex tracing. The shading underneath shows the time of the 
 murmurs. After digitalis. To continue the digitalis further is 
 dangerous. 
 
 cause of this sudden death. I have, for example, been 
 shown tracings of the slow pulse (Figs. 25 and 26), with 
 characteristic coupled beats, which occurs in cases of 
 auricular fibrillation that are under the influence of 
 digitalis, and have been informed that the patients died 
 suddenly. On inquiry, I found that, notwithstanding 
 the evidences of a sufficiency, the drug was continued in
 
 242 PRINCIPLES OF TREATMENT 
 
 large doses. I was asked once to see a man who was 
 said to be dying of heart-failure. He had to sit up in 
 bed and he breathed heavily; his face was livid. He 
 had dropsy, an enlarged liver, and a large and irregular 
 heart beating at a rate of 130 to 140 per minute (auri- 
 cular fibrillation.) I told his doctor to give the digitalis 
 till he showed evidences of a sufficiency, either by the 
 slowing of his heart or by nausea, and then to stop it. 
 After five days the doctor telephoned to tell me that 
 the patient was wonderfully free from distress, could 
 lie flat, and had a good colour, that the dropsy had 
 almost gone, and that the pulse-rate was between 70 and 
 80. I told him to stop the digitalis for a few days, and 
 then, if the pulse-rate increased, to give smaller doses, 
 and I advised him to find out the exact quantity which 
 kept the rate about 80. Three days later he telephoned 
 again to say that during his visit that morning the 
 patient had fallen back and died. Until the time of 
 death the patient had been going on well. I asked the 
 doctor if he had stopped the digitalis as I told him 
 and he replied in the negative, saying that, as it had 
 done the sick man such a lot of good he had continued 
 it, in spite of my directions. 
 
 On making inquiries regarding a few other similar 
 cases of sudden death, I had no difficulty in recognising 
 that the patients had been victims of auricular fibrilla- 
 tion, and that digitalis had been continued after it 
 affected the heart. Seeing that I myself have been fol- 
 lowing the line of treatment which consists in giving 
 digitalis till evidences of its action are obtained, then 
 stopping it and resuming it later, for over fifteen years, 
 and seeing that I have never had a sudden death from 
 the use of the drug, I am disposed to think that, just as 
 there is danger in giving chloroform beyond a certain 
 stage, so there is danger when digitalis is pushed too 
 far. On the other hand, if the indications I 
 have given are followed, the catastrophe of death may 
 be avoided.
 
 PRINCIPLES OF TREATMENT 243 
 
 Strophantus. 
 
 Notwithstanding the assertion that the action of 
 strophanthus differs from that of digitalis, I could never 
 in practice detect any difference. Digitalis is, perhaps, 
 more apt to produce intestinal disturbances, as nausea, 
 than strophanthus, and so, occasionally, when there is 
 an objection to the use of digitalis by reason of the 
 easy production of nausea, strophanthus has been a 
 useful substitute. I have found strophanthus produce 
 diarrhoea very readily in a few cases. On the whole, I 
 may repeat that, when digitalis has failed to do good 
 in my hands, strophanthus and other drugs of the same 
 class (squills, cactus grandiflorus) have also failed. 
 
 The tincture of strophanthus was found by my co- 
 workers and myself to be only half as effective as digi- 
 talis. This conclusion was based upon the fact that 
 double the quantity had to be given as a rule before a 
 result was obtained. The tincture of strophanthus 
 should not be prescribed in a mixture with water, as 
 Cushny has shown that it deteriorates and after a few 
 days becomes inert in such a mixture. 
 
 Intravenous injections of strophanthin ( T ^o of a grain) 
 act speedily, but I do not advise their use in general 
 practice if the doctor knows how to treat his patient 
 intelligently by the use of digitalis. Moreover, the call 
 for the use of strophanthin injections is a very infre- 
 quent one ; and when it does arise the same end which 
 is served by intravenous injection can be accomplished 
 in a few days by the oral administration of the drug. 
 
 Hypodermic injections of digitalin and strophanthin 
 we found to be without any result, the drug evidently 
 not being absorbed. 
 
 The nitrites. 
 
 The principal effect of the nitrites is a dilatation of 
 the arterioles. It is now accepted that the cause of the 
 
 r 2
 
 244 PRINCIPLES OF TREATMENT 
 
 dilatation is stimulation of the nerves and muscles of 
 the vessel-walls. This effect is accompanied by an 
 acceleration of the heart-rate and a great fall in the 
 arterial pressure. When, for any reason, a sudden effect 
 of this kind upon the heart is wanted, the nitrites are 
 the most potent drugs that can be employed. A few 
 drops (3-10 minims) of nitrite of amyl inhaled produce 
 this effect in a few seconds. The face becomes flushed 
 and the patient is conscious of a throbbing in the head. 
 If the use of the drug be continued the patient becomes 
 faint and giddy and is forced to lie down. The drug 
 should never be continued beyond this stage. In a few 
 minutes the effect passes off, and the blood-pressure, 
 which has undergone a sudden fall, rises gradually and 
 may even become higher than it was before the inhala- 
 tion. 
 
 Other nitrites, such as nitroglycerin (dose T ^-<j- to T V 
 of a grain in tablets or in alcoholic solution), erythrol 
 tetranitrite (dose 1 grain in pills), sodium nitrite (1 to 
 2 grains in pills or solution), act in the same way as 
 amyl nitrite but more slowly ; the effect remains slightly 
 longer. 
 
 Spiritus aetheris nitrosi (sweet spirits of nitre) is a 
 very popular remedy. It contains traces of ethyl 
 nitrite, and is often prescribed in doses of 30 to 60 
 minims on account of its supposed effect in relaxing the 
 blood-vessels. As it is usually prescribed in water the 
 nitrite which it contains evaporates rapidly, and the 
 effect produced by it is due to ether and alcohol only. 
 
 The best effect of the nitrites is obtained in cases 
 requiring a rapid therapeutic action ; angina pectoris 
 is an example. Some of the slower acting nitrites are 
 recommended as reducers of a high blood-pressure, but 
 I have had no satisfactory results from their use, nor 
 does it seem a reasonable procedure to use them, when, 
 as so often happens, the increased blood-pressure may 
 be due to some irritating substance circulating in the 
 blood — e.g., in kidney disease.
 
 PRINCIPLES OF TREATMENT 245 
 
 Sedatives. 
 
 Little benefit is likely to arise from treatment so long 
 as a patient is worried or sleepless. I have already 
 referred to the importance of rest ; it is often necessary 
 to seek the aid of drugs to obtain rest and sleep and 
 freedom from worry and other excitations ; in these cir- 
 cumstances, sedative drugs, used with discrimination, 
 are of the greatest service. 
 
 The bromides are the most useful drugs in this respect. 
 In all cases of mild degrees of heart-failure, where the 
 patient is able to get about, but where he is worried, 
 sleepless, irritable, or apprehensive, the bromides are 
 extremely useful and of far more value than other 
 cardiac drugs. I have for many years employed the 
 bromide of ammonium, for I find that the patients are 
 not so depressed by its use as they are when taking 
 the bromide of potassium. The drug should be pushed 
 until a slight lassitude is induced, or even until the 
 patient becomes torpid, and this is true especially in 
 severe cases of angina pectoris. The doses employed are 
 twenty grains, two or three times a day, according to 
 the severity of the case. 
 
 For sleeplessness the milder hypnotics — the bromides, 
 phenacetin, veronal, and sulphonal — may first be tried. 
 If these fail resort must be had to chloral or opium. 
 In great restlessness, due to dyspnoea, Cheyne-Stokes 
 respiration, or cardiac asthma, one of these drugs should 
 be carefully given until the desired effect is obtained ; 
 five to ten grains of chloral every two hours, or £ grain 
 of morphine (J grain hypodermically) repeated every two 
 hours will often suffice. When there is oedema of the 
 lungs or bronchitis the opiates should be avoided, as 
 they tend to check the free expulsion of the phlegm, 
 and danger may arise from this cause. Neither chloral 
 nor opium should be continued for more than a few 
 days, as the patients become sick, mentally confused, 
 and very troublesome.
 
 246 PRINCIPLES OF TREATMENT 
 
 Oxygen. 
 
 The administration of oxygen in affections of the heart 
 has been practised for many years, but the results on 
 the whole are disappointing. Though there is certainly 
 a limited field where the remedy seems to be of use, it 
 is difficult to lay down precisely the conditions which 
 call for its use. I have given it in a great variety of 
 cases, in some with excellent results, in the majority 
 with no appreciable benefit, or only temporary relief. 
 Even in patients suffering from apparently similar affec- 
 tions the results have been unequal ; for instance, a few 
 patients suffering from cardiac asthma have been greatly 
 relieved, while others have experienced no benefit. This 
 difference of effects caused me to look more closely into 
 the symptoms present, and I found that those patients 
 who got benefit always showed evidence of cyanosis. 
 
 The conditions in which I have found oxygen occa- 
 sionally of benefit are Cheyne-Stokes respiration, cardiac 
 asthma, angina pectoris, and heart-block. Sometimes, 
 in cases of angina and cardiac asthma, the patient has 
 had a better night when the oxygen has been taken a 
 quarter of an hour before going to bed. In most cases 
 relief has occurred when the oxygen was taken during 
 an attack of dyspnoea or pain, or, in cases of extreme 
 heart-block, during the attack of unconsciousness. 
 
 I have followed Leonard Hill's method of administra- 
 tion by giving the patient large doses. Hill employs a 
 mask which encloses the patient's head, and the oxygen 
 is poured into the mask from the cylinder, so that the 
 patient breathes practically pure oxygen. I have used, 
 in many cases, a lady's hat-box, with a piece cut out 
 for the neck. The head is enclosed in the box, the lid 
 put on, and the oxygen given through a hole. The head 
 is thus surrounded by an atmosphere of almost pure 
 oxygen. By this method, Hill states, a far greater 
 amount of oxygen is taken up into the blood than by 
 any other. The duration of an administration is from
 
 PRINCIPLES OF TREATMENT 247 
 
 ten to twenty minutes. Parkinson has carried out a 
 series of observations on the effect of oxygen given to 
 healthy people in this way ; he finds that the oxygen 
 almost invariably reduces the rate of the heart, though 
 only to a slight extent. 
 
 Atropine. 
 
 The principal effect of atropine upon the circulatory 
 system is said to be due to its action in paralysing the 
 cardiac inhibitory terminations. In practice the drug 
 has been found to be of use in rare cases of heart-block 
 where there has been difficulty in the passage of the 
 stimulus from auricle to ventricle. When this state of 
 matters exists, any increase in the difficulty may result 
 in the complete stoppage of the stimulus. As it is well 
 known that vagal action does produce this delay in the 
 transmission of the stimulus, atropine, given in such 
 cases, may cause removal of the heart-block. The drug 
 should be given by hypodermic injection in doses of 
 i-uo ot ^0 grain of the sulphate, and repeated in half 
 an hour if necessary. 
 
 Other drugs. 
 
 A great number of agents are used in cardiac therapy, 
 but it is doubtful if many of them have any real effect 
 on the heart. Some undoubtedly, as, for example, 
 alcohol and hot fluids, can show evidence of a reaction ; 
 the activity of these in producing a dilatation of the 
 arterioles can be employed with benefit when a rapid 
 effect is desired — e.g., in attacks of faintness or pros- 
 tration. It is scarcely necessary at this time of day 
 to add a warning regarding the use of alcohol in milder 
 forms of heart-failure, and particularly in those with a 
 neurotic tendency. The temporary benefit thus ob- 
 tained may lead to a too frequent use of the drug. The 
 danger of a habit being created cannot be overlooked. 
 
 Other drugs, such as caffeine, strychnine, and oil of 
 camphor, act probably on the nervous system, and, by
 
 248 PRINCIPLES OF TREATMENT 
 
 producing some exhilaration, prove useful in cases where 
 a temporary exhaustion causes distress. But it cannot 
 be too strongly insisted upon that, though these reme- 
 dies are often employed in cases of the most diverse 
 kind — for instance, where there is a rapid heart in pneu- 
 monia, and where there is a sluggish ventricle in heart- 
 block — they are without any perceptible effect on the 
 heart and their potency is very limited. They should 
 not be relied upon in cases of real heart exhaustion.
 
 INDEX
 
 INDEX 
 
 Abnormal rhythm in relation to 
 
 sudden breathlessness, 57 
 Abscess, pelvic, as cause of cardiac 
 
 pain, 82 
 Abscesses, as cause of poisoned 
 
 heart, 196 
 Acute affections of the heart — 
 
 dilatation in, 188 
 
 in relation to high temperature, 
 187 
 
 in rheumatic fever, 189 
 
 septic endocarditis in, 191 
 
 systolic murmurs at apex and base 
 in, 188 
 
 treatment of, 190 
 Adams-Stokes syndrome, 63 
 Adult type of irregularity, 143, 149 
 
 age incidence, 149 
 
 patient's sensations in, 149 
 
 prognosis, 153 
 
 recognition of, 149 
 Affections of the myocardium, 121 
 Age incidence in — 
 
 adult type of irregularity, 149 
 
 aortic regurgitation, 1 19 
 
 irregular action of the heart, 143 
 
 paroxysmal tachycardia, 182 
 Ague, 187 
 Alcohol — 
 
 as cause of poisoned heart, 196 
 
 as provoking cause of extra-systoles 
 
 *5 2 
 
 in treatment of angina pectoris, 80 
 
 in treatment of heart affections, 
 247 
 Amyl nitrite, 244 
 
 in treatment of angina pectoris, 
 80, 244 
 Anaemia, systolic murmur in, 103 
 
 Anaesthesia and prognosis, 213 
 
 in angina pectoris, 213 
 
 in auricular fibrillation, 213, 214 
 
 in fat, bronchitic subjects, 214 
 
 in heart-block, 214 
 
 in heart exhaustion, 213 
 Anaesthesia, cause of sudden death 
 
 in, 214 
 Angina pectoris, 69, 246 
 
 and auricular fibrillation, 86 
 
 and cardiac asthma, 59 
 
 areas of pain in, 70, 71 
 
 as indication of extent of damage 
 to heart, 75 
 
 as indication of grave progressive 
 disease, 77 
 
 effect of effort in, 70 
 
 effect of gastric condition on, 75 
 
 gravity of, 73 
 
 in aortic regurgitation, 1 19 
 
 in relation to aortic disease, 77 
 
 in relation to syphilis, 77 
 
 pain during sleep in, 78 
 
 physical conditions provoking, 72 
 
 prognosis in, 79, 209 
 
 pulsus alternans with, 155 
 
 systolic murmur with, 105 
 
 tobacco in, 78 
 
 toxic condition of the heart in, 78 
 
 treatment of, 79, 244 
 
 with chronic Bright's disease, 79 
 Aortic diastolic murmur, 116 
 
 in pregnancy, 212 
 
 in rheumatic fever, 189 
 
 in septic endocarditis, 192 
 
 in syphilis, 77 
 Aortic regurgitation, 116 
 
 age factor in, 119 
 
 angina pectoris m, 119 
 
 atheromatous changes as cause of, 
 
 bleeding from the nose in, 118 
 
 25'
 
 252 
 
 INDEX 
 
 Aortic regurgitation (conl. ) 
 blood pressure in, 118 
 damage to valves in relation to 
 
 degree of heart-failure, 117 
 due to syphilis, 119 
 excitability of heart in, 118 
 heart-failure in, 119, 120, 184 
 hypertrophy of heart in, 117, 133 
 in pregnancy, 212, 213 
 pain in, 119 
 patients able sometimes to lead 
 
 active lives, 116 
 prognosis in, 118, 119, 120 
 pulse in, 118 
 rate of heart in, 118 
 response to effort as prognostic 
 
 sign in, 118 
 size of heart in, 117, 133 
 syncope in, 119 
 vaso-motor disturbance in, 119 
 violent beating of the heart in, 
 119 
 Aortic stenosis, 105, 106 
 Aortic systolic murmur, 105 
 Apex beat — 
 
 in dilatation of the heart, 124 
 in hypertrophy of the heart, 131 
 Appendicitis, chronic, as cause ot 
 
 poisoned heart, 196 
 Arm, left, relations of to angina 
 
 pectoris, 71, 82 
 Atheromatous changes as cause of 
 
 aortic regurgitation, 119 
 "Athlete's heart," 132 
 Athletic heart, bogey of, 125 
 Atropine, treatment of heart-block 
 
 by, 247 
 Attitude of patient — 
 in palpitation, 179 
 in treatment of heart failure, 226 
 Auricle, paralysis of, 162 
 Auricular fibrillation, 27, 136, 157, 
 233, 234, 235 
 after effort, 185, 186 
 and "back pressure," 158 
 and heart failure, 159, 163, 166, 
 
 167, 233, 234 
 and paroxysmal tachycardia, 163, 
 
 180 
 as indication of meaning of heart- 
 failure, 158 
 blood-pressure in, 203 
 case of, described, 161 
 clinical symptoms of, 164, 234 
 digitalis as cause of, 164, 170, 
 
 232 
 digitalis in, 159, 232, 233, 234, 235 
 
 Auricular fibrillation {cont. ) 
 
 dilatation in, 127 
 
 disappearance of presystolic murmur 
 at onset of, 161 
 
 discovery of, 161 
 
 effect of on heart as guide to prog- 
 nosis and treatment, 159 
 
 experimentally produced, 162 
 
 in mitral stenosis, no, 115 
 
 in pregnancy, 212, 213 
 
 in relation to sudden breathless, 
 ness, 57, 234 
 
 in rheumatic hearts, 161 
 
 in the elderly, 161 
 
 manner of approach to death in, 
 169 
 
 murmurs related to, 165, 166 
 
 nature of, 162, 234 
 
 patient's sensations in, 164 
 
 persistence of, 162 
 
 pulse rhythm in, 164, 165, 234, 
 
 235 
 rapid disappearance of symptoms 
 
 in, 167, 233 
 rapid pulse in, 170, 234 
 remote effect of rheumatic fever, 
 
 189 
 rhythm of heart in, 164, 234, 235 
 sudden death in, 169 
 violent exertion as cause of, 164 
 with aortic regurgitation, 170 
 Auricular flutter, 10, 136, 172 
 bromides in treatment of, 176 
 degree of cardiac inefficiency in, 
 
 . . x 74. 
 
 digitalis in treatment of, 176, 237 
 
 dilatation of heart in, 174 
 
 electrocardiograph of, 174 
 
 heart failure in, 174 
 
 nature of, 172, 173, 180 
 
 prognosis in, 175 
 
 pulsus alternans in, 155 
 
 supply of blood to brain in, 174 
 
 symptoms of, 174 
 
 syncope in, 65 
 
 treatment of, 175, 176 
 
 unconsciousness in, 61, 174 
 Auriculo-ventricular bundle, 61, 
 
 189 
 Auscultatory method of taking 
 blood pressure, 154, 206 
 
 B 
 
 ; Back pressure," and auricular fibril- 
 lation, 158
 
 INDEX 
 
 253 
 
 Bandaging of limbs in treatment of 
 
 dropsy, 226 
 Baths — 
 
 cold, after-reaction in, 89 
 in dilatation of the heart, 130 
 in treatment of heart disease, 229 
 Nauheim, 230 
 Belt, abdominal, in treatment of sense 
 
 of exhaustion, 89 
 Bleeding from the no~e in aortic 
 
 regurgitation, 118 
 Blood-pressure, 200 
 
 auscultatory method of taking, 154, 
 
 206 
 danger of, as sole basis of diagnosis, 
 
 205 
 difficulty of reducing, 203, 204 
 effect of drugs on, 203 
 fallacies in readings, 200, 202 
 height of, in hypertrophy of the 
 
 heart, 134 ' 
 in aortic regurgitation as index of 
 
 heart's efficiency, 118 
 in auricular fibrillation, 203 
 in irregular action of the heart, 203 
 instruments, 206 
 methods of research in, 205 
 variations in, in health, 201 
 Brain, blood-supply of, in auricular 
 
 flutter, 174 
 Breast, pain in left, 81 
 
 pain in left, in relation to angina 
 pectoris, 82 
 Breathing, Cheyne-Stokes (see also 
 under Cheyne-Stokes), 57 
 irregular, 57 
 Breathlessness, 9, 55 
 
 as sign of heart failure, 45 
 
 at rest, 45, 55, 56 
 
 cardiac asthma, 58 
 
 cause of, 55 
 
 differentiation of types of, 56 
 
 extreme, in aortic regurgitation, 
 
 extreme, in heart failure, 184 
 
 in angina pectoris, 85 
 
 in mitral stenosis, 115 
 
 in paroxysmal tachycardia, 184 
 
 in poisoned heart, 193, 197 
 
 in pregnancy, 21 1 
 
 relation of, to exertion, 55 
 
 sudden, 57 
 Bright's disease, chronic, 79, 136, 
 
 137, 240 
 Bromides, 245 
 
 in auricular flutter, 176 
 
 in hypersensitive nervous cases, 84 
 
 Bromides {cont. ) 
 
 in palpitation of the heart, 179 
 in paroxysmal tachycardia, 184 
 Bromide of ammonium, 245 
 Bromide of potassium, 245 
 
 Cactus grandiflorus, 243 
 Caffeine, 247 
 Camphor, oil of, 247 
 Cardiac asthma, 58, 136, 245 
 
 and Cheyne-Stokes respiration, 59 
 
 oxygen in treatment of, 246 
 
 pulsus alternans with, 155 
 Cause of heart failure, 185 
 Character of murmur as indication of 
 
 damage to valve, 103 
 Cheyne-Stokes respiration, 57, 136, 
 240, 245 
 
 and cardiac asthma, 59 
 
 in angina pectoris, 86 
 
 oxygen in treatment of, 246 
 
 patient's sensations in, 58 
 
 sense of suffocation in, 58 
 
 significance of, 58 
 Children — 
 
 dilatation of heart, physiological, 
 in, 125 
 
 estimation of heart's efficiency in, 
 96 
 
 examination of, 95 
 Chloral— 
 
 in treatment of angina pectoris, 80 
 
 in sleeplessness, 245 
 Chloroform anaesthesia, in heart 
 
 disease, 214 
 Coarctation of the aorta, 215 
 Coffee— 
 
 as provoking cause of extra-systoles, 
 
 x 5? 
 
 in palpitation of the heart, 179 
 
 Cold hands and feet — 
 
 as symptom of hypersensitive ner- 
 vous system, 83 
 with sense of exhaustion, 89 
 "Compensation," 135, 158 
 Confinement complicated by septic 
 
 endocarditis, 191 
 Congenital heart disease, 214 
 and prognosis, 214 
 and tubercle, 215 
 Constipation, as cause of poisoned 
 
 heart, 196 
 Constriction, sense of, in angina 
 pectoris, 70
 
 254 
 
 INDEX 
 
 Consumption in relation to poisoned 
 heart, 199 
 
 Convulsions in heart-block, 63 
 
 Corrigan pulse, 145 
 
 Cyanosis in auricular fibrillation, 166, 
 167 
 in congenital heart disease, prog- 
 nosis with, 214 
 
 D 
 
 "Decompensation," 135, 158 
 Degeneration myocardial, 135 
 Degenerative changes in myocar- 
 dium ; pulsus alternans with. 
 
 dyspnoea with, 136 
 " Delirium cordis," 163 
 Diagnosis — 
 
 of acute affections of the heart, 187 
 of adult type of irregularity, 149 
 of angina pectoris, 70, 71 
 of aortic regurgitation, 117, 118, 
 
 of auricular fibrillation, 164 
 of auricular flutter, 172, 173, 174 
 of functional murmurs, IOI 
 of heart-block, 62 
 of heart-failure, 66 
 of palpitation, 178 
 of paroxysmal tachycardia, 181 
 of poisoned heart, 196 
 of pulsus alternans, 154, 156 
 of septic endocarditis, 192 
 of " soldier's heart," 194 
 Diarrhoea in relation to " soldier's 
 
 heart," 194 
 Diastolic blood pressure, 203, 206 
 Diastolic murmur (see under Mur- 
 mur, diastolic) 
 in relation to auricular fibrillation, 
 165, 166 
 Diet in treatment of heart affections, 
 
 227 
 Digitalin, Nativelle's granules, 236 
 Digitalis, 20, 231 
 
 action of depending on disease 
 
 present, 232 
 as cause of auricular fibrillation, 
 164, 232 
 heart-block, 116, 232 
 new (abnormal) rhythms, 232 
 dangers attending administration 
 
 of, 241, 242 
 diuretic effect of, 239 
 
 Digitalis (cont. ) 
 
 effect of, on Cheyne-Stokes respira- 
 tion, 58 
 pulse in auricular fibrillation, 
 236 
 heart unaffected by, 232 
 in treatment of auricular fibrilla- 
 tion, 159, 160, 170, 232, 233, 
 
 234. 2 35 
 auricular flutter, 176, 237 
 dilatation of the heart, 129 
 heart failure, 233, 240 
 pneumonia, 240 
 method of administration, 235, 236 
 susceptibility of the heart to, in 
 auricular fibrillation, 160, 232, 
 
 z 33 
 Dilated heart, efficiency of, 126, 131 
 Dilatation of the heart, 121 
 factors producing, 122 
 overstrain not sole cause of, 127 
 physical signs of, 123, 124 
 physiological, 124 
 physiological, in children, 125 
 prognosis in relation to, 126, 131 
 systolic murmurs in relation to, 103 
 with acute affections of the heart, 
 
 188 
 with angina pectoris, 86 
 with auricular fibrillation, 167, 
 
 126, 127 
 with auricular flutter, 174 
 with dropsy, 67, 127 
 with heart failure, 123, 126, 127 
 with middle and later life, 125 
 with paroxysmal tachycardia, 181, 
 
 183 
 with poisoned heart, 193, 198 
 with pulsus alternans, 155 
 with rheumatic fever, 189 
 with septic endocarditis, 191 
 with valvular disease, 129 
 Diphtheria followed by irregular 
 
 action of the heart, 145 
 Disappearance of angina pectoris in 
 
 heart failure, 86 
 Dropped beat of heart-block, differ- 
 entiation from extra-systole, 
 149 
 Dropsy, 66, 129, 135, 137 
 digitalis in treatment of, 239 
 in angina pectoris, 86 
 in auricular fibrillation, 57, 129, 
 
 163, 166, 167, 234 
 in heart failure, 48, 66, 67 
 in poisoned heart, 197, 198 
 in pregnancy, 21 1
 
 INDEX 
 
 255 
 
 Dropsy (cont.) 
 
 in relation to .sudden breathlessness, 
 
 57, 127 
 prognosis in relation to, 209 
 
 treatment of by rest, 226 
 Ductus Arteriosus patent, prognosis 
 
 in, 214 
 Dullness, cardiac, extent of in 
 
 dilatation, 124 
 Dyspepsia with sense of exhaustion, 
 
 90 
 Dyspnoea (see also under Breath- 
 lessness) 55, 72, 136, 245 
 extreme, in aortic regurgitation, 
 
 119 
 in auricular fibrillation, 57, 166, 
 
 167 
 in healthy persons, 72 
 in myocardial degeneration, 136 
 in pulsus alternans, 155 
 oxygen in the treatment of, 246 
 
 Early signs of disease, importance 
 of, 5> 6 
 
 Effort (see also Exertion) — 
 
 effect of on poisoned heart, 197 
 exciting cause of angina pectoris, 
 
 70 
 
 onset of heart-failure after, 185 
 
 Electro-cardiogram of auricular 
 
 flutter, 174 
 Embolism of retinal arteries in 
 
 septic endocarditis, 192 
 Endocarditis, septic, 188, 191 
 after confinement, 191 
 chronic infections, 192 
 diagnosis of, 192 
 dilatation in, 191 
 
 embolism of retinal arteries in, 192 
 febrile attacks, indefinite, in, 191 
 hsematuria in, 192 
 hemiplegia in, 191 
 infarction in, 191 
 
 in pyaemia and puerperal septi- 
 caemia, 192 
 invasion of myocardium in, 191 
 murmur, aortic diastolic, in, 192 
 systolic, in, 191 
 
 tricuspid, loud, rasping, in, 
 192 
 onset, insidious, of, 191 
 painful erythematous nodules in, 
 192 
 
 Endocarditis, septic {conl.) 
 
 perspiration in, 191 
 
 purpura in, 192 
 
 rigors in, 191 
 Endocardium, invasion of,in rheumatic 
 
 fever, 189 
 Epigastric pulsation, 124 
 Erysipelas in relation to acute affec- 
 tions of the heart, 190 
 Erythematous nodules, painful, in 
 
 septic endocarditis, 192 
 Erythrol tetranitrite, 244 
 Examination of the patient, 92 
 Excitement as cause of palpitation, 
 
 178 
 Exercises — 
 
 in treatment of dilatation of the 
 heart, 130 
 
 in treatment of heart disease gener- 
 ally, 228 
 Exertion — 
 
 effect on heart's action, 9 
 
 violent, as cause of auricular fibrilla- 
 tion, 164 
 Exhaustion — 
 
 in poisoned heart, 193, 197 
 
 of " rest force," signs of, 45 
 Exhaustion, sense of — 
 
 a vaso-motor phenomenon, 87 
 
 dilatation in, 90 
 
 extra-systoles in, 90 
 
 how caused, 88 
 
 nutrition in, 90 
 
 palpitation in, 90 
 
 provoking agent, 90 
 Extra systole, 26, 136, 137, 142, 
 
 149, 2 3 2 
 digitalis as cause of, 232 
 in acute affections of the heart, 
 
 153 
 auricular fibrillation, 27, 164 
 
 pregnancy, 26 
 
 pulsus alternans, 154 
 
 relation to age, 26 
 patient's sensations in, 164 
 prognosis in cases of, 153 
 
 Fainting attacks, 60 
 
 cause of, 60 
 Fear of dissolution in paroxysmal 
 
 tachycardia, 181 
 Febrile attacks, indefinite, in septic 
 
 endocarditis, 191 
 
 effect of exertion in, 195
 
 256 
 
 INDEX 
 
 Feelings, terrifying, in adult type of 
 irregularity, 150 
 
 Fevers — 
 
 effect of, on extra systoles, 153 
 followed by sense of exhaustion, 
 
 9 1 . 
 
 in relation to acute affections of the 
 
 heart, 187 
 in relation to auricular flutter, 172 
 irregular action of the heart in, 
 
 *45 
 systolic murmurs in, 106 
 Fibrillation of auricle. See under 
 
 Auricular fibrillation. 
 Fibrillation of Ventricle, 214 
 Fibrous tissue in hypertrophied heart, 
 
 134 
 Flushing — 
 
 as symptom of hypersensitive ner- 
 vous system, 83 
 dusky, in auricular fibrillation, 
 167 
 Flutter, auricular. See under Auri- 
 cular nutter. 
 Fluttering sensations in chest, 164 
 Food, dry, in treatment of heart con- 
 ditions, 227 
 Functional murmurs, 101 
 diagnosis of, 101 
 in fevers, 102 
 Functional symptoms, value of, 52 
 Future of the patient, 21 
 
 G 
 
 "Gallop rhythm" in myocardial 
 
 exhaustion, 136 
 General practitioner as investigator, 
 
 32 
 Giddiness, 9, 87 
 " Growing pains," 189 
 
 H 
 
 Hsematuria in septic endocarditis, 
 
 192 
 Haemorrhage in mitral stenosis, 115 
 Hay, John, 153 
 Heart, acute affections of (see also 
 
 Acute affections of the heart), 
 
 187 
 " Heart attacks,'' 177 
 
 Heart-block — 
 
 Adam-Stokes syndrome in, 63 
 
 atropine in, 247 
 
 cause of, 61 
 
 explanation of tracing of, 62 
 
 in mitral stenosis, 115 
 
 occurring after fevers, 106 
 
 oxygen, during unconsciousness in, 
 246 
 
 partial, 63 
 
 unconsciousness in, 61 
 Heart contractions starting at ab- 
 normal place, 180 
 Heart, dilatation of (see also Dila- 
 tation of the heart), 122 
 Heart failure, 37, 136 
 
 auricular fibrillation in relation to, 
 159, 163, 166, 167, 170 
 
 auricular flutter in relation to, 174 
 
 breathlessness, intense in, 184 
 
 cause of, 41, 185 
 
 definition of, 38 
 
 differentiation of, from poisoned 
 heart, 193, 197, 198 
 
 differentiation of, when due to 
 mitral stenosis and aortic 
 regurgitation, 120 
 
 digitalis in treatment of, 233 
 
 earliest sign of, a subjective sensa- 
 tion, 42, 44 
 
 exhaustion of, "rest force" in, 45 
 
 in aortic regurgitation, 1 19, 184 
 
 in mitral stenosis, no, in, 114, 
 184 
 
 in paroxysmal tachycardia, 181 
 
 in pregnancy, 212 
 
 in relation to treatment, 222, 224 
 
 jugular veins in, 185 
 
 liver, enlarged in, 185 
 
 objective signs of, 66 
 
 oedema of lungs with, 184 
 
 prognosis in, 208, 209 
 
 response of heart to effort in, 44 
 
 rest in treatment of, 226 
 
 sudden, 184 
 
 symptoms of, 185 
 
 systolic murmurs in, 105 
 
 unconsciousness in, 185 
 
 value of signs in, 43, 44 
 
 without increase in the size of the 
 heart, 105, 126 
 Heart from youth to old age, 97 
 Heart, hypertrophy of (see also 
 Hypertrophy of the heart), 
 
 131 
 Heart in rheumatic fever (see also 
 
 Rheumatic fever), 189
 
 INDEX 
 
 257 
 
 Heart, invasion of, by disease 
 
 agents, 188 
 Heart, irregularities (see also 
 
 Irregular action of the heart), 
 
 138 
 Heart muscle at work and at rest, 
 
 39, 40 
 Heart muscle in relation to pain, 
 
 53, 54 
 Heart, overstrain of, 185 
 Heart, poisoned (see also Poisoned 
 
 heart), 189, 193 
 Heart sounds with pulsus alternans, 
 
 154 
 Hemiplegia in endocarditis, 191 
 High blood pressure, persistent, in 
 
 hypertrophy of the heart, 134 
 Hill, Dr. Leonard, method of giving 
 
 oxygen, 246 
 History of disease, methods of study- 
 ing, 18 
 Hyperalgesia, 81 
 Hypertrophy of the heart- 
 cause of, 132 
 
 "compensation" in, 134, 135 
 extent of, a sign of degree of mis- 
 chief present, 117 
 in aortic regurgitation, 117, 133 
 indication of inefficiency, 135 
 in kidney disease, 134 
 in mitral stenosis, 131 
 morbid, 133 
 of left auricle, 132 
 
 ventricle, 131, 132 
 of right ventricle, 132 
 physiological, 132 
 significance of, 134 
 signs of, 131 
 with adherent pericardium, 133, 
 
 with persistent high blood-pressure, 
 134 
 
 Indrawing during systole in dilata- 
 tion of the right heart, 124 
 
 Infants, irregular action of the heart 
 in, 145 
 
 Infarction in septic endocarditis, 
 .191 
 
 Infection, conditions supervening on, 
 188 
 heart exhaustion in, 82 
 
 Infection [cont. ) 
 
 in relation to irregular action of the 
 heart, 145 
 "soldier's heart," 194 
 Influenza — 
 
 followed by irregular action of the 
 
 heart, 145 
 in relation to acute infections of the 
 heart, 190 
 Insurance, life, 140 
 Intermittent heart, 26, 149 
 Intestinal disturbances — 
 
 as cause of poisoned heart, 196 
 diet in treatment of, 227 
 Irregular action of the heart, 8, 
 138 
 Adam-Stokes syndrome, 63 
 adult type of, 143, 149 
 
 prognosis in, 153 
 age incidence in, 143 
 after fevers, 145 
 blood pressure in, 203 
 convulsions with, 63 
 differentiation between youthful 
 type of, and auricular fibrilla- 
 tion, 164 
 early attempts to investigate, 141 
 in auricular fibrillation, 163 
 in health, 98 
 in infants, 145 
 in neurotics, 145 
 in relation to life insurance, 140 
 in sudden breathlessness, 57 
 jugular pulse in, 141 
 patient's sensations in, 164 
 persistent, in mitral stenosis, no 
 respiratory type of, 144 
 significance of not recognised, 139 
 strides in knowledge of, 138, 139 
 sudden onset of, in mitral stenosis, 
 
 110 
 types recognised, 143 
 unconsciousness with, 61 
 vagus or sinus, 145 
 youthful type of, 107, 143, 144 
 " Irritable heart of soldiers," 194 
 Irritable heart with sense of exhaus- 
 tion, 90 
 
 J 
 
 Jaundice in auricular fibrillation, 
 
 167 
 Joint affections in relation to acute 
 
 affections of the heart, 190 
 Jugular pulse, 141 
 
 S
 
 2 5 8 
 
 INDEX 
 
 Jugular veins — 
 
 in auricular flutter, 174, 175 
 in heart failure, 185 
 
 K 
 
 Kidney disease with hypertrophy of 
 
 the heart, 66 
 Kidneys, congestion of (see also under 
 
 Bright' s Disease), 66 
 
 Legs, pain in, on exertion, 73 
 
 Levy, 214 
 
 Lewis, Dr. Thomas, 136 
 
 Lister, 214 
 Liver — 
 
 enlargement of, 66 
 in heart failure, 185 
 in poisoned heart, 197 
 in relation to sudden breathless- 
 ness, 57 
 pulsating in paroxysmal tachy- 
 cardia, 181, 183 
 Lividity of face and extremities, 57 
 London Hospital, 233 
 Lungs — 
 
 crepitations at bases in relation to 
 
 heart failure, 67 
 dullness at bases in relation to heart 
 
 failure, 67 
 oedema of, 67 
 
 with acute heart failure, 184 
 
 M 
 
 MacWilliam, Dr., 169, 206, 214 
 Massage in treatment of dropsy, 226 
 Measles followed by irregular action 
 
 of the heart, 145 
 Mediastinitis, adhesive, hypertrophy 
 
 of heart in, 134 
 Mid-Diastolic Murmur, 61 
 "Mitral Pulse"— 
 
 in auricular filbrillation, 1 15, 163 
 significance of onset of, in mitral 
 
 stenosis, 115 
 Mitral ^Regurgitation, value of as 
 
 sign of heart affection, 100, 
 
 103 
 
 Mitral Stenosis, 19, 108, 131, 223 
 aetiology of, 112, 1 13 
 and heart-block, 61 
 breathlessness and palpitation in, 
 
 during pregnancy, 212 
 haemorrhage from lungs in, I 1 5 
 heart failure in, 184 
 prognosis in, 114, 116 
 progressive lesion, 112 
 rate of progress of, 1 14 
 when murmurs appear and how 
 they alter in, 108 
 Mitral systolic murmur, 105 
 " Mock angina," 83 
 Morphia in cardiac asthma, 59 
 Mount Vernon Hospital, 233 
 Murmurs, 99 
 
 aortic diastolic in septic endo- 
 carditis, 192 
 syphilis, 77 
 "crescendo" of mitral stenosis, 
 
 109 
 diastolic, 212, 108 
 diastolic in rheumatic fever, 189 
 in relation to auricular fibrillation, 
 165, 166 
 "diminuendo" of mitral stenosis, 
 
 109 
 effect opposition on, 102 
 in healthy hearts, 97, 98, 99, 101, 
 
 103 
 mid-diastolic, 61 
 
 mitral-stenotic, disappearance of, 
 Iio 
 in relation to auricular fibrillation, 
 
 . l6 5 . 
 musical, in aortic area, with pulsus 
 
 alternans, 134 
 
 indicating a damaged valve, 103 
 
 presystolic, 212 
 
 as remote effect of rheumatic 
 
 fever, 190 
 
 rough, as indication of damaged 
 
 valve, 103 
 
 systolic, at apex and base, 188 
 
 estimation of value of, 103, 
 
 104 
 
 in myocardial exhaustion, 136 
 
 in poisoned heart, 193, 198 
 
 in septic endocarditis, 191 
 
 meaning of in fevers, 106 
 
 physiological and functional, 102 
 
 soft, in rheumatic fever, 189 
 
 with heart-failure, 105 
 
 with youthful type of irregularity, 
 
 148
 
 INDEX 
 
 259 
 
 Murmurs {cont.) 
 
 tricuspid, loud, rasping, in septic 
 endocarditis, 192 
 stenotic, in relation to auricular 
 fibrillation, 165, 166 
 Myocardial degeneration, 135 
 cardiac asthma in, 136 
 Cheyne-Stokes breathing in, 136 
 in chronic Bright's disease, 136 
 in elderly patients, 136 
 Myocardial exhaustion, signs of, 
 
 136 
 Myocardium, affections of, 121 
 
 condition of in mitral stenosis, 
 
 "4 
 
 condition of in relation to systolic 
 
 murmurs, 104 
 invasion of in rheumatic fever, 
 189 
 septic endocarditis, 191 
 
 N 
 
 Nativelle's granules of digitalin, 
 
 236 
 Nauheim baths, 130, 230 
 Nervous system — 
 
 hypersensitiveness of, in relation to 
 
 heart disease, 81 
 hypersensitive, prognosis and treat- 
 ment, 84 
 symptoms of, 83 
 Neurotic patients — 
 
 irregular action of the heart in, 
 
 . J 45 
 palpitation in, 178 
 
 Nitrites — 
 
 in treatment of angina pectoris, 80, 
 
 244 
 signs of over-dose of, 244 
 treatment by, 244 
 effects of, 244 
 Nitro-glycerin, 244 
 Nodal rhythm, 162 
 Nose, bleeding in aortic regurgitation, 
 118 
 
 O 
 
 Objective signs of heart-failure, 
 66 
 
 (Edema of ankles and legs in heart- 
 failure, 66 
 
 (Edema (cont.) 
 
 of ankles and legs in paroxysmal 
 
 tachycardia, 18 1 
 of lungs, acute, in heart failure, 6, 
 67, 184 
 Oertel, graduated exercises of, 229 
 Old age, the heart from youth to, 
 
 ?7 . . 
 Onset, insidious, of septic endocar- 
 ditis, 191 
 Opium — 
 
 in angina pectoris, 80 
 in sleeplessness, 245 
 when to avoid, 245 
 Orthopnoea, 55, 56, 135 
 
 in auricular fibrillation, 167 
 Osier, Sir Wm., 192 
 Out-thrust, systolic, in dilatation of 
 
 left heart, 124 
 Overstrain of the heart, 185 
 and dilatation, 127, 128 
 bogey of, 125 
 in war, 186 
 
 symptoms often regarded as in- 
 dicating, 185 
 Overwork as cause of heart exhaustion, 
 
 74, 76 
 Oxygen in treatment of heart affec- 
 tions, 246 
 
 in angina pectoris, 246 
 
 in cardiac asthma, 245 
 
 in Cheyne-Stokes respiration, 245 
 
 in dyspnoea, 246 
 
 in heart-block during unconscious- 
 ness, 246 
 
 Pain — 
 
 abdominal, localisation of, 14 
 during sleep, in angina pectoris, 
 
 7 8 
 effect of position on, in poisoned 
 
 heart, 197, 198 
 
 in angina pectoris, 70, 71 , 85 
 
 in aortic regurgitation, 119 
 
 in left chest, 81 
 
 in myocardial exhaustion, 136 
 
 in poisoned heart, 197, 198 
 
 localisation of, 12, 14 
 
 memory of, 16 
 
 radiation of, in disease, 13 
 Pallor of hands and fingers in 
 
 poisoned heart, 198 
 Palpitation, 8, 177 
 
 attitude in, 179
 
 260 
 
 INDEX 
 
 Palpitation (cont.) 
 
 bromides in, 179 
 
 coffee and tea in, 179 
 
 differentiation of, from paroxysmal 
 tachycardia, 178 
 
 effect of visceral disturbance on, 
 179 
 
 in mitral stenosis, 115 
 
 in neurotic patients, 178 
 
 in poisoned heart, 193, 197 
 
 in valvular disease, 178 
 
 occurrence of, 178 
 
 patient's sensations in, 178, 179 
 
 prognosis in, 179 
 
 pulse in, 179 
 
 treatment of, 179 
 Parkinson, Dr., on giving oxygen, 
 
 247 
 Paroxysmal tachycardia, 10, 136, 
 173, 180 
 
 age incidence in, 182 
 
 auricular fibrillation in, 163, 164, 
 180 
 
 breathlessness in, 181 
 
 bromides in, 184 
 
 cause of, 180 
 
 dilatation in, 129, 181, 183 
 
 disappearance of symptoms in, 181, 
 182 
 
 drugs in, 184 
 
 duration of, 180 
 
 fear of dissolution in, 181 
 
 heart-failure in, 181 
 
 heart-sounds in, 181 
 
 jugular veins in, 181 
 
 liver, pulsations of, in, 181, 
 
 183 
 oedema of legs in, 181 
 patient's sensations in, 180, 181 
 prognosis in, 182, 183 
 pulse in, 181 
 pulsus alternans in, 155 
 rheumatic fever in relation to, 182, 
 
 183 
 symptoms of, 180 
 treatment of, 183, 184 
 unconsciousness in, 181 
 valve lesions in, 183 
 Patient's sensations, 48, 49, 50 
 as early sign of disease, 6, 8, 11, 
 
 . *? 
 
 as indication in treatment, 229 
 
 in auricular fibrillation, 164 
 
 in paroxysmal tachycardia, 180, 
 
 181 
 in poisoned heart, 193, 197 
 in soldier's heart, 194 
 
 Pericardium, adherent, hyper- 
 trophy of heart in, 133, 134 
 Perspiration in septic endocarditis, 
 
 191 
 Phenacetin in sleeplessness, 245 
 Physiological murmurs, 101 
 
 diagnosis of, 101, 102 
 Pneumonia — 
 
 extra-systoles in, 153 
 
 in relation to acute affections of the 
 heart, 190 
 
 pulsus alternans in, 155 
 Poisoned heart, 189, 193, 196 
 
 abscesses as cause of, 196 
 
 alcohol as cause of, 196 
 
 appetite in, 197 
 
 breathlessness in, 193, 197 
 
 chronic appendicitis as cause of, 
 196 
 
 constipation as cause of, 196 
 
 diagnosis of, 193, 196 
 
 differentiation of, from heart-failure, 
 
 193, 198 
 dilatation in, 193, 198 
 dropsy in, 197 
 effect of position on pain in, 197, 
 
 198 
 of smoking on pain in, 198 
 exhaustion in, 193, 197 
 heart-failure in, 197 
 increased pulse rate in, 193, 198 
 intestinal disturbances in causation 
 
 of, 196 
 liver, enlarged in, 197 
 pain in, 197 
 pallor of hands and fingers in, 
 
 198 
 palpitation in, 193, 198 
 patient's sensations in, 193, 197 
 physical signs of, 198 
 prognosis in, 199 
 symptoms of, 196, 197, 198 
 systolic murmur in, 193, 198 
 tobacco as cause of, 1 96 
 treatment of, 199 
 
 vaso-motor irritability in, 197, 198 
 Pregnancy in relation to heart 
 
 affections, 2 1 1 
 aortic regurgitation in, 212 
 auricular fibrillation in, 212 
 breathlessness in, 211 
 diastolic murmur in, 212 
 dropsy in, 211 
 
 forbidden in heart cases, 213 
 mitral stenosis in, 212 
 presystolic murmur in, 212 
 Premature heat, 149
 
 INDEX 
 
 261 
 
 Presystolic murmur, 109 
 
 disappearing in auricular fibrilla- 
 tion, no, 165, 166 
 
 Principles of treatment, 220 
 
 Production of symptoms, 51 
 
 Prognosis in heart affections, 21, 
 207 
 effects of treatment in relation to, 
 
 208, 209 
 formation of, 2IO, 211 
 guarded, 217, 218 
 in anaesthesia, 213 
 in angina pectoris, 79, 209 
 in aortic reguigitation, 117, 118, 
 
 119, 120 
 in auricular fibrillation, 167, 210 
 in auricular flutter, 175 
 in congenital heart disease, 214 
 in elderly patients, 209 
 in extra-systole, cases with, 153 
 in hypersensitive nervous system, 
 
 8 4. 
 
 in palpitation, 179 
 
 in paroxysmal tachycardia, 182, 
 
 183 
 in patent ductus arteriosus, 214 
 in poisoned heart, 199 
 in pregnancy, 211 
 in pulsus alternans, 155 
 in relation to functional efficiency 
 
 of the heart muscle, 207 
 in relation to signs of heart failure, 
 
 208, 209 
 mystery in relation to, 216 
 personal element in, 215 
 "reserve force" in relation to, 
 
 208 
 " rest force," 209 
 statistical methods in, 219 
 Progress of disease, need of recog- 
 nition of symptoms of, 17 
 Protective symptoms, value of, 53 
 " Pseudo angina," 83 
 Puerperal septicaemia, endocarditis 
 
 in, 192 
 Pulsation, epigastric, 124 
 Pulsation, liver, in paroxysmal tachy- 
 cardia, 181, 182 
 Pulse- 
 in aortic regurgitation, 118 
 in palpitation, 179 
 in paroxysmal tachycardia, 181 
 in pyaemia and puerperal sep- 
 ticaemia, 192 
 rapid, in auricular flutter, 175 
 rhythm of, in auricular fibrillation, 
 164, 165 
 
 Pulsus alternans, 137, 153 
 
 auscultatory method of diagnosing, 
 
 154 
 
 diagnosis of, 154 
 
 differentiation from pulsus bi- 
 
 geminus, 154, 156 
 digitalis as cause of, 232 
 evidences of heart-failure with, 155 
 heart, sounds in, 154 
 in relation to cardiac asthma, 59 
 musical murmurs with, 154 
 prognosis in, 155 
 Pulsus bigeminus, 150, 151 
 
 conditions in which it appears, 154 
 differentiation from pulsus alternans 
 
 154, 156. 
 Purpura in septic endocarditis, 192 
 Pyaemia, endocarditis in relation to, 
 
 192 
 
 Questioning the patient, 93 
 
 R 
 
 Eapid pulse (auricular flutter), 172, 
 
 175 
 Rate of heart — 
 
 in aortic regurgitation as index of 
 
 cardiac vigour, 118 
 in paroxysmal tachycardia, 180 
 in poisoned heart, 193, 198 
 persistent increase of, in acute fevers, 
 106 
 " Reserve force," 40, 45, 208 
 Respiratory irregularity, 144 
 Response to effort as index of sig- 
 nificance of systolic murmurs, 
 104 
 Rest — 
 
 in treatment of angina pectoris, 80 
 exhaustion of the heart, 226 
 dropsy, 226 
 
 hypersensitive nervous system, 84 
 "Rest force," 40, 45, 208 
 Retinal embolism in septic endo- 
 carditis, 192 
 Rheumatic fever, 19, 27, 107, 136, 
 169, 212 
 auricular fibrillation or flutter as 
 remote effect of, 189
 
 262 
 
 INDEX 
 
 Rheumatic fever (cunt.) 
 
 cause of aortic regurgitation, 119 
 
 diastolic murmur in, 189 
 
 dilatation of the heart in, 189 
 
 drugs in, 191 
 
 followed by extra-systoles, 153 
 
 followed by irregular action of the 
 heart, 145, 147 
 
 in acute affections of the heart, 189 
 
 in relation to auricular flutter, 172 
 mitral stenosis, 108, 113 
 
 in relation to paroxysmal tachy- 
 cardia, 182, 183, 188 
 
 pericarditis in, 190 
 
 positive evidence of heart mischief 
 in, 190 
 
 pres3'stolic murmur in relation to, 
 190 
 
 soft systolic murmur in, 189 
 
 symptoms of invasion of heart in, 
 189 
 
 treatment of acute affections of the 
 heart in, 190 
 Rhythm, gallop, in myocardial ex- 
 haustion, 136 
 Rigors in septic endocarditis, 191 
 Riva-Rocci blood-pressure instrument, 
 
 206 
 Rough murmur indication of dam- 
 aged valve, 103 
 
 Schott, resistance-exercises of, 229 
 Second sound, doubling of, 109 
 Sedatives, 245 
 Senile changes in relation to auricular 
 
 flutter, 172 
 Sensations of patient (see under 
 
 Patient's sensations) 
 Sensation, fluttering, in the chest, 
 
 164 
 Sense of exhaustion, 87 
 Sensitiveness of viscera, 13, 53 
 Septic endocarditis, 191 
 Shivering in hypersensitive nervous 
 
 system, 83 
 Sino-auricular node, 144 
 Sinus irregularity, 145 
 Skin, yellow, accompanying sense of 
 
 exhaustion, 90 
 Sleeplessness — 
 
 and heart exhaustion, 74, 82, 224 
 provoking cause of extra-systoles, 
 
 152 
 treatment of, by sedatives, 245 
 
 Slowing of whole heart, transient, 
 
 144 
 Sodium nitrite, 244 
 " Soldier's heart," 194 
 
 infection in relation to, 194 
 
 patient's sensations in, 194 
 Sphygmo-manometer, 200 
 Spiritus setheris nitrosi, 244 
 Squills, 243 
 Starling, Professor, on dilatation of 
 
 the heart, 122 
 Stenosis — 
 
 aortic, 105 
 
 mitral, 108 
 Stomach — 
 
 fullness of, in relation to angina 
 pectoris, 75 
 
 palpitation in connexion with, 
 179 
 Strophanthns, 243 
 
 as substitute for digitalis, 243 
 
 intravenous administration of, 243 
 Strychnine, 247, 248 
 Sudden heart failure, 184 
 Sulphonal, 245 
 
 Symptoms, rapid disappearance of, 
 in paroxysmal tachycardia, 181, 
 182 
 Syncope, 60, 87 
 
 and heart-block, 61 
 
 due to extreme frequency of heart- 
 rate, 65 
 
 due to vagal stimulation, 60 
 
 in aortic regurgitation, 119 
 Syphilis— 
 
 and angina pectoris, 77 
 
 in aortic regurgitation, 119 
 Systolic blood pressure, 203, 206 
 Systolic murmurs — 
 
 accompanying heart failure, 105 
 
 in poisoned heart, 193, 198. 
 
 meaning of, in fevers, 106 
 
 organic in origin, 103 
 
 physiological and functional, 102 
 
 Tea— 
 
 as provoking cause of extra systoles, 
 
 152 
 
 in palpitation, 179 
 Teeth, defective, 91 
 Temperature — 
 
 effect of, on heart and blood-vessels, 
 187, 188
 
 INDEX 
 
 263 
 
 Temperature (cont.) 
 
 in relation to acute affections of 
 the heart, 187 
 Tenderness — 
 
 in chest wall in auricular fibrilla- 
 tion, 167 
 in left chest, 81 
 
 over liver, in auricular fibrillation, 
 167 
 Thrill preceding first sound, 109 
 Tobacco — 
 
 as cause of poisoned heart, 
 
 194 
 as provoking cause of extra-systoles, 
 
 in angina pectoris, 78 
 Toxins as cause of sense of exhaus- 
 tion, 90 
 Treatment, 220 
 
 and the care of the heart muscle, 
 
 224 
 baths in, 229 
 by alcohol, 247 
 by atropine, 247 
 by digitalis, 231 
 by sedatives, 245 
 by strophanthus, 243 
 by the nitrites, 243 
 change of occupation in, 225 
 diet in, 227 
 
 essential object of, 222 
 exercise in, 228 
 in relation to diagnosis, 224 
 heart-failure, 223, 224 
 progressive disease of the heart, 
 
 223 
 valve defects, 223 
 of angina pectoris, 79 
 of auricular fibrillation by digitalis, 
 232 
 flutter, 175, 176 
 flutter by digitalis, 237 
 of dilatation, 129 
 of hypersensitive nervous system, 
 
 84 
 of palpitation, 179 
 of paroxysmal tachycardia, 183, 
 
 184 
 of poisoned heart, 199 
 of sense of exhaustion, 89, 90 
 principles of, 220 
 rest in, 226 
 Tricuspid murmur, loud rasping in 
 
 septic endocarditis,, 192 
 Tubercle and congenital heart 
 
 disease, 215 
 Typhoid fever, 187 
 
 U 
 
 Unconsciousness — 
 
 due to auricular flutter, 61, 174 
 faulty cardiac action, 61 
 heart-block, 61 
 heart-failure, 185 
 paroxysmal tachycardia, 1 81 
 with convulsions, 63 
 Uterus, effect of disturbances of, 
 palpitation, 179 
 
 " Vagus irregularity," 144, 145, 148 
 Valves, vegetations on, 192 
 Valvular defects in relation to treat- 
 ment, 223 
 Valvular disease — 
 palpitation in, 178 
 paroxysmal tachycardia in, 183 
 youthful type of irregularity in, 148 
 (see also under Murmurs) 
 Vaso-dilator drugs in treatment of 
 
 angina pectoris, 80 
 Vaso-motor disturbance, associated 
 with angina pectoris in aortic 
 regurgitation, 119 
 associated with syncope, 119 
 as symptom of hypersensitive 
 
 nervous system, 83 
 in aortic regurgitation, 119 
 in poisoned heart, 197, 198 
 Vegetations on valves, 192 
 Veins, jugular- 
 filling as result of pressure on 
 
 abdomen, 89 
 in paroxysmal tachycardia, 181 
 Ventricle, fibrillation of, 169, 214 
 Veronal, 245 
 
 W 
 
 Wasting in auricular fibrillation, 167 
 Withering, Dr., on digitalis, 231 
 Worry in relation to heart exhaustion, 
 74, 82, 224, 245
 
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