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if not all, of such cases, will sooner or later be found to have suffered from some abnormality.

The association of bradycardia with fatty degeneration of the heart has been found experimentally to have been a delusion, and where it does exist it is accidental only.

Most cases of bradycardia are due to traumatism of the cervical vertebra, involving an injury of that portion of the spinal column. The explanation of this causal relation is that from this portion of the cord the spinal accessory nerve arises; this nerve acting the part of the anterior column or root of a spinal nerve, even a concussion of the cord at the origin of the spinal accessory will produce a temporary slowness of the pulse, while severe injury of the cervical part of the cord or disease of the cervical membranes, or disease or injury at the base of the brain, involving a compression of the above mentioned nerve, will produce permanent slowness of the pulse.

The action of many poisons in slowing the heart is explicable by the influence such poisons have upon the nerves and nerve centers. Cases of severe bradycardia are always associated with dilatation of the heart and usually attended by a mitral systolic murmur.

The condition mentioned as delirium cordis is comparatively common in gouty and dilated hearts, as a temporary phenomenon; treatment directed to the restoration of the compensation usually removes such condition, unless the lesion has, progressed so far as to be irremediable.

Breathlessness.—This symptom is of very great importance and significance in cardiac disease. When we come to consider the numerous and diverse methods by which this symptom may be produced in diseases of the heart, we can fully appreciate the frequency with which a disturbance of pulmonary function may occur. I merely mention here some of those mechanical causes serving to intensify the breathlessness in heart disease, viz.: excessive hypertrophy, pericardial or pleuritic effusion, catarrhal and oedematous conditions from serous effusions, pulmonary infractions, due to thrombosis and embolism, possibly resulting in pulmonary gan

grene, pneumothorax occasionally, hemorrhages, depending upon intense congestion of embolic infraction. In addition to all of these mechanical causes we have that characteristic breathlessness or "air hunger" of the Germans, due to disturbances of the pulmonary circulation alone, in which, in the entire absence of any obstruction to the entrance or the exit of air from the lungs, the patient may suffer from breathlessness, due entirely to a deficient oxygenation of the blood. The peculiarity of this form of breathlessness consists in that it is manifested only upon exertion; it is one of the earliest and most significant symptoms of a ruptured compensation. During quietude the heart may be enabled to carry the blood with sufficient force through the lungs, but upon the slightest exertion a passive congestion occurs in the lungs, leading to deficient oxygenation; hence I am in the habit, in every case where I suspect heart disease, to inquire particularly as to whether the patient suffers from shortness of breath after even slight exertion.

The amount of lesion is not to be measured by the extent of breathlessness, but its gravity is dependent upon the degree in which the compensation is broken, may certainly be so: thus a patient may only blow a little in going up a hill or ascending a stair, or his shortness of breath may be so great as to compel him to stop on attempting either of these feats, or it may be so extreme as to be distressing on making such trifling exertion as sitting up or turning in bed; at the same time there is no true dysponce; that is to say, there is no obstruction to either inspiration or expiration, and there may be no curtailment of air space. The breathing while the patient is at perfect rest is quiet and natural, yet from cardiac causes the difficulty is so great of getting the blood aerated, that the slightest exertion produces a gasping disquietude, extremely characteristic. There is another form of cardiac asthma, so-called, which, though not dependent upon exertion, is equally independent of pulmonary lesion. In these cases the condition comes on suddenly; frequently when the patient is asleep he is awakened with palpitation, pain, weakness of the heart, and occasionally nausea and vomiting. This form of cardiac asthma is most usually senile

and associated with mild degeneration, rather than valvular lesion. It is usually brought about by some reflex gastric disturbance affecting an enfeebled heart in this unusual manner. It is often the beginning of the end of those affected and the first intimation of the approaching end.

In this connection, it is important to remember that cardiac breathlessness is not necessarily due to actual cardiac disease, as it may be dependent upon some abnormal condition of the blood itself, and we must determine by further examination whether we have to do with a hæmic or cardiac lesion.

Cough. It goes without saying that cough is a symptom which is apt to occur with greater or less frequency in connection with heart diseases, as so many cases are attended by passive congestion of the mucous membrane of the bronchi and air cells, and by pulmonary œdema and catarrhal processes, involving the bronchi; hence in every case attended by this symptom, the possibility of a cardiac origin should be remembered.

Recently I had a case of this kind where the intense capillary bronchitis was of such severe a nature as to threaten the life of the patient, was entirely of cardiac origin, due to dilatation and impairment of the pulmonary circulation. The necessity of recognizing the cardiac origin of this symptom is apparent when we bear in mind that unless treatment is directed toward measures for restoring the circulation, the patient may die and the cause of the trouble be entirely unrecognized.

Hæmoptysis. This is another symptom whose cardiac origin is frequently overlooked. The same causes that produced cough and other symptoms also contribute to pulmonary hemorrhage, which may arise from a ruptured vessel, from intense congestion, or it may depend upon an embolic infraction.

Apparently, genuine pneumonic attacks are often entirely of embolic origin. Balfour is authority for this statement, "that for hæmoptysis we shall find a cardiac cause almost as frequently as any other." From what has gone before, it is easy to understand how such could be the case.

Pain. This symptom in the cardiac region is a common event in most all diseases of the heart. It occurs also very frequently where no cardiac disease is present; thus we have a pain of neuralgic character occurring in the anæmic, debilitated, neurotic and gouty invididuals. In these cases pain is superficially located and is rather an intercostal myalgia.

In cases where the cardiac pain is associated with imperfect nutrition of the heart muscle itself, the pain becomes more permanent and severe. Then if we have a physical cause producing an obstruction of the circulation requiring an excessive power on the part of the heart to overcome the same, we have an additional strain brought to bear upon the cardiac muscle, which it resents as indicated by its painful action; hence there are comparatively few cases of heart disease in the uncompensated stage which are not attended by more or less pain, and a cessation of the same signifies restoration of compensation.

I shall not stop to speak of the pain incident to aortic aneurism, and shall refer very briefly to that due to angina pectoris. In the latter condition we have the depressing influence of pain; the most acute and severe that the human frame can experience. The heart, as it were, is seized by a mailed hand, producing that appalling agony with which is associated the sense of impending death, and may result in that event even in the first attack. In such cases there is a gradual decrease of the aortic pressure dependent upon a diminution of the heart's force, the pulse becoming enfeebled by degrees until it ceases. In cases not proving fatal, the pain ceases as suddenly as it comes on, the patient being puzzled to know what has happened, and terrified at the prospect of a recurrence.

It is beyond the province of this article to discuss the causes of this form of cardiac pain or to differentiate between the true and the so-called false angina pectoris. I may say, however, that in all probability the predisposing cause is anæmia of the cardiac plexus of general or local origin. An exciting cause directly or reflexly still further diminishes the blood supply or in some other mode influencing the cardiac nerves.

One of the most common causes affecting the nutrition of the heart muscle, as well as its nervous supply, being an atheromatous condition of the coronary arteries.

Dropsy. An exceedingly common secondary result of cardiac disease is dropsy. This symptom is one of the earliest to show itself as result of decrease of arterial pressure or transference of intravascular pressure from the arteries to the veins. These two conditions are not exactly synonymous, for the aortic pressure may fall suddenly and fatally without the presence of any concomitant or increased intravenous pressure, but the latter is never developed without the former.

Dropsy, dependent upon heart disease, always begins across the instep, gradually filling up the lower extremities, the face and upper part of the body remaining free. But, as a dropsy of anæmia comes on in the same way, this can not be accepted as certainly indicative of a heart lesion, but must only be considered as a hint that the heart may be affected; the cardiac origin or otherwise can be determined by further examination.

When we bear in mind the frequency with which cardiac disease is complicated by anæmic conditions, and by an accompanying kidney involvement, we can appreciate to what extent, how often. and in what manifold forms dropsy may occur as an accompaniment of cardiac disease, and how severe may be its results when it becomes general, or involves the lungs. These mere mechanical results adding enormously to the patient's suffering and requiring most active measures to affect relief.

It is surprising as well as gratifying to the beginner in medical practice to find how readily and rapidly dropsy, due to failure of heart compensation, may be removed by directing attention to its sourse, an enfeebled circulation.

Digestive Symptoms. Of all the secondary phenomena connected with cardiac diseases, the symptoms due to digestive disturbances are most important, because so frequently they are supposed to be due to primary disease of the digestive organs, and so long as treatment is directed to cure without recognition of the

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