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the urine, the other had great suppression, with hæmaturia, but no dropsical condition. I never saw a case before with so great suppression of the urine without dropsy.

These are a few of the cases of dropsy that came under my professional care. If by this paper I have saved one in the future from an untimely fatal prognosis I shall feel repaid for my effort.

SOME CONSIDERATIONS CONCERNING THE HEART IN RELATION TO ITS OWN AND OTHER MALADIES.

(A Plea for the Proper Estimation of the Cardiac Apparatus as a Symptomand State-Producing Factor.)

BY EDWARD R. SNADER, M.D., PHILADELPHIA, Pa.

IN this day of specialism and specialists we are prone to forget that the wonderful mechanism of the body is a unified whole, not a collection of organs differentiated from an apparent unit into a multiplication of highly-specialized, function-performing organs that have no dependence upon other parts of the body for the carrying out of the work of life.

The importance of the heart and blood vessel system in its power to become a factor in the production of symptoms and conditions cannot be overestimated by the general practitioner or by the specialist. The frequent dependence of diseases, apparently local in origin, upon organic or functional affections of the heart is, to my mind, a proven fact. Both the general practitioners and specialists are chargeable upon the score of insufficient investigation of disease, and there is real danger to progress in medicine in assuming that simply giving a name to a disease and treating it in a stereotyped fashion is fulfilling the physician's whole duty.

I hold that a correct diagnosis is, in the vast majority of cases, of paramount importance. I hold, too, that a diagnosis must be a comprehensive one-a diagnosis of the tissue conditions involved, of the general and local effects of the lesion or state, and of the possible dependence of the condition, apparently local, upon another and may-be distant organ, or if of distinctive origin in situ; in other words, a diagnosis for the purpose of rationally applying therapeutic measures for the cure or amelioration of the disease, as well as to give name to it and furnish prognostic data.

The heart and blood vessel system is so intimately connected with the nutrition of all parts of the body, that the cardiac influence is frequently the dominant one, not only in acute but in chronic diseases, local and general. While the heart is the centre of nutrition, it is easily obvious that outlying conditions and diseases affect the heart both directly and indirectly. The centre influences the circumference; the circumference influences the centre.

There exists a mutual and indissolvable interdependence of the great mechanism, the human frame, and it is to this dominant interdependence of conditions and causes, playing in a consistent cycle, with which rational diagnosis, rational prognosis, and, above all, rational therapeutics, has to deal.

Related to all organs, it would seem impossible that the heart, as an underlying factor, capable of producing symptoms and states of the system, and of modifying and originating local diseases and general conditions, should be overlooked in the investigation of maladies. The cardiac apparatus is often overlooked, completely ignored, and some organs are practically assumed to be able to perform their functions independent of cardiac help. In a theoretical way, in a sort of dreamy mental conception, the heart is known to be in some way connected with the nutrition of the part; but the vital fact of the absolute dependence of the economy upon the functional integrity of the heart is not felt, sensed, LIVED, if you please; and hence the importance of the condition of the heart and its power of modifying nutrition is overlooked or underestimated in the investigation of many local and general diseases.

In a broad sense, the heart is back of all disease phenomena, and of all physiological phenomena, and it is plainly our duty to justly estimate the exact rôle it plays in the production of symptoms directly or circuitously, and how special states or conditions boomerang back upon the circulatory centre, producing vicious pathological circles.

It seems to me an obvious practical fact that the heart, as an organ, can be unable to perform its alloted functions perfectly independently of the presence of actual and discoverable organic defect. In other words, a heart, the orifices and valves of which are perfect, the cavities of which are normal, the walls of which are unaffected in their essential structural elements, may be too weak to perform its work. A cardiac apparatus, too, may be deficient in working

power without the presence of any of the so-called classical functional heart diseases. It is obviously then, not sufficient, in the investigation of a case, to examine the heart, and, finding the valves and openings perfect, and noting the absence of hypertrophy, of dilatation, of fatty degeneration, of myocarditis, to conclude that the heart is not a factor capable of causing some of the symptoms present or of modifying the whole clinical picture. The heart may possibly be the cardinal mischief-maker, notwithstanding gross pathological changes in its structure have been excluded. Of course, if a heart is obviously diseased, it is much more likely to cause symptoms than if it is not organically affected; but, on the other hand, it must not be forgotten that a diseased heart may be fairly equal to the demands usually made upon it. My plea is that the heart be measured as to its competence to perform its functions, whether it be the seat of actual disease or not.

Now, while it is true that the heart may be incapable of properly meeting the demands made upon it, it is equally true that the heart may do more than is required of it and hence give rise to symptoms and states requiring correction. Some hearts that are obviously hypertrophied do not give rise to much systemic or local disturbance: some give rise to a great deal, and some hearts, not hypertrophied at all, occasionally, for brief periods, overact and become symptomproducing factors.

My experience shows that many headaches have a cardiac origin, dependent upon a too weak or a too strong heart. Some cephalalgias, readily referable causatively to some other than a cardiac origin, have a heart element in them that cannot be overlooked. Vertex and occipital headaches are often ameliorated by attention to the cardiac apparatus, other things being equal. Two bad cases of what might improperly be called cerebral neurasthenia were found, after careful investigation, to be dependent, one upon cerebral anæmia, due to aortic stenosis, the other upon cerebral hyperæmia, due to simple cardiac overaction. Vertigos, even symptomatically of gastric origin, are often quickly ameliorated by medicines directed more or less specifically toward the control of the circulation. In some such cases I have thought that the gastric affection was secondary to the cardiac incompetency, and that by getting in on the "ground floor" of the symptomatic building, as it were, I was able the more speedily to afford relief.

Weak heart action, generally however, with intermittency, in some middle-aged individuals, gives rise to a dull, indefinitely-located headache, with what might be termed graphically half-vertigo (a feeling as if they were about to become dizzy) and slow cerebration.

Tinnitus aurium, dependent upon cerebral atheroma, can often be distinctly ameliorated by dilating the arteries and strengthening the heart, if that organ be incompetent, or by soothing and regulating it, if it be too active. Murmurs are apt to be heard in the ear by patients suffering from Eustachian obstruction, and this is true whether the heart's valves be normal or not. Removal of the Eustachian obstruction, together with sedation or strengthening of the heart's action, as required, sometimes gives happy results.

Even the eye does not escape the general dominance of the heart. One case (aortic stenosis and mitral regurgitation), according to an Old-School oculist, had frequent retinal hemorrhages; another mitral case had frequent alternating hemiopsia, mostly horizontal, obvious enough to her to be a decided annoyance; another had transitory anæmia of the retina; and still another (a young woman, with mitral regurgitation) had progressive myopia. Anti-syphilitic treatment failed utterly, and the only drugs that seemed to have the slightest effect in staying the progress of the malady were those having a direct tonic effect upon the heart.

Catarrhal processes of the naso-pharynx are sometimes dependent upon the condition of the gastro-enteric tract, and the latter are not infrequently secondary to weak cardiac action, and are occasionally ameliorated by direct attention to the heart. Whenever I note excessive venous engorgement, marked oedema, decided dilatation, or pulsation in the vessels, or too great redness, I examine the central organ of circulation in order to determine whether the heart is a contributing factor, directly or indirectly, to the pathological picture in the pharynx.

If

Epistaxis is a frequent symptom of valvular heart disease, and also occurs independently of discoverable structural change. of cardiac origin, nasal hæmorrhage is magically controlled by regulating the circulation. I have confirmed this point many times. Such nosebleeds, however, are often conservative, and need no treat

ment.

The larynx is often held responsible for coughs that are really of

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