TOXIC DISTURBANCES AND HEART RATE

Under this head it is not proposed to consider disturbances of the heart due to infections, to cardiac disease, or to localized or general acute or chronic disease, but to discuss disturbances due to the absorption of irritants froth the intestines, and to alcohol, tobacco and caffein.

It is hardly necessary to repeat that various toxins which may seriously irritate the heart may be absorbed from the intestines during fermentation or putrefactives processes in either the small or the large intestines. The heart may be slowed by some, made rapid by others, and it is often made irregular. The relation of the absorption of intestinal toxins to increased blood pressure has already been described, and the necessity of removing from the diet anything which perpetuates or increases intestinal indigestion in all cases of high blood pressure has already been referred to several times. The indications that such a condition of the intestines is present are irregular action of the bowels, a large amount of intestinal gas, sometimes watery stools, often a coated tongue, and the presence of indican in the urine.

INTESTINAL PUTREFACTION

The most successful procedure in the management of intestinal putrefaction is to remove meat from the diet absolutely. Laxatives in some form are generally indicated, and one of tile best is agar- agar. Of course aloin and cascara are always good laxatives, with an occasional dose of calomel or saline, if such seem indicated. Some of the solid hydrogen peroxid-carrying preparations (magnesium peroxid, calcium peroxide [Footnote: See N. N. R., 1916, p. 232]) have been advised as bowel antiseptics, but they are not more successful than many of the salicylic acid preparations,' and perhaps none is more efficient than salol (phenyl salicylate) in a dose of 0.3 gm. (5 grains), three or four times a day. Washing out the colon with high injections is often of great value, but should not be continued too long lest the rectum become habituated to distention, and bowel movements not take place without an enema.

Lactic acid bacilli, best the Bulgarian, arc often of value in intestinal fermentation. A tablet may be eaten with a little lactose or a small lump of sucrose after each meal. Or yeast may be taken in the forth of brewer's yeast, a tablespoonful in a glass of water, two or three times a day, or one sixth of an ordinary compressed yeast cake dissolved is a glass of `eater and taken once or twice a day. Or various forms of lactic acid fermented milk may be successful.

Any particular food which causes fermentation in the intestine of the patient should be eliminated from his diet; the patient must be individualized as to fruits, cereals and vegetables, Nit, as stated above, meat should ordinarily be withheld for a time at least.

ALCOHOL

Enough has already been said of the value and limitations of alcohol as a therapeutic agent. As a beverage, when constantly used, it is liable to cause obesity, gastric indigestion, arteriosclerosis, myocardial degeneration, chronic nephritis and cirrhosis of the liver. Its first action is undoubtedly as a food, if not too large amounts are taken, and therefore it is a protector of other food, especially of fat and starch. A habitue, then, especially if he has reached the age at which he normally adds weight, increases his tendency to obesity, and the first mistake in his nutrition is made. If lie takes too much alcohol when he eats or afterward, his digestion will be interfered with. Sooner or later, then, gastritis and stomach indigestion develop, with consequent intestinal indigestion. If lie takes strong alcohol, like whisky, oil an empty stomach, he may sooner or later cause serious disease of the mucous membrane of the stomach, first chronic gastritis, and later atrophy of the glands of the stomach.

Alcohol with meals which contain meat tends to the production of an increased amount of uric acid. Alcohol taken before meals on an empty stomach causes sudden vasodilatation after absorption. It goes quickly to the liver, irritates it, and little by little causes congestions of the liver, so that sooner or later sclerosis of this organ develops.

Alcohol probably causes arteriosclerosis not by its action per se, but indirectly by causing gastro-intestinal indigestion and insufficiency of the liver, as a result of which more toxins circulate in the blood, tending to produce arteriosclerosis. Sooner or later these irritants cause kidney irritation, and chronic interstitial nephritis may develop. just which process becomes the farthest advanced and finally kills the patient is an individual proposition and cannot be foretold. The finale may be cirrhosis of the liver, uremia, arteriosclerosis, apoplexy or myocarditis with dilatation or coronary disease.

While small, more or less undiluted closes of alcohol, as whisky or brandy, may cause quick stimulation of the heart by reflex irritation of the esophagus and stomach, vasodilatation occurs as soon as the alcohol is absorbed, and if large closes are absorbed, vasomotor paresis may occur, temporarily at least.

During acute fever processes with an increased pulse rate, provided shock or collapse is not present, small or medium-sized doses of alcohol, by dilating the peripheral blood vessels and increasing the peripheral circulation, may relieve the tension of the heart and slow the pulse by the equalization of the circulation. Some of this action may be due to the narcotic effect of alcohol on the cerebrum. Alcohol may thus in many instances act for good. Overdoses, as shown by cerebral excitation, flushing of the face and increased pulse rate, will do harm; in fact, many a patient with a serious illness, as typhoid fever or pneumonia, is made delirious by alcohol. Large doses of alcohol in shock or collapse are contraindicated.

Chronic overuse of alcohol may cause chronic myocarditis and fatty degeneration of the heart, with later weakening of the heart muscle and dilatation.

In acute alcohol poisoning the pulse may become very rapid and weak, and the patient may die of heart failure. This is often seen in delirium tremens. The administration in this condition of enormous doses of digitalis by the stomach is inexcusable, and the reason that such patients survive such digitalis poisoning is that the stomach does not absorb during this cardiac prostration.

A treatment as successful as any in this heart weakness in delirium tremens is morphin sulphate, 1/2 grain, and atropin, 1/15 grain, given hypodermically, with the administration of digitalis hypodermically for its later action on the heart. If the heart is contracting very rapidly, an ice-bag over the precordia will often quiet it. If the pulse is very weak, the cerebral sedatives more frequently used in delirium tremens, such as chloral, bromids, paraldehyd, etc., are generally contraindicated. A hot foot-bath and an ice-cap on the head sometimes aid in establishing a more general equalization of the circulation. It may often be necessary to administer strychnin, although if the patient is greatly excited it should be withheld as long as possible. For the same reason camphor, coffee and other cardiac stimulants which cause cerebral excitation should be withheld.

If the patient is in alcoholic coma, the pulse is generally slow, although it may be of low pressure unless the patient is otherwise diseased. Caffein or coffee is here indicated, and the patient should be kept warm lest he lose necessary heat. The stomach should be emptied by an emetic, often best by apomorphin hypodermically, unless the pulse is excessively weak. Strychnin may also be given, and digitalis, hypodermically, if it seems indicated. Camphor is another cardiac and cerebral stimulant that is valuable in these cases.

The treatment of an actual degeneration of the heart from overuse of alcohol is similar to the sane condition from other causes.

CAFFEIN

Caffein can irritate the heart and cause irregularity and tachycardia, especially in certain persons. In fact, some can never take a single cup of coffee without having an attack of palpitation, and many times when coffee and tea have been unsuspected by the patient as the cause of cardiac irritability, their removal from the diet has stopped the symptoms, and the heart has at once acted normally.

Caffein is a stimulant and tonic to the heart, increasing its rapidity and the strength of the contractions. It is also a cerebral stimulant, one of the most active that we possess among the drugs. It increases the blood pressure, principally by stimulating the vasomotor center and by increasing the heart strength. It acts as a diuretic, not only by increasing the circulatory force and blood pressure, but also by acting directly on the kidney. This action on the kidney contraindicates the use of caffein in any form, except in rare instances, when there is acute or chronic nephritis. The increased blood pressure caused by caffein also contraindicates its use when there is hypertension. Caffein first accelerates the heart and later may slow it and strengthen it; but if the dose is large or too frequently repeated, the apex of the heart ceases to relax properly and there is an interference with the contraction of the ventricles, the heart muscle becomes irritable, and a tachycardia may develop.

Therefore when a heart has serious lesions, whether of the myocardium or of the valves, with compensation only sufficient, the action of caffein in any form is contraindicated. The fact that it raises the blood pressure, thus increasing the force against which the heart must act, and that it irritates the heart muscle to more sturdy or irregular contraction, indicates that a patient with a heart lesion or with a nervously irritable heart should never drink tea and coffee or take caffein in any beverage.

Many patients cannot sleep for many hours after they have taken coffee or tea, as the cerebral stimulation of caffein is projected for hours after its ingestion. Caffein does not absorb so quickly and therefore does not act so quickly when taken in the form of tea and coffee as it does when taken as the drug or as a beverage which contains the alkaloid. Persons who are nervously irritable, excited and overstimulated cerebrally, with or without high blood pressure, should not take this cerebral and nervous excitant. This is true in early childhood and in youth, and continues true as age advances, in most persons. It is a crime to present caffein as a soda fountain beverage to children and young persons when the excitement of the age is such as already to overstimulate all nervous systems and all hearts.

A considerable majority of persons over 40 learn that they cannot drink tea or coffee with their evening meal without finding it difficult to sleep. Such patients, of course, should omit this stimulant. Some patients have already recognized this fact and its cause; others must be told. The majority of adults are probably no worse and may be distinctly benefited by the morning cup of coffee and the noon coffee or tea, provided the amount taken is not large. It seems to be a fact that the drinking of coffee is on the increase, especially as to frequency. Certainly the five o'clock tea, with women, is on the increase, and we must deal with one more cerebral and nervous excitant in our consideration of what we shall do to slow this rapid age.

TOBACCO

In spite of the fact that a large number of men today do not smoke, more and more frequently every clinician has a patient who smokes too much. The accuracy with which he investigates these cases depends somewhat on his personal use of tobacco, and therefore his leniency toward a fellow user. Perhaps the percentage of young boys who smoke excessively is larger than the percentage of men. Whether or not the term "excessive" should be applied to any particular amount of tobacco consumed depends entirely on the person. What may be only a large amount for one person may be an excessive amount for another, and even one cigar a day may be too much for a person is as much for him as five or more cigars for another. If one is to judge by the internal revenue report it will appear that, in spite of the public school instruction as to the physiologic action of tobacco and its harm, and in spite of the antitobacco leagues, the consumption of tobacco is enormously on the increase.

Alexander Lambert [Footnote: Lambert, Alexander: Med. Rec., New York, Feb. 13, 1915] in studying periodic drinkers and alcoholics, finds that most patients are suffering from chronic tobacco poisoning, and if they stop their smoking, their drinking sometimes ceases automatically.

Howat [Footnote: Howat: Am. Jour. Physiol., February, 1916.] has shown that nicotin causes serious disturbances of the reflexes of the skin of frogs.

Edmunds and Smith [Footnote: Edmunds and Smith: Jour. Lab. and Clin. Med., February, 1916.] of Ann Arbor find that the livers of dogs have some power of destroying nicotin, but their studies did not show how tolerance to large doses of nicotin is acquired.

Neuhof [Footnote: Neuhof, Selian: Sino-Auricular Block Due to Tobacco Poisoning, Arch. Int. Med., May, 1916, p. 659.] describes a case of sino-auricular heart block due to tobacco poisoning. Intermittent claudication has been noted from the overuse of tobacco, as well as cramps in the muscles and of the legs.

A long series of investigations of the action of tobacco on high school boys and students of colleges seems to show that the age of graduation of smokers is older than that of nonsmokers, and that smokers require disciplinary measures more frequently than nonsmokers.

Some years ago investigation was made by Torrence, of the Illinois State Reformatory, in which there were 278 boys between the ages of 10 and 15 years. Ninety-two percent of these boys had the habit of smoking cigaretes, and 85 percent were classed as cigarete fiends.

The most important action of nicotin is on the circulation. Except during the stage when the person is becoming used to the tobacco habit, in which stage the heart is weakened and the vasomotor pressure lowered by his nausea and prostration, the blood pressure is almost always raised during the period of smoking.

The heart is frequently made more rapid and the blood pressure is certainly raised in an ordinary smoker, while even a novice may get at first an increase, but soon he may become depressed and have a lowering of the pressure. While a moderate smoker may have an increase of 10 mm. in blood pressure, an excessive smoker may show but little change. Perhaps this is because his heart muscle has become weakened. If the person's blood pressure is high, the heart may not increase in rapidity during smoking, and if he is nervous beforehand and is calmed by his tobacco, the pulse will be slowed. It has been shown that the blood pressure and pulse rate may be affected in persons sitting in a smoke-filled room, even though they themselves do not smoke. The length of time the increased pressure continues depends on the person, and it is this diminishing pressure that causes many to take another smoke. The heart is slowed by the action of nicotin on the vagi, as these nerves are stimulated both centrally and peripherally. An overdose of nicotin will paralyze the vagi. The heart action then becomes rapid and perhaps irregular. The heart muscle is first stimulated, and if too large a dose is taken, or too much in twenty-four hours, the muscle becomes depressed and perhaps debilitated. The consequence of such action on the heart muscle, sooner or later, is a dilation of the left ventricle if the overuse of the tobacco is continued.

There is, then, no possible opportunity for any discussion as to the action of tobacco on the circulation. Its action is positive, constantly occurs, and it is always to be considered. The only point at this issue is as to whether or not such an activity is of consequence to the individual. The active principle of tobacco is nicotin, besides which it contains an aromatic camphor-like substance, cellulose, resins, sugar, etc. Other products developed during combustion are carbon monoxid gas, a minute amount of prussic acid and in some varieties a considerable amount of furfurol, a poison. From any one cigar or cigaret but little nicotin is absorbed, else the user would be poisoned. It is generally considered that the best tobacco comes from Cuba, and in the United States from Virginia. While it has not been definitely shown that any stronger narcotic drug occurs in cigarets sold in this country, it still is of great interest to note that a user who becomes habituated to one particular brand will generally have no other, and the excessive cigaret-smoker will generally select the strongest brand of cigarets. The same is almost equally true of cigar smokers.

Besides the effect on the circulation, no one who uses tobacco can deny that it has a soothing, narcotic effect. If it did not have this quieting effect on the nervous system, the increased blood pressure would stimulate the cerebrum. Following a large meal, especially if alcohol has been taken, the blood vessels of the abdomen are more or less dilated by the digestion which is in process. During this period of lassitude it is possible that tobacco, through its contracting power, by raising the blood pressure in the cerebrum to the height at which the patient is accustomed, will stimulate him and cause him to be more able to do active mental work. On the other hand, if a person is nervously tired, irritable, or even muscularly weary, a cigar or several cigarets will increase his blood pressure, take away his circulatory tire, soothe his irritability, and stop temporarily his muscular pains or aches and muscle weariness. If the user of the tobacco has thorough control of his habit, is not working excessively, physically or mentally, has his normal sleep at night and therefore does not become weary from insomnia, he may use tobacco with sense and in the amount and frequency that is more or less harmless as far as he is concerned. If such a man, however, is sleepless, overworked or worried, if he has irregular meals or goes without his food, and has a series of "dinners," or drinks a good deal of alcohol, which gives him vasomotor relaxation, he finds a constantly growing need for a frequent smoke, and soon begins to use tobacco excessively. Or the young boy, stimulated by his associates, smokes cigarets more and more frequently until he uses them to excess.

Just what creates the intense desire for tobacco to the habitue has not been quite decided, but probably it is a combination of the irritation in the throat, especially in inhalers; of the desire for the rhythmic puffing which is a general cerebral and circulatory stimulant; for the increased vasomotor tension which many a patient feels the need of; for the narcotic, sedative, quieting effect on his brain or nerves; for the alluring comfort of watching the smoke curl into the air or for the quiet, contented sociability of smoking with associates. Probably all of these factors enter into the desire to continue the tobacco habit in those who smoke, so to speak, normally.

The abnormal smokers, or those who use tobacco excessively, have a more and more intense nervous desire or physical need of the narcotic or the circulatory stimulant effect of the tobacco, and, consequently, smoke more and more constantly. They are largely inhalers, and frequently cigaret fiends.

It is probable that tobacco smoked slowly and deliberately, when the patient is at rest, and when he is leading a lazy, inactive, nonhustling life, such as occurs in the warmer climates, is much less harmful than in our colder climates, where life is more active. Something at least seems to demonstrate that cigaret smoking is more harmful in our climate than in the tropics.

It has been shown by athletic records and by physicians' examinations of boys and young men in gymnasiums that perfect circulation, perfect respiration and perfect normal growth of the chest are not compatible with the use of tobacco during the growing period. It is also known that tobacco, except possibly in minute quantities, prevents the full athletic power, circulatorily and muscularly, of men who compete in any branch of athletics that requires prolonged effort.

The chronic inflammation of the pharynx and subacute or chronic irritation of the lingual tonsil, causing the tickling, irritating, dry cough of inhalers of tobacco, is too well known, to need description.

Many patients who oversmoke lose their appetites, have disturbances from inhibition of the gastric digestion, and may have an irregular action of the bowels from overstimulation of the intestines, since nicotin increases peristalsis. Such patients look sallow, grow thin and lose weight. These are the kind of patients who smoke while they are dressing in the morning, on the way to their meals, to and from their business, and not only before going to bed, but also after they are in bed. It might be a question as to whether such patients do not need conservators. The use of tobacco in that way is absolutely inexcusable, if the patient is not mentally warped. Cancer of the mouth caused by smoking, blindness from the overuse of tobacco, muscular trembling, tremors, muscle cramps and profuse perspiration of the hands and feet are all recognized as being caused by tobacco poisoning, but such symptoms need not be further described here.

The reason for which physicians most frequently must stop their patients from using tobacco, however, is that the heart itself has become affected by the nicotin action. The heart muscle is never strengthened by nicotin, but is always weakened by excessive indulgence in nicotin, the nerves of the heart being probably disturbed, if not actually injured. The positive symptoms of the overuse of tobacco on the heart are attacks of palpitation on exertion lasting perhaps but a short time, sharp, stinging pains in the region of the heart, less firmness of the apex beat, perhaps irregularity of the heart, and cold hands and feet. Clammy perspiration frequently occurs, more especially on the hands. Before the heart muscle actually weakens, the blood pressure has been increased more or less constantly, perhaps permanently, until such time as the left ventricle fails. The left ventricle from tobacco alone, without any other assignable cause, may become dilated and the mitral valve become insufficient. Before the heart has been injured to this extent the patient learns that he cannot lie on his left side at night without discomfort, that exertion causes palpitation, and that he frequently has an irregularly acting heart and an irregular pulse. He may have cramps in his legs, leg-aches and cold hands and feet from an imperfect systemic circulation. In this condition if tobacco is entirely stopped, and the patient put on digitalis and given the usual careful advice as to eating, drinking, exertion, exercise and rest, such a heart will generally improve, acquire its normal tone, and the mitral valve become again sufficient, and to all intents and purposes the patient becomes well.

On the other hand, a heart under the overuse of tobacco may show no signs of disability, but its reserve energy is impaired and when a serious illness occurs, when an operation with the necessary anesthesia must be endured or when any other sudden strain is put on this heart, it goes to pieces and fails more readily than a heart that has not been so damaged.

If a patient does not show such cardiac weakness but has high tension, the danger of hypertension is increased by his use of tobacco, and certainly in hypertension tobacco should be prohibited. The nicotin is doing two things for him that are serious: first, it is raising his blood pressure, and second, it will sooner or later weaken his heart, which may be weakened by the high blood pressure alone. Nevertheless a patient who is a habitual user of tobacco and has circulatory failure noted more especially about or during convalescence from a serious illness, particularly pneumonia, may best be improved by being allowed to smoke at regular intervals and in the amount that seems sufficient. Such patients sometimes rapidly improve when their previous circulatory weakness has been a subject of serious worry. Even such patients who were actually collapsed have been saved by the use of tobacco.

Whether the tobacco in a given patient shall be withdrawn absolutely, or only modified in amount, depends entirely on the individual case. As stated above, no rule can be laid down as to what is enough and what is too much. Theoretically, two or three cigars a day is moderate, and anything more than five cigars a day is excessive; even one cigar a day may be too much.