October 2 



3> 



1894J 



NA TURE 



629 



This is, indeed, what we find, for a heart whose nutrition has 

 been weakeneii by disease of the arteries, and consequent im- 

 perfect supply of blood to the cardiac muscle, is unable to meet 

 any increased resistance if this should he offered to it, and pain 

 is at once felt. In such cases, unless they be far advanced, we 

 find, precisely as we might expect, that walking on the level 

 usually cau^es no pain, but the attempt to ascend even a slight 

 rise, by which the muscles are brought into more active exertion, 

 [brings on pain at once. Vet here again we find, as we should 

 expect, that if the patient is able to continue walking, the pain 

 1 passes off and does not return. These phenooiena would be 

 i inexplicable were it not for Ludwig's observations on circulation 

 (through the muscles, but in the light of these observations 

 everything is made perfectly intelligible. Walking on the flat, 

 by causing no violent exertion of the muscle;, produces no 

 ' mechanical constriction of the vessels, and thus does not increase 

 the blood pressure. The greater exertion of walking up a hill 

 has this effect, but if the patient is able to continue his exertions, 

 the increased dilatation of the vessels — a consequence of mus- 

 cular activity — allows the pressure again to fall, and relieves the 

 pain. 



As muscular exertion continues and the vessels of the muscles 

 become dilated, the flow of blood from the arteries into the 

 veins will tend to become much more rapid than usual. The 

 pressure in the arterial system will consequently fall, but that 

 in the veins will become increased, and unless a corresprnding 

 dilatation occurs in the pulmonary circulation, blood will tend 

 to accumulate in the right side of the heart, the right ventricle 

 will be unable to empty itself completely, shortness of breath 

 will arise, and even death may occur. At first the right side of 

 the heart is affected, and the apex beat disappears from the 

 normal place and is felt in the epigastrium, but the left ven- 

 tricle also becomes dilated, though whether this is simply 

 through nervous influence tending to make it act concordantly 

 with the right, or for some other reason, it is at present im- 

 possible to say. Severe exertion, even for a few minutes, may 

 produce this condition in healthy persons,' and when the 

 exertion is over-continued it may lead to permjnent mischief. 

 More especially is this the case in young growing boys, and it 

 is not merely foolish, it is wicked to insist upjn boys engaging 

 in games or contests which demand a long-continued over- 

 exertion of the heart, such as enforced races and paper- 

 chases extending over several miles. Intermittent exertion, 

 either of a single muscle or of a group of mubcles, or of the 

 whole body, appears to lead to better nutrition and increased 

 strength and hypertrophy, but over-exertion, especially if it 

 continues, leads to impaired nutrition, weakness, and atrophy. 

 If we watch the movements of young animals, we fin I that 

 they are often rapid, but fitful and irregular and varied in 

 character, instead of being steady, regular, and uniform. They 

 are the movements of the butterfly, and not of the bee. The 

 varied plays of childhood, the gambols of the lamb, and the . 

 frisking of the colt, are all well adapted to increase the strength 

 of the body without doing it any injury ; but if the colt, instead 

 of being allowed to frisk at its own free will, is put in harness, 

 or ridden in races, the energy which ought to have gone to 

 growth is used up by the work, its nutrition is affected, its 

 powers diminished, and its life is shortened. The rules which 

 have been arrived at by the breeders of horses ought to be care- 

 fully considered by the teachers of schools, and by the medical 

 advisers who superintend the pupils. 



In youth and middle age every organ of the body is adapted 

 ifor doing more work than it is usually called upon to do. Every 

 organ can, as it is usually termed, make a spurt if required ; 

 but as old age comes on this capacity disappears, the tissues 

 become less elastic, the arteries become more rigid and less 

 capable of dilating and allowing freer flow of blood to any 

 part, whether it be the intestine, the skin, the brain, the 

 muscles, or the heart itself. Mere rigidity of the arteries supply- 

 ing the muscles of the heart will lessen the power of extra 

 exertion, but if the vessels be not only rigid, but diminished in 

 calibre, the muscles of the limbs and the heart itself will Iw 

 {unfit even for their ordinary work, and will tend to fail on the 

 slightest over-exertion. This fact was noticed by Sir Henjamin 

 Brodie, who, when speaking of patients with degenerating and 

 contracted arteries, such as lead to senile gangrene, said : 

 " Such patients walk a short distance very well, but when they 

 attempt more than this, the muscles seem to be unequal to the 

 task, and they can walk no further. The muscles are not abso- 

 1 Sthott. Verharndl. ties IX. Con£;rcs;cs in Med. zu Wien, IJ90. 



NO. 1304, VOL 50.] 



lutely paralysed, but in a state approaching to it. The cause 

 of all this is sufficiently obvious. The lower limbs require 

 sometimes a larger and sometimes a smaller supply of blood. 

 During exercise a larger supply is wanted on account of the 

 increased action of the muscles ; but the arteries being ossified 

 or obliterated, and thus incapable of dilatation, the increased 

 supply cannot beobtained. This state of things is not peculiar 

 to the lower limbs. Wherever muscular structures exist the 

 same cause will produce the same effect. Dr. Jenner first, and 

 Dr. I'arry, of Bath, afterward, published observations which 

 were supposed to prove that the disease which is usually called 

 "angina pectoris depends on ossification of the coronary 

 arteries. . . . When the coronary arteries are in this condition 

 they may be capable of admitting a moderate supply of blood 

 to the muscular structure of the heart ; and as long as ihe 

 patient makes no abnormal exertion, the circulation goes on 

 well enough ; when, however, the heart is excited to increased 

 action, whether it be during a fit of passion, or in running, or 

 walking upstairs, or lifting weights, then the ossified arteries 

 being incapable of expanding so as to let in the additional 

 quantity of blood, which, under these circumstances, is required, 

 its action stops and syncope ensues ; and I say that this e.x.ictly 

 corresponds to the sense of weakness and want of muscular 

 power which exists in persons who have the arteries of the legs 

 obstructed or ossified." ' 



But thi; syncope and stoppage of the heart mentioned by 

 Brodie are not the only consequences of impaired cardiac 

 nutrition. The heart may be still able to carry on the circu- 

 lation, but the patient may suffer intense pain in the process. 

 The outside of the heart was found by Harvey to be insensible 

 to light touches, but the inside of the heart appears to be much 

 more sensitive either to touch or pressure. 



A knowledge of the mode of circulation of blood through 

 the muscles enables us to understand not only the pathology of 

 angina pectoris, but the rationale of various methods of treat- 

 ing patients suffering from angina pectoris or other forms of heart 

 disease. In most cases, our object is a twofold one— to increase 

 the piwer of the heart, and to lessen the resistance it has to 

 overcome. In some cases, we require also to aid the elimination 

 of water which has so accumulated as to give rise to oedema 

 of the cellular tissues, or dropsy of the serous cavities. In our 

 endeavours to produce these beneficial changes in our p.itients, 

 we employ regimen, diet, and drugs, and it is evident that as in 

 one case the condition of a patient's heart may be very ditferent 

 indeed from that in another, the regimen which may be useful 

 to one may be fatal to the other. We have already seen that 

 sudden and violent exertion may raise the blood pressure, and 

 so lead to intense cardiac pain or to stoppage of the heart and 

 instant death ; while more gentle exercises, by increasing the 

 circulation through the muscles, may lessen tne pressure and 

 give relief to the heart. 



The methods of increasing the muscular circulation may be 

 roughly divided into three, according as the patient lies, stands, 

 or walks. First, absolute rest in bed with massage ; - second, 

 graduated movements of the muscles of the limbs and body 

 while the patient stands still ; third, graduated exercises io 

 walking and climbing. 



The second of these methods has been specially worked out by 

 the brothers Schott, of Nauheioi, and the third is generally con- 

 nected with the name of Oertel It is obvious that in cases of 

 heart disease where the failure is great and the patient is unable 

 even to stand, much less to walk, where breathlessness is 

 extreme and dropsy is present or is advanced, the second 

 .and third methods of treatment are inapplicable. It is 

 in such cases that the method of absolute rest in bed. not allow- 

 ing the patient to rise for any purpose whatever, hardly allowing 

 hin to feed himself or turn himself in bed, proves advantageous. 

 The appetite is usually small, the digestion imperfect, and flatu- 

 lence troublesome ; and here an absolute milk diet, like that 

 usually employed in typhoid fever, is often most serviceable. being 

 easily taken and easily digested, while the milk sugar itself has 

 a diuretic action, and tends to reduce dropsy. But while simple 

 rest prevents the risk of increased arterial tension and consequent 

 opposition to the cardiac contractions which might arise from 

 muscular exertion, such benefits as would accrue from 

 muscular exertion and increased circulation would be lost 

 were it not that they can be supplied artificially by massage. 



■ ' " Lectures on Pathology and Surgery," by Sir Uenjamin Brodie. 

 (London, 1846, p. 360.) _ 



- Practitiontr^ vol. li., p. 190. 



