Disturbances of the Heart | Page 8

pulmonic sound and it may
become louder than the second aortic sound, showing a cardiac
deficiency. If, on the other hand, the right ventricle becomes
insufficient, or is insufficient, the second pulmonic sound is weaker
than normal, and the prognosis is bad.
Barach [Footnote: Barach: Am. Jour. Med. Sc., July, 1916, p. 84]
presents what he terms "the energy index of the circulatory system." He
has examined 742 normal persons, and found that the pressure pulse

was anywhere from 20 to 80 percent of the diastolic pressure in 80 per
cent of his cases, while the average of his figures gave a ratio of 50
percent; but he does not believe that it holds true that in a normal
person the pressure pulse equals 50 percent of the diastolic pressure.
Barach does not believe we have, as yet, any very accurate method of
determining the cardiac strength or circulatory capacity for work. He
does not believe that the estimate of the pressure pulse is indicative of
cardiac strength. He believes that the important factors in the
estimation of the circulatory strength are the systolic pressure, which
shows the power of the left ventricle, the diastolic pressure, which
shows the intravascular tension during diastole as well as the peripheral
resistance, and the pulse rate, which designates the number of times the
heart must contract during a minute to maintain the proper flow of
blood. He thinks that these three factors are constantly adapting
themselves to each other for the needs of the individual, and he finds,
for instance, that when the left ventricle is hypertrophied and the output
of blood is therefore greater, then the pulse will be slowed. His method
of estimation is as follows: For instance, with a systolic pressure of 120
mm. and a diastolic pressure of 80 mm., each pulse beat will represent
an energy equal to lifting 120 mm. plus 80 mm., which equals 200 mm.
of mercury, and with seventy-two pulse beats the force would be 72 X
200, which equals 14,400 mm. of mercury. He finds an average
circulatory strength based on examining 250 normal individuals by the
index, which he terms S, D, R (systolic, diastolic rate), to be 20,000
mm. of mercury per minute.
Katzenstein [Footnote: Katzenstein: Deutsch. med. Wehnsehr., April
15, 1915.] finds, after ten years of experience, that the following test of
the heart strength is valuable: He records the blood pressure and pulse,
and then compresses the femoral artery at Poupart's ligament on the
two sides at once. He keeps this pressure up for from two to two and
one-half minutes, and then again takes the blood pressure. With a
sound heart the blood pressure will be higher and the pulse slower than
the previous record taken. If the blood pressure and pulse beat are not
changed, it shows that the heart is not quite normal, but not actually
incompetent. When the blood pressure is lower and the pulse
accelerated, he believes that there is distinct functional disturbance of

the heart and loss of power, relatively to the change in pressure and the
increase of the pulse rate. He further believes that a heart showing this
kind of weakness should, if possible, not be subjected to general
anesthesia.
Stange [Footnote: Stange: Russk. Vrach, 1914, xiii. 72.] finds that the
cardiac power may be determined by a respiratory test as follows: The
patient should sit comfortably, and take a deep inspiration; then he
should be told to hold his breath, and the physician compresses the
patient's nostrils. As soon as the patient indicates that he can hold his
breath no longer, the number of seconds is noted. A normal person
should hold his breath from thirty to forty seconds without much
subsequent dyspnea, while a patient with myocardial weakness can
hold his breath only from ten to twenty seconds, and then much
temporary dyspnea will follow. Stange does not find that pulmonary
conditions, as tuberculosis, pleurisy or bronchitis, interfere with this
test.
Williamson [Footnote: Williamson: Ant. Jour. Med. Sc., April, 1915, p.
492.] believes that we cannot determine the heart strength accurately
unless we have some method to note the exact position of the
diaphragm, and he has devised a method which he calls the
teleroentgen method. With this apparatus he finds that a normal heart
responds to exercise within its power by a diminution in size. The same
is true of a good compensating pathologic heart. He thinks that a heart
which does not so respond by reducing its size after exercise has a
damaged muscle, and compensation is more or less impaired.
Practical conclusions to draw from the foregoing suggestions are:
1. An enlargement of the heart after exercise can be well shown only by
fluoroscopic examination, and then best by some accurate method of
measurement.
2. The blood pressure