distribution of the oxygenated blood returning from the lungs. The proper adjustment of these activities or functions depends upon: (a) Normal rhythmicity; (b) normal excitability of the cardiac muscle; (c) normal conduction of the nerve impulse to the muscle, and (d) normal contractility of the cardiac muscle. To use the parlance of the autoist, the "timer" of the heart, the center guarding and maintaining the rhythm and synchronism of the heart action necessary to the proper performance of function, is a small collection of nervous elements located in the These various influences may be mechanical in origin-dependent upon the blood supply of the heart itself, or due to the action of toxin upon any or all parts of the cardiac mechanism; toxins which may be of bacterial origin or generated in the metabolism of the body, as in exopthalmic goitre. Disturbances of the heart may be due to a weakening of the heart, or may be independent of any such weakening. Even in health the rate may vary within wide limits. in different individuals or in the same individual at different times. Rapidity of the heart beat is frequently heart structure and known as the auriculo- closely associated with stimuli affecting the ventricular bundle of His. The heart is the most marvelous motor known, not the least of its wonders being its remarkable power of adaptability to varying conditions and demands. The amount of work actually done by the heart depends upon the size of the ventricular cavity during diastole (the passive period of filling); the number and intensity of the ventricular contractions; and the degree of constriction of the peripheral blood vessels, all being dependent to a perceptible extent upon numerous factors arising in the body as a whole, which factors, though more or less independent of, nevertheless, intimately associated with the cardiac mechanism. The remarkable adaptability of the heart is usually looked upon as a function of the muscle itself, due, perhaps, to a mechanical response to overdistension, at times, again, to a reflex mechanism responding to various stimuli affecting its nerve centers and its conductive mechanism. It is evident, therefore, that variations in the character of the cardiac rhythm, either as to character or quality, may be due to conditions affecting the contractile power or tonicity of the cardiac muscle; to those interfering with the conduction of nerve impulses to the unimpaired muscle; to those causing the production of aberrant impulses, or to a combination, in varying degree, of all of these factors. vagus nerve. Thus, the rapid pulse often seen in the terminal stages of meningeal diseases is due to excessive stimulation of the vagus with resultant fatigue. The rapidity of anemias, of exertion, and that seen in convalescents, however, is probably due to the stimulation of either an over-excitable muscle or of the nerve elements by the chemical products of muscular activity. The increased rate of fever is the result of stimulation of the central endings of the accelerator nerves, and also of the cardiac muscle itself, modifications of this rule being due to the action of toxins, in all probability, which, perhaps, either depress the muscle or interfere with the conductivity of the nervous elements. Slowing of the heart is also closely related to factors influencing the pneumogastric nerve, direct or reflex, though the ominous slowing of the pulse in diphtheria is probably due to changes in the cardiac muscle itself. Cardiac arhythmia presents a complex and intricate problem, being due to numerous and varying causes affecting either the muscular system, the timing mechanism, or the paths by which the nerve impulses are conducted to the muscle-factors which it is inexpedient to discuss here. From the foregoing it is evident that, while the pulse will indicate the occurrence of almost all abnormalities of the cardiac function, it conveys little or no information as to the cause. Nevertheless, a careful, keen consideration of the pulse may often detect conditions of import and significance, and the method, though simple, is worthy of study and careful application. A few words as to the method of taking the pulse are not out of place, for the information obtained is in direct proportion to the correctness of the technic. The Blood Vessel: While the radial artery is the vessel most commonly used, it must be remembered that any peripheral artery not too deeply placed is available and suitable, and the carotid and temporal are frequently used, occasionally the brachial. Position: When the arm is utilized, it is important that it be placed in a position free from restraint, flexion, or muscular compression of the vessels, for a faulty position may greatly modify any pulse. The forearm should be slightly flexed, the wrist thrown slightly backward, and very slightly supinated. Method: Three fingers should be lightly placed over the artery, and, when there is any suspicion of abnormalities, over the artery of each wrist. There is nothing more indicative of faulty training than the onefingered approach so often seen. The following points may-and should -be determined: (1) Rate or frequency. (2) Regularity of rhythm. (3) Uniformity of strength. (4) Synchronism and equality of right and left radial pulses. (5) The tension-that is, the force required to obliterate the pulse as measured by the degree of pressure made by the proximal finger until the pulse is imperceptible to the distal fingers. The first three points are almost instantaneously determined. Ordinarily it is sufficient to count the rate for 15 seconds and multiply by four to obtain the rate per minute, but if any abnormality of rhythm, taken for at least a minute, and, if excessively rapid, it may be necessary to count only every second or third beat. Significance of Variations of the Pulse In certain valvular lesions, not infrequently, some systoles are inefficient and do not yield a pulse wave. The pulse record by palpation in such cases is, therefore, useless and misleading. Occasionally the pulse cannot be cut off by the upper finger. This is a recurrent pulse and does not denote excessive tension but rather an unusually free communication and recurrent flow from the palmar arch. If there is a unilateral weakening or absence of the pulse, be sure that there is no constriction or muscular compression, and that there is no abnormality of the radial vessels, before jumping at conclusions. This may be determined by comparing the brachials of both sides. An unequal force in succeeding beats is an important evidence of deficient cardiac strength and of possible oncoming cardiac collapse. Do not mistake a full, bounding pulse for a high tension pulse because of faulty technic. Any bodily exertion, even so slight as a readjustment of the position in bed, or the use of the bed-pan, will temporarily affect the frequency of the pulse, as will, also, mental excitement or the digestive processes. Age is an important factor. In the first year, 130 to 140 is within normal limits, the rate gradually decreasing until 75 to 80 is reached after the sixteenth year. In women the rate is normally from five to eight beats. faster than in men. The rate increases 8 to 10 beats per minute for each degree of temperature above normal, and in general any increase out of proportion to this constitutes a danger signal, especially in diseases where the pulse rate is an exception to this rule. Instances of a high temperature associated with a relatively low pulse are tuber fever, and lobar pneumonia, or febrile ailments associated with organic heart lesions. In feverish children a rapid pulse is of far less significance than in the adult-a point to be remembered. In incipient tuberculosis a persistently over-rapid pulse is one of the most constant early signs. An excessively rapid, “running" pulse, associated with a lack of accentuation, is often a forerunner of death. An excessively slow pulse may be associated with a physiologic condition, but is more generally connected with organic disease of the heart or brain. In acute infections, any sudden or decided drop, unless associated with a crisis, is very suggestive of danger and the patient should be carefully watched for other signs and the pulse taken frequently. Remember that the chart shows merely the rate. The other important characteristics will only be found on the record if they are observed and noted. Christmas Bells* KATHLEEN LOCKHART LATTA. In the dawn of Christmas morning, before the sky grew bright, A mother lay on her snowy bed breathing with labored breath, They send their glorious cadence, North, South, and East and West. Of the realms of Eternal Morning, and a Day with never a night. * Written at a bedside in Albuquerque, New Mexico, some years ago by the author. FLORENCE MEREDITH, M.D. Associate Professor of Hygiene and Preventive Medicine Women's Medical College, Philadelphia, Pa. If there is one force more than another that is of value in the search for the haunts of tuberculosis, and for the education of families and communities on the prevention of tuberculosis, and for the care that results in the cure of the disease, it is the tuberculosis health nurse. Wherever the public health nurse is given an opportunity, it has been shown that there is nothing more valuable, especially in case finding and preventive work. Nowadays there is a school nurse in almost every town whose duty it is to aid in bettering health conditions among school children. Although the work of school nurses carries them into every field of health, they can and do exert considerable influence in the prevention of tuberculosis. An authority has suggested that all primary school teachers should be trained nurses, for the problem of the early education of children deals as fully with the education of the body in health as it does with the mind in knowledge. The nurse who comes into contact with school children has a tremendous opportunity to help in reducing the peril of tuberculosis. By watching for early signs of all kinds of infection, by observing and correcting faulty conditions of the nose and throat, A TUBERCULOSIS VISITING NURSE IN AN INDIANA TOWN, HAS A UNIQUE HOUSE IN WHICH SHE RECEIVES HER CHARGES, THE HOUSE IS MOVED FROM PLACE TO PLACE, HAD NOT A FIGHTING CHANCE FOR HEALTH UNTIL THE NURSE FOUND THEM AND PUT THEM IN THE OPEN AIR SCHOOL. raising the standard of health of an entire with tuberculosis. They can show families community. District nurses have been responsible for early detection of cases of tuberculosis, and for making the arrangements necessary for the checking of the disease. They can particularly encourage the subnormal, not only the actually ill, to get interested in their health so as to bring it to normal. It is this class that furnish the recruits for the huge army of a million tuberculosis patients in the vital necessity of protecting infants and children from this infection. They can do more perhaps than anyone else to persuade families of the crime of letting little children remain in the home with those who are coughing up tuberculosis germs by the billion every 24 hours. There is no one else who has so good an opportunity for sidetracking early tuberculosis, or for actually. introducing preventive measures. Nurses |