The pathogenesis of congestive heart failure was long elucidated by the backward theory, but in the light of many newer knowledges, such as the studies of cardiac catheterization, radioactive isotopes, renal clearance test, hormones, electrolytes and body fl uid, this problem must be now reinterpreted. Since we have been engaged in the study of this clinical syndrome recently; ranging the results obtained in our clinic, I atempt to make some consideration about its pathogenesis and treatment.
The homodynamic changes in the patients with congestive heart failuer were as follows: the cardiac output and index measured by T-1824 or radioactive P 32 werd decreased, the venous pressure increased in almost all patients, and the static blood pressure after death were also increased. The cerebral blood flow by nitrous oxide was decreased, and the renal blood flow by PAH clearance was most strikingly decreased.
Then we observed the syndrome from the metabolic respect: the arterial blood revealed anoxic anoxemia, the cerebral metabolism was also abnormal with decreased cerebral oxygen consumption and decreased cerebral utilization of glucose. In the body fluid balance, the volume of total body water by antipyrin method was markedly increased, and the increase of interstitial volume by thiocyanate or mannitol space was more evident than that of plasma. The volume of intracellular compartment was in some cases slightly increased and in other cases slightly decreased, representing that there were two occasions i. e. both extra- and intracellular overhydration, and extracellular overhydration with intracellular dehydration. The electroyte concentrations of blood serum were almost in normal range, but there were some cases representing hypertonic or hypotonic edema. The acid-base balance of the serum tended to slight respiratory alkalosis, but no metabolic abnormality. We performed the balance study during thiomerin diuresis: the water loss was observed not only from extracellular but also from intracellular compartment, and K was taken in cells or putt out from cells, suggesting that K played a role in increasing the intracellular osmotic pressure.
We could not proove the hyperfunction of adrenal cortex, for the urinary 17 Ketosteroid and chemocorticoid were decreased in all cases. The antidiuretic substance in serum was increased. The hepatic functions were moderately impaired in the patimits.
In understanding the pathogenesis of the syndrome of congestive heart failure, it may be inadequate to examine only the cardiovascular dynamics, but the various complicated metabolic events must be considered. From our hemodynamic and metabolic studies in our clinic, I suppose the possible chain of events of congestive heart failure as Fig.
In the treatment, digitalis is most effective agent acting to heart itself, and it is also. excellent in melabolic aspect that digitalis promote physiologic diuresis with balanced clectrolytes like rest-diuresis. We observed that exercise results in the same changes of hemodynamics and body fluid blance in congestive heart failure such as increased venous pressure, decreased renal excretion of Na and watter, increased extracellular fluid. For the dietary Na-restiction we have used ion exchange resin prepared in our laboratory since 3 years and gaind gut results. Mercurial diuretics are most powerful, increasing the Na-, Cl- and K-clearance, and we observed many case recovered by only diuretic measures. It may be important, however, that these diuretic agent often produce electrolyte inbalance of body fluid, leading to the intractable heart failure.

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