DISTURBANCES OF THE HEART
by
OLIVER T. OSBORNE, A.M., M.D.
Part 2 out of 5
tension, or in great excitement, or with mental worry, all of which
tend, as long as there is health, to increase the blood pressure.
These men may add weight from the age of 40 on, or they may be thin
and wiry. Besides the hypertension there is likely to be a too
sturdily acting heart, which is often hypertrophied, and there is an
accentuated closure of the aortic valve. There may be dizziness, or
no head symptoms at all. Nicotin is likely to be an etiologic factor
in this class.
These women and these men may all be improved by proper treatment,
and the condition may not develop into arteriosclerosis or
nephritis.
Neurotic conditions, and in some instances neurasthenic conditions,
may show a blood pressure higher than normal. Lead may be a cause of
increased blood pressure, and diabetics occasionally have a high
pressure, although more frequently there is a lowering of blood
pressure in diabetes.
Richman believes that syphilis is the most common cause of
hypertension and arteriosclerosis without renal disease. When
arteriosclerosis and renal disease are combined, of course the
highest systolic readings occur. He thinks that when high tension
occurs under 40 years of age, kidney disease is generally the cause.
Of course it may be the only cause later in life.
High blood pressure due to syphilitic conditions may be greatly
improved by the proper treatment, although some one or more blood
vessels are likely to have been seriously damaged. Although these
patients may live for many years, they are likely to have an
apoplexy, cerebral disease or an aneurysm.
While hypertension is not a disease, and while it often should not
be combated, still, as it is always the forerunner of more serious
trouble, there can be no excuse for not most seriously considering
it and generally attempting its reduction. At the moment high
tension is discovered, there may be no special symptoms; but
troublesome symptoms are always pending, and while the patient need
not be unduly alarmed, there is no excuse for not rearranging the
individual's life so as to prolong it. This is not to state that
every high tension must be lowered, but every hypertension must be
studied and a safer systolic pressure caused if it is possible
without interfering with the person's efficiency. A high diastolic
pressure, one above 105, certainly must receive immediate attention,
and a diastolic pressure of 110 must be lowered, if possible. On the
other hand, a high systolic pressure without a high diastolic
pressure should not be rapidly lowered, else depression will be
caused.
SYMPTOMS
In hypertension, as long as the heart, which is probably
hypertrophied, remains perfectly competent, there are few symptoms,
and the person does not seek advice until he notices one or more of
several possible conditions. He may be dizzy, his head may feel full
and tight, he may have headaches, or he may have some cardiac pain
or distress. Other persons do not seek advice until there is a
slight weakening of the heart, showing the strain under which it is
laboring. In most of these high tension cases, the patients have
rather a slow heart, provided the heart is sufficient. Eyster and
Hooker [Footnote: Eyster and Hooker: Am. Jour. Physiol., May, 1908.]
found that the slowing of the heart in high blood pressure is due to
action through the vagus nerves either from the inhibitory center in
the medulla or reflexly by stimulation of the peripheral nerves of
the vessels.
Another symptom for which the patient frequently seeks advice is
that he is unable to relax from his business cares, when off duty.
He also finds that he works at a higher tension, and that coffee and
tea, alcohol and tobacco stimulate him more than usual. He sleeps
restlessly, and dreams at night. He has an increased frequency of
urination in the morning, especially after taking coffee, and
sometimes gets up once or twice at night to urinate. He is irritable
at times; short breathed on exertion, and sometimes has indigestion.
He may have pains or aches in his heart. He may find that he
dislikes to lie on his left side.
However much it may upset the patient and render him more nervous to
inform him that his blood pressure is too high, it is necessary to
give him this information. People now suspect the condition, and
they frequently seek their physicians to determine if the blood
pressure is too high and, from reading health journals, more or less
realize some of the things, at least, that must be done to decrease
the pressure. Consequently, the very things that are advised or
ordered give the patient the diagnosis, whether he is told directly
or not. Hence, we must talk freely with the patient, much as we do
in heart defects, and get his cooperation, stating how frequent the
condition is, how often it is readily improved, and how little it
may interfere with long life.
Wiener and Wolfner [Footnote: Wiener, Meyer, and Wolfner, M. L.: A
Reaction of the Pupil, Strongly Suggestive of Arteriosclerosis with
Increased Blood Pressure, THE JOURNAL A. M. A., July 17, 1915, p.
214.] state that they have found with blood pressure that the pupils
of the eyes are larger than normal, and that they readily contract
to the stimulus of light, but immediately return to their previous
size.
PROGNOSIS
Janeway [Footnote: Janeway, T. C.: A Clinical Study of Hypertensive
Cardiovascular Disease, Arch. Int. Med., December, 1913, p. 755.]
presented statistics of 458 patients with high blood pressure, 67
percent of whom were men. Of these 458 patients 212 had died, and he
found that the women with high blood pressure lived longer than men
with high blood pressure. They did not seem as likely to have
apoplexy or cardiac failure. About 85 percent of high tension cases
occur between the ages of 40 and 70.
While he believes that a systolic pressure of over 160 mm. is
pathologic, he does not find that any definite prognostic
conclusions can be drawn from the height of the pressure. Of course
the most important concomitant symptoms of high pressure are
cardiac, renal, and cerebral, and the typical headache, as he terms
it, is a symptom of serious import. In considering headache in
persons over 40, we must eliminate the eye headaches produced by the
need of presbyopic glasses or by the need of stronger lenses, as
this need is a frequent cause of headache. Dizziness and vertigo may
occur without headache, and drowsiness, though not so frequent a
symptom as insomnia, often occurs.
Janeway finds that all kinds of apoplectic attacks may occur from
simple transient aphasia to complete hemiplegia, and thirteen of his
patients who had died and thirteen of those living at the time of
this report showed failure of eyesight as an initial symptom of
arterial disease.
Janeway deplores the too frequent diagnosis of neurasthenia in these
patients. This diagnosis probably accounts for the frequency with
which neurasthenics have been said to have high blood pressure.
Patients with high blood pressure may show all kinds of symptoms
simulating neurasthenia, but hypertension is a much better diagnosis
than neurasthenia for such patients, and will lead to more rational
treatment.
Ninety-seven of these patients had hemorrhages somewhere, most
frequently epistaxes, sometimes hemoptysis. Janeway did not find
that purpuric spots on the skin occurred early in the disease in any
of his patients.
Gastro-intestinal disturbances were not much in evidence unless the
kidneys were insufficient. Intermittent claudication in the legs
occasionally occurred. While angina pectoris and edema of the lungs
were not infrequent causes of death in men, it was a rare cause of
death in women. Dyspnea is a frequent symptom, and one for which
many patients seek medical advice.
A constant systolic blood pressure of over 200 shows a probability
that the patient will ultimately die either of uremia or of
apoplexy. Janeway found that those patients who are to die from
cardiac weakness show cardiac symptoms early in their disease. He
found that rapid continuous loss of weight pointed to an early fatal
termination.
Of the 212 patients who had died, seventy-one had shown cardiac
insufficiency at the time of the first examination; twenty-one
showed albumin or casts at that time. Of course it should be
repeatedly emphasized that chronic interstitial nephritis may be in
evidence with either albumin or casts alone, or without either being
present.
Janeway sums up his conclusions by stating that "from the time of
the development of symptoms indicative of cardiovascular or renal
disease, four years will witness the death of half the men and five
years of half the women. By the tenth year half the remainder will
have died, leaving one fourth both of the men and the women who have
lived beyond ten years." The causes of death he would place in the
following order: gradual cardiac failure; uremia; apoplexy; some
complicating acute infection; angina pectoris; accidental causes;
acute edema of the lungs and cachexia. An early occurrence of
myocardial weakness shows a 50 percent probability that death will
be caused by cardiac insufficiency. Heart pains comprise another
important indicator of future cardiac death, perhaps not an angina.
Nocturnal polyuria would indicate a uremic death in about 50 percent
of the patients, and typical headache or cerebral symptoms show the
probability of uremic death in more than 50 percent, and death from
apoplexy in a large number of the other 50 percent As just stated,
rapid loss of weight is a bad symptom.
Janeway [Footnote: Janeway, T. C.: A Study of the Causes of Death in
One Hundred Patients with High Blood Pressure, THE JOURNAL A. M. A.,
Dec. 14, 1912, p. 2106.] has previously reported seven patients with
hypertension who had diabetes. Diabetes generally, on the other
hand, causes a low blood pressure. Patients with this trouble and
with hypertension, and without nephritis, probably have an increased
secretion from the suprarenals.
We may sum up the prognosis in hypertension as follows: Hypertension
alone is not of unfavorable omen; if it is not readily reduced by
ordinary means, it is more serious. If associated with kidney, heart
or liver defect, it is most serious. If there are such serious
conditions as edema, ascites, lung congestion, cyanosis and great
dyspnea, the prognosis is dire.
Obesity being a cause of high blood pressure, it should be treated
more or less energetically, even if the individual does not continue
to add weight.
Stone [Footnote: Stone, W. J.: The Differentiation of Cerebral and
Cardiac Types of Hyperarterial Tension in Vascular Disease, Arch.
Int. Med., November, 1915, p. 775.] believes that the higher the
diastolic pressure the greater danger there is of cerebral death,
while a patient with a very high systolic, but a diastolic pressure
of 100 or lower, is in more danger of cardiac death. He urges a
greater consideration of the pressure pulse in determining the load
of the heart and the great danger from a sustained diastolic
pressure of over 105 as sooner or later bound to cause myocardial
symptoms. This load of the heart is also shown by an increased pulse
rate and increased respiratory efforts. In cardiac failure, as the
systolic pressure falls the diastolic is likely to be increased, and
the pressure pulse thus diminishing, allows insufficient blood to go
to the medullary centers, and death soon occurs. Therefore, in acute
illnesses a sustained pressure pulse gives a better prognosis than a
diminishing pressure pulse. The strenuous measures that should he
used to lower a high diastolic pressure are contraindicated when the
diastolic pressure is already low, even if the systolic pressure 1s
high. If a high systolic pressure begins to fall more or less
rapidly the heart shows fatigue, and should be stimulated by
digitalis or strophanthin.
Rowan [Footnote: Rowan, J. J.: The Practical Application of Blood
Pressure Findings, THE JOURNAL A. M. A., March 18, 1916, p. 873.]
finds that a diastolic reading of 100 mm. or more usually means that
there is a narrowing of the lumen of the vessels, owing to
stimulation of the vasoconstrictors, although it may mean the
existence of a true arterial fibrosis. While a real atheroma
generally causes a reduction in diastolic blood pressure, or at
least but slight increase, he has found in syphilitic cases with
arteriosclerosis a high diastolic pressure. If the blood pressure
cannot be reduced by ordinary measures, arteriosclerosis is probably
present. Several blood pressure examinations must be made, while the
patient is being treated, to establish the diagnosis.
Rowan finds the reading of the pulse pressure to be of great
importance, as this will indicate, sometimes before any other
symptom is present, that the patient is either improving or doing
badly, and it also aids in indicating the proper medicinal
treatment.
In arteriosclerosis the systolic pressure may be high while the
diastolic is low; hence there is a large pressure pulse. If the
heart becomes weak the systolic pressure will drop, and any
improvement caused, especially in aortic regurgitation, is by an
increase of the systolic pressure.
Rowan finds, as has long been recognized, that a conclusion as to
whether or not cerebral hemorrhage will occur cannot be made from
the condition of the radial arteries, as patients with soft radials
may suffer from cerebral hemorrhage, while those "with hard,
sclerosed, pipestem-like arteries may live to a great age and die of
anything rather than apoplexy."
Swan, [Footnote: Swan: Interstate Med. Jour., March, 1915, p. 186.]
has studied the blood pressure in fifty cases of disturbed thyroid,
and finds that functional myocardial tests show that the myocardium
is nearly always disturbed in these patients.
Before taking up the subject of treatment of high blood pressure, it
may be suggested that a high diastolic pressure with a falling
systolic pressure may require vasodilators on the one hand or
cardiac tonics on the other, and sometimes the decision can be made
only by proper tests. In other words, if the diastolic pressure is
lowered the heart will be relieved. On the other hand, if the
diastolic is being raised by an increased venous pressure from a
failing heart, digitalis, strychnin and caffein may be of benefit in
lowering the diastolic as well as raising the systolic. However, if
there is a high systolic and a low diastolic pressure, vasodilators
are often contraindicated.
TREATMENT
In this rapid high tension age the physician should be as energetic
in teaching prevention of arterial hypertension as he is in
preventing contagion. As infectious diseases are reduced in
frequency, more patients live to die of diseases later in life, and
(as previously stated) diseases with hypertension are on the
increase. It is therefore the duty of the physician to urge youths
and adults to abstain from all kinds of excesses so common in this
age. We live at such speed, even the children, that this caution is
almost daily needed. We must caution against severe athletic
competition, against personal "stunts," against recreation excesses,
even golfing, automobiling and dancing, against excess in the use of
tobacco, in eating, in late dinners, in coffee, tea and alcohol. We
must take better care of patients during their convalescence from
some serious illness lest they have circulatory debility by becoming
strenuous too soon after their recovery. The pregnant woman must be
more carefully watched, not only for her own sake, but also for the
sake of her child. Intestinal indigestion, while not the cause of
all disturbances that occur in man after 40, is still an important
element in his deterioration and degeneration, and it should be
prevented if possible.
The tendency for hypertension and arteriosclerosis to occur early in
life in patients who have suffered some serious acute infection,
whether blood poisoning, typhoid fever, or other, shows that in all
probability in these acute illnesses the internal secretions are so
disturbed that the suprarenal activity is greater than normal, while
the thyroid activity may be less than normal, and hypertension is
the consequence. Therefore, these infected patients who recover
should probably have a longer convalescence in order for the more
delicate structures of the body, such as the internal secreting
glands, to have a better chance to recover and become normal.
The enumeration of these causes and the causes that have been
mentioned before not only suggest, but also direct the treatment of
hypertension after it has occurred. The most important of all
treatment for hypertension is rest. That means for an individual,
well except for his hypertension, a vacation, that is, a rest from
physical and mental labor. For a patient who is in serious trouble
from hypertension, bed rest is the most important element in the
management. As has been previously shown, good sleep lowers the
blood pressure, and Brooks and Carroll [Footnote: Brooks, Harlow,
and Carroll, J. H.; A Clinical Study of the Effects of Sleep and
Rest on Blood Pressure, Arch. Int. Med., August, 1912, p. 97.]
showed that the greatest drop in blood pressure occurs in the first
part of the night's sleep. In other words, a patient who lies awake
long loses the best part of his night's rest as far as his
circulation is concerned. This is one more reason for abstinence
from tea and coffee in the evening by those patients who are at all
disturbed by the caffein. On the other hand, patients who are not
seriously ill should not remain for days in bed, as the blood
pressure does not tend to continue to fall, although the heart may
become weakened by such bed rest. This is especially true if the
patient is nervous and irritable and objects to such confinement.
A systolic pressure much over 200 probably never goes down to
normal, and if such a high systolic pressure goes down to below 170,
we should consider the treatment successful.
Every active treatment of hypertension should begin with a thorough
cleaning out of the intestinal canal by purgation, best with mercury
in some form. Then the diet should be modified to meet the
individual case and the person's activity. If the blood pressure is
dangerously high, he should receive but little nourishment, best in
the form of cereals and skimmed milk.
On the other hand, if he has edema or dropsy, or if the heart showed
signs of weakness, large amounts of liquids should certainly not be
given, and in such cases it is better that he receive small
quantities of milk if that agrees, rather than large quantities of
skimmed milk. The amount of water should also be fitted to the
circulatory ability and the condition of the kidneys.
When more or less active treatment does not soon lower the
hypertension, and especially a high diastolic pressure, the
prognosis is bad. In a patient who is in more or less immediate
danger from his hypertension, the food and liquid taken, the care of
the bowels, and the measures used to cause secretions from the skin
must all be governed by the condition of his other organs. There is
no excuse for excessive, strenuous measures when the heart is
failing or when the kidneys are becoming progressively insufficient.
Strenuosity in treatment is as objectionable in these cases as is
neglect of treatment in earlier stages of the trouble.
Bie [Footnote: Bie: Ugesk. f. Laeger, March 4, 1915.] believes there
is no direct connection between the blood pressure and the anatomic
condition in the kidneys, although abnormal conditions in the two
are almost invariably found parallel.
A patient with simple hypertension and otherwise well, which means
that his diastolic pressure is at least no higher than 110, should
have his diet, tobacco, coffee and tea regulated; should have
recreation periods one or more times a week, and vacations not too
infrequently; should take some brisk purgative once or twice a week,
and may receive one or other of the physical treatments for the
reduction of blood pressure, whether Turkish baths or electric light
baths. If he does not sleep well, there is no hypnotic drug so
valuable in his case as chloral. This should not be long given, but
it will produce the purest kind of sleep and lowers the blood
pressure.
If any other drug is needed, nitroglycerin is the best. If
arteriosclerosis is present, sodium iodid in small doses, 3 grains
two or three times a day, is valuable. Larger doses of sodium iodid
are not needed, unless it is advisable to give such doses for a
short period. The value of iodid in these cases is best obtained by
small doses long continued. If the patient is obese, shall doses of
thyroid extract long continued are of value, such as 2 or 3 grains
once a day. If the thyroid extract causes the heart to become more
rapid, it should be discontinued.
Whether the diet should be meat protein free, or whether meat may be
allowed once a day, depends entirely on the individual and on his
physical activities. It is frequently a mistake to take all meat out
of his diet.
When there is obesity, the bulk of the food should be greatly
diminished, and anything that tends to stimulate the patient's
appetite should be withheld. This means all condiments, and at times
even salt. Sugar should be greatly reduced, and starches greatly
reduced, but he must have some. In other words, he should not be cut
down to a diabetic diet. No more liquid should be taken with the
meals than is essential to swallow the food. Water should be taken
between meals. There is no question that almost every one today
should have a very light breakfast, except perhaps those who labor
hard physically and are exposed for hours, daily, to the
inclemencies of the weather. Such patients probably need more food.
It is also well, in hypertension cases, to have one day a week in
which a very minimum amount of food is taken, whether that be milk,
or skimmed milk, or a small amount of carbohydrate, without protein
food.
If the foregoing management does not reduce hypertension, the
kidneys are generally beginning to become involved in the sclerotic
degeneration, whether the urine shows such a condition or not. On
the other hand, there are exceptions to this rule.
As indican in the urine gives evidence of putrefactive changes in
the intestines and the probability of the absorption of toxins from
the intestines, although we have no real proof that these toxins are
the direct cause of hypertension, our patient is undoubtedly
physically better, and will have less arterial tension when this
intestinal condition is removed. Therefore, our treatment of the
individual is not a success as long as such fermentation and
putrefaction persist. If such putrefaction cannot be removed by diet
and laxatives and mental rest and the prevention of physical
strenuosity, radical changes in diet are advisable, although it may
not be necessary to continue such a diet more than a few days at a
time. A rigid milk diet for a few days may change the flora of the
intestine completely; then a vegetable diet may be given, with
return to a mixed diet; or the various lactic acid bacilli may be
given, or one of the various fermented milks may be the diet, the
object being to change the flora in the intestine and thus modify
the ferments. So-called bowel antiseptics, such as salol, for a
short time may be of advantage. Colon washings may be of great
advantage. Liquid petroleum may be advantageous.
Besides preventing the absorption of toxins from the intestine, we
must prevent such absorption from any latent infection. The most
frequent kind of such infection is pyorrhea alveolaris.
A simple method that sometimes is an efficient aid in lowering the
blood pressure is complete muscular and mental relaxation. The
patient lies down for a while in the middle of the day and relaxes
every muscle of his body. With this he may take slow breathing
exercises. He should be in a dark room, quiet if possible, and
alone, and should teach his brain to be for a short time mentally
inert.
The physical methods of lowering the blood pressure are
hydrotherapeutic, whether by warm baths or more strenuously by
Turkish baths, by hot air baths (body baking) which is occasionally
very efficient, or, perhaps more now in vogue, by electric light
baths. The duration of these baths, and the frequency, must be
determined by the results. If the heart is made rapid, and the heart
muscle shows signs of weakness, the duration of these baths must not
be long, and they may be contraindicated. These baths are most
efficient in lowering the blood pressure when the patient reclines
for several hours after the bath. The amount of sweating that is
advisable in these cases depends on the condition of the heart. If
the heart muscle is insufficient, profuse sweating is inadvisable.
Also if the kidneys are insufficient, profuse sweating is
inadvisable as tending to concentrate the toxins in the blood. On
the other hand, when the surface of the body tends to be cool, and
there are internal congestions, the value of these baths is very
great. Sometimes the electric light baths increase the tension
instead of diminishing it, and when properly used they may be of
benefit in some cases of hypotension. The frequency of the baths and
the question of how many weeks they should be intermittently
continued, depend on the individual case. After a course of such
treatment sometimes patients have a diminished systolic blood
pressure not only for weeks, but even for months, provided they do
not break the rules laid down for them.
The Nauheim baths, while stated not to raise the blood pressure, are
not much advocated in hypertension, and Brown [Footnote: Brown:
California State Jour. Med., November, 1907, p. 279.] who made more
than 500 observations of patients of all ages, found that the full
strength Nauheim bath would raise the blood pressure in all feverish
and circulatory conditions. He also found that a fifteen minute
sodium chlorid bath, 7 pounds to 40 gallons, at a temperature of
from 94 to 98 degrees F., lowered the pressure from 10 to 15 mm.
This is not different from the effect obtained from a fifteen minute
warm bath at from 94 to 98 degrees F., or a fifteen minute mustard
bath of the same temperature. In other words, the slight irritation
of mustard or of salt in a warm bath made no special difference in
the amount of lowering of the blood pressure. On the other hand, he
found that a fifteen minute calcium chlorid bath, 1 1/2 pounds to 40
gallons, at 94 degrees F., raised the blood pressure 15 mm.
The autocondensation treatment to lower the blood pressure is not so
satisfactory as it was hoped to be. The blood pressure can thus be
lowered, but it soon again rises, and probably generally more
rapidly than after the bath treatments, and in some persons it
causes considerable depression. Van Rennselaer [Footnote: Van
Rensselaer: Month. Cycl. and Med. Bull., November, 1912, p. 643.]
has reviewed this subject of high frequency treatment, and recalls
the fact that Nicola Tesla demonstrated, in 1891, the form of
electricity which we now term high frequency. High frequency means
more than 10,000 cycles per second, at which frequency muscles do
not contract and pain is not felt, whereas in medicine the frequency
of the currents used runs up into the hundreds of thousands, or even
into the millions. The French investigator, d'Arsonval, studied the
physiologic action of these high frequency currents and found that
the respiration and heart are made more rapid and the blood pressure
is reduced, while the intake of oxygen is increased and the carbon
dioxid excretion is increased. The temperature may rise. The
excretion of the urinary solids is mostly increased. Perspiration
may be caused, and he believes the glandular activities are
increased. In a word, metabolic changes in the body are made more
active and the blood pressure is lowered.
Besides the effect of altitude on blood pressure, as previously
declared, patients with dangerously high blood pressure should, if
possible, not be subjected to intense cold. In other words, a person
with hyper-tension, if financially able, should not remain in a cold
climate during the winter. On the other hand, even if he is stout
and feels sufficiently warm with light clothing during the winter,
his skin becoming chilled adds to his tension. Therefore he should
be clothed as warmly as he will tolerate.
After a period which may be termed the normal period of hypertension
in normal life, as age advances the systolic tension may lower,
provided there is no kidney lesion. This is due to the slowly
developing chronic myocarditis and a lessening of the tension and
therefore lessening of the resistance to the heart. This may be
nature's method of lengthening the life of the individual. In other
words, as the arteries grow older the force of the heart slightly
lessens, the blood pressure lowers, and the individual is safer.
This frequently occurs in otherwise perfectly normal individuals,
without treatment.
When the blood pressure is suddenly excessively high from any cause,
venesection may be life saving, and should perhaps be more
frequently done than it is. It may save a heart that is in agony
from tension, and may prevent an apoplexy. It is of little value
except temporarily in uremic conditions, but at other times it may,
at the time, save life and allow other methods of reducing the
dangerous tension to become effective. A chronic high tension
patient may be repeatedly bled, although such treatment will not
long save life, as the blood pressure in many such cases soon
returns to its previous height.
Some very high tension cases, especially in women at the menopause,
and where there is no kidney involvement, have the blood pressure
reduced successfully only by large doses of thyroid, sometimes well
combined with bromids, especially if the thyroid causes excitation.
Such treatment persisted in for a time may cause months of
improvement, and even years.
DRUGS IN HYPERTENSION
The drugs that are mostly used to lower blood pressure are nitrites
or drugs which are like nitrites, and these are nitroglycerin,
sodium nitrite, erythroltetra nitrate and amyl nitrite, and the
frequency of their use is in the order named. Other drugs used to
lower blood pressure are iodids, thyroid, alkalies, chloral, bromids
and aconite, the latter rarely.
Amyl nitrite is required only when a sudden immediate effect is
desired in angina pectoris or in some other serious spasmodic
condition. Sodium nitrite is more likely to upset the stomach than
is nitroglycerin. It acts, however, a little longer, but not enough
to warrant its frequent selection. The dose of sodium nitrite is
from 0.03 to 0.06 gm. (1/2 grain to a grain), best in tablet form
and given with plenty of water. The tablet should of course be
dissolved or crushed with the teeth. It should not be given on an
empty stomach, as it may cause considerable irritation and pain. It
more or less actively lowers the blood pressure for about an hour.
Erythrol tetranitrate is preferred by some clinicians who find that
its effect lasts somewhat longer. There is probably, however, no
better nitrite or nitrate than nitroglycerin. While it acts but a
short time, it acts effectively, and although no nitrite has
vasodilating effects for any length of time from one dose, when the
doses are given repeatedly and for days at a time, the blood
pressure will generally be more or less reduced. The dose is from
1/500 to 1/100 grain, three or four times a day, or every three
hours, as desired. The best form in which to use it is in a very
soluble tablet, and the tablet should not be dissolved unless
intense immediate action is desired. It acts when absorbed from the
tongue almost as rapidly as when given hypodermically; it acts in
two or three minutes, and the blood pressure may drop from 20 to 30
mm. In experimental tests the action does not last more than from
fifteen minutes to half an hour, but clinically the effect of
repeated doses is much more satisfactory. Spirit of glyceryl
trinitrate or spirit of Nitroglycerin, dose 1 minim, keeps well if
care is taken to guard against evaporation of alcohol; tablets if
well made and kept in bottles properly corked, will retain their
activity for months.
The closer a physician is to the laboratory, the less he believes in
the value of nitroglycerin in hypertension. The nearer he is to
clinical work the more he believes in it. It is a fact that in some
instances, even with a dose as small as 1/200 grain of
nitroglycerin, three or four times in twenty-four hours, the blood
pressure will be lower, whatever the diet is and whatever the other
treatments are, than if the patient does not take the nitroglycerin.
Also the value of these short relaxation periods from the standpoint
of a strained and tired heart should not be underestimated, the same
as the value of a night's rest, or the value of a recreation period
of an hour or two. If a patient has hypotension and a systolic
pressure of 110, and is given nitroglycerin, the very unpleasant
results from its administration will be immediately noticed. Hence
nitroglycerin is one of the most valuable drugs that we possess for
the treatment of hypertension, and some patients are even benefited
by as small a dose as l/500 grain. Lawrence [Footnote: Lawrence, C.
H.: The Effect of Pressure-Lowering Drugs and Therapeutic Measures
on Systolic and Diastolic Pressure in Man, Arch. Int. Med., April,
1912, p. 409.] found that the fall of diastolic pressure from
nitrites was about half of the fall of systolic pressure. When there
is no kidney lesion a very high systolic pressure falls more under
nitroglycerin than does a medium high systolic pressure.
Alkalies, whether potassium or sodium citrate or sodium bicarbonate,
are often of advantage in so changing and aiding metabolism, or
perhaps reducing the irritation from hyperacidity or a mild
condition of acidosis, that their administration causes a lowering
of blood pressure.
While iodids may not be direct vasodilators and do not render the
blood more aplastic or diminish its viscosity, as shown by Capps
[Footnote: Capps, J. A.: Effect of Iodids on the Circulation and
Blood Vessels in Arteriosclerosis, THE JOURNAL A. M. A., Oct. 12,
1912. p. 1350.] still, iodids in small doses, 0.1 to 0.2 gm. (1-1/2
to 3 grains) given from once to three times a day, after meals
(these small doses do not disturb the stomach), will stimulate the
thyroid gland to greater activity, and when this gland secretes
properly, the blood pressure is somewhat lowered. Of course, in
syphilitic sclerosis large doses of iodids are indicated and are
valuable.
In obese patients with hypertension, in the hypertension of women at
the menopause, and in hypertension with insufficient kidneys,
thyroid medication is often of great value. Sometimes a small dose
of from 0.1 to 0.2 gm. (1 1/12 to 3 grains) once a day is all that
is needed. At other times, especially when there is no marked
arteriosclerosis and no marked kidney or liver lesion, very high
blood pressures are reduced only by very large doses, even as much
as 10 grains a day. Such treatment is often of very great benefit.
Of course, if one of the persons under consideration has symptoms of
hyperthyroidism, or if small doses of thyroid cause palpitation, the
treatment is not indicated, on the one hand, and should be stopped,
on the other. Sometimes when the blood pressure cannot be reduced,
in these cases without apparent organic lesions, and thyroid
treatment is more or less successful, but at the same time causes
great excitation, it may be combined with bromid medication, and
then the benefit is sometimes very great.
A patient who cannot sleep and who has hypertension may receive
bromids if he is very irritable or if there are symptoms of thyroid
irritability; but the most successful sleep and lowering of blood
pressure is caused by chloral. A dose of 0.5 gm. (7 1/2 grains) at
night is generally sufficient and need not be long continued.
Chloral has been frequently given to reduce pressure in 0.2 to 0.25
gm. (3 or 4 grain) doses, three times a day, after meals.
Bromids, of course, will lower the blood pressure, but they depress
all metabolism, interfere with digestion, and are not advisable for
any length of time. However, in some cases they cause a marked
improvement in the patient's condition.
Patients under treatment with chloral, bromids, and thyroid
especially, should be carefully watched and the treatment modified
to meet the varying conditions. Patients under iodid need not be
seen so frequently; those under nitroglycerin or alkalies still less
frequently. But all patients under the active management of
hypertension should be seen at from one to three week intervals, and
the urine should be repeatedly examined and the blood pressure
carefully recorded.
HYPOTENSION
A low systolic pressure and a low diastolic pressure may not cause
any symptoms or give any cause for anxiety. It does show, especially
if the systolic pressure is below normal for the age of the person,
a lack of reserve power, and such patients will not well stand
serious illnesses, operations, injuries or serious physical and
mental strains. If there is a low systolic pressure and a high
diastolic pressure, this shows impairment of the heart, whether or
not any other organic lesion is present.
Generally speaking, a low systolic pressure shows a weak acting
heart muscle, and a very low diastolic pressure shows a dilated
condition of the arterioles. In aortic regurgitation this low
diastolic pressure is constantly in evidence, and, if the systolic
pressure is not below normal, does not signify that the circulation
is insufficient. If the systolic pressure is not very low but the
diastolic is high, vasodilator drugs, by lowering the diastolic and
increasing the pulse pressure, are often of benefit. If there is
increased venous congestion and increased venous pressure and a high
diastolic pressure with a low systolic pressure, digitalis not only
will often raise the systolic pressure, but also will lower
diastolic by improving the general circulation and removing venous
congestion.
While intestinal indigestion and absorption of toxins often tend to
raise the blood pressure, some toxins thus absorbed, especially of
the ptomain variety, lower blood pressure and cause shock, perhaps
by weakening the muscle of the heart or by acting on the vasodilator
vessels; or they may cause dilation of the vessels of the abdomen
and in this manner lower blood pressure.
Very low blood pressure after exertion, after severe physical
exercise, or after competitive athletic tests shows that the heart
cannot sustain such strains and should not be again subjected to
them. In severe mental and physical strains the suprarenals may be
inhibited in their activities, and a hypotension, more or less
prolonged, may result.
Sewall [Footnote: Sewall: Am. Jour. Med. Sc., April, 1916, p. 491]
believes that hypotension is frequently due to splanchnic stasis,
and that sluggish circulation in this region, especially when the
person is in the erect posture, is an important factor in general
physiologic disturbances or lack of general tone. When the
splanchnic vessels are dilated there is also a lack of proper tone
to the cerebral vessels, and this may be a cause of mental weariness
and neurasthenia. While ptosis of organs in the abdomen and a
flaccid condition of the musculature of the abdomen are frequent
causes of this splanchlnic stasis, and therefore hypotension,
especially in women, it is quite possible that suprarenal
insufficiency will allow this condition of the splanchnic vessels to
occur frequently.
Serious illness and infections will lower the blood pressure
sometimes to a dangerous point. Of course, hemorrhages lower the
blood pressure. Shock and collapse cause lowering of blood pressure,
frequently to a fatal point, and Cornwall [Footnote: Cornwall: New
York Med. Jour. March 7, 1914, p. 470.] finds that a patient may
live several hours with a systolic pressure below 60, and several
days when it is below 70; that he may walk around with a systolic
pressure of 90, provided the pressure pulse is sufficiently large,
that is, that the diastolic pressure is low enough to cause a
circulation of blood. Of course, if the difference between the
systolic and the diastolic pressure is diminished to the vanishing
point, the patient cannot stand it, and dies. It should be
remembered that just before death venous pressure is likely to rise,
and this may raise the diastolic pressure.
With the progressive toxemia of typhoid fever the blood pressure
will become lowered from the myocardial degeneration. Of course, the
blood pressure will drop suddenly from a hemorrhage, but Piersol
[Footnote: Piersol: Pennsylvania Med. Jour., May, 1914, p. 625]
finds that with perforation the peritoneal irritation may cause a
rise of blood pressure, and he thinks that this sign may precede for
several hours more positive signs of the accident.
As in other infections, the blood pressure will fall in scarlet
fever; but if it suddenly rises, a kidney complication is to be
looked for. The blood pressure always falls in diphtheria, and
always falls in acute rheumatism; consequently, strenuous sweating
measures in the treatment of rheumatism should not be used as soon
as the blood pressure has become low.
Failing circulation in pneumonia, if accompanied by low blood
pressure, requires different treatment from the failure of
circulation in these cases when the blood pressure is high. Hence
the relationship of the systolic to the diastolic pressure in
pneumonia is of very great importance in deciding on the proper
treatment. In one instance the blood pressure must be lowered; in
the other, the heart must be stimulated.
While tobacco, in ordinary conditions, raises the blood pressure,
after the heart has been seriously injured by the nicotin, the blood
pressure is likely to be found lower, and such patients are quickly
benefited by the withdrawal of the tobacco and the administration of
digitalis.
Anemia almost invariably causes low blood pressure. Also in a
patient who has hypotension without any distinct evidence of
disease, especially if there has been any possible exposure to
tuberculosis, that disease should be suspected and every test made
to eliminate such a cause.
Serious cachexia, such as that caused by carcinoma or other growths,
gives low blood pressure. Diabetes causes low blood pressure,
provided there are no nephritis and no marked suprarenal
stimulation.
Excessive use of alcohol, while tending to promote hypertension by
the disturbances that it causes, may give, by causing a weak heart
muscle, a permanent low blood pressure. A single large dose of
alcohol always lowers the blood pressure.
Arteriosclerosis frequently reaches a stage when the blood pressure
is low, and with atheroma of the arteries of the arms a true blood
pressure is difficult to obtain. Addison's disease, or any other
organic lesion of the suprarenals, will lower the pressure, while
stimulation of the suprarenals increases the pressure. Any great
drain on the system, whether from diabetes without nephritis, or
from profuse diarrhea of any type, will cause hypotension.
Occasionally a girl with chlorosis who is not menstruating may have
an increased blood pressure. Many of the hemorrhagic or purpuric
conditions will show a hypotension.
Meningitis in various forms may show a hypertension from cerebral
and nervous irritation. Neurasthenic patients quite generally have
hypotension, although occasionally with suprarenal disturbance they
may have an increased tension.
In the hypotension of surgical shock and in shock during anesthesia,
Henderson's findings [Footnote: Henderson: Am. Jour. Physiol., 1910,
xxvii, 158.] that hyperoxygenation and insufficient carbon dioxid
may be partially responsible for the condition should be remembered,
and it has long been known that carbon dioxid congestion, as caused
by laughing gas anesthesia, for instance, increases the blood
pressure.
A systolic pressure of 110 mm. or lower in an adult should be
considered hypotension, anything below 105 mm. calls for treatment,
and a systolic pressure of 100 or lower in an adult calls for rest
from all active duties.
These patients are weary, they have mental and physical tire, may
get short breathed, may have palpitation of the heart, and often
have headaches and dizziness from imperfect circulation in the head.
There may be edemas of the legs and ankles toward night. If such
patients have the systolic blood pressure raised even a small
amount, or if the diastolic pressure, which is very low, is raised
even a small amount, they immediately feel better.
If the kidneys are normal, they should have meat as part of their
diet. If they are not nervous and irritable, coffee and tea should
be allowed, except at the evening meal. While sleep may tend to
lower pressure somewhat, these patients' hearts require a long bed
rest; in other words, they should go to bed at an early hour. They
should rise early, however, in the morning, and, as recommended by
Goodman, [Footnote: Goodman: Am. Jour. Med. Sc., April, 1914, p.
503.] they should perform mild calisthenic exercises before
dressing.
The increased muscle tone thus caused raises the blood pressure
somewhat, and the great depression before breakfast is not
experienced. These patients rely oil their morning coffee for
bracing. If they have much indigestion at night which keeps them
awake so that they do not get good comfortable rest, their largest
meals should be the morning and noon meals, and the evening meal
should be very light.
Pendent abdomens or ptosed abdominal organs should be held up by
proper abdominal bandages or corsets.
If the bowels are constipated, only the vegetable laxatives should
be used, if it drug is needed at all. Salines should not be allowed,
or other cathartics which cause profuse watery discharges. If a
brisk purge is required, castor oil is the best.
Plenty of fresh air, and mild exercises in the open air all tend to
increase the pressure. Graded walking, climbing, or other more
interesting exercises are advisable, as all tending to raise the
pressure, provided that at no time are they carried to the point of
exhaustion.
Forced feeding may be useful. Cool sponging in the morning, if there
is proper reaction, is often of benefit. Iron may be indicated;
bitter tonics may be indicated. Digitalis and strychnin are often of
advantage. Caffein may be used as a drug as well as given in coffee
and tea. Atropin may be of value in some forms of hypotension.
At times with a low systolic pressure, but a relatively high
diastolic pressure, nitroglycerin is valuable.
More or less actite hypotension may occur in hot weather or with
overheating, often termed heat exhaustion. Such patients should, if
possible, go to a cooler region, whether to the seashore or to the
mountains is unimportant. The treatment of dangerous sudden low
blood pressure, as shock, will be discussed elsewhere.
PERICARDITIS
ACUTE PERICARDITIS
As this inflammation is generally secondary to some other condition,
its treatment cannot be positively outlined. Furthermore, it is
often a terminal condition, and in such instances the results of
treatment are of necessity nil. The most frequent terminal cause is
nephritis; other terminal causes are pulmonary tuberculosis,
adjacent abscesses, cancer or other growth.
The most frequent infectious cause is rheumatism; other infectious
causes are cerebrospinal fever, typhoid fever, acute miliary
tuberculosis, pneumonia and Sepsis. Accidental causes are traumatism
and an adjacent inflammation of the pleura.
The result of an inflammation of the pericardium may be a fibrous
exudate, or an exudate which is both serous and fibrous, or one in
which pus is present in considerable amount.
The onset of pericarditis may be more or less acute, or it may
commence insidiously. For this reason, during severe illness, and
especially in those diseases which are known to have pericarditis
often as a sequence, frequent examination of the heart should be
made as a routine procedure.
SYMPTOMS AND SIGNS
If there is pain or much aching in the cardiac region, it tends to
disappear with the exudate, if such is to occur, in the same way as
does the pain of pleurisy. If there is much exudate, the pressure on
the heart of course increases, the cardiac dulness enlarges, dyspnea
occurs and even perhaps later cyanosis. As the exudate accumulates,
the patient must lie higher and higher in order that the fluid may
gravitate to the lowest part of the sac and give the heart the
greatest ability to work. Reflex pain may occur from disturbances of
the pneumogastric nerve, or from the weight and pressure of the
enlarged and heavy pericardium. Reflex vomiting may be a troublesome
and distressing symptom.
Acute pericarditis occurring in rheumatism, in acute infections, and
from simple injuries tends to recovery. In dry pericarditis with
serious adhesions, or if adhesions occur as a sequence of acute
pericarditis, the future prognosis is bad, as myocarditis may
develop and sudden death or acute dilatation may occur. As stated
above, if pericarditis develops during the progress of chronic
disease, such as interstitial nephritis, or during sepsis, or from
abscesses or growths in the region of the pericardium, the prognosis
is bad.
TREATMENT OF ACUTE PERICARDITIS
In acute pericarditis, absolute mental as well as physical rest is
essential. Even if the patient does not appear to be seriously ill
and has not much fever, he should not be allowed to have visitors,
to discuss business matters, or to carry on any conversation,
however little exciting. Anything which increases the heart beat
increases the irritation of the inflamed surfaces of the
pericardium. He should not be allowed to sit up, either to eat or to
attend to the calls of Nature. These rules are imperative, and when
they are followed the pain is less, the heart beats less rapidly, is
less hampered by pressure from whatever exudate may be present, and
the adhesions which are liable to form will be less in amount and
less serious for the future work of the heart.
The treatment, of course, depends largely on the cause of the
pericarditis, as, if the cause is one of those just enumerated in
which the prognosis is dire, any treatment directed toward the
pericardial inflammation is almost useless. The periearditis under
these conditions will be more or less benefited, if at all affected,
by the treatment directed toward the cause.
The indications for treatment in all other instances are:
1. To attempt to abort the inflammation.
2. To stop the pain.
3. To limit, if possible, the amount of exudate, and to diminish the
exudate already present.
4. To diminish the rapidity of the heart and to strengthen it.
1. Abortive Treatment.--For many years bloodletting was considered
of the greatest importance in the early treatment of this disease;
but owing to the fact that, except from traumatism, pericarditis
rarely occurs except as a sequela of acute disease after the patient
has been sick along time, or as a terminal condition in a patient
who has long been chronically diseased and therefore has already
lost more or less strength, venesection has been nearly abandoned.
Leeches may be used over the region of the pericardium, and cups are
sometimes used. Dry cupping is more frequently used. These measures
sometimes seem to reduce the inflammation, and certainly often
relieve pain, but the most valuable local treatment is cold, which
may be applied either in the form of an ice bag or by a small coil
through which ice water is caused to flow by siphonage. Cold may be
applied more or less continuously, depending on the sensations of
the patient. The bag or ice cap must not be overfilled and must not
be heavy, as the patient often cannot stand pressure over the
pericardium. Sometimes the relief from pain and the diminution of
the number of the heart beats is marked, and for this reason alone
the cardiac inflammation may be inhibited. If cold applications are
not tolerated by the patient (and they often are not in children)
warm applications may be used, such as an electric pad or cloths
wrung out of hot water and covered with oiled silk, and the pain
will often be relieved thus. While hot applications would not tend
to abort the inflammation, they probably do not tend to promote it.
A diminished diet, of small amount at a time, and such purging as
the patient's strength will allow are essential in attempting to
hasten recovery.
Just what can be done locally or generally to combat the
inflammation actively must depend on the cause. When the
inflammation occurs as a complication of acute rheumatism, it has
been suggested that salicylates, which arc not inhibiting rheumatism
and may be depressant to the heart, should be stopped if they are
being administered; but if the salicylates are apparently improving
the inflammation in the joints, pericarditis would not
contraindicate their continued use. Except in large doses,
salicylates probably do not depress the heart. In pericarditis it is
perhaps well always to administer an alkali in some form unless
otherwise contraindicated, whether or not the cause is rheumatism. A
diminished alkalinity of the blood would always increase the
likelihood of an augmented amount of pericardial or endocardial
inflammation. The blood must be kept strongly alkaline. It is
possible that one of the reasons why pericarditis or endocarditis
occurs so frequently in serious prolonged fevers is that the patient
has not eaten enough cereals or other carbohydrates, and the system
has become more or less endangered by acidosis. Carbohydrate
starvation is inexcusable with our present understanding of the
danger from acideinia, and even from a diminished amount of alkalies
in the blood.
The cause of pericarditis being so varied, any anti-toxin treatment
or any vaccine treatment could be indicated only if the cause of the
inflammation rendered the serum or vaccine advisable.
2. Stopping the Pain.--Nowhere else in the body should pain be so
speedily combated as when it occurs in the region of the heart.
Morphin, with or without atropin, as deemed best, should be
administered hypodermically in the amount and with the frequency
necessary to stop the pain and quiet the restlessness. As stated
above, the frequent need for morphin may be prevented by use of the
ice bag. Morphin might even be considered an abortive treatment, as
nothing tends so much to inhibit this inflammation as the quietude
of the heart caused by the absence of pain, the production of sleep
and the prevention of restlessness, muscle twitching and muscle
movements. The more quiet the patient is, the more quiet is the
heart.
If for any reason morphin is contraindicated, and if pain is not a
symptom, the patient's nerves may be quieted and rest may be given
by sodium bromid, or by veronal-sodium, the dose of the former being
2 gm. (30 grains) two or three times in twenty-four hours, according
to its action and the necessity for it, and the dose of the latter
0.2 gm. (3 grains) once in six hours, if deemed necessary.
Especially if there are cerebral symptoms, as typically presented in
cerebrospinal meningitis, and especially if the arterial tension is
low, the subcutaneous administration of an aseptic ergot will quiet
the central nervous system, increase the blood pressure, quiet the
heart, and prolong the action of a single dose of morphin. It is the
best plan to administer ergot deep into the muscles, with the
deltoid as the place of choice. If the skin is properly cleansed,
the syringe clean and the preparation of the drug aseptic, no
inflammation or abscess will ever occur. If there is any painful
swelling, a wet alcohol dressing to the part will soon relieve it.
The frequence with which ergot should be so administered depends on
the results and the indications. Once in twelve hours for several
doses is generally the best method for its use.
3. The Exudate.--When a fluid exudate into the pericardium has
occurred from inflammation that is, when it is not an exudate from
disturbed kidneys or circulation--it will continue to increase to
some extent in spite of any treatment. Just how much this exudate
may be prevented by the use of small blisters over or around the
heart, and just how much watery stools and diuresis may prevent the
advance of the exudate is difficult to determine. Small blisters,
properly applied, have many times seemed to be the determining
factor in stopping the increase in the fluid, or to have been the
starting cause of the resorption of the exudate.
The amount of purging that should be caused by saline cathartics
such as sodium sulphate (Glauber salt), potassium and sodium
tartrate (Rochelle salt), or the official compound jalap powder
cannot be declared dogmatically. Saline purging should be governed
by the character of the circulation. If the heart is strong, the
pulse not weak, and the blood pressure good, nothing is more
valuable in this condition. Portal depletion is of great advantage,
especially if the amount of liquid ingested is kept as low as
possible, so that the blood vessels may become thirsty and thus tend
to absorb an exudate wherever they find it. Much harm has been done,
however, and death has been caused by saline purgatives in
endeavoring to relieve edemas from a failing heart or to prevent a
uremia from kidney inflammation. The depression following such
purging is often serious. If the circulation is weak, dependence
should be placed on purgation by some of the simple vegetable
cathartics or a small dose of calomel. While it is advisable to give
a saline in concentrated solution, it should not be so strong as to
cause vomiting. With our better understanding of magnesium
absorption and the depressant effect of magnesium on the nervous
system, magnesium salts should not be used in serious conditions.
Diuretics often do not act well when most needed. The simplest
diuretic is potassium citrate, given in wintergreen or peppermint
water, in doses of 2 gm. (30 grains), three or four tunes in twenty-
four hours. One or more of the vegetable, nonirritant diuretics may
be tried if preferred. If the sickness preceding the pericarditis
was not a long fever, and the heart muscle is considered in good
condition, digitalis in small doses may be the best possible
diuretic. Incidentally it will slow the heart, if there is not much
elevation of temperature, and will give some cardiac rest.
Although the patient's diet should be limited in bulk, and
especially in amount of liquids, good nutrition should soon be
given. Systemic weakness certainly tends to increase the exudate;
systemic strength aids in absorption of the exudate.
Iron is early indicated, and nothing is better than 5 drops of the
tincture of chlorid of iron in a little lemonade or orangeade,
administered once in eight hours.
If the exudate tends to decrease, it perhaps may be hastened by the
local application of tincture of iodin over the cardiac region. Also
the administration of small doses of an iodid, as 0.3 gm. (5 grains)
of sodium iodid, given in plenty of water three times a day, is
useful. An iodid circulating in the blood seems to aid absorption.
It has long been believed that iodin in the blood tends to promote
absorption of thickened, left-over material from exudates, and to
prevent the formation of strong fibrous adhesions. Until our
knowledge is more exact in this matter, it is advisable to use iodid
as suggested. If the above-named dose is not tolerated, less should
be given.
If in spite of all the therapeutic measures suggested, the fluid
increases and the pericardium becomes more distended and the heart's
action more labored, paracentesis must be done. The point at which
the aspirating needle should be inserted into the pericardium
depends somewhat on the conditions in each individual case. It is
often best to insert an exploratory needle first. This will
determine the fluidity and character of the exudate. If pus is
found, a more radical surgical procedure than simple paracentesis
must be done immediately. The point of puncture for aspiration most
frequently chosen is in the fourth or fifth intercostal space, about
an inch to the left of the sternal margin. Paracentesis is also
often done in the region of the normal apex beat. The position of
the patient is determined by his dyspnea; he should lie in the
position most comfortable for him. The fluid should be withdrawn
slowly and the pulse carefully watched. The withdrawal of a small
amount of fluid may later seem to be the starting cause of
resorption of the rest of the fluid. On the other hand, it may often
be not of more value than the simple removal of the immediate
pressure, the fluid may again accumulate, and more radical surgery
must be performed.
4. To Strengthen the Heart.--Most of the methods of meeting this
indication have already been stated, namely, absolute rest; absolute
quiet; the use of the bed pan; any movement that must be made should
be deliberate; the nurse and other attendants must be quiet;
necessary conversation must be brief, and every method must be used
to quiet and prevent the heart's action from becoming rapid. The
food taken should be small in amount and nonstimulating; that is, no
tea or coffee should be given, and nothing too hot or too cold.
Movements of the bowels should be caused with the least possible
general disturbance. If the patient does not sleep, he must be made
to sleep. The whole body and the nervous system must have periods of
rest. If the heart is very weak, small closes of morphin may be
used. If the heart is not weak, bromids or chloral may be given. If
the blood pressure is high, such hypnotics will lower it, or if the
heart is strong and the condition does not contraindicate it,
aconite may be used in small doses, for a day or two, unless the
fever is high and it seems advisable to use one of the coal-tar
antipyretics, which reduce the blood tension and the heart activity.
As stated above, pain must not be allowed. Sometimes, when the heart
has not been injured by prolonged fever, digitalis in small doses
may slow the heart and act for good.
Convalescence.--The convalescence should be prolonged as in any
other cardiac inflammation. The patient should be given more and
more nourishing food, and the iron tonic may be changed to a capsule
containing 0.05 gm. of quinin and 0.05 gm. of reduced iron, three
times a day.
It is a question as to when patients convalescent from pericarditis
should be permitted exercise. It has been thought that gentle
movements and possibly exercise, sooner than theoretically
justified, might cause the heart to beat a little more actively and
possibly prevent the formation of tight adhesions between the two
layers of the pericardium. Whether such activity of the heart will
prevent adhesions is something that has not been determined.
The small doses of sodium iodid, perhaps 0.2 gm. (3 grains) two or
three times a day, should be continued for some time. Iodid in this
dosage does no harm and may do a great deal of good.
ADHERENT PERICARDITIS
Following dry pericarditis or pericarditis with an exudate,
especially when the exudate is fibrinous in character, the fibrous
substance which is not absorbed or resorbed may develop into
connective tissue, and the two pericardial surfaces become
permanently grown together, causing the so-called adherent
pericarditis. These adhesions between the two surfaces of the
pericardium may be general throughout the entire pericardial sac, or
they may be limited to some one or more parts of the pericardium.
Perhaps one of the most frequent points of adhesion is the anterior
part of the pericardium, while the apex is the part most likely to
be free, even when other parts of the pericardium have grown
together. This freedom of the apex is probably due to the constant
and more extensive motion of the apical portion of the heart, and is
the reason that it has been suggested, as referred to under acute
pericarditis, that, other conditions not contraindicating, the
patient may be allowed to move about a little during convalescence
to cause the heart to beat more actively. Sometimes the surfaces of
the pericardium are not closely adherent to each other, but bands of
adhesion stretch from one surface to the other.
After adhesions have taken place between the two layers of the
pericardium, the action of the heart is impaired, serious
interference with the cardiac action may develop, and sudden death
may occur. If the heart is given all the rest possible during the
acute phase of the disease, there will be less likelihood of the
surfaces becoming so irritated that adhesions readily form. Anything
which permits complete absorption and resorption of tile exudate
will tend to prevent these hampering adhesions. If the adhesions are
such as to cause irregular heart, recurrent pain and the danger of
sudden death, surgical help has been suggested. This surgical
procedure is to remove a portion of the ribs, perhaps of the third,
fourth and fifth, to allow the heart more freedom of action to
compensate for the impairment of its activity from the adhesions.
Such an operation was first suggested by Brauer of Heidelberg in
1902.
The question of the best method of producing anesthesia in this
condition of the heart is a serious one. A patient might die during
the anesthesia; but he might also die at any time from cardiac
spasm. In certain instances, in adults, local anesthesia might be
sufficient. Pain reflexes, however, would be serious. Such an
operation would be indicated when the apex is fixed so that there is
a constant sensation of hugging of the heart at the fourth and fifth
ribs, with paroxysms of pain and cardiac weakness.
MYOCARDIAL DISTURBANCES
While the myocardium is the most important muscle structure of the
body, it has but recently been studied carefully or well understood
clinically or pathologically. A heart was "hypertrophied" or
"dilated" or perhaps "fatty." It suffered from "pain," "angina
pectoris," from some "serious weakness" or from "coronary disease,"
and that ended the pathology and the clinical diagnosis. This is the
age of heart defects; no one can understand a patient's condition
now, whatever ails him, without studying his heart. No one can treat
a patient properly now without considering the management of the
circulation. No one should administer a drug now without considering
what it will do to the patient's heart.
Although we are scientifically interested in the administration of
specific treatments, antitoxins and vaccines; although we have a
better understanding of food values, and order diets with more
careful consideration of the exact needs of the individual, and
although we are using various physical methods to promote
elimination of toxins, poisons and products of metabolism, we have
until lately forgotten the physical fact that one thirteenth of the
weight of a normal adult is blood. A man who weighs 170 pounds has
13 pounds of blood. This proportion is not true in the obese, and is
not true in children. Whether the person is sick in bed, miserable
though up and about, or beginning to feel the first sensations of
slight incapacity for his life work, his ability properly to
circulate this one thirteenth of his weight through the various
arterial and venous channels and capillary tracts must, with the
increasing tension and speed of our lives, be taken into
consideration.
The more and more frequently repeated statements that the operation
was successfully performed but that the patient died of shock, and
that the typhoid fever and the pneumonia were being successfully
combated, but that the patient died of heart failure, together with
the increase in arteriosclerosis, cardiac disturbances and renal
disease, emphatically present the necessity of more carefully
studying the circulation. A better understanding and the constant
study of the blood pressure shows nothing but the necessity of the
age. The unwillingness of the patient to suffer pain, even for a few
minutes, without some narcotic, generally a cardiac debilitating
drug, means that, if he is a sufferer from chronic or recurrent
pain, he has taken a great deal of medicine which has done his heart
no good. Repeated high tension of life raises the blood pressure and
puts more work on the heart. Therefore the heart is found weary, if
not actually degenerated, when any serious accident, medical or
surgical, happens to the patient.
The requirements of the age have, then, necessitated that the heart
be more carefully studied, and therefore the heart strength and its
disturbances are better understood. The mere determination as to
where the apex beat is located, and as to what murmurs may be
present is not sufficient; we must attempt to determine the probable
condition of the myocardium. The following conditions are
recognized: (1) acute myocarditis, (2) chronic myocarditis
(fibrosis, cardiosclerosis), (3) fatty degeneration, and (4) fatty
heart.
ACUTE MYOCARDITIS
Probably most acute infections cause more or less myocarditis,
depending on their intensity and their prolongation. This
disturbance of the heart is often unrecognized, and has been simply
referred to as "the heart growing weaker from the fever process."
The acute infections most likely to cause a myocarditis are
rheumatism, influenza, sepsis, cerebrospinal meningitis, diphtheria,
typhoid fever, scarlet fever, and mouth and throat infections. It is
probably rare when acute endocarditis occurs that more or less
myocarditis is not present. The acute myocarditis may develop some
fatty degeneration, and with this softening and weakening of the
heart muscle acute dilatation readily occurs, which may be a cause
of sudden death, or, if less serious, may be the cause of prolonged
disability, if the heart ever recovers its original size and
strength.
The symptoms are often indefinite, and the diagnosis of the
condition hardly possible. It may be taken for granted, however,
that hardly any serious illness can long continue without cardiac
muscle disturbance. If endocarditis is present, soft systolic
murmurs soon appear. With the acute myocarditis developing, the apex
beat is less positive, less accentuated, and later it becomes
diffuse and even feeble. The closure of the aortic valve is less
typically sharp, showing that the blood vessels are not so
thoroughly filled. The peripheral circulation is not so active, the
blood pressure falls, and the heart becomes more rapid, especially
on the least exertion. All of these signs indicate myocardial
weakness.
The treatment of this condition is largely preventive. It should be
well recognized that prolonged high fever, prolonged insufficient or
improper nutrition, prolonged acute pain, and especially prolonged
septic processes will always cause myocardial degeneration. It
should be recognized that after ether and chloroform anesthesia,
especially after chloroform, the heart muscle may be disturbed and
the tonicity be lost. Therefore after anesthesia, after operations,
and after all illnesses which have lasted more than a few days, the
convalescence of the patient must be more or less deliberate. Sudden
rising, sudden erect posture, the exertion of walking too early,
going up stairs too early or taking moderate, and later severe
exercise too early, may cause dilatation of the heart muscle that
has become weakened by acute myocarditis. If acute myocarditis is
believed or known to be present, cardiac tonics such as digitalis
should not be given; large doses of strychnin should not be given;
vasocontractors such as ergot should not be given; large amounts of
food or large bulks of liquid should not be taken into the stomach
at one time; in fact, unless there is some special indication, the
twenty-four hour amount of fluid should be diminished. The surface
circulation and the muscle circulation should be improved by such
cold or warm water applications as the disease or condition calls
for. Massage should be early inaugurated to promote the return
circulation. The heart should be treated as though it were the
frailest of Venetian glass and would crack with the least rough
handling, or even with a rapid change of temperature, great cold or
too much heat. A prolonged, tedious convalescence, with the return
to activity so graded as to give the heart no strain, and to keep
its work always just below what it is able to do, will often mean
return to perfect strength and health.
No cardiac debilitating drug should be administered when myocarditis
has been surmised or diagnosed. The safest hypnotic, if one is
needed, is morphin in small doses. If there are weakening
perspirations, atropin should be given, especially as it is also a
circulatory stimulant. Calcium in almost any form seems to be of
value in the majority of heart conditions. It is a sedative to the
nervous system, and is certainly indicated in acute myocarditis.
Calcium lactate is perhaps the best salt to administer, in doses of
0.25 gm. (4 grains), three or four times in twenty-four hours.
Calcium glycerophosphate may be used, in powder form or in capsule,
in doses of 0.30 gm. (5 grains) three or four times in twenty-four
hours; or lime-water may be given.
An exact prognosis of this inflammation is impossible. We do not
know how far an acute myocarditis may progress and entire recovery
take place; we do not know how slight a myocarditis may cause
serious symptoms. Clinically we know that many patients after
serious illness never again have perfect circulatory strength. Other
patients almost die of heart failure and yet apparently absolutely
recover their ability to do hard physical work.
CHRONIC MYOCARDITIS: FIBROUS
Chronic myocarditis may develop on an acute myocarditis, but is
generally a slowly progressive chronic process from the beginning;
it occurs mostly in persons past middle life, and as a rule is not
primarily associated with rheumatism or valvular disease of the
heart. Perhaps generally the term "chronic myocarditis" is
incorrect, as a real inflammatory condition is not present and has
not been present; it is really a degenerative process with the
development of connective tissue, a fibrosis and more or less
hardening of the arterioles, a cardiosclerosis. In many instances
this fibrosis is associated with fat deposits or fatty degeneration.
The disease is often caused by a narrowing or obstruction or
calcareous degeneration of the coronary arteries, thus diminishing
the blood supply to the heart muscle. This chronic myocardial
degeneration is often a part of the general arteriosclerosis, and is
an important factor in what is termed cardiovascular-renal disease.
In simple chronic renal diseases the heart first normally
hypertrophies to overcome the increased blood tension and increased
resistance.
The principal causes of this degeneration are normal old age, or
premature age caused by various conditions. In other words, anything
which hastens arteriosclerosis will cause myocardial degeneration.
The causes recognized as most frequently producing this condition
are syphilis; gout; repeated attacks of rheumatism; excess in the
use of alcohol (meaning repeated daily too large amounts, as well as
actual dipsomania); the overuse of tobacco; excess in drinking tea
or coffee; general overeating, and excessive eating of meat in
particular, if the organs of elimination do not work perfectly and
if such eating causes or allows putrefactive changes in the
intestines; and progressive, prolonged wasting diseases, such as
tuberculosis and cancer. It has also seemed in some cases that the
only cause was excessive, hard physical labor, including excessive
athletic work, and in other cases that prolonged anxiety and worry
have been causes of cardiac degeneration and actual cardiac failure.
Prolonged absorption of toxins from mouth and tonsil infections may
be a not infrequent cause.
These myocardial changes are sometimes associated with chronic
pericarditis and chronic endocarditis, and may accompany or follow
valvular disease of the heart. Failure of compensation in valvular
disease and dilatation of the heart are sequences which occur sooner
or later.
SYMPTOMS AND SIGNS
The symptoms of chronic myocardial degeneration are progressive
weakness, slight at first, noticeable on exertion (and what was not
considered exertion becomes such), as evidenced by slight
palpitation, slight shortness of breath, leg weariness and mental
tire. The heart frequently becomes more rapid, not only with
exertion and change of position to the erect, but even after eating.
Slight cardiac stimulants, as coffee, affect the heart more than
previously; there is some sleeplessness, more or less troublesome,
and more or less indigestion. There may be mental irritability and
some mental deterioration, as shown in various ways. There are
likely to be slight edemas of the lower extremities toward night.
The amount of urine may diminish. A previously high blood pressure
becomes lower. The pulse may be occasionally intermittent, and later
actually irregular.
The physical signs often show an enlargement of the heart, with
increased activity at first, from irritability of the heart and a
lack of perfect coordination; later the heart may show typical signs
of weakness. Not infrequently a heart suffering from fibrosis acts
perfectly until some sudden exertion, as lifting, running or serious
illness causes it suddenly to become weak. Such a heart rarely
regains its former strength. This occurs frequently to those who
have supposed themselves to be in perfect physical health. Some
sudden strain which they have previously been able to endure without
injury, such as carrying a weight upstairs, cranking a refractory
engine, pumping up a series of tires, or walking rapidly with a
younger or more active companion, will suddenly give cardiac
distress signals, serious exhaustion and more or less lengthy
prostration, perhaps for an hour or so, or perhaps for several days.
Permanent cardiac weakness may follow, or compensation may again
occur, to be more easily broken later. Slight cardiac pains and
sensations referred to the cardiac region become frequent. Disliking
to lie on the left side, when previously the patient has been able
to sleep on this side without discomfort, is an evidence of cardiac
disturbance. There may be no real pains, but the patient becomes
conscious of his heart, perhaps for the first time in his life. This
alone is an indication of coming trouble.
If these signs and symptoms develop late in life, or at any age with
other symptoms of sclerosis or senility, little can be done
therapeutically except to afford temporary relief and to prevent the
occurrence of acute attacks of cardiac distress or dyspnea. If the
disturbance is really due to chronic cardiac degeneration, the
sooner the patient learns that his ability is restricted, that his
life is narrowed, the better for his future.
MANAGEMENT
The advice he should receive is well understood: to avoid physical
efforts; to avoid mental tire; to avoid overeating or overdrinking
of any foods or liquids; to reduce or abstain from alcohol, coffee,
tea and tobacco, depending on what seems advisable in the individual
case; to reduce the amount of meat eaten, especially if there is
intestinal indigestion; to relieve intestinal indigestion; to cause
free daily movements of the bowels; to abstain from any food which
tends to cause gastric or intestinal flatulence; to abstain from
such foods as contain nucleins, if the patient is gouty; to take
frequent warm baths (not too hot) to promote the secretions and the
circulation in the skin, and to take such daily exercise as seems
advisable. If the patient cannot take exercise, simple calisthenics
or massage should be instituted.
Whether nitroglycerin or other nitrite is advisable depends on the
peripheral blood pressure. If the blood pressure is low, or not
higher than is best for the patient, such treatment would be
inadvisable. If, from the supposed cause, iodid seems to be
indicated, it should be given in small doses and continued for some
time. It is often wise, however, to give small doses, as 0.10 or
0.20 gm. (2 or 3 grains) once or twice in twenty-four hours, for a
long period, to any patient who leas fibrosis or selerosis in any
form. Iodid tends to prevent the progress of connective tissue
formation. It is quite possible that some of its value is in
activating a sluggish or imperfectly acting thyroid gland. If the
patient is old, his thyroid is subinvoluting, and a little more of
its activity will be of advantage. Many diseases which cause chronic
myocarditis also cause, later, subactivity of the thyroid. Thyroid
extract may be indicated if the patient is obese.
If, in spite of this management and treatment, the patient has
cardiac asthma attacks, with or without pain, especially if there
are pendent edemas, the question arises as to whether or not
digitalis should be given. In such cases one cannot tell without
trying whether digitalis will be of benefit or will cause more
discomfort. 11 small dose of an active preparation should be given
at first twice in twenty-four hours, and after a week once in
twenty-four hours, its action being carefully watched and the
decision as to whether the dose is too large or too small arrived
at. It may do a great amount of good; it can cause increased cardiac
pains. If used carefully and stopped when it appears not to be
acting well, it will do no harm.
Chilling of the surface of the body should be avoided; sudden cold
or sustained severe cold, which increases the contraction of the
peripheral blood vessels and puts more strain on the heart muscle,
is to be avoided if possible. More hours in bed at night and lying
down after the heavier meals of the day will tend to give the heart
the kind of rest it needs. Also complete rest for one day a week, or
a rest of several days at a time, and a rest, both mental and
physical, with such walking, golfing or riding as seems advisable,
for at least one month every year, will prolong the lives of these
patients, and may make an imperfect heart act well for months and
years. If the patient is anemic he should, of course, receive some
nonastringent iron; a. tablet of saccharated ferric oxid
(Eisenzucker), in small doses, 0.20 gm. (3 grains), once or twice in
twenty-four hours, is sufficient.
The prognosis of a case diagnosed as chronic myocarditis or chronic
degeneration of the heart is doubtful, as one cannot tell until
several weeks or months of observation whether this particular heart
also has fatty degeneration or not. If there is fatty degeneration,
the prognosis is bad. If there is no serious fatty degeneration, the
patient, with the modified life outlined, may live for a long time.
Acute dilatation from any serious strain on the heart may occur, and
if there is fatty degeneration it is liable to occur at any time.
Attacks of cardiac asthma are always serious, and always damage the
heart a little more.
FATTY DEGENERATION
Fatty degeneration of the heart muscle may be caused by acute
poisoning (as phosphorus, arsenic, etc.), by serious infections, or
it may follow fibrosis of the heart or coronary artery disease. The
symptoms are those of serious circulatory weaicnens, which does not
seem to improve under any ordinary management. It is difficult, if
the heart is enlarged, to determine whether there is more or less
serious acute dilatation or whether the heart muscle has suffered
fatty degenration.
The treatment of such a patient requires the best of judgment as to
the amount of food and liquid that should be given, the regulation
of the administration of laxatives, the sponging of the body, the
means of producing sleep if there is insomnia, how much reading,
conversation or amusements should be allowed, how much stimulation
by stryclmin or other stimulating drug should be given, and whether
or not very small doses of digitalis should he tried. These are all
matters for individualizing, and for the best medical judgment which
we are called on to give. How much repair can take place in a heart
muscle when fatty degeneration has started we do not know. Such
treatment will give the heart the only chance it has to recuperate,
but the prognosis is bad.
FATTY HEART
The cause of deposits of fat around the heart or in between its
chambers is the same as the cause of general obesity. These patients
are likely to be obese, or at least to have large abdomens with
large deposits of fat around the abdomen. This fat in itself will
interfere somewhat with abdominal respiration. This tends to cause
dyspnea, and the heart tends to be disturbed from these causes, if
much fat is not really in the pericardium. The symptoms are those of
imperfect heart action; the patient is dyspneic on exertion or in
leaning over, the heart acts rapidly on such exertion, the patient
puffs, perspires easily, and becomes leg weary, sedentary in his
habits, and more or less incapacitated for work. He may not be a
large eater; if he is, and his eating habit is corrected, the
prognosis is better than if he is putting on weight in spite of
eating sparingly.
The general treatment is that for obesity, and if the heart muscle
is intact, various depletion methods may be inaugurated. More and
more exercise, sweatings from Turkish baths, electric-light baths,
body baking, vigorous massage and more or less purging are all
valuable. Anything which reduces the general weight will help the
heart. The prognosis is often good.
ENDOCARDITIS
It should be understood that especially in acute conditions a
positive separation of endocarditis from myocarditis is incorrect.
Acute endocarditis can probably not occur without some inyocarditis,
and myocarditis probably does not occur without some endocardial
disturbance and perhaps some pericardial irritation. This is
especially true in endocarditis which occurs during any acute
infection, even in rheumatism. The greater the amount of
pericarditis, the more serious is the acute condition. The greater
the amount of myocarditis, the more doubtful is the heart strength
in the near future. The greater the amount of endocarditis, the
greater the doubt of freedom from future permanent valvular lesions.
Endocarditis may be divided into: acute mild (simple) endocarditis,
acute malignant (ulcerative, infective) endocarditis, chronic
endocarditis and valvular disease.
ACUTE MILD ENDOCARDITIS
This inflammation of the endocardium is generally confined to the
region of the valves, and the valves most frequently so inflamed are
the mitral and aortic. There may be a slight inflammation or actual
ulceration and loss of tissue. Vegetations more or less constantly
occur on the inflamed surfaces, with more or less danger of
particles becoming loosened and moving free in the blood stream,
causing embolic obstruction in different parts of the body. There is
also more or less probability of serious adhesions or contractions
occurring from the healing of the ulcerated surfaces. The future
health and welfare of the valves depend on the fact that the
inflammation has healed without contractions or adhesions.
It is often difficult to decide when acute endocarditis has
developed; but with the knowledge that the endocardium often becomes
inflamed during almost any of the acute infections, the physician
should repeatedly examine the heart for murmurs, for muffled closure
of the valves, or for other evidences of endocarditis or myocarditis
during the acute infective process.
It has been shown positively that acute endocarditis is due to
micro-organisms, generally streptococci, staphylococci or
pneumococci, and, more frequently than once believed, gonococci. The
most frequent causes are acute rheumatic fever, diphtheria,
pneumonia, cerebrospinal meningitis, scarlet fever, erysipelas,
influenza, chorea, gonorrhea, sepsis and typhoid fever. It may also
follow a follicular tonsillitis or some infection of the mouth or
throat with or without arthritis. Tuberculosis may also occasionally
cause an endocarditis. Organisms may be found in a terminal simple
endocarditis due to a chronic disease, as tuberculosis or cancer;
such inflammations may have been caused by circulating toxins.
It will be noticed by the foregoing classification that the terms
"mild" and "malignant" endocarditis are used. The purpose is to
convey the fact that there may be no etiologic distinction between
the two forms, and it is impossible to decide clinically in the
beginning of an endocardial inflammation which form is present. In
the malignant form the infection is probably more serious or the
infective germs are more active, the ulcerations deeper, and the
likelihood of emboli and the seriousness of such embolic infarcts
more serious and more dangerous. The differences in inflammation in
the two cases is really one of degree, and the classification is
made to coincide with this probable fact. it is, of course,
clinically recognized that endocarditis following certain diseases,
especially rheumatism, is of the simple or mild type, while that
termed ulcerative endocarditis may occur apparently as a primary or
general infection, and the causative bacteria, as a rule, are
readily discovered in the blood. The Streptococcus viridans is one
of the most dangerous of these bacteria.
A SECONDARY AFFECTION
Mild endocarditis is rarely a primary affection, and is almost
invariably secondary to one of the diseases named above. Nearly 75
percent of secondary endocarditis occurs as a complication of acute
articular rheumatism and chorea, or subsequently. On the other hand,
about 40 percent of all patients with acute articular rheumatism
develop endocarditis, sometimes perhaps so mild as to be hardly
discoverable. This complication is most likely to occur during the
second or third week of rheumatic fever. It is not sufficiently
recognized that a subacute arthritis, recurring tonsillitis, open
and concealed infections in the mouth, and even a condition of the
system with acute, changeable and varying joint and muscle pains may
all develop a mild endocarditis, even with subsequent valvular
lesions. Therefore in all of these conditions the decision can be
made only as to how much rest the patient must have or how serious
the condition is to be considered by careful examination of the
heart in every instance.
Children are more liable than adults to this complication,
especially with rheumatism. Therefore, acute mild endocarditis with
future valvular lesions occurs most frequently during childhood and
adolescence, and if one attack has occurred, a subsequent infection,
especially of rheumatism, is liable to cause another acute
endocarditis.
PATHOLOGY
The part of the heart most affected is the part which has the most
work to do--the left side of the heart--and of this side the left
ventricle and therefore the mitral and aortic valves; the most
frequent valve to be inflamed and to stiffer permanent disability is
the a mitral valve, the valve which in its inflamed condition is
subjected to the greatest amount of pressure and therefore
irritation. Not infrequently soft systolic murmurs are heard at the
pulmonary and tricuspid valves during acute endocarditis. It is
rare, however, that these valves are so affected during childhood or
adult life as to be permanently disabled.
Whether a diminished alkalinity of the blood in rheumatism has
anything to do with the cause of the frequent complication of
endocarditis has not been determined. Whether the administration of
alkalies to the point of increasing the alkalinity of the blood is
any protection against the complication of endocarditis has also not
been positively demonstrated, although clinically such treatment is
believed by a large number of practitioners to be wise.
A chronic endocarditis with permanent lesions of the valves may
become an acute inflammation with an infectious provocation.
It has been shown that even in a few hours after endocarditis has
started, little vegetations composed of fibrin, with white blood
cells, red blood pigment and platelets, may develop. Practically in
all instances such vegetations develop, and later become more or
less organized into connective tissue. These little vegetations,
generally minute, perhaps not exceeding 4 mm. in height, are
irregular in contour like a wart. Some of these may have small
pedicles, and as such, of course, are more likely to become loosened
and fly off into the blood stream. It is of interest to note that
these little vegetations are more likely to be on the left side of
the heart than the right; on the valves than any other part, and on
the mitral valve than on the aortic. The consequence is a more
frequent permanent disability of the valves of the left side of the
heart, and of these more frequently the mitral. Although these
little vegetations and excrescences sooner or later become mostly
connective tissue, still fibrin and white blood cells may form thin
layers over them, more or less permanent. In this fibrin are
frequently found bacteria, even when there has been no recent acute
inflammation. The deeper layers of the endocardium during acute
inflammation may become infiltrated with young cells, with resultant
softening and destruction of the intercellular substance. This
softening and some swelling of the lower layers of the endocardium
allow the pushing up of these extravasated blood cells which, being
covered with fibrin, makes the little vegetations above described;
and as just stated, the fibrin may form a more or less permanent
cap. If this cap is disintegrated or lost and the cells under it
washed away in the blood stream, ulceration takes place, which may
be more or less serious, even to the perforation of a valve or
actual erosion of one of its cusps, and the parts of the valves most
seriously affected are the parts which strike against each other on
closure; as previously stated, the parts subjected to the greatest
strain and the greatest amount of friction during the inflammation
are the parts most seriously affected afterward.
If a perforation has occurred, it may make a permanent leak. If an
erosion of the edge of the valve has occurred, it may make permanent
insufficient closure. If the valve has become thickened and
stiffened during the cicatricial healing, it may not only be
incompetent, but may not open perfectly, and a narrowed orifice may
be the consequence. During the healing of these granulating ulcers
there may be thickening of the part or shrinking of the tissue, and
the valve may become shortened by adhesion to the wall, or the cusps
of the valve may adhere together so that the valve becomes
permanently unable to open properly or to close properly, or to do
either.
Not infrequently and probably more frequently than we recognize,
recovery without any of the pathologic lesions just described
follows mild endocarditis. The occurrence of simple endocarditis is
undoubtedly frequent during acute disease, and is unrecognized
because there are no lesions of the heart at the time or
subsequently; but valvular lesions only too frequently follow the
endocarditis which occurs with rheumatism. Occasionally the
ulcerations become serious, and ulcerative endocarditis or malignant
endocarditis develops on the mild inflammation. In this form the
little vegetations are liable to become loosened, fly off into the
blood stream, and cause emboli in different parts of the body.
Recently Fraenkel [Footnote: Fraenkel: Beitr. z. path. Anat. u. z.
allg. Path., 1912, iii, 597.] concluded that the microscopic nodules
which occur in endocarditis in the myocardium, and which consist of
the several varieties of white blood corpuscles first referred to by
Aschoff in 1904, are characteristic only of acute rheumatism.
Fraenkel found these nodules in the myocardium in a case of chorea,
showing the close relationship between it and rheumatism.
While repeated careful examination of the heart during acute
infections will generally show signs of endocarditis if it is
present, even if there are no subjective symptoms, the disease may
be so insidious as not to be noted until a valvular lesion occurs.
Often, however, during the course of the disease, especially in
rheumatism, there is a slight increase in fever and there is a
discomfort complained of in the region of the heart, frequently
accompanied by slight dyspnea. Real pain is seldom present unless
the pericardium is affected. If the myocardium is much inflamed at
the same time, the heart becomes more rapid and the blood tension
lowered, and the apex beat diminished in intensity and perhaps not
palpable. If there is pain, with or without pericarditis, it is
often referred to the epigastrium, especially in children. The
patient is often nervous, restless and sleepless. In simple
endocarditis emboli rarely occur. If they do, of course the signs
will be in the part in which the infarct occurs. Besides the
diminished intensity of the apex beat and its greater diffusion, the
valve sounds may be muffled, and sooner or later there may be
systolic murmurs over the different orifices. Of course systolic
murmurs may be due to a disturbed condition of the blood, but if
they occur with the above-mentioned symptoms and signs, endocarditis
should be diagnosed. If the heart becomes seriously weak and the
patient suffers much dyspnea, myocarditis should be known to be
present with the endocarditis. If there is a diastolic murmur, there
can be no question of serious endocarditis having occurred.
Unexplainable palpation during acute illness liar been thought to be
a distinct symptom of endocarditis.
TREATMENT OF ENDOCARDITIS
As mild endocarditis rarely occurs primarily but is almost always
secondary to some acute disease, its immediate treatment is only a
slight modification of that of the disease which is causing it. A
complication which is so frequent should always be expected, and
consequently warded off or prevented, if possible. Knowledge of the
diseases which are most liable to cause endocarditis makes frequent
heart examinations a necessity, to note when it arrives. While an
extra heart tire, sleeplessness, and the circulation of unnecessary
toxins from a bad condition of the bowels and from improperly
selected food all make this complication more liable, its occurrence
is, nevertheless, often unpreventable.
The most efficacious preventive pleasures are sleep, rest, the
stopping of pain, prevention of exertion, proper food which does not
cause flatulence or other indigestion, good, sufficient daily
movements of the bowels, the prevention of intestinal distention,
and maintenance of a clean, moist surface of the body, produced by
such sponging and bathing as the temperature demands.
The disease having developed, the indications for treatment are
really few; in fact, the treatment is mostly negative. There is
generally but little local pain; the temperature from simple
endocarditis alone is not high and the acute symptoms tend to abate.
Local Treatment.--Endocarditis having been diagnosed, especially if
there is palpation or pain, an ice bag over the heart is often of
considerable value, but not so efficient as in pericarditis. It
often tends to quiet the heart, and may be of some value reflexly in
slowing the inflammation. If it causes restlessness, however, and
does not lessen the pain (which in some instances it may increase),
it certainly should be stopped. Children, in whom this complication
so frequently occurs, generally do not bear the ice bag well.
Sometimes it may be advisable to substitute warm applications, and
often a great deal of comfort is derived from them, the patient soon
going to sleep. One of the greatest values of either cold or hot
applications is diminution of the discomfort from the cardiac
disturbance, and the stopping of any pain which may be present. If
they do not do this, there is no object in using either cold or
heat.
The discomfort from blisters over the heart during the acute stage
of endocarditis is greater than any good which they can do. In
adults a few small blisters may be used intermittently around the
borders of the heart, after the acute symptoms are over, to act
reflexly on the heart and possibly aid absorption of inflammatory
products. Sometimes improvement seems to follow such treatment; it
certainly can do no harm.
During convalescence, the skin over the heart may be painted with
iodin, repeated often enough to cause stimulation without injuring
the skin; it seems at times to be of value. Various iodin or iodid
ointments have been used, but they probably have no more value than
the administration of small doses of iodid.
Systemic Treatment.--As this complication most frequently occurs
during acute rheumatism, the question arises as to the value or
harmfulness of salicylates and alkaline drugs. With our recent
better understanding of the action on the heart of pure salicylates
(either natural or synthetic saliclic acid, which have been shown to
act identically, if equally pure), we must believe that in any
ordinary dosage they will injure the heart but rarely. While
salicylic acid will not prevent endocarditis, it should he
continued, if it is of benefit with regard to the arthritis. The
indication for its use depends on its effect on the joints. As it
acts at times almost as a specific in rheumatism, it would seem that
it should be of value in the endocarditis caused by rheumatism. On
the other hand, the endocarditis occurs during the second or third
week of acute rheumatism, after the blood has been thoroughly
saturated with salicylic acid. Therefore it certainly does not tend
to prevent rheumatic endocarditis; hence for this complication alone
salicylic acid is not indicated.
ALKALIES
Anything which tends to increase the acidity of the tissues and to
diminish the alkalinity of the blood, whether from starvation or
outer causes, seems to pro-duce endocardial and myocardial
irritation, if not actual inflammation. Therefore in a disease like
rheumatism, which seems to be made worse by anything which increases
the acidity, alkalies are obviously indicated, and it is probable
that an increased alkalinity of the blood tends to prevent
endocardial irritation, and may soothe an inflammation already
present. Until we have some positive knowledge to the contrary,
alkalies should be freely administered during endocarditis,
especially during rheumatic endocarditis. Potassium citrate in 2 gm.
(30 grain) closes, in wintergreen water, should be given every three
to six hours, depending on how readily the urine is made alkaline.
This may be given with the salicylic acid treatment, and also when
the salicylic acid has been stopped. It may be well, if sodium
salicylate is being used, to give also sodium bicarbonate, the
sodium bicarbonate often preventing irritation of the stomach from
the sodium salicylate, the dose being equal parts of the sodium
salicylate and the sodium bicarbonate administered in plenty of
water. If some other form of salicylic acid is preferred,
novaspirin, which is methylene-citryl-salicylic acid and contains 62
percent of salicylic acid, is perhaps the least irritant to the
stomach of the salicylic preparations. This drug is decomposed in
the intestine into its component parts, salicylic acid and
methylene-citric acid. If this drug is combined with sodium
bicarbonate, the disintegration into its component parts would be
likely to occur in the stomach.
IRON
It is essential for the welfare of the patient, especially after a
long illness before the complication of endocarditis could occur,
and in rheumatic fever, in which all meat and meat extractives have
been kept from the diet, that small doses of iron should be
administered daily. Not only the fever process, but also the
salicylic acid tends to prevent the healthy normal growth of red
corpuscles. and such patients suffering from rheumatism are often
seriously anemic after the aente inflammation has ceased. The iron
administered may be 5 drops of the tincture of the chlorid, in
lemonade or orangeade, twice in twenty-four hours (and it should be
remembered that lemon and orange burn to alkalies in the system and
do not act as acids); or 0.1 gm. (1 1/2 grains) of reduced iron in
capsule twice in twenty-four hours, or a 3 grain tablet of
saccharated ferric oxid (Eisenzucker) twice in twenty-four hours.
OPIUM
As so many times repeated, real pain must be stopped, and morphin,
either by the mouth or hypodermically, should be used to the point
of stopping such pain. If the patient is a young child, codein
sulphate or the deodorized tincture of opium may be used in the dose
found sufficient, and either one will act satisfactorily. The dose
given should be small but repeated sufficiently often to stop the
pain. The dose necessary for the given individual will soon be
learned, and that dose may be repeated at such intervals as the
condition may require. Sometimes the hypnotic selected, if one is
needed, will be sufficient to quiet the cardiac aches or pains.
BROMIDS AND CHLORAL
If there is much restlessness and the circulation is good, that is,
if myocarditis is probably not present, the bromids may be of great
value, especially in children. The dose should be sufficient to
quiet the nervous system. The drug may be discontinued after a few
days, if the conditions improve. If the bromid, except in large
doses, will not cause sleep, a sufficient dose of chloral should be
given. Chloral is one of the most satisfactorily acting drugs which
we have to produce sleep and to cause cardiac rest. While it should
not be given if there is real cardiac weakness, the good which it
does is so much greater than the possible bad effect on the heart,
that it should not be forgotten for some newer hypnotic. The worst
part of this drug is its taste, and the best way to administer it is
to have it in solution in water and the dose given on cracked ice
with a little lemon juice to be followed by a good drink of water
and a piece of orange pulp for the patient to chew. Ordinarily a
bad-tasting drug such as chloral is well administered in
effervescing water, but effeverscing waters are generally
inadvisable when there is any kind of inflammation of the heart, as
they are liable to cause distention of the stomach and pressure on
the heart. Some physicians prefer chloralamid as a less disagreeable
drug and one which acts almost as efficiently as chloral. As the
close of this must be larger than the dose of chloral, it is a
question of doubt as to which is the better drug to use. Of the
newer hypnotics, veronal=sodium (sodium-diethyl-barbiturate) is
among the best. It acts quickly, is less depressant and is a safer
salt than most of the other newer hypnotics. It is the readily
soluble sodium salt of veronal (diethyl-barbituric acid). When
combined with any active drug, sodium seems to make it less toxic
and less depressant. The dose of this drug is from 0.2 to 0.3 gm. (3
to 5 grains).
PREVENTION
If the patient is weak, the circulation depressed, the blood
pressure low, and the heart rapid, the drug advisable to produce
rest and sleep is almost always morphin or some other form of opium.
Morphin, with few exceptions, is a cardiac tonic and a cardiac
stimulant, unless the dose is much too large. As long as the bowels
are daily moved and the food is not given at the time of the full
action of the morphin, when digestion might be delayed or interfered
with, in most patients the action of this drug during serious
illness is entirely for good. The greatest mistake in using morphin
for the production of sleep, or for physical and mental rest and
comfort when there is not severe pain, is in giving too large a
dose. If pain is not severe, or due to inflammatory distention of
some undilatable part, to pressure on some nerve, to distention of
some tube by a calculus or to some serious injury to the nerves,
large doses of morphin are not needed. Small doses will act much
more efficiently. It is excessively rare that a hypodermic of one-
fourth grain of morphin sulphate is needed, except for the
conditions enumerated. It is often a fact that so small a dose as
one-eighth grain of morphin or even one-sixth grain will cause
sufficient stimulation of a nervous patient, because its primary
stimulant effect on the spinal cord is greater than its depressant
effect on the brain, to require another dose (one-fourth grain
altogether) to give such a patient rest. On the other hand, this
patient may many times be quieted by one-tenth grain of morphin
sulphate on account of the size of the dose being not sufficient to
stimulate the spinal cord. Many a time clinically when one-eighth
grain has failed, a dose of one-fourth grain having been apparently
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