DISTURBANCES OF THE HEART
by
OLIVER T. OSBORNE, A.M., M.D.
Part 4 out of 5
and the heart.
Calcium: It has lately been learned that calcium is an element which
a heart needs for perfect activity. Many patients who are ill lose
their calcium, and they may not receive a sufficient amount of it
unless milk is given them. Even if such patients are taking milk,
the heart and the whole general condition sometimes such; to improve
when calcium is added to the diet. It may be given either in the
form of lime water, calcium lactate or calcium glycerophosphate. If
a medium-sized dose is given three or four times in twenty-four
hours, it is sufficient and will often act for good.
Whether calcium can do harm in a chronic endocarditis or an
arteriosclerosis to offset the value that it seems to have in
quieting the nervous system and in being of value to a weak or
nervously irritable heart is a question which has not been decided.
Theoretically lime should not be given when there is a tendency to
calcification, or when a patient is past middle age. Lime seems to
be essential to youth, and to the welfare of nervous patients.
EMERGENCIES
5. Cardiac Emergency Drugs.--Besides some of the drugs already
mentioned (such as camphor hypodermically, nitroglycerin when
indicated, strophanthin hypodermically or intravenously, caffein and
strychnin), often ergot, suprarenal vasopressor principle, pituitary
vasopressor principle, atropin and morphin should be considered.
When there is low blood pressure, venous stasis, pulmonary
congestion, cyanosis and a laboring, failing heart, intramuscular
injections of ergot, with or without coincident venesection, may be
the most valuable method of combating the condition. Life has been
saved in this kind of sudden acute cardiac failure in valvular
disease. When venesection is not indicated in certain conditions of
low blood pressure and heart failure, ergot has saved life. It
causes contraction of the blood vessels and seems to tone the heart.
Incidentally it quiets the central nervous system. If the blood
pressure is much increased by it, the ergot should not be repeated,
as too much work should not be thrown on the heart muscle. Often,
however, it may be administered intramuscularly with advantage in
aseptic preparation as offered in ampules, at the rate of one ampule
every three hours for two or three times, and then once in six hours
for a few times, the future frequency depending on the indications.
Epinephrin and Pituitary Extract: The blood pressure-raising
substance of the suprarenals or of the pituitary gland (hypophysis
cerebri) has been much used in heart failure. These substances
certainly would not be indicated in high blood pressure; they are
indicated in low blood pressure. They have been given intravenously;
they are frequently given hypodermically. They often act rapidly
when a solution in proper dose is dropped on the tongue. The blood
pressure rise from epinephrin is quickly over; that from the
pituitary extract lasts longer. In large doses, or when it is too
frequently repeated, epinephrin depresses the respiration. Pituitary
extract acts as a diuretic. Sterilized solutions of both, put up in
ampules ready for hypodermic medication, are obtainable, the
strength offered generally being 1 part of the active principle to
10,000 of the solution. Hypodermic tablets of epinephrin may also be
obtained. Stronger solutions of 1 part to 1,000 may be dropped on
the tongue, or tablets may be dissolved on the tongue. The blood
pressure is temporarily raised and the heart stimulated by these
treatments, but epinephrin is not used so often for cardiac failure
as it was a short time ago.
The most satisfactory action, especially from the epinephrin, is
from small doses frequently repeated. Sometimes in serious
emergencies it has been found to be of value when given
intravenously in physiologic saline solution. The close, of course,
should be very small. In circulatory weakness in acute illness,
epinephrin has been given regularly, a few drops (perhaps the most
frequent dose is 5) of a 1: 1,000 solution, on the tongue, once in
six hours. Such a dosage may be of value, and certainly is better
than the administration of too much strychnin. Much larger or more
frequent doses are likely, as just stated, to depress the
respiration.
Besides the small amount of blood pressure-raising substance
secreted by the hypophysis cerebri. it has not been shown that any
other gland of the body furnishes vasopressor substance except the
suprarenals.
Atropin: When there is great cardiac weakness, atropin may be used
to advantage. The dose is from 1/200 to 1/150 grain hypodermically,
not repeated in many hours. It will whip up a flagging heart, more
or less increase the blood pressure, cause cerebral awakening, and
may often be of value. If there is any idiosyncrasy against atropin,
if the throat and mouth are made intensely dry, or if there is
serious flushing or cerebral excitement, the dose should not be
repeated.
Morphin: This would rarely be considered as an emergency drug in
cardiac weakness. A small dose of it, not more than one-eighth
grain, especially if combined with atropin, will often quiet and
brace a weak heart, especially when there is cardiac pain. Just
which drug or drugs should be used and just which are not indicated
can never be specifically outlined in a textbook, a lecture or a
paper. The decision can be made only at the bedside, and then
mistakes, many times unavoidable, are often made.
In all conditions of shock with cardiac failure, the blood vessels
of the abdomen and splauclinic system are dilated, and more or less
of the blood of the body is lost in these large veins, and the
peripheral and cerebral blood pressure fails. The advantage in such
a condition of firm abdominal bandages, and of raising the foot of
the bed or of raising the feet and legs, need only be mentioned to
be understood.
It is a pretty good working rule, in cardiac failure, not to do too
much. On the other hand, life is frequently saved by proper
treatment, and the physician repeatedly saves life as surely as does
the surgeon with his knife.
CONVALESCENCE
When compensation has been restored, the patient may be allowed
gradually to resume his usual habits and work, provided these habits
are sensible, and the work is not one requiring severe muscular
exertion. Careful rules and regulations must be laid down for him,
depending on his age and the condition of his arteries, kidneys and
heart muscle. It should be remembered that a patient over 40, who
has had broken compensation, is always in more dancer of a
recurrence of this weakness than one who is younger, as after 40 the
blood pressure normally increases in all persons, and this normal
increase may be just too much for a compensating heart which is
overcoming all of the handicap that it can withstand. Such patients,
then, should be more carefully restricted in their habits of life,
and also should have longer and more frequent periods of rest.
The avoidance of all sudden exertion in any instance in which
compensation has just been restored is too important not to be
frequently repeated. The child must be prevented from hard playing,
even running with other children, to say nothing of bicycle riding,
tennis playing, baseball, football, rowing, etc. The older boy and
girl may need to be restricted in their athletic pleasures, and
dancing should often be prohibited. Young adults may generally,
little by little, assume most of their ordinary habits of life; but
carrying heavy weights upstairs, going up more than one flight of
stairs rapidly, hastening or running on the street for any purpose,
and exertion, especially after eating a large meal, must all be
prohibited. Graded physical exercise or athletic work, however, is
essential for the patients' future health, and first walking and
later more energetic exercise may be advisable.
These patients must not become chilled, as they are liable to catch
cold, and a cold with them must not be neglected, as coughing or
lung congestions are always more serious in valvular disease. Their
feet and hands, which are often cold, should be properly clothed to
keep them warm. Chilling of the extremities drives the blood to the
interior of the body, increases congestion there, and by peripheral
contraction raises the general blood pressure. A weak heart
generally needs the blood pressure strengthened, but a compensating
heart rarely needs an increase in peripheral blood pressure, and any
great increase from any reason is a disadvantage to such a heart.
The patient should sleep in a well ventilated room, but should not
suffer the severe exposures that are advocated for pulmonary
tuberculosis, as severe chilling of the body must absolutely be
avoided.
The peripheral circulation is improved, the skin is kept healthy,
the general circulation is equalized, and the heart is relieved by a
proper frequency of warm baths. Cold baths are generally
inadvisable, whether the plunge, shower or sponging; very hot baths
are inadvisable on account of causing a great deal of faintness;
while warm baths are not stimulating and are sedative. The Turkish
and Russian bath should be prohibited. They are never advisable in
cardiac disease. With kidney insufficiency, body hot-air treatment
(body-baking), carefully supervised, may greatly benefit a patient
who has no dilatation of the heart and who has no serious broken
compensation. Surfbathing, and, generally, sea-bathing and lake-
bathing are not advisable. The artificial sea-salt baths and carbon
dioxid baths may do some good, but they do not lower the general
blood pressure so surely as has been advocated, and probably no
great advantage is apt to be derived from such baths. If a patient
cannot properly exercise, massage should be given him
intermittently.
Any systemic need should be supplied. If the patient is anemic, he
should receive iron. If he has no appetite, he should be encouraged
by bitter tonics. If sleep does not come naturally, it must be
induced by such means as do not injure the heart.
Perhaps there is no better place in this series on diseases of the
heart to discuss the diet in general and the resort treatment than
at this point, as the question is one of moment after convalescence
from a broken compensation, at which time every means must be
inaugurated to establish a reserve heart strength to overcome the
daily emergencies of life.
DIET AND BATHS IN HEART DISEASE
The diet in cardiac diseases has already incidentally been referred
to. The decision as to what a patient ought to eat or drink must
often be modified by just what the patient will do, and, as we all
know, it is absolutely necessary to make some concessions in order
for him to aid us in hastening his own recovery or in preventing him
from having relapses. Consequently, we cannot be dogmatic with most
patients with chronic heart disease. Parents should be prohibited
from allowing children or adolescents with heart disease to drink
tea, coffee or any alcoholic stimulant. The young boy and young man
must absolutely be prohibited from indulging in tobacco at all.
There is no excuse for allowing these stimulants or foods in such
cases. If the patient is older and has been accustomed to tea and
coffee, one cup of coffee in the morning may be allowed, provided a
decaffeinated coffee is not found satisfactory. Whether a small cup
of coffee or a cup of tea is allowed at noon is again a matter for
individualization; they should rarely be allowed after the noon
meal. In a patient who has been accustomed to alcohol regularly
(generally an older patient), careful judgment should be used in
deciding whether or not a small amount of alcohol daily should be
allowed. It should never be in large amounts, even of a dilute
alcohol like beer; it may be a weak wine; it may be a small amount
of diluted whisky, if seems best. Ordinarily the patient is better
without it. If he is used to smoking and a small amount does not
raise the blood pressure much, it may do him no harm to smoke a
small mild cigar once or twice a clay. On the other hand, if a hard
smoker suddenly has heart failure, whether from exertion, from
chronic disease or from acute illness, a small amount of smoking is
of advantage as it tends to remove cardiac irritability, to raise
the blood pressure, and actually to quiet and improve the
circulation. It is unwise during acute circulatory failure to take
tobacco away entirely from a chronic tobacco user.
The character of the food which each patient should receive depends
on his blood pressure and his age. The older person with a tendency
to high blood pressure should have the protein (especially meat)
reduced in amount, as any putrefaction in the intestine with
absorption of products of such maldigestion irritates the blood
vessels, raises the blood pressure, and injuries the kidneys. On the
other hand, a young patient should receive a sufficient meat diet
rather than be overloaded with vegetables and starches, to the easy
production of fermentation and gas. Flatulence from any cause must
be avoided. It dilates the stomach and intestines, causing them to
press on the diaphragm, so that the heart and respiration are
interfered with. Also, an increased abdominal pressure, especially
if there is any edema or dropsy, is bad for the circulation. A
distended, tense abdomen is serious in cardiac failure. On the other
hand, a flaccid, flabby, lax abdomen should be well bandaged in
cardiac failure with low blood pressure.
Children do well on a milk diet, but it should be remembered that
excessive amounts of any liquid, even milk and water, are
inadvisable, if the circulation is poor and there is a tendency to
dropsy. It has been recommended at times to limit a patient's diet
for a week or so to a small amount of milk, not more than a quart in
twenty-four hours. If such a patient is in bed and does not require
carbohydrates, sugars or stronger proteins or more fat, such a
restricted diet may aid in establishing circulatory equilibrium,
although he will lose in nutrition. The excretory organs are
relieved by the decreased amount of excretory product, the digestive
system is rested and the circulation is improved. Such a limited
diet should not be tried longer than a week, but it may be the
turning point of circulatory improvement.
The ordinary diet for a convalescing heart patient should be small
in bulk, of good nutritive value, and should represent all the
different elements for nutrition. This means a small amount of meat,
once a day to older patients, twice a day to those who work hard or
for young patients; such vegetables as do not cause indigestion with
the particular patient, and these must be individualized; such
fruits as are readily digested, especially cooked fruits; generally
plenty of butter, cream, olive oil if the nutrition is low, and
milk, depending on the age of the patient or the ease with which it
is digested. Soups, on account of their bulk and low nutritive
value, should be avoided. Anything that causes indigestion, such as
fried foods, hot bread, oatmeal or any other gummy, sticky,
gelatinous cereal should be avoided; also spices, sauces and strong
condiments. Anything that is recognized as especially loaded with
nuclein and xanthin bodies, such as liver, sweetbreads and kidneys,
should be prohibited, as tending to cause uric acid disturbance; and
the more tendency to gout or uric acid malmetabolism the more
irritated are the arteries and the more disturbed the blood
pressure. Sugars should be used moderately unless the patient is
thin and feels cold, in which case more may be given, provided there
are no signs of gout or disturbed sugar metabolism. Sugar is at
times a good stimulant food. Very cold and very hot drinks or food
should be avoided.
Many times these patients have a diminished hydrochloric acid
secretion, and such patients thrive on 5 drops of dilute
hydrochloric acid in water, three times a day, after meals. When
their nutrition has improved and the digestion becomes perfect,
hydrochloric acid will generally be sufficiently secreted and the
medication may be stopped.
If the patient is overweight, this obesity must be reduced, as
nothing more interferes with the welfare of the heart than
overweight and overfat. In these cases the diet should be that
required for the condition. If there are edemas, or a tendency to
edemas, the decision should be made whether salt (sodium chlorid)
should be removed from the diet. Unless there is kidney defect,
probably it need not be omitted, and a long salt-free diet is
certainly not advisable. This salt-free diet has been recommended
not only in nephritis and heart disease, but also in diabetes
insipidus and in epilepsy. It is of value if there is edema in
nephritis; it is of doubtful value in heart disease; it is rarely of
value in diabetes insipidus; and in epilepsy its value consists
probably in allowing the bromid that may be administered to have
better activity in smaller doses, the bromin salt being substituted
in the metabolism for the chlorin salt.
THE RESORT TREATMENT OF CHRONIC HEART DISEASE
In line with the continued growing popularity of special resorts and
special cures for different types of disease, resort or sanatorium
treatment for chronic heart disease has grown to considerable
popularity during the last twenty years or more. The most popular of
these resorts owe their success to the personality of the
physicians, who have made heart disease a life study.
Perhaps the most noted of these resorts for the cure of heart
disease is that at Bad Nauheim, Germany, which was inaugurated by
Dr. August Schott and Prof. Theodore Schott, and is now conducted by
the latter, Dr. August Schott having died about fifteen years ago.
Hundreds of patients and many physicians have testified to the value
and benefit of the treatment carried out at this institution.
The method of treatment largely employed at these heart resorts is
to withdraw all, or nearly all, of the active drugs that the patient
may be taking, and to substitute physical and physiologic methods of
therapy. These include bathing, regulation of the diet, and
exercise. This exercise consists of two varieties: exercise of the
muscles against the resistance of an attendant, and exercise by
walking on inclined planes or up hills. The treatment is aimed at
chronic heart disease, to develop a greater cardiac reserve
strength; the whole object of the treatment is to strengthen the
myocardium, either in conditions of its debility or in conditions of
diminished compensation in valvular disease. Any treatment that will
develop a reserve heart strength to be called on in emergencies,
more or less similar to the reserve strength of a normal heart,
tends to prolong the patient's life and health.
Patients with acute heart failure or acute loss of compensation,
with more or less serious edemas, should rarely take the risk of
traveling any distance to be treated at an institution. As a general
rule they are better treated for a few weeks or months at home.
After the broken compensation is repaired, a reserve strength of the
heart may well be developed by a visit to one of these institutions,
if the patient can afford it.
The Oertel treatment consists chiefly in diminishing the fluids
taken into the body, and in graduated mountain climbing. By
diminishing the fluids taken, the work of the heart is diminished,
as the blood vessels are not overfilled and may be even underfilled.
The diet is carefully regulated with the object of removing all
superfluous fat from the body. The third leg of the tripod of the
Oertel treatment is the gradually increasing hill and mountain
climbing to educate the heart by graded muscular training to become
strong, perfectly compensatory, and later to develop a reserve
strength. This particular cure is especially adapted to the obese,
who have weakened heart muscles.
NAUHEIM BATHS
At Nauheim, under the direction of Dr. Theodore Schott, baths form
an important part of the treatment. These baths are of two kinds,
the saline and the carbonic acid. The medicinal constituents of the
saline bath are sodium chlorid and calcium chlorid, the strength of
each varying from 2 to 3 percent The baths at first arc given at a
temperature of 95 F., and as the patient becomes used to them and
can take them without discomfort, the temperature is gradually
reduced. The patient remains in the bath from five to ten minutes.
After the bath he is dried with towels and rubbed until the
cutaneous circulation becomes active. He must then lie down for an
hour. These baths are repeated for two or three days, and are
omitted on the third and fourth days, to be resumed on the following
day. After a few baths have been taken, the carbon dioxid baths are
commenced, beginning with a small quantity of the gas which is later
gradually increased. This course of baths should be continued from
four to eight weeks. Unless there is some special reason for taking
them at some other period of the year, they are taken more
advantageously during the warm months.
Besides the baths, all important part of the treatment at Nauheim
consists in the exercises against resistance. These are usually
given an hour or more after a bath, and are taken with great
deliberation; their effect is carefully watched by an intelligent
attendant so that no harm may be done by the exercise.
During this treatment the food is, of course, carefully regulated
with the aim of giving a mixed, sufficient, easily digestible and
easily assimilated diet. All highly seasoned dishes, all
effervescent drinks and anything that tends to cause gas in the
stomach and intestines are prohibited. Coffee and tea are not
allowed, except coffee without caffein; and it may be noted that it
has recently been shown that caffein is one of the surest of drugs
to raise the blood pressure, and is therefore generally not
desirable when the heart muscle requires strengthening. Because of
its tendency to raise blood pressure and weaken cardiac muscle,
tobacco is entirely forbidden at Nauheim, except in a few individual
instances, and then the amount allowed is a minimum one. Large
amounts of liquid are not allowed because they distend the stomach,
raise the blood pressure and increase the pumping work of the heart.
One of the greatest advantages of the treatment at an institution
like Nauheim is the general hopeful spirit instilled into the
patients, who are so many times seriously depressed by the knowledge
of a heart weakness and the realization of their physical inability
to do what other persons are able to do. Also, it is of great value
to send a patient to a resort where the climate is good and the
scenery is lovely and soothing. No disease, perhaps, needs
cheerfulness and pleasantness and lack of anxiety, or frets more
than does cardiac weakness. A tuberculous patient may sit on a
mountain top with snow blowing about him, and recover; a heart
patient must have sunshine and comfort.
The results of such sanatorium treatment of heart disease are often
evident not only to the patient by an increase of general muscle
strength, the ability to do ordinary things and perhaps even sustain
muscular effort without dyspnea and cardiac discomfort, but also to
the physician by the physical signs. The contraction of the heart
becomes stronger and the normal sounds more decided; murmurs which
were entirely due to dilated ventricles and insufficiency disappear,
while the permanent murmurs may become louder from a more forceful,
normal action of the heart muscle. The pulse becomes slower, and the
blood pressure, from being too low, becomes normal for the age of
the individual. The heart will often also actually decrease in size,
and the apex beat become localized rather than diffuse, The liver
becomes reduced in size; the urine is less concentrated, and if
there were traces of albumin after exertion, these disappear.
It should perhaps be emphasized that not a little benefit from these
resort treatments may be due to the withdrawal of unnecessary drugs.
Many heart patients are overdrugged.
This sort of treatment is contraindicated in some kinds of heart
disease, as heart weakness due to arteriosclerosis with high blood
pressure, to aneurysm of the thoracic or abdominal aorta, and to
nephritis.
So many heart patients have been improved by the Nauheim treatment
that the question arises as to whether the treatment can be
conducted at home or in a sanatorium near home, when the patient is
unable to go to this resort; that is to say, Can we establish this
treatment for the majority of patients who have chronic heart
disease? Of course, even at home, the sodium chlorid and calcium
chlorid baths may be given, and one may obtain the salts all
prepared to make the carbon dioxid bath; the exercises may be given,
and walking on various ascending grades may be inaugurated. All
patients will be more or less benefited, provided they will carry
out the treatment. Unfortunately, the surroundings at a patient's
home are generally adverse to perpetuating these treatments long
enough to develop the muscular strength of the heart to the reserve
desired. If a patient appears pretty well, especially if he is
stimulated by his family to believe that he is well, he thinks the
continuation of the treatment entirely unnecessary, and unless he
goes to a resort where he sees other patients with similar
conditions able to do what he is not able to do, and therefore is
stimulated to acquire their ability by the treatment outlined, he
will not follow his physician's directions. There are several
sanatoriums in this country where the diet, hydrotherapy and
exercise necessary for developing heart strength are carried out,
and patients are sent to some of them with great advantage.
It has been found that these stimulant baths do not act well in
mitral stenosis, if the left ventricle is small. If the left
ventricle is unable to receive and therefore send out into the
systemic circulation sufficient blood to dilate the peripheral
capillaries under the irritation of the baths or the vasodilator
effects of the baths, the bath treatment does harm instead of good.
A patient who has mitral stenosis and also a small left ventricle
will be found to be poorly developed, badly nourished, and to have
poor peripheral circulation.
As elsewhere stated, the improvised carbon dioxid bath, to stimulate
the skin so as to reduce the blood pressure, is not satisfactory.
Other methods of reducing blood pressure, when it is too high, are
much more effective.
HEART DISEASE IN CHILDREN AND DURING PREGNANCY
A common characteristic in a large proportion of middle-aged or old
patients with heart disease is the presence of degenerative changes
in the myocardium, the valves, or the arteries of the heart. In
children, on the other hand, the most common disturbances of the
heart are acute inflammations affecting its different structures,
and due in most instances to acute infections. Myocarditis and
endocarditis occur frequently, and pericarditis occasionally. As in
adults, rheumatism is the most common cause of inflammation of the
structures of the heart, but rheumatism causes inflammation of the
heart much more frequently in children than in adults. Besides this
infection, the most frequent causes of inflammation of the heart in
children are diphtheria, scarlet fever, typhoid fever, measles and
influenza, with the frequency, perhaps, in the order named.
Diphtheria frequently gives rise to myocarditis, which results in
dilatation of the heart. This may occur in the second or third week
of the course of the disease, and even up to the eighth and tenth
week from the beginning of the disease. The myocarditis due to
diphtheria is not always the cause of sudden death occurring during
the disease, as such a fatal result may be due to paralysis of
nervous origin. In scarlet fever, inflammation of the heart may be
due directly to the poison of the disease, or it may be secondary to
a nephritis which is so frequent a complication of scarlet fever. It
is probable that the inflammation of the skin in scarlet fever,
preventing normal secretion, may be a cause of a sometimes increased
blood pressure and also of the nephritis, both of which conditions
may predispose to the cardiac complication. Erysipelas may cause
acute inflammation of the heart, perhaps for the same reason.
A certain proportion of cardiac diseases in children, especially
endocarditis, seems to be due to a general septic infection which
results in the so-called septic, infectious or malignant
endocarditis. There is sometimes a tendency in certain children, and
perhaps in certain families, for the heart to become readily
infected during an infectious disease, more than in other children
who suffer from the same disease. Sometimes the heart becomes
inflamed in rheumatic children without any joint affection
occurring; the inflammation in the heart may be the only
manifestation of the disease.
This etiology of cardiac affections of children indicates the
directions in which therapeutic efforts should be aimed. In children
who are under the more or less constant care of the family
physician, the possibility of the occurrence of some cardiac
affection should be borne in mind, especially in children in
families which are known to be affected with what may be called a
rheumatic diathesis--families in which several members have suffered
from rheumatism. It is reasonable to suppose that children who are
delicate and feeble, who do not have sufficient fresh air, who do
not take sufficient exercise, and who are not properly fed are more
liable to be affected with cardiac complications in the presence of
infectious diseases than children who have had plenty of fresh air,
an abundance of exercise and a sufficient amount of proper food.
At the present day it is hardly necessary to insist on the
importance of giving every child an adequate amount of fresh air. It
is possible, however, that this gospel has been overworked, and it
is not infrequently necessary to caution some parents that there is
danger of impairing their children's health by too much exposure.
The old ideas of the influence of exposure to cold and dampness in
the production of rheumatism have not yet been so far abandoned that
we can entirely neglect the possibility of rheumatism being
developed, at least, by the exposure to cold winds and dampness of
children who are otherwise predisposed to this disease. It is
possible that the enormously increasing number of children with
adenoids and enlarged tonsils, who need operative measures for their
removal, may have these conditions aggravated by too much exposure
to the inclemency of variable, harsh weather.
It is not necessary to state that proper exercise develops the
heart, as it does all the other muscles; but at the same time it is
necessary to caution parents against allowing their children to
indulge in too violent and too prolonged exercise. Young children
probably stop often enough in their play not to overwork their
hearts. Older boys and girls, especially boys, are inclined to take
too severe athletics, such as long-distance running, competitive
rowing, violent football and rapid cycling. It should be emphasized
to school-masters, gymnasium teachers and athletic trainers that a
boy who is larger than he should be at his age has not the
circulatory ability that the older boy of the same size has. The
overgrown boy has all he can do to carry his bulk around at the
speed of his age and youth. The addition of competitive labor
overreaches his reserve heart power, and he readily acquires a
strained, injured heart. On the other hand, moderate indulgence in
walking, baseball, swimming, rowing and golf should be commended. It
is not exactly the exercise that does him the harm, it is the
competitive element in it. Until a boy is well developed in his
internal reserve strength, he should not compete with other boys who
are better developed. His pride makes him do himself injury.
Dietetic fads are so prevalent today that there is danger that many
children will not receive an adequate amount of nutriment, that they
will be fed an excess of such foods as are likely to produce damage
to their constitutions, or that they will be given food which does
not contain all the different elements of nutrition to satisfy their
economy and their growth. While it is now generally acknowledged
that an excess of meat is not beneficial to any one, on the other
hand a moderate amount is necessary for individuals who are working
or are mentally active, especially for growing children. Also a too
great limitation of the child's diet to farinaceous foods, and
especially the allowance of too much sugar and sugar-producing food,
is liable to encourage the development of rheumatism. A mixed diet,
not excessive in amount, and prepared so that it will be digested
without difficulty, is most useful, and it should include in
suitable proportions meat, milk, eggs, vegetables, starches and
fruit. These should all be taken at regular intervals, thoroughly
chewed, and should not be taken in excess.
If a child has had an attack of heart inflammation, a myocarditis or
an endocarditis, greater care should be taken of him not only when
he is well but especially when he becomes ill of any other disease.
If the child has had a rheumatic inflammation of the heart, or has
had rheumatism without such a complication, it is considered by some
clinicians wise to give a week's treatment with salicylates at
intervals of three or four months, for two or three years, perhaps.
It is hard to determine how much value this prophylactic treatment
has. If the child's surroundings cannot be changed and lie is
subjected to the same conditions of possible reinfection, it may be
a wise precaution, much like the prophylactic administration of
quinin in malarial regions. If a child has developed a cardiac
inflammation during any disease, the treatment is that previously
outlined.
An important part of prophylaxis and treatment of a cardiac
affection during the course of any disease is the prevention of
serious anemia. During sickness the patient is liable to become more
or less anemic, but the administration of iron, in the manner
previously suggested, during the course of the disease, and
especially during rheumatism, will prevent the anemia becoming rapid
or severe.
CARDIAC DISEASE IN PREGNANCY
It is so serious a thing for a woman with valvular lesion or other
cardiac defect to become pregnant that no young woman with heart
disease should be allowed to marry. Perhaps every normal heart
during pregnancy hypertrophies somewhat to do the extra work thrown
on it, but it may easily become weakened and show serious
disturbance as its work grows harder and the distention of the
abdomen and the upward pressure on the diaphragm increase. This
pressure perhaps generally displaces the apex of the heart to the
left and causes the heart to lie a little more horizontal. If the
patient is normal, there may be a gradually increasing blood
pressure all through the months of pregnancy, and if the kidneys are
at all disturbed this pressure is increased, and there is, of
course, much increased resistance to the circulation during labor.
The better the heart acts, the less likely are edemas of the legs
during pregnancy. It is thus readily seen that pregnancy is a
serious thing for a damaged heart. The reserve strength of the heart
muscle, as has been previously stated, is much less in valvular
compensation than that of the normal heart, and this reserve force
is easily overcome by the pregnancy, and loss of compensation occurs
with all of its usual symptoms.
The most serious lesion a woman may have, as far as pregnancy is
concerned, is mitral stenosis. An increased abdnominal pressure
interferes with her lung capacity, and her lungs are already
overcongested. The left ventricle may be small with mitral stenosis,
and therefore her general systemic circulation poor. For those two
reasons mitral stenosis should absolutely prohibit pregnancy. While
many women with well compensated valvular disease go through
pregnancy without serious trouble, still, as stated above, they
should be advised never to marry. If they do marry, or if the lesion
develops after marriage, warning should be given of the seriousness
of pregnancies.
If a woman becomes pregnant while there are symptoms or signs of
broken compensation, there can be no question, medically or morally,
of the advisability of evacuating the uterus. The same ruling is
true if during pregnancy the heart fails, compensation is broken,
and the usual symptoms of such heart weakness develop, provided a
period of rest in bed, with proper treatment, has shown that the
heart will not again compensate. Under such a condition delay should
not be too long, as the heart may become permanently disabled. If,
during pregnancy in a patient with a damaged heart, albuminuria
develops and the blood pressure is increased, showing kidney
insufficiency, there can be no question of delay, from every point
of view, and labor must be precipitated; the uterus must be emptied
to save the mother's life.
If a pregnant woman is known to have a degenerative condition of the
myocardium, or arteriosclerosis, the danger from the pregnancy is
serious, and the pregnancy should rarely be allowed to continue.
Even if no serious symptoms occur during the term of the pregnancy,
and the heart continues to compensate sufficiently for its defect,
labor should never be allowed to be prolonged. The tension thrown on
the heart during labor is always severe, and has not infrequently
caused acute heart failure by causing acute dilatation, and in these
damaged hearts tediousness and severe, intense exertion should not
be allowed. Proper anesthetics and proper instrumentation should be
inaugurated early.
Patients who have successfully passed through the danger of
pregnancy with cardiac lesions, possibly relieved by radical
treatments, should be warned against ever again becoming pregnant.
If this warning does not prevent future pregnancies, the family
physician and his consultant must decide just what it is proper to
do. It is to be understood that no uterus should ever be emptied
until one or more consultants have approved of such treatment.
Sometimes serious heart weakness develops during the later weeks of
pregnancy, requiring the patient to remain in bed and receive every
advantage which rest, proper care and well judged medicinal
treatment will give the circulation.
If the heart is weak and there have been signs of myocardial
weakness or loss of compensation, the sudden loss of abdominal
pressure after delivery may allow the blood vessels of the abdomen
to become so overfilled as to cause serious cerebral anemia and
cardiac paralysis. Therefore in such cases a tight bandage must
immediately be applied, and it has even been suggested that a
weight, as a bag of sand weighing several pounds, be placed
temporarily on the abdomen. The greatest possible care should be
given these women during and after labor.
Acute dilatation is not an infrequent cause of death during ordinary
labor, and is more apt to occur in these cardiac patients. If signs
of acute dilatation of the heart occur, with associated pulmonary
edema, venesection (especially if there has not been much uterine
hemorrhage), with the coincident intramuscular injection of one or
two syringefuls of aseptic ergot, will often be found to be life-
saving treatment. Septic infections after parturition are prone to
cause endocarditis and myocarditis, and a malignant endocarditis may
develop from uterine infection or uterine putridity.
DEGENERATIONS
CORONARY SCLEROSIS
While disease of the coronary arteries may occur without general
arteriosclerosis, it is so frequently associated with it that it is
necessary to give a brief description of the general disease.
Arteriosclerosis or arteriocapillary fibrosis is really a
physiologic process naturally accompanying old age, of which it is a
part or the cause, and it should be considered a pathologic
condition only when it occurs prematurely. It may, however, occur at
almost any age after 30, and is beginning to be frequent between 40
and 50. In rare instances it may occur between 20 and 30, and even
in childhood and youth. It is much more frequent in men than in
women. Its most common cause is hypertension; in fact, hypertension
generally precedes it. The most frequent cause of hypertension today
is the strenuousness of life, the next most frequent cause being the
toxins circulating in the blood from overeating, overdrinking,
overuse of tobacco and the overuse of caffein in the form of coffee,
tea or caffein drinks. Another common cause of arteriosclerosis
occurring too early is the occurrence of some serious infection in a
person, typhoid fever and sepsis being most frequent. Syphilis is a
frequent cause, especially of that form of arteriosclerosis which
shows the greatest amount of disease in the aorta. Mercury used in
the treatment of syphilis is more liable, however, than syphilis to
be the cause of arteriosclerosis. Although this drug, even with the
arsenic injections now in vogue, is necessary for the cure of
syphilis, it probably tends to raise the blood pressure by
irritating the kidneys and by diminishing the thyroid secretion,
both of these occurrences predisposing to arteriosclerosis. From the
fact that lead poisoning causes an increased blood pressure, lead is
a probable cause of arteriosclerosis. With the greater knowledge of
the danger of poisoning possessed by those who work in lead, chronic
lead poisoning is becoming rare, as evidenced by the lessening
frequency of wrist drop and lead colic.
Chronic nephritis is often a coincident disease, but the causes of
the arteriosclerosis and the nephritis are generally the same.
Alcohol, except as a part of overeating and as a disturber of the
digestion, is perhaps not a direct cause of arteriosclerosis, as
alcohol is a vasodilator. Hard physical labor and severe athletic
work may cause arteriosclerosis to develop, and it is liable to
develop in the arteries of the parts most used.
Hypertension is generally a prelude to arteriosclerosis, and
everything which tends to increase tension promotes the disease;
everything which tends to diminish tension more or less inhibits the
disease. Therefore a subsecretion of the thyroid predisposes to
arteriosclerosis, and increased secretion of the suprarenals
predisposes to arteriosclerosis, the thyroid furnishing vasodilator
substance and the suprarenals vasopressor substance to the blood.
Furthermore. if these secretions are abnormal, protein metabolism is
more or less disturbed.
While arteriosclerosis often occurs coincidently with gout, and gout
apparently may be a cause of arteriosclerosis, still the two
diseases are widely dissociated, and the causes are not the same.
Although the arterial pressure has been high before arteriosclerosis
developed, and may remain high for some time in the arteries, unless
the heart fails, the distal peripheral pressure, as in the fingers
and toes, may be poor in spite of the high blood pressure. When the
left heart begins to fail, pendent edema readily occurs.
PATHOLOGY
The pathology of arteriosclerosis is a thickening and diminishing
elasticity of the arteries, beginning with the inner coat and
gradually spreading and involving all the coats, the larger arteries
often developing calcareous deposits or thickened cartilaginous
plates--an atheroma. If the thickening of the walls of the smaller
vessels advances, their caliber is diminished, and there may even be
complete obstruction (endarteritis obliterans). On the other hand,
some arteries, especially if the calcareous deposits are
considerable, may become weakened in spots and dilation may occur,
causing either smaller or larger aneurysms.
Histologically the disease is a connective tissue formation
beginning first as a round-cell infiltration in the subendothelial
layer of the intima. This process does not advance homogeneously;
one side of an artery may be more affected than the other, and the
lumen may be narrowed at one side and not at the other, allowing the
artery to expand irregularly from the force of the heart beat. As
the disease continues, the internal elastic layer is lost, the
muscular coat begins to atrophy, and then small calcareous granules
may begin to be deposited, which may form into plates. In the large
arteries, the advance of the process differs somewhat. There may be
more actual inflammatory signs, fatty degeneration may occur, and
even a necrosis may take place.
However generally distributed arteriosclerosis is, in some regions
the disease is more advanced than in others, and in those regions
the most serious symptoms will occur. The regions which can stand
the disease least well are the brain and coronary arteries, and next
perhaps the legs, at the distal parts at least, where the
circulation is always at a disadvantage if the patient is up and
about.
SYMPTOMS
The symptoms are increased tension, which means, sooner or later,
hypertrophy of the left ventricle and an accentuated closure of the
aortic valve. This alone means more and more tendency to aortic
irritation and aortic valve irritation, with inflammation, and later
deposits of calcareous material, perhaps with stiffening of the
aortic valve and narrowing, aortic stenosis being the result. If
such a patient with the disease advanced to this stage must
overwork, or sustains any severe muscle strain, an aneurysm of the
aorta may occur. In the meantime, with the advancing degeneration of
the cerebral arteries, some sudden cerebral congestion, caused by
leaning over, lifting, vomiting or hard coughing, may rupture a
cerebral vessel, and all the symptoms of apoplexy are present. If
small hemorrhages occur in the arterioles of the extremities, of
course the prognosis is not serious. Sometimes some of the smaller
vessels of the brain may become obstructed and cerebral degeneration
occur. If distal vessels become obstructed, as of the toes or feet,
gangrene takes place unless the obstruction occurs at a place where
the collateral circulation could save the part from such a death.
These are some of the ultimate results of serious and final
arteriosclerosis. The more frequent result, when the disease has not
advanced so far, is a failing heart, either from degenerative
myocarditis, coronary sclerosis or dilatation, with all the symptoms
of coronary sclerosis and angina pectoris, or with the symptoms of
failing circulation.
With high blood pressure to the point of beginning endarteritis, a
gradually increasing force of the apex beat occurs, the aortic
closure is accentuated as just described, the pulse is slow, the
tensity of the arteries depends on the stage of the disease, and
when the disease is actually present, the palpable arteries do not
collapse on pressure. They soon lose their elasticity, and if this
occurs in parts which are soft and flexible, the arteries become
more or less tortuous by the force of the blood current twisting and
bending them, owing to the irregularity of their hardening. The
extremities readily become numb, or the part "goes to sleep," as it
is termed. This occurs frequently at night. Sooner or later some
edema of the feet and legs occurs in the latter part of the day.
Sometimes abdominal colic attacks occur, caused by disturbed
circulation. Various disturbances of metabolism may occur, depending
on the circulation in the different organs or on coincident disease,
and the liver, pancreas and kidneys may be affected.
The blood pressure, if taken in the arms especially, may appear
excessively high, but really the actual pressure in the blood
vessels may be low. This is on account of the inability to compress
the hardened arteries. A heart may be weak and actually need
strengthening even while the blood pressure reading is high.
The treatment of this disease is successful only in its prevention,
and consists in treatment of hypertension before arteriosclerosis is
present. When the disease is actually present, there is nothing to
do except for the patient to stop active labor, never to overeat or
overdrink, to prevent, if possible, toxemias from the bowels, to
keep the colon as clean as possible, and for the physician to give
the heart such medicinal aids as seem needed, vasodilators if the
heart is acting too strongly, possibly small doses of cardiac tonics
if the heart is acting weakly; always with the knowledge that a
degenerative myocarditis may be present in considerable amount, or
that coronary sclerosis may be present.
As stated above, coronary sclerosis probably seldom occurs without
more general arteriosclerosis. Obstruction of the coronary arteries,
however, not infrequently occurs at their orifices in conjunction
with sclerosis of that region of the aorta and of the aortic valve.
The more these arteries are diseased and the more they are
obstructed, the more the myocardium of the heart becomes
degenerated, softened and weakened, when dilatation of the
ventricles, especially the left, is liable to occur. Sooner or later
such a condition will cause attacks of angina pectoris and more or
less pronounced symptoms of chronic myocarditis and fatty
degeneration, as previously described.
TREATMENT
The treatment of a suspected coronary sclerosis is the same as that
of general arteriosclerosis--primarily the elimination of anything
which tends to cause high tension or to produce chronic
endarteritis. When either general or local arteriosclerosis is
present, the treatment which should be inaugurated comprises
anything which would tend to inhibit the endarteritis and the
classification--necessary periods of rest, the interdiction of all
physical effort or physical strain, and the regulation of the diet,
digestion and elimination. Perhaps there is no greater preventive of
the advance of this disease than a diet considerably less than would
be suitable for the same person when in perfect health and at his
regular work. The amount of protein especially should be reduced,
and the meal hours should be regular. Ordinarily all tea, coffee and
tobacco should be forbidden, and alcohol should be allowed only to
the aged, if allowed at all.
It has long been considered that iodin would inhibit abnormal
connective tissue growth. Iodin most readily reaches the blood as
sodium or potassium iodid. Large amounts of iodin are not needed to
saturate the requirements of the system for iodin, from 0.1 to 0.2
gm. (1 1/2 to 3 grains) preferably of sodium iodid, twice a day,
after meals given with plenty of water, being sufficient; but it
should be continued in one or two doses a day not only for weeks,
but for months. Whether this iodid or iodin acts per se, or acts by
stimulating the thyroid gland to increased activity and therefore to
more normal activity, so that it is the thyroid secretion which is
of benefit, it is difficult to decide. In view of the fact that in
advanced years the thyroid is always subsecreting, and after the
very diseases which cause arteriosclerosis or during the diseases
which cause arterinsclernsis the thyroid is generally subsecreting,
it would appear that the value of iodin is in its effect in
stimulating the thyroid gland.
If a small amount of thyroid secretion is evidenced by other
symptoms, thyroid extract should be given. The dose need not be
large, and should be small, but should be given for a considerable
length of time. If the patient seems to be improving on small doses
of iodid, however, and the thyroid is supposed not to be very
deficient, it is better not to administer thyroid extract, unless
the patient is obese.
A serum treatment given intravenously, hypodermically, by the mouth,
and by the rectum was inaugurated some years ago (1901 and 1902).
and is known as the "Trunecek serum." This first consisted of sodium
sulphate, sodium chlorid, sodium phosphate, sodium bicarbonate and
potassium sulphate in water in such amounts as to stimulate the
blood plasma. Later small amounts of calcium and magnesium phosphate
were added to the solution to be injected. These injections seemed
to lower the blood pressure, but it is doubtful whether they have
any greater ability than a proper regulation of the diet to inhibit
arteriosclerosis. At any rate, these injections are but seldom used.
An important means of inhibiting disturbance from any
arteriosclerosis which should be employed when possible is the
climate treatment. Warm, equable climates, in which there are no
sudden radical changes, are advantageous when coronary sclerosis is
suspected, and warm climates are valuable in promoting the
peripheral circulation and lowering the blood pressure in
arteriosclerosis. These patients always require more heat than
normal persons, always feel the cold severely, and their hearts
always have much less disturbance, fewer irregularities and fewer
attacks of pain during warm weather than during cold weather.
Simple hydrotherapeutic measures are also necessary for these
patients, but baths should not be used to the point of causing
debility and prostration. Applications of cold water in any form are
generally inadvisable. Very hot baths are also inadvisable; but
pleasantly warm baths, taken at such frequency as found to be of
benefit to the individual, relax the peripheral circulation relieve
the tension of the internal vessels, lessen the work of the heart,
and promote healthy secretion of the skin, the skin of
arteriosclerotic patients often being dry. This dry skin is
especially frequent if there is any kidney insufficiency, which so
soon and so readily becomes a part of the arteriosclerotic process.
If the patient is old, small doses of alcohol may act
physiologically for good. In these arteriosclerotic patients the
activities of alcohol should be considered from the drug point of
view, not from that of all intoxicating beverage. Other drugs are
considered in the discussion of hypertension.
If the heart actually fails, the treatment becomes that of chronic
myocarditis and of dilatation.
Not infrequently in sclerosis of the arteries, especially of the
coronary arteries, the blood pressure is not high, but low, and the
heart is insufficient. In such patients cardiac tonics may be
considered, but they must be used with great care. Digitalis may be
needed, but it should be tried in small doses. It often makes a
heart with arteriosclerosis have severe anginal attacks. On the
other hand, if the heart pangs or heart aches and the sluggish
circulation are due to myocardial weakness without much actual
degeneration, digitalis may be of marked benefit. The value of
digitalis in doubtful instances will be evidenced by an improved
circulation in the extremities, a feeling of general warmth instead
of chilliness and cold, an increased output of urine, and less
breathlessness on slight exertion.
ANGINA PECTORIS
This is a name applied to pain in the region of the heart caused by
a disturbance in the heart itself. Heart pains and heart aches from
various kinds of insufficiency of the heart, or heart weakness, are
not exactly what is understood by angina pectoris. It is largely an
occurrence in patients beyond the age of 30, and most frequently
occurs after 50, although attacks between the ages of 40 and 50 are
becoming more frequent. It is a disturbance of the heart which most
frequently attacks men, probably more than three fourths of all
cases of this disease occurring in men; in a large majority of the
cases the coronary arteries are diseased.
Various pains which are not true angina pectoris occur in the left
side of the chest; these have been called pseudo-anginas. They will
be referred to later. True angina pectoris probably does not occur
without some serious organic disease of the heart, mostly coronary
sclerosis, fatty degeneration of the heart muscle, adherent
pericarditis and perhaps some nerve degenerations. Various
explanations of the heart pang have been suggested, such as a spasm
or cramp of the heart muscle, sudden interference with the heart's
action, as adherent pericarditis, a sudden dilatation of the heart,
an interference with the usual stimuli from auricle to ventricle and
therefore a very irregular contraction, a sudden obstruction to the
blood flow through a coronary artery, or a sudden spasm from
irritation associated with some of the intercostal or more external
chest muscles causing besides the pang a sense of constriction.
Perhaps any one of these conditions may be a cause of the heart
pang, and no one be the only cause.
In a true angina, death is frequently instantaneous. In other
instances, death occurs in a few minutes or a few hours; or the
patient's life may be prolonged for days, with more or less constant
chest pains and frequent anginal attacks. Here there is a gradual
failing of the heart muscle, with circulatory insufficiency, until
the final heart pang occurs.
Anginal attacks before the age of 40, presumed, from a possible
narrowing of the aortic valve, to be due to coronary sclerosis, are
frequently due to a long previous attack of syphilis. In these
cases, active treatment of the supposed cause should be inaugurated,
including perhaps an injection of the arsenic specific, and
certainly a course of mercury and iodid, with all the general
measures for managing and treating general arteriosclerosis, as
previously described.
SYMPTOMS
The pain of true angina pectoris generally starts in the region of
the heart, radiates up around the left chest, into the shoulders,
and often down the left arm. This is typical. It may not follow this
course, however, but may be referred to the right chest, up into the
neck, down toward the stomach, or toward the liver. The attack may
be coincident with acute abdominal pain, almost simulating a gastric
crisis of locomotor ataxia. There may also be coincident pains down
the legs. It has been shown, as mentioned in another part of this
book, that disturbances in different parts of the aorta may cause
pain and the pain be referred to different regions, depending on the
part affected.
Instances occasionally occur in which a patient had an anginal
attack, as denoted by facial anxiety, paleness, holding of the
breath, and a slow, weak pulse, without real pain. This has been
called angina sine dolore. The patient has an appearanece of anxious
expectation, as though he feared something terrible was about to
happen.
The position of the patient with true angina pectoris is
characteristic. He stops still wherever he is, stands perfectly
erect or bends his body backward, raises his chin, supports himself
with one hand, leans against anything that is near him, and places
his other hand over his heart, although he exercises very little
pressure with this hand. The position assumed is that which will
give the left chest the greatest unhampered expansion, as though he
would relieve all pressure on the heart.
Besides the feeling of constriction, even to some spasm, perhaps, of
the intercostal muscles, respiration is slowed or very shallow,
because of the reflex desire of the patient not to add to the pain
by breathing. The face is pale, the eyes show fear, and the whole
expression is almost typical of cardiac anxiety. The patient feels
that he is about to die. The pulse is generally slowed, may be
irregular, and may not be felt at the wrist. The blood pressure has
been found at times to be increased. It could of course be taken
only in those cases in which there were more or less continued
anginal pains; the true typical acute angina pectoris attack is
over, or the patient is dead, before any blood pressure
determination could be made. When there is more or less constant
ache or frequent slight attacks of pain, the blood pressure may be
raised by the causative disease, arteriosclerosis. During the acute
attack with inefficient cardiac action and a diminished force and
frequency of the beat, the peripheral blood pressure can only be
lowered.
The duration of an acute attack, that is, the acute pain, is
generally but a few seconds, sometimes a few minutes, and rarely has
lasted for several hours. In the latter cases some obstruction to an
artery has been found at necropsy, but not sufficient to stop the
circulation at a vital point. Repeated slight attacks, more or less
severe, may occur frequently throughout one or more days, or even
perhaps a series of days, caused by the least exertion, even that of
turning in bed.
While most cases of sudden death with cardiac pain are due to a
local disease in or around the heart, it is quite probable that some
disturbance in the medulla oblongata may cause acute inhibitory
stoppage of the heart through the pneumogastric (vagi) nerves. The
power of the pneumogastric reflex to inhibit the action of the heart
is, of course, easily demonstrated pharmacologically. Clinically
reflexes down these nerves interfering with the heart's action cause
faintness and serious prostration, if not actual shock, and perhaps,
at times, death. The most frequent cause of such a reflex is
abdominal pain, perhaps due to some serious condition in the
stomach, to gastralgia, to an intestinal twist, to intussusception
or other obstruction, or to hepatic or renal colic. A severe nerve
injury anywhere may cause such a heart reflex. Hence serious nerve
pain must always be stopped almost immediately, else cardiac and
vasomotor shock will occur. In serious pain morphin becomes a life
saver.
MANAGEMENT
While a number of causes of true cardiac pain may be eliminated by
improvement in any loss of compensation, by improvement of the heart
tone, by more or less recovery from myocardial or endocardial
inflammation, and by the withdrawal of nicotin, which may cause
cardiac pains, still, true angina pectoris once occurring is likely
to be caused by a progressive, incurable condition, and the attacks
will become more frequent until the final one. It is possible that a
true angina may be due to a coronary artery disease or obstruction,
and that a collateral circulation may become established and repair
the deficiency. While this probably can take place, it must be rare.
Occasionally when the intense pain has ceased, the patient may be
nauseated and actually vomit, or he may soon pass a large amount of
urine of low specific gravity, or have a copious movement of the
bowels.
The first attack, and subsequent ones more and more readily, are
precipitated by any exertion which increases the work of the heart,
as walking up hill, walking against the wind, going upstairs,
physical strains, as suddenly getting out of bed, leaning over to
put on the shoes, straining at stool, or even mental excitement.
Exertion directly after eating a large meal is especially liable to
precipitate an attack. Food which does not readily digest, or food
which causes gastric flatulence may precipitate attacks. Any
indiscretion in the use of coffee, tea, alcohol or tobacco may be
the cause of the attack.
For treatment of the immediate pain, if the physician arrives soon
enough, anything may be given which quickly relieves local or
general arterial spasm and spasm of the muscles. The moment that the
heart and its arterioles relax, the attack is often over. The most
quickly acting drug for this purpose is amyl nitrite, inhaled. If
amyl nitrite is not at hand, or has been found previously to cause
considerable disturbance of the head or a feeling of prolonged
faintness, nitroglycerin is the next most rapidly acting drug. It
may be given hypodermically, or a tablet may be dissolved on the
tongue. The amyl nitrite should be in the emergency case of the
physician in the form of ampules, or may be carried by the patient
after he has had one or more attacks. The ampules now come made of
very thin glass with an absorbent and silk covering ready for
crushing with the fingers, and are thus immediately ready for
inhalation. One of these is generally all that it is necessary to
use at any one time. Nitroglycerin, if given hypodermically, should
be in dose of 1/100 grain. If given by mouth the dose should be the
same, repeated in ten minutes if the pain has not stopped.
Almost coincidently with the administration of nitroglycerin or the
amyl nitrite, a hypodermic injection of 1/8 or 1/6 grain of morphin
sulphate should be given without atropin, as full relaxation is
desired without any stimulation of atropin.
Alcohol is also a valuable treatment of this pain, when the drugs
mentioned are not at hand. The dose should be large; whisky or
brandy is best, and should be administered in hot or at least warm
water. The physiologic action of alcohol, which dulls or benumbs the
nervous system and dilates the peripheral blood vessels, is exactly
in line with the clinical indications.
If a patient is home and at rest at the time of an attack, a hot-
water bag but slightly filled, or a pad electrically heated, may be
placed over the heart some times with marked advantage and relief
from pain. Occasionally even such gentle applications are not
tolerated.
After the attack is over, absolute rest for some hours, at least, is
positively necessary. If the attack was severe, the patient should
rest several days, as there seems to be a great tendency for such
attacks to come in groups, the cause being acutely present for at
least some time. But little food should be given; nothing very hot
or very cold, and no large amount of liquids; gentle catharsis may
be induced on the following day, if deemed advisable; no stimulating
drugs should be administered, and nothing which would raise the
blood pressure.
The question often arises as to whether or not the patient shall be
told of the seriousness of his condition. It is hardly wise to
withhold this knowledge from him, and generally is not necessary.
The ordinary alert patient knows how serious the condition is by his
own feelings, and will even reprove or joke with his physician for
minimizing the danger. It is best that the whole subject be
discussed carefully with him and his life regulated and ordered, and
emergency drugs prepared and given him with proper instructions, to
the family, so that he may possibly prevent other attacks and, if
they occur, may have the best immediate treatment.
The acute symptoms being over, a careful analysis of the probable
cause of the anginal attack should be made. If it is a general
sclerosis, the treatment should be directed to that condition. If it
is a myocarditis, a fatty degeneration of the heart or a fatty
heart, this should be properly treated as previously described. If
it is due to a toxemia from intestinal disturbance, that may readily
be remedied. If due to nicotin, it need not again occur from that
reason, and perhaps the damage caused by the nicotin may be removed.
Any organic kidney trouble must, of course, be managed according to
its seriousness, and if there is hypertension without any serious
lesion, the treatment should be directed toward its relief.
Not infrequently, whether a patient is suffering from real angina
pectoris or a pseudo-angina pectoris, the absorption of toxins irons
the intestines, due to indigestion and fermentation, adds to these
cardiac pains, and may even be a cause of them. Consequently,
eliminative treatment and a temporary rigid diet, and various
treatments to prevent intestinal indigestion, are of great value in
angina pectoris.
It may be even advisable for twenty-four hours or so to give nothing
but water, and then perhaps a skimmed milk diet for a few days. This
treatment, combined with almost absolute rest, and later graded
exercise, with other measures to lower the blood pressure, and with
the absence of tobacco, sometimes is very successful treatment.
PSEUDO-ANGINA
While this name is more or less unfortunate, it has long been in
vogue as a designation for pains and disturbances referred by a
patient to his heart. Therefore with the distinct understanding that
if the diagnosis is correct the name is a misnomer, it may be
allowable to discuss under this heading some of the attacks which
may simulate an angina and must be separated from a true angina.
To decide whether pain in the region of the heart or irregularity of
its action is due to organic disease, to functional disturbance, or
to referred causes is often extremely difficult. Some of the most
disturbing sensations in the region of the heart are not due to any
organic trouble, and yet the patient is fearful that such sensations
mean some kind of heart disease, and therefore becomes exceedingly
anxious and watches and mentally records every sensation in the left
chest. This is unfortunate, as the patient may learn to note, if he
does not actually count, his heart beats, while normally he should
sense nothing of his heart's activity. On the other hand, as just
stated, it may be almost impossible to decide that this disturbance
of the heart is not due to an organic cause, but is entirely
functional, or due to some extraneous reason.
It seems justifiable in every case of irregular heart action to
assure the patient that the condition can be improved, which in most
instances is the truth. There can be no question of such urgent
assurance, if it is decided that the cause is not in the heart
itself, or at least is not organic. Irregularities in the heart's
action will be discussed later. At this time discussion will be
limited to pain which is not true angina pectoris, but which is in
the region of the heart or is referred to it.
Intercostal neuralgia is more likely to occur on the left side of
the chest than on the right. This is particularly unfortunate, as
tending to cause these pains to be referred to the heart. The
localization of tender spots along the course of a nerve with
demonstration of these to the patient and the diagnosis stated is
all the assurance that he requires.
Careful questioning, and if necessary scientific examination of the
stomach, may show that the patient has hyperchlorhydria, ulcer of
the stomach or duodenum, dilatation of the stomach, or some growth
in the stomach as a cause for the pain referred to the region of the
heart. Gallstones in the gallbladder may also give such referred
pains. Other lesions in the abdomen may cause pain referred to the
cardiac region. Not only will the demonstration of these causes and
their treatment assure the patient that he has not neuralgia of his
heart, but also, if curable, the cause of the pain may be removed.
Dry pleurisy of the left chest is not an infrequent cause of these
pains, and of course serious disease of the lungs, as tuberculosis,
unresolved pneumonia, pleuritic adhesions, ennphysema and tumor
growths, may all be the cause of a referred cardiac pain, the heart
being disturbed secondarily.
A stomach cramp is a not infrequent cause of serious pain referred
to the heart, and the rare condition of cardiospasm must also be
remembered as a cause of pseudo-angina. In other words, the
interpretation of these pseudo-anginas means a careful diagnosis of
the condition, and, as previously stated, not only must the above-
named causes be excluded, but also the reverse must be remembered:
that many disturbances treated as other conditions really are due to
cardiac weakness. The diagnosis of a real angina pectoris from a
false angina may not be difficult. A real angina generally occurs
after exertion of some kind, be that exertion ever so slight. False
angina may occur at any minute with or without exertion. Pain
referred to the heart which awakens a patient at night is not likely
to be a true angina; nervous patients are prone to have such night
attacks of cardiac disturbance of various kinds. A true angina
causes the patient's face to look anxious and pale, with the
breathing repressed. A false angina shows no such paleness, allows
deep breathing, crying and lamenting, and allows the patient to move
about in bed, or about the room. The true angina makes the patient
absolutely still and quiet: he hardly dares to speak or tell what he
is feeling and fearing. True angina is of course much more frequent
in older persons, while false anginas occur in the young, and
especially in the neurotic. With all the other manifestations of
hysteria, palpitation and cardiac pain are often symptoms.
It should not be decided, however apparently self-evident that a
referred pain is not due to cardiac lesion until a careful
examination of the patient has been made. Real cardiac disturbance
can of course occur at any time in a neurotic or hysterical patient,
and there should be no mistakes of omission from carelessness or
neglect on the part of the physician.
Other frequent causes of more or less disturbance of the heart's
action, often accompanied by pain, are overexertion, worry and
mental anxiety, and intestinal toxemias due to too much protein or
disturbed protein digestion. Frequent causes are tobacco, and the
overuse of tea and coffee. Many a patient's pseudo-anginas are
corrected by stopping tea and coffee. The effects of caffein and
tobacco on the heart will be considered later when toxic
disturbances are under discussion.
The above-mentioned causes of pseudo-anginas have only to be named
to indicate the treatment which will prevent the pain attacks. At
times, the cause being intangible, it may be necessary to change the
whole life and metabolism of the patient, as so often necessary in
hysteria, neurasthenia, gout, intestinal fermentation and kidney
inefficiency. Besides a rearrangement of the diet and measures for
causing proper activity of the bowels, massage, exercise and
hydrotherapy should lie utilized toward the end of improving the
nutrition of every part.
TREATMENT OF PSEUDO-ANGINAS
The treatment of these pseudo-angibas depends, of course, on the
diagnosis of the cause, and the cause should be eliminated or
modified. If the heart shows real disturbance from this reflex
cause, the treatment aimed toward it depends on whether the heart
action is weak or strong and the circulation poor or good. If the
circulation is poor, digitalis in small doses may be needed, either
5 drops of an active tincture twice a day, or 8 or 10 drops once a
day. If digitalis is not indicated, strophanthus sometimes is
valuable. While strophanthus has been shown not to be a real cardiac
tonic like digitalis, still there seems to be a nervous sedative
action when it is given by the mouth, and it often does good in
these cases. The dose is 5 drops of the tincture, in water, three
times a day, after meals. Strychnin in small doses may be needed,
but in these patients, who are generally nervous, it is usually
better not to give it.
One of the best sedatives to a heart that is irregular in its action
and not acting strongly is lime; a good way to administer it is in
the form of calcium lactate, and the dose is 0.3 gm. (5 grains), in
powder or capsule, three times a day, after meals.
If the circulation is good and the heart is strong, and yet these
irregular pains and irregular contractions occur, the bromids act
favorably and successfully. This is probably on account of their
ability to quiet the central nervous system, to quiet and soothe the
irritability of the heart, and to relax the peripheral blood
vessels. The dose should be from 0.5 to 1 gm. (7 1/2 to 15 grains),
in water, three times a day, after meals. It is not necessary or
advisable to continue the bromid very long. Whatever general tonic
or eliminative treatment the patient, requires should be given. The
value of hydrotherapy, massage and graded exercise should not be
forgotten.
STOKES-ADAMS DISEASE: HEART BLOCK
Stokes-Adams disease, or the Stokes-Adams syndrome, is a name
applied to a combination of symptoms which was described by Stokes
in 1846, and had been observed by Adams in 1827. The disease is
characterized by bradycardia and cerebral attacks, either syncope or
pseudo-apoplectic or convulsive attacks.
To understand the phenomena of this disease, it will be well to
refer to the first chapter of this book. Until 1893, when His
described the bundle of muscle fibers which is now known by his
name, the transmission of the cardiac stimulus to contraction was
not understood. It has been found, by studying the pathology of
Stokes-Adams disease, as well as by clinically noting with
instruments the contractions of different parts of the heart, that
these slow heart beats are really due to interruptions of the
impulse passing from auricle to ventricle through the bundle of His,
and degeneration in this region is generally the cause of Stokes-
Adams disease. The auricles often beat many times more frequently
than the ventricles, even two or three times as frequently, and, of
course, these auricular contractions are not transmitted to the
arterial system, and the radial pulse notes only the contractions of
the ventricles. The phrase that is used to describe this
nontransmission of the auricular stimulus to the ventricles is
"heart block."
While this disease almost invariably has a pathology, cases have
occurred in which no lesion of the heart could be found, but it
generally occurs coincidently with arteriosclerosis, in which the
coronary arteries are more or less involved and the arterial system
of the brain may be diseased. It occurs more frequently in men than
in women, and in them mostly after middle, or in advanced, life. The
previous history of the patient has often disclosed syphilis. The
intermittence of the pulse may be regular or irregular, and may not
be constant in the early stages of the disease; but when the disease
is established, the rate of the pulse may be reduced to forty,
thirty, or even twenty beats a minute, and it has been known to be
even less. When these intermittences are regular, perhaps two beats
to one intermittence, or three beats to one intermittence are the
most frequent types. When the auricles also beat slowly, perhaps the
vagiare for some reason overstimulated and thus inhibit the heart's
activity.
The attacks of syncope are doubtless due to anemia of the medulla,
because of the infrequent ventricular contractions. This anemia of
the medulla and of the brain may also cause an epileptic seizure, or
a partial paralytic seizure without any apparent paralysis. It is
probable, however, that in these cases there may be coincident
arterial disease in the brain. These sudden syncopal attacks are
likely to occur when a patient suddenly rises from a reclining
posture, especially if he has been asleep. Many persons whose
circulation is none too strong may feel faint on suddenly rising,
but in a person whose pulse is slow and the circulation weak the
danger of causing anemia of the brain by the sudden erect posture is
much increased. Slight faint turns are of frequent occurrence with
these patients; or the faintness may be so rapid and so intense that
the patient may drop in his tracks. Venous pulsation in the neck is
generally marked, showing an impeded contraction of tile right
auricle.
If the auricles are heard or found by instrumental readings to
contract more frequently than the ventricles, the trouble is quite
likely to be a heart block from disease in the heart itself, in the
bundle of His. If the heart is slowed as a whole, the trouble might
be due to diseased arteries or pressure from a growth, a gumma,
perhaps, or other brain tumor in the region of the pons Varolii or
medulla oblongata; or a hemorrhage into the fourth ventricle,
causing pressure, could be the cause.
TREATMENT
The treatment of true Stokes-Adams disease is unsuccessful. If
general arteriosclerosis is present, that condition should be
treated. Digitalis would seem almost invariably contraindicated,
although it is of value in extrasystoles without heartblock, or in
conditions which are not Stokes-Adams disease; but if this disease
was considered present, digitalis would probably do harm. Sometimes
strychnin is of benefit.
Atropin has sometimes caused stimulation of the heart to more normal
rapidity. Its benefit is generally only temporary, as most patients
cannot take atropin regularly without having it cause a disagreeable
drying of the throat and skin, a stimulation of the brain, and an
undesired raising of the blood pressure, to say nothing of its
action on the eyes.
The only value of the nitrites is when the blood pressure is high
and the nitrite action is desired on that account.
Coffee or caffein often causes these hearts to become irritable; it
certainly raises the blood pressure, and therefore is not generally
advisable. Both tea and coffee should generally be prohibited.
During the acute faint attack, camphor is one of the best
stimulants. Alcohol may be of benefit. If syphilis is a cause of the
condition, iodids are always valuable. If syphilis is not a cause
and arteriosclerosis is present, small doses of iodid given for a
long period are beneficial, although it may not much reduce the
blood pressure or decrease the plasticity of the blood. Iodid is a
stimulant to the thyroid gland, and therefore it is on this account
valuable.
An excellent stimulant to the heart is thyroid secretion or thyroid
extract. Theoretically thyroid extracts should be the treatment for
a slow-acting heart. It sometimes seems of benefit to these
patients, but it often causes such nervous excitation and
irritability as to preclude its use. The dose of thyroid for this
purpose would be small, about one-fourth to one-half grain of the
active substance three times a day. To be of any value, the
preparation must be good.
Epinephrin has been shown by Hirtz [Footnote: Hirtz: Arch d. mal. du
coeur, February, 1916] to overcome experimental heart block. It is
not clear just how it acts, but it could well be tried in heart
block when the blood pressure is not too high. A few drops of an
epinephrin solution 1:1,000 may be placed on the tongue, and
repeated three times a day, or from 5 to 10 minims of a weaker
solution may be given hypodermically.
The usual precautions against overeating, overdrinking, severe
physical exercise, sudden movements, overuse of tobacco, etc.,
should all be urged on the patient. The disease is sooner or later
fatal, although the patient may live some years. Death is generally
sudden.
It is understood that this disease must he separated from the
condition of bradycardia inherent in a few persons who have a slow
pulse throughout their life, without any untoward symptoms.
CARDIOVASCULAR RENAL DISEASE
With the strennousness of this era, this disease or condition, which
may be regarded as one of the accompaniments of normal old age, has
become of grave importance, and nowadays frequently develops in
early middle life. If it is diagnosed in its incipiency, and the
patient follows the advice given him, the progress of the disease
will generally be inhibited, and a premature old age postponed.
In the beginning the symptoms and signs of this disease are
generally those of hypertension, and the treatment and management is
that advised in hypertension. If the kidneys show irritation, as
manifested by the presence of albumini and casts in the urine, or if
they show insufficiency in the twenty-four-hour excretion of one or
more salts or other excretory product, the diet and life must be
more carefully regulated than advised in hypertension, and the
treatment becomes practically that of chronic interstitial
nephritis.
Sooner or later, in most instances of this disease, whether
hypertension, chronic endarteritis or interstitial nephritis or any
combination of these conditions is most in evidence, the heart will
hypertrophy. As long as the circulation in the heart itself is good
and not impaired by coronary sclerosis, and as long as this slowly
developing chronic myocarditis has not advanced far, cardiac
symptoms will not be in evidence; but if these conditions occur, or
if the blood pressure is so greatly increased as to damage the
aortic valve or strain and dilate the left ventricle, symptoms
rapidly appear, and the heart must be carefully watched.
Subsequently, as the disease advances, if the patient does not die
of angina pectoris, apoplexy or uremia, the symptoms of cardiac
decompensation will develop. As the heart begins to fail, a
dilatation of the right ventricle causes passive congestion of the
kidneys, and the chronic interstitial nephritis may progress more
rapidly. It is often difficult to decide which is more in evidence,
heart insufficiency or kidney insufficiency. The more the heart
fails, the more albumin will generally appear in the urine, and the
lower the blood pressure, especially the diastolic. The more
insufficient the kidneys, the higher the blood pressure, especially
the diastolic. The location of the edema will aid in deciding which
condition is most in evidence. If the edema is pendent in feet, legs
and perhaps genitals when the patient is up, with its disappearance
at night, and more or less backache and pitting of the back in the
morning, it is the heart that is most rapidly failing. If there is
more general edema, the hands and face puffing, and there are
considerable nausea and vomiting, headache and drowsiness, and
perhaps muscular twitchings, with neuralgic pains, the most serious
trouble at that particular time lies in the kidney insufficiency.
Kisch [Footnote: Kisch: Med. Klin., Feb. 27, 1916.] sums up the
procedural symptoms and signs of cerebral hemorrhage. The heart is
generally enlarged and hypertrophied. The patient is likely to be
overweight or adding weight, and to suffer from intestinal
indigestions. Signs of sclerosis of the blood vessels of the brain
are evidenced by transient dizziness; headaches; impaired sleep;
loss of memory, especially for names and words; slight disturbances
of speech, momentary perhaps, and more or less temporary localized
numbness of the hands or feet, or arms or legs, with perhaps
flushing of some part of the body, or little localized spasms of
vessels of other parts of the body, causing chilliness.
There is also a marked hereditary tendency to apoplexy.
Cadwalader, [Footnote: Cadwalader, W. R.: A Comparison of the Onset
and Character of the Apoplexy Caused by Cerebral Hemorrhage and by
Vascular Occlusion, The Journal A. M. A., May 2, 1914, p. 1385.]
after considerable investigation, has come to the conclusion that
large hemorrhages into the brain are the rule in apoplexy, and that
small hemorrhages are rare, and he is inclined to think that even
small, as well as large hemorrhages, are more frequently fatal than
supposed. In other words, he thinks that many of the nonfatal
hemiplegias are caused by vascular obstruction and softening and not
by hemorrhage. He finds that sudden death, or death within a few
minutes, does not occur from hemorrhage, even if the hemorrhage is
large, though a rapidly developing and persistent coma usually
indicates a hemorrhage. If the coma is not profound and is slow in
its onset, with symptoms noticed by the patient, and cerebral
disturbance, he believes it to be caused generally by softening of
the cerebral center, due to some obstruction of the blood flow, and
not to hemorrhage. While occasionally a slowly increasing loss of
consciousness may be due to hemorrhage, he thinks it is doubtful if
real hemorrhage ever occurs without loss of consciousness, while
softening of some part of the cerebrum may occur without
unconsciousness. He thinks that the size of the hemorrhage is of
more importance than its situation in causing the profoundness of
the symptoms, but he repeats that nonfatal cases of hemiplegia are
generally caused by vascular occlusion and subsequent softening, and
not by hemorrhage.
TREATMENT
While it is urged, in preventing the actual development of this
disease, and in slowing its progress, that it is advisable to lower
a high blood pressure, we must remember that this blood pressure mad
be compensatory, and many times should not be much lowered without
due consideration of the symptoms and the patient's condition. It is
better not to use drugs of any kind in this incipient condition. The
hypertension should be regulated by the diet; the purin bases and
meat should be reduced to a minimum; tea, coffee and alcohol should
be prohibited, and tobacco should be either entirely stopped or
reduced to a minimum. Regulated exercise is always advisable, the
amount of such exercise depending on the condition of the
circulation. Ordinary walking and graduated walking or graduated
hill climbing and golfing are good exercise for these patients.
Mental and physical strenuosity must be stopped, if the disease is
to be slowed. Sleeplessness must be combated, and perhaps actually
treated medicinally, and for a time sufficient doses of chloral are
perhaps the best treatment. The administration of chloral must
always be carefully guarded to avoid the acquirement of dependence
on the drug. Mouth and other infections should be sought and
removed. Warm baths, Turkish baths, electric light baths or body
baking may be advisable, and certainly obesity must always be
combated by a regulation of the diet. In obesity, stimulants to the
appetite, such as spices, condiments, and even sometimes salt, must
be prohibited. Butter, cream, sugar and starches must be reduced to
a minimum. A small amount of bread and a small amount of potatoes
should be allowed. Liquids with meals should be reduced. Fruits
should be given freely. Intestinal indigestion should be corrected,
and free daily movements of the bowels should be caused. If the
patient is obese, and especially if the blood pressure is high, the
administration of thyroid extract is very beneficial. This is
particularly true in women suffering from this disease; but the
patient should be carefully observed during its administration. It
may be advisable to administer small doses of iodid instead of the
thyroid treatment, or coincidently with it. Nitrites had better be
postponed, if possible, for cardiac emergencies.
White, [Footnote: White: Boston Med. and Surg. Jour., Dec. 2, 1915.]
after studying 200 cases of heart disease, finds that men are more
subject to auricular fibrillation, auricular flutter, heart block
and alternation of the pulse than are women. The greater frequency
of syphilis in men than in women should be considered in this
difference in frequency.
White finds that hyperthyroidism of long standing is often attended
with auricular fibrillation. He does not find that alcohol, tea and
coffee play much part in causing these serious disturbances of the
heart. His conclusions on this subject are certainly a surprise, and
do not coincide with the experience of many others. It would seem
that one of the causes of the greater frequency of these
disturbances in men would be the amount of alcohol and tobacco used
by men.
When the heart begins to fail from a gradually progressing
myocarditis, the pulse rate generally increases, especially on the
least exertion, and on fast walking may be as high as 120 or 130 a
minute, or even higher. It may be found near 100 on the least
exertion, even after some minutes of rest. These patients must have
more or less absolute bed rest. When this condition occurs in old
age, however, prolonged bed rest is inadvisable, for if the heart
once loses its energy, in such cases, it is practically impossible
to cause a return of normal function. However, in all acute cardiac
insufficiency in this disease, due to some heart strain or exertion
that was unusual, a bed rest of from one to two weeks and then
gradually getting up and returning to normal activity is the proper
treatment, and will generally be successful in restoring more or
less compensation. These patients may well recline in bed with
several pillows or with a back rest. During any cardiac anxiety in
this kind of insufficiency the patient breathes better when he is
sitting up or reclining with the head and shoulders high. The reason
for this is probably because his heart has more space in this
position--the same reason that he breathes better when his stomach
is empty. Very indicative of the coming cardiac insufficiency is the
inability to lie at night on the left side. The pressure of the
body, especially if the person is stout, interferes with the heart
action and causes dyspnea and distress. Some short, fat patients
with cardiac distress caused by this disease must even stand up to
relieve the condition, the erect position giving still more space
for the action of the heart.
Before these patients get up, after a period of bed rest, slight
exercises should be done, perhaps resistant exercises, to see what
the effect is on the heart, and also gradually to cause increase in
cardiac strength, much as any other training exercise. Whatever
exercise increases the heart rate more than twenty-five beats is too
strenuous at that particular period. The exercise should then be
still more carefully graduated. If the systolic blood pressure is
altogether too low for the age of the person or for the previous
history, it should be allowed to become higher, if possible, before
much exercise is begun.
The diet should be nutritious, but, of course, modified by the
condition of the stomach, intestines and kidneys, and whether or not
the patient is obese. The bulk of the meal should be small, and
nutriment should be given at three or four hour intervals during the
daytime.
The Karell milk diet or so-called "cure" was first presented in 1865
by Phillippe Karell, physician to the Czar of Russia. This treatment
was more or less forgotten until lately, when it has been more
frequently used in kidney, liver and heart insufficiency. Its main
object in kidney and heart disease is to remove dropsies. In cardiac
dropsy it is advised to give 200 c.c. of milk for four doses at four
hour intervals, beginning at 8 o'clock in the morning. Whether the
milk is taken hot or cold depends on the desire of the patient. This
treatment is supposed to be kept up for six days, and during this
time no other fluid is given and no solid food allowed. During the
next two days an egg is added to this treatment, given about 10
o'clock in the morning, and a slice of dry toast, or zwieback, at 6
p. m. Then up to the twelfth day the food is gradually increased,
first to two eggs a day, then more bread, then a little chopped
meat, then rice or some cereal, and by the end of two weeks the
patient is about back to his ordinary diet. During this period the
bowels are moved by enema or by some vegetable cathartic, or even
castor oil. If thirst is excessive, the patient must have a little
water, and if the desire for solid food is excessive, even Karell
allowed a little white bread and at times a little salt. He
sometimes even prolonged the period of treatment to five or six
weeks.
Various modifications of this treatment have been suggested, such as
skimmed milk, and more in quantity, or a cereal is added more or
less from the beginning, and perhaps cream. The diuretic action of
this treatment is not always successful. Also, sometimes the
treatment is even dangerous, the heart and circulation becoming
weaker than before such treatment was begun. Certainly the treatment
should be used in cardiac insufficiency with a great deal of care,
although it is often very valuable treatment. It should be
emphasized that most patients with cardiac dropsy receiving the
Karell treatment or a modification of it should also receive
digitalis in full doses, and should have daily free movement of the
bowels. It should be urged, however, that too free catharsis in
cardiac weakness is to be avoided, and the prolonged use of salines,
and sometimes even one administration is contraindicated. Before
cardiac failure has occurred in this disease, once a week a dose of
calomel or a brisk saline purge is advisable, and is good treatment;
but when cardiac weakness has developed, free catharsis is rarely
indicated, although the bowels should be daily moved, and vegetable
laxatives are the best treatment. The upper intestine and the liver
and kidneys may be relieved by a more or less abrupt modification of
the diet, or even a starvation period, and the bowels will generally
become cleaned; but frequent profuse purging with salines or some
drastic cathartic puts the final touch on a cardiac failure.
Recently Goodman [Footnote: Goodman, E. H.: The Use of the "Karell
Cure" in the Treatment of Cardiac, Renal and Hepatic Dropsies, Arch.
Int. Med., June, 1916, p. 809.] presented a report of his studies of
the Karell treatment in cardiac, renal and hepatic dropsies. He
finds that patients with uremia ordinarily should not be subjected
to the Karell cure, such patients needing more fluid.
As long as the patient remains in bed, and as long as his ability to
exercise is at a minimum, gentle massage is advisable.
In these cases of cardiac weakness, with or without dropsy, unless
the diastolic pressure is very high, digitalis is valuable. If there
is no cardiac dropsy, but other symptoms of heart tire are manifest
and the blood pressure is high, the nitrites are valuable. The
amount should be sufficient to lower the blood pressure. Sometimes
the diastolic pressure is high and the systolic low and the pressure
pulse small because of heart insufficiency; such a condition is
often improved by digitalis. In other words, with a failing heart
digitalis may not make a blood pressure higher, and often does not;
it may even lower a diastolic pressure, and the moment that the
pressure pulse becomes sufficient, the patient improves. Under this
treatment of digitalis, rest and regulated diet, a dilated left
ventricle with a systolic mitral blow often becomes contracted and
this regurgitation disappears.
The amount of digitalis that is advisable has been frequently
discussed. It should be given in the best preparation obtainable,
and should be pushed gradually (not suddenly) to the point of full
physiologic activity. While it may be given at first three times a
day in smaller doses, it later should be given but twice a day, and
still later once a day, in a dose sufficient to cause the results.
As soon as the full activity has been reached it may be intermitted
for a short time; or it may be given a longer time in smaller
dosage. In renal insufficiency associated with cardiac
insufficiency, its action is subject to careful watching. If there
is marked advanced interstitial nephritis, digitalis may not work
satisfactorily and must be used with caution. If, on the other hand,
a large part of the kidney trouble is due to the passive congestion
caused by circulatory weakness, digitalis will be valuable.
In sudden cardiac insufficiency, provided digitalis has not been
given in large doses a short time before, strophanthin may be given
intravenously once or at most twice at twenty-four-hour intervals.
If, in this more or less serious condition of the heart weakness,
there is great sleeplessness, a hypnotic must sometimes be given,
and the safest hypnotic is perhaps 3 / 10 grain of morphin. One of
the synthetic hypnotics, where the dose required is small, may be
used a few times and even a small dose of chloral should not be
feared when sleep is a necessity and large doses of synthetics are
inadvisable on account of the condition of the kidneys.
The value of the Nauheim baths with sodium chlorid and carbonic acid
gas still depends on the individual and the way that they are
applied. If the blood pressure is low and the circulation at the
periphery is poor, they bring the blood to the surface, dilating the
peripheral vessels, and relieving the congestion of the inner organs
and abdominal vessels, and they often will slow the pulse and the
patient feels improved. If they are used warm, a high blood pressure
may not be raised; if the baths are cool, the blood pressure will
ordinarily be raised. Provided the patient is not greatly disturbed
or exhausted by getting into and out of the bath, even a patient
with cardiac dilatation may get some benefit f rom such a bath, as
there is no question, in such a condition, that anything which
brings the blood to the muscles and skin relieves the passive
internal congestion. Sometimes these baths increase the kidney
excretion. At other times these, or any tub baths, are
contraindicated by the exertion and exhaustion they cause the
patient; and cool Nauheim baths, or any other kind of baths, are
inadvisable with high blood pressure.
DISTURBANCES OF THE HEART RATE
ARRHYTHMIA
While this terns really signifies irregularity and intermittence of
the heart, it may also be broadly used to indicate a pulse which is
abnormally slow or one which is abnormally fast, a rhythm which is
trot correct for the age, condition and activity of the patient.
Irregularity in the pulse beat as to volume, force and pressure,
except such variation in the pulse wave as caused by respiration, is
always abnormal. While an intermittent pulse is of course abnormal,
it may be caused in certain persons by a condition which does not in
the least interfere with their health and well-being.
As to whether a slow or a more or less (but not excessively) rapid
pulse in any one is abnormal depends entirely on whether that speed
is normal or abnormal for that person. As a general rule the heart
is more rapid in women than in men. It is always more rapid in
children than in adults, and generally diminishes in frequence after
the age of 60, unless there is cardiac weakness or some cardiac
muscle degeneration. The average frequence of the pulse in an adult
who is at rest is 72 beats per minute, but a frequency of 80 is not
abnormal, and a frequency of 65 in men is common; 60 is infrequent
in men but normal, while up to 90 is not abnormal, especially in
women, at the time the pulse is being counted.' It should always be
considered that in the majority of patients the pulse is slightly
increased while the physician is noting its rapidity. Anything over
90 should always be considered rapid, unless the patient is very
nervous and this rapidity is considered accidental. Anything below
60 is abnormally slow. In children under 10 or 12 years of age,
anything below 80 is unusual, and up to 100 is perfectly normal, at
least at such time as the pulse is counted and the patient is awake.
Referring to the first chapter of this book, it will be noted that
many physiologic factors must enter into the production of the
normal regularity of the pulse. The stimulus must regularly begin in
the auricle, must be perfectly transmitted through the bundle of His
to the ventricles, the ventricles must normally contract with the
normal and regular force, the valves must close normally and at the
proper time, the blood pressure in the aorta must be normally
constant to insure the perfect transmission of the blood to the
peripheral arteries and to insure the normal circulation through the
coronary arteries, and the arterioles must be normally elastic. The
nervous inhibitory control through the vagi must also be normal, and
there must be no abnormal reflexes of any part of the body to
interfere with the normal vagus control of the heart.
While the heart beats from an inherent musculonervous mechanism,
nervous interference easily upsets its normal regularity. It may be
seriously slowed by nervous shock, fear or sudden peripheral
contractions, spasm of muscles, or convulsive contractions, or it
may be stimulated to greater rapidity by nervous excitement. It may
be slowed or made rapid by reflex irritations, and it may be
seriously interfered with by cerebral lesions; pressure on the vagus
centers in the medulla oblongata will make it very slow. Various
kinds of poisons circulating in the blood, both depressants and
excitants, may affect the rapidity or the regularity of the heart.
Therefore, if it is decided that a given heart is abnormally slow or
abnormally rapid or is decidedly irregular or intermittent, the
various causes for such interference with its normal activity must
be investigated and admitted or excluded as causative factors.
Many investigations of the rhythm of children's pulses have been
made, and some of the later investigations seem to show that not
more than 40 percent are regular, the remaining 60 percent varying
from mild irregularity to extreme irregularity.
Scientifically to determine the exact character of a pulse which is
discovered by the finger on the radial artery and the stethoscope on
the heart to be irregular, tracings of one or more arteries, veins
and the heart should be taken. Two synchronous tracings are more
accurate than one, and three of more value than two in interpreting
the exact activity and regularity of the heart.
ETIOLOGY
The cause of an irregularly acting heart in an adult may be organic,
as in the various forms of myocarditis, in broken compensation of
valvular disease, Stokes-Adams disease, coronary disease, auricular
fibrillation, auricular flutter, cerebral disease, and toxemias from
various kinds of serious organic disease. The cause may be more or
less functional and removable, such as tea, coffee, alcohol,
tobacco, gastric indigestion and intestinal toxemia; or it may be
due to functional disturbances of the heart, such as that due to
what has been termed extrasystole, or to irregular ventricular
contractions. A frequent cause of irregular heart action in women,
more especially of increased rapidity, is hyperthyroidism.
There may be an arrhythmia due to some nervous stimulation, probably
through the pneumogastric, so that the pulse varies abnormally
during respiration, being accelerated during inspiration and
retarded during expiration more than is normally found in adults.
This condition is frequent in children, and is noticed in neurotic
adults and sometimes during convalescence from a serious illness.
Nervous and physical rest, with plenty of sleep and fresh, clean air
so that the respiratory center is normally stiniulated, will
generally improve this condition in an adult.
Extrasystoles causing arrhythmia give a more or less regularly
intermittent pulse, while the examination of the heart discloses an
imperfect beat or the extrasystole which is not transmitted or acted
on by the ventricles, and hence the intermittency in the peripheral
arteries. This condition may be due to some toxemia, nervous
irritability, or some irritation in the heart muscle. Good general
elimination by catharsis, warm baths to increase the peripheral
circulation, a low diet for a few days, abstinence from any toxin
which could cause this cardiac irritation, extra physical and mental
rest, sometimes nervous sedatives such as bromids, and perhaps a
lowering of the blood pressure by nitroglycerin, if such is
indicated, or an increase of the cardiac tone by digitalis if that
is indicated, will generally remove the cardiac irritation and
prevent the extrasystoles, and the heart will again become regular.
It should be carefully decided whether there is beginning heart
block or beginning Stokes-Adams disease, in which case digitalis
should not be used. This disease is not frequent, while
extrasystoles of a functional character are very frequent. Sometimes
this functional disease persists without any apparent injury to the
individual as long as the ventricle does not take note of these
extra auricular systoles and does not also become extra rapid. If
the ventricle does contract with this increased rapidity, it soon
wears itself out, and the condition becomes serious.
In this kind of arrhythmia, if there are no contraindications to
digitalis, it is the logical drug to use from its physiologic
activities, slowing the heart by its action on the vagi and causing
a steadier contraction of the heart; clinically this treatment is
generally successful. If digitalis should, however, cause the heart
to become more irritable, it is acting for harm, and should be
stopped.
TREATMENT
One has but to refer to the enumerated causes of irregular heart
action to determine the treatment. In that caused by extrasystole,
the treatment has just been suggested. In irregular heart caused by
serious cardiac or other lesions the treatment has already been
described, or is that of the disease that has a badly acting heart
as a complication. If the irregularity is caused by toxins, the
treatment is to stop the ingestion of the toxin and to promote the
elimination of what is already in the system; how much of the
irregularity was due to the toxin and how much is inherent
disturbance in the heart can then be determined. If the cause of a
toxemia developed in the system, perhaps most frequently from
intestinal putrefaction, increased elimination and a regulation of
the diet will cure the condition.
The valvular lesions most apt to cause irregular action of the heart
are mitral insufficiency or mitral stenosis. The lesion which is
most apt to cause auricular fibrillation and more or less
permanently irregular heart is perhaps mitral stenosis. Another
frequent cause of more or less permanent irregularity is the
excessive use of alcohol.
While an irregular pulse and an irregular heart are always of more
or less serious import, still, as the extrasystoles of the auricle
are better understood and more frequently recognized, and the habits
and life of the patients (most frequently men) are regulated and
revised, frequently a pulse and heart which would be rejected by any
medical examiner for an insurance company becomes, in a few weeks or
a few months, a perfectly acting heart, and remains so sometimes for
years. It also is not quite determinaible whether a heart that is so
misbehaving has a recurrence of such misbehavior more readily than a
heart which has never been so affected. However this may be, the
cause having been determined or presumed by the physician, it should
be so impressed on the patient that he does not again repeat the
insult to his heart.
AURICULAR FIBRILLATION: AURICULAR FLUTTER
Auricular fibrillation is at times apparently a clinical entity much
as is angina pectoris, but it is often a symptom of some other
condition. At times auricular fibrillation is only a passing
symptom, and is rapidly cured by treatment. A real auricular
fibrillation shows a semiparalysis of the auricles, and during this
condition normal systolic contractions do not occur, although there
are small rapid twitchings of different muscle fibers in the
auricles. Although it was once thought that the auricle was
paralyzed in this condition, it probably simply loses its coordinate
activity. Auricular fibrillation and auricular flutter are probably
simply different degrees of the same condition, and any contractions
of the auricles over 200 per minute may be termed an auricular
flutter, and below that the term auricular fibrillation may be used.
When ventricular fibrillation occurs, the condition is serious and
the prognosis bad. Both auricular fibrillation and auricular flutter
may be temporary or permanent, and the exact number of fibrillations
or tremblings of the auricular muscle can be noted only by
electrical instruments.
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