Disturbances of the Heart Part 16

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 alb.u.min 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, compet.i.tive 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 compet.i.tive 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 compet.i.tive 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 const.i.tutions, 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, alb.u.minuria 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 pa.s.sed 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 a.s.sociated 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 p.r.o.ne 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 a.s.sociated 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 a.r.s.enic 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 h.o.m.ogeneously; 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.