Disturbances of the Heart Part 18

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 a.s.sure 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 p.r.o.ne 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, ma.s.sage, 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, ma.s.sage 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 pa.s.sing 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 alb.u.mini 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 interst.i.tial nephritis.

Sooner or later, in most instances of this disease, whether hypertension, chronic endarteritis or interst.i.tial 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 pa.s.sive congestion of the kidneys, and the chronic interst.i.tial 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 alb.u.min 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 appet.i.te, such as spices, condiments, and even sometimes salt, must be prohibited. b.u.t.ter, 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 s.p.a.ce 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 s.p.a.ce 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 quant.i.ty, 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 ma.s.sage is advisable.