Disturbances of the Heart Part 2

Many persons with these symptoms of cardiac tire think that they are house-tired, shop-tired, or office-tired, and take on a physical exercise, such as walking, climbing, tennis playing or golf playing, to their injury. Such tired hearts are not ready yet for added physical exercise; they should be rested first.

The treatment of this cardiac tire is not complete until the tonsils, gums, teeth and the nose and its accessory sinuses are in good condition. Various other sources of chronic poisoning from chronic infection should of course be eliminated, whether an uncured gonorrhea, prostat.i.tis, some chronic inflammation of the female pelvic organs, or a chronic appendicitis.

Longcope [Footnote: Longcope, W. T.: The Effect of Repeated Injections of Foreign Protein on the Heart Muscle, Arch. Int. Med., June, 1915, p. 1079.] has recently shown that repeated, and even at times one protein poisoning can cause degeneration of the heart muscle in rabbits. Hence it is quite possible that repeated absorption of protein poisons from the intestines may injure the heart muscle as well as the kidney structure; consequently, in heart weakness, besides removing all evident sources of infection, we should also give such food and cause such intestinal activity as to preclude the absorption of protein poison from the bowels.

CLa.s.sIFICATION OF CARDIAC DISTURBANCES

For the sake of discussing the therapy of cardiac disturbances in a logical sequence, they may be cla.s.sified as follows:

Pericarditis Acute Adherent

Myocarditis Acute Chronic Fatty

Endocarditis Acute, simple malignant Chronic Valvular Lesions Broken compensation Cardiac drugs Diet Resort treatment Cardiac disease in children Cardiac disease in pregnancy Coronary sclerosis Angina pectoris Pseudo-angina Stokes-Adams disease Arterial hypertension Cardiovascular-renal disease Arrhythmia Auricular fibrillation Bradycardia Paroxysmal tachycardia Hyperthyroidism Toxic disturbances Physiologic hypertrophies Simple dilatation Shock Stomach dilatation Anesthesia in heart disease

BLOOD PRESSURE

The study of the blood pressure has become a subject of great importance in the practice of medicine and surgery. No condition can be properly treated, no operation should be performed, and no prognosis is of value without a proper consideration of the sufficiency of the circulation, and the condition of the circulation cannot be properly estimated without an accurate estimate of the systolic and diastolic blood pressure. However perfectly the heart may act, it cannot properly circulate the blood without a normal tone of the blood vessels, both arteries and veins. Abnormal vasodilatation seriously interferes with the normal circulation, and causes venous congestion, abnormal increase in venous blood pressure, and the consequent danger of shock and death. Increased arterial tone or tonicity necessitates greater cardiac effort, to overcome the resistance, and hypertrophy of the heart must follow.

This hypertrophy always occurs if the peripheral resistance is not suddenly too great or too rapidly acquired. In other words, if the peripheral resistance gradually increases, the left ventricle hypertrophies, and remains for a long time sufficient. If, from disease or disturbance in the lungs, the resistance in the pulmonary circulation is increased, the right ventricle hypertrophies to overcome it, and the circulation is sufficient as long as this ventricle is able to do the work. If either this pulmonary increased pressure or the systemic increased pressure persists or becomes too great, it is only a question of how many months, in the case of the right ventricle, and how many years, in the case of the left ventricle, the heart can stand the strain.

If the cause of the increased systemic tension is an arterial fibrosis, sooner or later the heart will become involved in this general condition, and a chronic myocarditis is likely to result.

If, on the other hand, there is a continuous low systemic arterial blood pressure, the circulation is always more or less insufficient, nutrition is always imperfect, and the physical ability of the individual is below par. It is evident, therefore, that an abnormally high blood pressure is of serious import, its cause must be studied, and effort must be made to remove as far as possible the cause. On the other hand, a persistently low blood pressure may be of serious import, and always diminishes physical ability. If possible, the cause should be determined, and the condition improved.

No physician can now properly practice medicine without having a reliable apparatus for determining the blood pressure both in his office and at the bedside. It is not necessary to discuss here the various kinds of apparatus or what is essential in an apparatus for it to give a perfect reading. It may be stated that in determining the systolic and diastolic pressure in the peripheral arteries, the ordinary stethoscope is as efficient as any more elaborate auscultatory apparatus.

It is now generally agreed by all scientific clinicians that it is as essential--almost more essential--to determine the diastolic pressure as the systolic pressure; therefore the auscultatory method is the simplest, as well as one of the most accurate in determining these pressures. Of course it should be recognized that the systolic pressure thus obtained will generally be some millimeters above that obtained with the finger, perhaps the average being equivalent to about 5 mm. of mercury. The diastolic pressure will often range from 10 to 15 mm. below the reading obtained by other methods. Therefore, wider range of pressure is obtained by the auscultatory method than by other methods. This difference of 5 or more millimeters of systolic pressure between the auscultatory and the palpatory readings should be remembered when one is consulting books or articles printed more than two years ago, as many of these pressures were determined by the palpatory method.

Sometimes the compression of the arm by the armlet leads to a rise in blood pressure. [Footnote: MacWilliams and Melvin: Brit. Med.

Jour., Nov. 7, 1914.] It has been suggested that the diastolic pressure be taken at the point where the sound is first heard on gradually raising the pressure in the armlet.

In some persons the auscultatory readings cannot be made, or are very unsatisfactory, and it becomes necessary to use the palpation method in taking the systolic pressure. In instances in which the auscultatory method is unsatisfactory, the artery below the bend of the elbow at which the reading is generally taken may be misplaced, or there may be an unusual amount of fat and muscle between the artery and the skin.

The various sounds heard with the stethoscope, when the pressure is gradually lowered, have been divided into phases. The first phase begins with the first audible sound, which is the proper point at which to read the, systolic pressure. The first phase is generally, not always, succeeded by a second phase in which there is a murmurish sound. The third phase is that at which the maximum sharp, ringing note begins, and throughout this phase the sound is sharp and intense, gradually increasing, and then gradually diminishing to the fourth phase, where the sound suddenly becomes a duller tone.

The fourth phase lasts until what is termed the fifth phase, or that at which all sound has disappeared. As previously stated, the diastolic pressure may be read at the beginning of the fourth phase, or at the end of the fourth phase, that is, the beginning of the fifth; but the difference is from 3 to 10 mm. of mercury, with an average of perhaps 5 mm.; therefore the difference is not very great. When the diastolic pressure is high, for relative subsequent readings, it is much better to read the diastolic at the beginning of the fifth phase.

It is urged by many observers that the proper reading of the diastolic pressure is always at the beginning of the fourth phase.

However, for general use, unless one is particularly expert, it is better to read the diastolic pressure at the beginning of the fifth phase. There can rarely be a doubt in the mind of the person who is auscultating as to the point at which all sound ceases. There is frequently a good deal of doubt, even after large experience, as to just the moment at which the fourth phase begins. With the understanding that the difference is only a few millimeters, which is of very little importance, when the diastolic pressure is below 95, it seems advisable to urge the reading of the diastolic pressure at the beginning of the fifth phase.

The incident of the first phase, or when sound begins, is caused by the sudden distention of the blood vessel below the point of compression by the armlet. In other words, the armlet pressure has at this point been overcome. Young [Footnote: Young: Indiana State Med. a.s.sn. Jour., March, 1914.] believes that the murmurs of the second phase, which in all normal conditions are heard during the 20 mm. drop below the point at which the systolic pressure had been read, is "due to whirlpool eddies produced at the point of constriction of the blood vessel by the cuff of the instrument." The third phase is when these murmurs cease and the sound resembles the first, lasting he thinks for only 5 mm. The third phase often lasts much longer. He thinks the fourth phase, when the sound becomes dull, lasts for about 6 mm.

TECHNIC

It is essential that the patient on whom the examination is to be made should be at rest, either comfortably seated, or lying down.

All clothing should be removed from the arm, and there should be no constriction by sleeves, either of the upper arm or the axilla. When the blood pressure is taken over the sleeve of a garment, the instrument will register from 10 to 30 mm. higher than on the bare arm. [Footnote: Rowan, J. J.: The Practical Application of Blood Pressure Findings, The JOURNAL A. M. A., March 18, 1916, p. 873.]

While it may be better, for insurance examinations, to take the blood pressure of the left arm in right handed persons as a truer indicator of the general condition, the difference is generally not great. The right arm of right handed persons usually registers a full 5 mm. higher systolic pressure than the left arm.

The patient, being at rest and removed as far as possible from all excitement, may be conversed with to take his mind away from the fact that his blood pressure is being taken. He also should not watch the dial, as any tensity on his part more or less raises the systolic pressure, the diastolic not being much affected by such nervous tension. The armlet having been carefully applied, it is better to inflate gradually 10 mm. higher than the point at which the pulsation ceases in the radial. The stethoscope is then firmly applied, but with not too great pressure, to the forearm just below the flexure of the elbow. The exact point at which the sound is heard in the individual patient, and the exact amount of pressure that must be applied, will be determined by the first reading, and then thus applied to the second reading. One reading is never sufficient for obtaining the correct blood pressure. The blood pressure may be read by means of the stethoscope during the gradual raising of pressure in the cuff, note being taken of the first sound that is heard (the diastolic pressure), and the point at which all sound disappears, as the pressure is increased (the systolic pressure). The former method is the one most frequently used.

By taking the systolic and diastolic pressures, the difference between the two being the pressure pulse, we learn to interpret the pressure pulse reading. While the average pressure pulse has frequently been stated as 30 mm., it is probable that 35 at least, and often 40 mm. represents more nearly the normal pressure pulse, and from 25 mm. on the one hand to 50 on the other may not be abnormal.

Faught [Footnote: Faught: New York Med Jour., Feb. 27, 1915, p.

396.] states his belief that the relation of the pressure pulse to the diastolic pressure and the systolic pressure are as 1, 2 and 3.

In other words, a normal young adult with a systolic pressure of 120 should have a diastolic pressure of 80, and therefore a pulse pressure of 40. If these relationships become much abnormal, disease is developing and imperfect circulation is in evidence, with the danger of broken compensation occurring at some time in the future.

It should be remembered that the diastolic pressure represents the pressure which the left ventricle must overcome before the blood will begin to circulate, that is, before the aortic valve opens, while the pressure pulse represents the power of the left ventricle in excess of the diastolic pressure. Therefore it is easy to understand that a high diastolic pressure is of serious import to the heart; a diastolic pressure over 100 is significant of trouble, and over 110 is a menace.

FACTORS INCREASING THE BLOOD PRESSURE

With normal heart and arteries, exertion and exercise should increase the systolic pressure, and generally somewhat increase the diastolic pressure. The pressure pulse should therefore be greater.

When there is circulatory defect or abnormal blood pressure, exercise may not increase the systolic pressure, and the pressure pulse may grow smaller. As a working rule it should be noted that the diastolic pressure is not as much influenced by physiologic factors or the varying conditions of normal life as is the systolic pressure.

In an irregularly acting heart the systolic pressure may vary greatly, from 10 to 20 mm. or more, and a ventricular contraction may not be of sufficient power to open the semilunar valves. Such beats will show an intermittency in the blood pressure reading as well as in the radial pulse. The succeeding heart beats after abortive beats or after a contraction of less power have increased force, and consequently give the highest blood pressure. Kilgore urges that these highest pressures should not be taken as the true systolic blood pressure, but the average of a series of these varying blood pressures. In irregularly acting hearts it is best to compress the arm at a point above which the systolic pressure is heard, then gradually reduce the pressure until the first systolic pressure is recorded, and then keep the pressure of the cuff at this point and record the number of beats of the heart which are heard during the minute. Then reduce the pressure 5 mm. and read again for a minute, and so on down the scale until the varying systolic pressures are recorded. The average of these pressures should be read as the true systolic blood pressure. During an intermittency of the pulse from a weak or intermittently acting ventricle, the diastolic pressure will reach its lowest point, and in auricular fibrillation the pressure pulse from the highest systolic to the lowest diastolic may be very great.

In arteriosclerosis the systolic may be high, and the diastolic low, and hence a large pressure pulse. When the heart begins to fail in this condition, the systolic pressure drops and the pressure pulse shortens, and of course any improvement in this condition will be shown by an increase in the systolic pressure. The same is true with aortic regurgitation and a high systolic pressure.

If the systolic pressure is low and the diastolic very low, or when the heart is rapid, circulation through the coronary vessels of the heart is more or less imperfect. Any increase in arterial pressure will therefore help the coronary circulation. The compression of a tight bandage around the abdomen, or the infusion of blood or saline solutions, especially when combined with minute amounts of epinephrin, will raise the blood pressure and increase the coronary circulation and therefore the nutrition of the heart.

MacKenzie [Footnote: MacKenzie: Med Rec., New York, Dec. 18, 1915.], from a large number of insurance examinations in normal subjects, finds that for each increase of 5 pulse beats the pressure rises 1 mm. He also finds that the effect of height on blood pressure in adults seems to be negligible. On the other hand, it is now generally proved that persons with overweight have a systolic pressure greater than is normal for individuals of the same age. He believes that diastolic pressure may range anywhere from 60 mm. of mercury to 105, and the person still be normal. A figure much below 60 certainly shows dangerous loss of pressure, and one far below this, except in profound heart weakness, is almost pathognomonic of aortic regurgitation. While the systolic range from youth to over 60 years of age gradually increases, at the younger age anything below 105 mm. of mercury should be considered abnormally low, and although 150 mm. at anything over 40 has been considered a safe blood pressure as long as the diastolic was below 105, such pressures are certainly a subject for investigation, and if the systolic pressure is persistently above 150, insurance companies dislike to take the risk. However, it should be again urged in making insurance examinations that psychic disturbance or mental tensity very readily raises the systolic pressure. MacKenzie believes that a diastolic pressure over 100 under the age of 40 is abnormal, and anything over the 110 mark above that age is certainly abnormal.

It has been shown, notably by Barach and Marks, [Footnote: Barach, J. H., and Marks, W. L.: Effect of Change of Posture--Without Active Muscular Exertion--on the Arterial and Venous Pressures, Arch. Int.

Med., May, 1913, p 485.] that posture changes the blood pressure.

When a normal person reclines, with the muscular system relaxed, there is an increase in the systolic pressure and a decrease in the diastolic pressure, with an increase in the pressure pulse from the figures found when the person is standing. When, after some minutes of repose, he a.s.sumes the erect posture again, the systolic pressure will diminish and the diastolic pressure increase, and the pressure pulse shortens.

Excitement can raise the blood pressure from 20 to 30 mm., and if such excitement occurs in high tension cases there is often a systolic blow in the second intercostal s.p.a.ce at the right of the sternum. This may not be due to narrowing of the aortic orifice; it may be due to a sclerosis of the aorta. On the other hand, it may be due entirely to the hastened blood stream from the nervous excitability. This is probably the case if this sound disappears when the patient reclines. If it increases when the heart becomes slower and the patient is lying down, the cause is probably organic.

This psychic influence on blood pressure is stated by Maloney and Sorapure [Footnote: Maloney and Sorapure: New York Med. Jour., May 23, 1914, p. 1021.] "to be greater than that from posture, than that arising from carbonic acid gas control of the blood, than that arising from mechanical action of deep breathing upon the circulation, and than that arising from removal of spasm from the musculature."

Weysse and Lutz [Footnote: Weysse and Lutz: Am. Jour. Physiol., May, 1915.] find that the systolic pressure varies during the day in normal persons, and is increased by the taking of food, on an average of 8 mm. The diastolic pressure is not much affected by food. This increased systolic pressure is the greatest about half an hour after a meal, and then gradually declines until the next meal.

Any active, hustling man, or a man under strain, has a rise of blood pressure during that strain, especially notable with surgeons during operation, or with brokers or persons under high nervous tension.

Daland [Footnote: Daland: Pennsylvania Med Jour., July, 1913.]

states that a man driving an automobile through a crowded street may have an increase of systolic pressure of 30 mm., and an increase of 15 mm. in his diastolic pressure, while the same man driving through the country where there is little traffic will increase but 10 mm.

systolic and 5 mm. diastolic. Fear always increases the blood pressure. This is probably largely due to the peripheral contractions of the blood vessels and nervous chilling of the body.

VENOUS PRESSURE

The venous pressure, after a long neglect, is now again being studied, and its determination is urged as of diagnostic and prognostic significance.