Disturbances of the Heart Part 7

The increased muscle tone thus caused raises the blood pressure somewhat, and the great depression before breakfast is not experienced. These patients rely oil their morning coffee for bracing. If they have much indigestion at night which keeps them awake so that they do not get good comfortable rest, their largest meals should be the morning and noon meals, and the evening meal should be very light.

Pendent abdomens or ptosed abdominal organs should be held up by proper abdominal bandages or corsets.

If the bowels are constipated, only the vegetable laxatives should be used, if it drug is needed at all. Salines should not be allowed, or other cathartics which cause profuse watery discharges. If a brisk purge is required, castor oil is the best.

Plenty of fresh air, and mild exercises in the open air all tend to increase the pressure. Graded walking, climbing, or other more interesting exercises are advisable, as all tending to raise the pressure, provided that at no time are they carried to the point of exhaustion.

Forced feeding may be useful. Cool sponging in the morning, if there is proper reaction, is often of benefit. Iron may be indicated; bitter tonics may be indicated. Digitalis and strychnin are often of advantage. Caffein may be used as a drug as well as given in coffee and tea. Atropin may be of value in some forms of hypotension.

At times with a low systolic pressure, but a relatively high diastolic pressure, nitroglycerin is valuable.

More or less act.i.te hypotension may occur in hot weather or with overheating, often termed heat exhaustion. Such patients should, if possible, go to a cooler region, whether to the seash.o.r.e or to the mountains is unimportant. The treatment of dangerous sudden low blood pressure, as shock, will be discussed elsewhere.

PERICARDITIS

ACUTE PERICARDITIS

As this inflammation is generally secondary to some other condition, its treatment cannot be positively outlined. Furthermore, it is often a terminal condition, and in such instances the results of treatment are of necessity nil. The most frequent terminal cause is nephritis; other terminal causes are pulmonary tuberculosis, adjacent abscesses, cancer or other growth.

The most frequent infectious cause is rheumatism; other infectious causes are cerebrospinal fever, typhoid fever, acute miliary tuberculosis, pneumonia and Sepsis. Accidental causes are traumatism and an adjacent inflammation of the pleura.

The result of an inflammation of the pericardium may be a fibrous exudate, or an exudate which is both serous and fibrous, or one in which pus is present in considerable amount.

The onset of pericarditis may be more or less acute, or it may commence insidiously. For this reason, during severe illness, and especially in those diseases which are known to have pericarditis often as a sequence, frequent examination of the heart should be made as a routine procedure.

SYMPTOMS AND SIGNS

If there is pain or much aching in the cardiac region, it tends to disappear with the exudate, if such is to occur, in the same way as does the pain of pleurisy. If there is much exudate, the pressure on the heart of course increases, the cardiac dulness enlarges, dyspnea occurs and even perhaps later cyanosis. As the exudate acc.u.mulates, the patient must lie higher and higher in order that the fluid may gravitate to the lowest part of the sac and give the heart the greatest ability to work. Reflex pain may occur from disturbances of the pneumogastric nerve, or from the weight and pressure of the enlarged and heavy pericardium. Reflex vomiting may be a troublesome and distressing symptom.

Acute pericarditis occurring in rheumatism, in acute infections, and from simple injuries tends to recovery. In dry pericarditis with serious adhesions, or if adhesions occur as a sequence of acute pericarditis, the future prognosis is bad, as myocarditis may develop and sudden death or acute dilatation may occur. As stated above, if pericarditis develops during the progress of chronic disease, such as interst.i.tial nephritis, or during sepsis, or from abscesses or growths in the region of the pericardium, the prognosis is bad.

TREATMENT OF ACUTE PERICARDITIS

In acute pericarditis, absolute mental as well as physical rest is essential. Even if the patient does not appear to be seriously ill and has not much fever, he should not be allowed to have visitors, to discuss business matters, or to carry on any conversation, however little exciting. Anything which increases the heart beat increases the irritation of the inflamed surfaces of the pericardium. He should not be allowed to sit up, either to eat or to attend to the calls of Nature. These rules are imperative, and when they are followed the pain is less, the heart beats less rapidly, is less hampered by pressure from whatever exudate may be present, and the adhesions which are liable to form will be less in amount and less serious for the future work of the heart.

The treatment, of course, depends largely on the cause of the pericarditis, as, if the cause is one of those just enumerated in which the prognosis is dire, any treatment directed toward the pericardial inflammation is almost useless. The periearditis under these conditions will be more or less benefited, if at all affected, by the treatment directed toward the cause.

The indications for treatment in all other instances are:

1. To attempt to abort the inflammation.

2. To stop the pain.

3. To limit, if possible, the amount of exudate, and to diminish the exudate already present.

4. To diminish the rapidity of the heart and to strengthen it.

1. Abortive Treatment.--For many years bloodletting was considered of the greatest importance in the early treatment of this disease; but owing to the fact that, except from traumatism, pericarditis rarely occurs except as a sequela of acute disease after the patient has been sick along time, or as a terminal condition in a patient who has long been chronically diseased and therefore has already lost more or less strength, venesection has been nearly abandoned.

Leeches may be used over the region of the pericardium, and cups are sometimes used. Dry cupping is more frequently used. These measures sometimes seem to reduce the inflammation, and certainly often relieve pain, but the most valuable local treatment is cold, which may be applied either in the form of an ice bag or by a small coil through which ice water is caused to flow by siphonage. Cold may be applied more or less continuously, depending on the sensations of the patient. The bag or ice cap must not be overfilled and must not be heavy, as the patient often cannot stand pressure over the pericardium. Sometimes the relief from pain and the diminution of the number of the heart beats is marked, and for this reason alone the cardiac inflammation may be inhibited. If cold applications are not tolerated by the patient (and they often are not in children) warm applications may be used, such as an electric pad or cloths wrung out of hot water and covered with oiled silk, and the pain will often be relieved thus. While hot applications would not tend to abort the inflammation, they probably do not tend to promote it.

A diminished diet, of small amount at a time, and such purging as the patient's strength will allow are essential in attempting to hasten recovery.

Just what can be done locally or generally to combat the inflammation actively must depend on the cause. When the inflammation occurs as a complication of acute rheumatism, it has been suggested that salicylates, which arc not inhibiting rheumatism and may be depressant to the heart, should be stopped if they are being administered; but if the salicylates are apparently improving the inflammation in the joints, pericarditis would not contraindicate their continued use. Except in large doses, salicylates probably do not depress the heart. In pericarditis it is perhaps well always to administer an alkali in some form unless otherwise contraindicated, whether or not the cause is rheumatism. A diminished alkalinity of the blood would always increase the likelihood of an augmented amount of pericardial or endocardial inflammation. The blood must be kept strongly alkaline. It is possible that one of the reasons why pericarditis or endocarditis occurs so frequently in serious prolonged fevers is that the patient has not eaten enough cereals or other carbohydrates, and the system has become more or less endangered by acidosis. Carbohydrate starvation is inexcusable with our present understanding of the danger from acideinia, and even from a diminished amount of alkalies in the blood.

The cause of pericarditis being so varied, any anti-toxin treatment or any vaccine treatment could be indicated only if the cause of the inflammation rendered the serum or vaccine advisable.

2. Stopping the Pain.--Nowhere else in the body should pain be so speedily combated as when it occurs in the region of the heart.

Morphin, with or without atropin, as deemed best, should be administered hypodermically in the amount and with the frequency necessary to stop the pain and quiet the restlessness. As stated above, the frequent need for morphin may be prevented by use of the ice bag. Morphin might even be considered an abortive treatment, as nothing tends so much to inhibit this inflammation as the quietude of the heart caused by the absence of pain, the production of sleep and the prevention of restlessness, muscle twitching and muscle movements. The more quiet the patient is, the more quiet is the heart.

If for any reason morphin is contraindicated, and if pain is not a symptom, the patient's nerves may be quieted and rest may be given by sodium bromid, or by veronal-sodium, the dose of the former being 2 gm. (30 grains) two or three times in twenty-four hours, according to its action and the necessity for it, and the dose of the latter 0.2 gm. (3 grains) once in six hours, if deemed necessary.

Especially if there are cerebral symptoms, as typically presented in cerebrospinal meningitis, and especially if the arterial tension is low, the subcutaneous administration of an aseptic ergot will quiet the central nervous system, increase the blood pressure, quiet the heart, and prolong the action of a single dose of morphin. It is the best plan to administer ergot deep into the muscles, with the deltoid as the place of choice. If the skin is properly cleansed, the syringe clean and the preparation of the drug aseptic, no inflammation or abscess will ever occur. If there is any painful swelling, a wet alcohol dressing to the part will soon relieve it.

The frequence with which ergot should be so administered depends on the results and the indications. Once in twelve hours for several doses is generally the best method for its use.

3. The Exudate.--When a fluid exudate into the pericardium has occurred from inflammation that is, when it is not an exudate from disturbed kidneys or circulation--it will continue to increase to some extent in spite of any treatment. Just how much this exudate may be prevented by the use of small blisters over or around the heart, and just how much watery stools and diuresis may prevent the advance of the exudate is difficult to determine. Small blisters, properly applied, have many times seemed to be the determining factor in stopping the increase in the fluid, or to have been the starting cause of the resorption of the exudate.

The amount of purging that should be caused by saline cathartics such as sodium sulphate (Glauber salt), pota.s.sium and sodium tartrate (Roch.e.l.le salt), or the official compound jalap powder cannot be declared dogmatically. Saline purging should be governed by the character of the circulation. If the heart is strong, the pulse not weak, and the blood pressure good, nothing is more valuable in this condition. Portal depletion is of great advantage, especially if the amount of liquid ingested is kept as low as possible, so that the blood vessels may become thirsty and thus tend to absorb an exudate wherever they find it. Much harm has been done, however, and death has been caused by saline purgatives in endeavoring to relieve edemas from a failing heart or to prevent a uremia from kidney inflammation. The depression following such purging is often serious. If the circulation is weak, dependence should be placed on purgation by some of the simple vegetable cathartics or a small dose of calomel. While it is advisable to give a saline in concentrated solution, it should not be so strong as to cause vomiting. With our better understanding of magnesium absorption and the depressant effect of magnesium on the nervous system, magnesium salts should not be used in serious conditions.

Diuretics often do not act well when most needed. The simplest diuretic is pota.s.sium citrate, given in wintergreen or peppermint water, in doses of 2 gm. (30 grains), three or four tunes in twenty- four hours. One or more of the vegetable, nonirritant diuretics may be tried if preferred. If the sickness preceding the pericarditis was not a long fever, and the heart muscle is considered in good condition, digitalis in small doses may be the best possible diuretic. Incidentally it will slow the heart, if there is not much elevation of temperature, and will give some cardiac rest.

Although the patient's diet should be limited in bulk, and especially in amount of liquids, good nutrition should soon be given. Systemic weakness certainly tends to increase the exudate; systemic strength aids in absorption of the exudate.

Iron is early indicated, and nothing is better than 5 drops of the tincture of chlorid of iron in a little lemonade or orangeade, administered once in eight hours.

If the exudate tends to decrease, it perhaps may be hastened by the local application of tincture of iodin over the cardiac region. Also the administration of small doses of an iodid, as 0.3 gm. (5 grains) of sodium iodid, given in plenty of water three times a day, is useful. An iodid circulating in the blood seems to aid absorption.

It has long been believed that iodin in the blood tends to promote absorption of thickened, left-over material from exudates, and to prevent the formation of strong fibrous adhesions. Until our knowledge is more exact in this matter, it is advisable to use iodid as suggested. If the above-named dose is not tolerated, less should be given.

If in spite of all the therapeutic measures suggested, the fluid increases and the pericardium becomes more distended and the heart's action more labored, paracentesis must be done. The point at which the aspirating needle should be inserted into the pericardium depends somewhat on the conditions in each individual case. It is often best to insert an exploratory needle first. This will determine the fluidity and character of the exudate. If pus is found, a more radical surgical procedure than simple paracentesis must be done immediately. The point of puncture for aspiration most frequently chosen is in the fourth or fifth intercostal s.p.a.ce, about an inch to the left of the sternal margin. Paracentesis is also often done in the region of the normal apex beat. The position of the patient is determined by his dyspnea; he should lie in the position most comfortable for him. The fluid should be withdrawn slowly and the pulse carefully watched. The withdrawal of a small amount of fluid may later seem to be the starting cause of resorption of the rest of the fluid. On the other hand, it may often be not of more value than the simple removal of the immediate pressure, the fluid may again acc.u.mulate, and more radical surgery must be performed.

4. To Strengthen the Heart.--Most of the methods of meeting this indication have already been stated, namely, absolute rest; absolute quiet; the use of the bed pan; any movement that must be made should be deliberate; the nurse and other attendants must be quiet; necessary conversation must be brief, and every method must be used to quiet and prevent the heart's action from becoming rapid. The food taken should be small in amount and nonstimulating; that is, no tea or coffee should be given, and nothing too hot or too cold.

Movements of the bowels should be caused with the least possible general disturbance. If the patient does not sleep, he must be made to sleep. The whole body and the nervous system must have periods of rest. If the heart is very weak, small closes of morphin may be used. If the heart is not weak, bromids or chloral may be given. If the blood pressure is high, such hypnotics will lower it, or if the heart is strong and the condition does not contraindicate it, aconite may be used in small doses, for a day or two, unless the fever is high and it seems advisable to use one of the coal-tar antipyretics, which reduce the blood tension and the heart activity.

As stated above, pain must not be allowed. Sometimes, when the heart has not been injured by prolonged fever, digitalis in small doses may slow the heart and act for good.

Convalescence.--The convalescence should be prolonged as in any other cardiac inflammation. The patient should be given more and more nourishing food, and the iron tonic may be changed to a capsule containing 0.05 gm. of quinin and 0.05 gm. of reduced iron, three times a day.

It is a question as to when patients convalescent from pericarditis should be permitted exercise. It has been thought that gentle movements and possibly exercise, sooner than theoretically justified, might cause the heart to beat a little more actively and possibly prevent the formation of tight adhesions between the two layers of the pericardium. Whether such activity of the heart will prevent adhesions is something that has not been determined.

The small doses of sodium iodid, perhaps 0.2 gm. (3 grains) two or three times a day, should be continued for some time. Iodid in this dosage does no harm and may do a great deal of good.

ADHERENT PERICARDITIS