Disturbances of the Heart / Discussion of the Treatment of the Heart in Its Various Disorders, With a Chapter on Blood Pressure

by Oliver T. Osborne

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.