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 IN ACUTE DISEASE

ACUTE DILATATION OF THE HEART IN ACUTE DISEASE

It has for a long time been recognized that in all acute prolonged illness the heart fails, sooner or later, often without its having been attacked by the disease. The prolonged high temperature causes the heart to beat more rapidly, while the toxins produced by the fever process cause muscle degeneration of the heart or a myocarditis, and at the same time the nutrition of the heart becomes impaired either by improper feeding or by the imperfect metabolism of the food given; hence the heart muscle becomes weakened, and cardiac failure or cardiac relaxation or dilatation occurs.

The specific germ of the disease, or the toxin elaborated by this germ, may be especially depressant to the heart, as in diphtheria, or the germ may be particularly prone to locate in the heart, as in rheumatism and pneumonia. But all feverish processes, sooner or later, if sufficiently prolonged, cause serious cardiac weakness and more or less dilatation.

Just exactly what changes take place in the muscle fibers of the heart in some of these fevers has not been decided. Whether an albuminous or parenchymatous degeneration of the muscle fibers or a fatty degeneration occurs, whether there is a real myocarditis that always precedes the dilatation, or whether the weakening and loss of muscle fibers or a diminished power of the muscle fibers occurs without inflammation, dilatation of the heart is always a factor to be considered, and frequently occurs in acute disease.

While it is denied that acute dilatation can occur in a sound heart, at the latter end of a serious illness the heart is never sound, and acute dilatation can most readily occur, though fortunately it is generally preventable. When the dilatation occurs suddenly, as indicated by a fluttering heart, a low tension, rapid pulse, dyspnea and perhaps cyanosis with venous stasis in the capillaries, death is imminent, although such patients may be saved by proper aid. Even when the dilatation is slower, as evidenced by a gradually increasing rapidity of the heart and a gradually lowering blood pressure, and with more evidences of exhaustion, death may occur from such heart failure in spite of all treatment.

Unless a patient dies from accident, as from a hemorrhage, from cerebral pressure or from some organic lesion in acute disease, the physician frequently feels that if he can hold the power and force of the circulation for several hours or days, the patient will recover from the disease, for in most acute diseases the patient has a good chance of recovery if his circulation will only hold out until the crisis has occurred or until the disease is ready to end by lysis. Therefore anything during the disease that tends to sustain, nourish, quiet and guard the heart means so much more chance of recovery, whatever else may or may not be done for the disease itself.

The best treatment of dilatation of the heart in acute disease is its prevention, and to prevent it means to recognize the condition which can cause it. These are

1. Prolonged high temperature. A short-lived temperature, even if high, is not serious. Prolonged temperature of even 103 F. or more is serious, and even that of 101 is serious if too long continued.

2. Exertion and excitement. Every possible means should be inaugurated to prevent muscular exertion and strain of the patient while in bed. Proper help in lifting and turning the patient should be employed, the bed-pan should be used, proper feeding methods should be adopted, and friends should be excluded so that the patient may not be excited by conversation.

3. Bad feeding. The diet should of course be sufficient, for the patient and proper for the disease, but any diet which causes a large amount of gas in the stomach, or tympanites, is harmful to the patient's circulation, to say nothing of any other harm, such as indigestion may do. All of the nutriments needed to keep the body in perfect condition should be given to a patient who is ill; in some manner he should receive the proper amounts of iron, salt, calcium, starch, protein, sugar and water.

4. Intestinal sluggishness. This means not only that tympanites should not be allowed, but also that necessary laxatives should be given. It would be wrong to prostrate a patient with frequent saline purgatives, but the bowels must move at least once every other day, generally better daily; and if the case is one of typhoid fever, they should be moved by some carefully selected laxative, and after the bowels have sufficiently moved, the diarrhea should be stopped by 1/10 grain of morphin, and the next day the bowels properly moved again.

5. Depressant drugs. In this age of cardiac failure, heart depressants of all types, and especially the synthetic products, should be given only with careful judgment, and, never frequently repeated or long continued.

6. Pain. This is one of the most serious depressants a heart has to combat; acute pain must not be allowed, and prolonged subacute pain must be stopped. Even peripheral troublesome irritations must be removed, as tending to wear out a heart which has all of the trouble it can endure.

7. Insomnia. Nothing rests a heart or recuperates a heart more than sleep. Insomnia and acute disease make a combination which will wear a heart out more quickly than any other combination. Sleep, then, must be produced in the best, easiest and safest manner possible.

8. A too speedy return to activity. The convalescence must be prolonged until the heart is able to sustain the work required of it.

The treatment of gradual dilatation in acute disease has been sufficiently discussed under the subject of acute myocarditis. The treatment of acute dilatation is practically the same as the treatment of shock plus whatever treatment must coincidently be given to a patient for the disease with which he is suffering. The treatment of shock will be discussed under a separate heading.