In the present state of our knowledge the adoption of the following principles in the management of a case of incipient fatty heart disease seems justifiable:
We must train the patient gradually but steadily to the giving up of all luxurious habits. He must adopt early hours, and pursue a system of graduated muscular exercises; and it will often happen that, after perseverance in this system, the patient will be enabled to take an amount of exercise with pleasure and advantage, which at first was totally impossible, owing to the difficulty of breathing which followed exertion. This treatment by muscular exercise is obviously more proper in younger persons than in those advanced in life. The symptoms of debility of the heart are often removable by a regulated course of gymnastics or by pedestrian exercise, even in mountainous countries, such as Switzerland or the Highlands of Scotland or Ireland. We may often observe in such persons the occurrence of what is commonly known as "getting the second wind," that is to say, during the first period of the day, the patient suffers from dyspnea and palpitation to an extreme degree, but by persevering, without over-exertion, or after a short rest, he can finish his day's work and even ascend high mountains with facility. In those advanced in life, however, as has been remarked, the frequent complications with atheromatous disease of the aorta, and affections of the liver and lungs must make us more cautious in recommending the course now specified.
Perhaps the most important therapeutic suggestion which Sir William Broadbent has to make with regard to the cardiac conditions that have come to occupy much of the patient's attention is of a negative character. He says that "patients suffering from these functional derangements of the heart usually make them a pretext for avoiding exercise and often for taking stimulants or drugs, whereas exercise and fresh air are what they need. The best way to prevent the expenditure of superfluous energy on the part of the heart in the form of palpitation is to give it a fair amount of legitimate physiological work to do." Personally I have found that most of the cardiac tonics seem to do harm, in the sense of increasing the subjective symptoms, except in cases where the patient is run down in general health because of failure to take sufficient food, when strychnin seems to be of avail and in the shape of nux vomica acts as an appetizer as well as a heart tonic. Sir William Broadbent has warned particularly with regard to the use of alcohol in these cases. [{327}] Most patients find that for the moment palpitation is lessened by alcoholic stimulation. They pay for it afterwards, however, by an increased sense of discomfort that sometimes lasts for 24 hours or more. As Sir William Broadbent declared, "To relieve one attack of palpitation or fainting by alcohol is to invite another, while the terrible danger of dropping into alcoholism is incurred."
Lest it should be thought that even Broadbent is a little old-fashioned and not quite to be trusted in the light of our present-day knowledge, and above all lest it might be feared that these older men made a better prognosis or emphasized the value of exercise more than is compatible with our recent discoveries in the physiology and pathology of the heart, it seems well to give MacKenzie's opinion of these cases in full. This is all the more important because, as I have said, the influence of German teaching has led to the formation of rather different opinions in America, especially among our younger physicians. Prof. Martius in this country in his lecture for the Harvey Society gave quite a serious prognosis for practically all heart irregularity. He almost went so far as to lay it down as a rule of diagnosis that whenever a heart beats irregularly there is something the matter with the heart muscle or good reason to suspect a myocardial lesion of some kind. MacKenzie's view is very different to this and he warns particularly against permitting the influence of an unfavorable attitude of mind on the part of these patients. He says:
The most serious thing about these cases is that the consciousness of having an irregularity sometimes makes a patient introspective and depressed. He keeps feeling his pulse, and communicates his doleful tale whenever he find a sympathetic ear.
As the process which gives rise to it in elderly people is the same as that which produces the tortuous temporal arteries, no more significance should be attached to the one symptom than to the other. I have followed cases for many years, and watched them pass through seasons of sickness and of stress, and have seen no reason to attach any serious import to this symptom. In rare instances the heart, from being occasionally irregular, has after many years become continuously irregular for short or long periods, and in a few the permanent establishment of the nodal rhythm has been the means of hastening the end. But this is infrequent, and in cases of cardio-sclerosis has only happened in advanced life, and the patient should on no account be frightened by being warned of the possible occurrence of this unlikely contingency. In younger and neurotic people I have never seen it lead to any bad results. It may appear in serious affections of the heart, as in febrile complaints, but it does not of itself add to the gravity of the condition, though I am not sure that when due to an acute infection of the heart, as in pneumonia and rheumatic fever, it may not be a sign of invasion of the myocardium by the diseased process.
If the patient is aware of the irregularity, he should be assured that there is no cause for alarm. It is useless to attempt to treat the irregularity itself. If in other respects the patient is well, then there is no need of any special treatment. If the patient be suffering from conditions which seem to promote irregularity, such as worry, fatigue, dyspepsia, the treatment should be devoted to the removal of the predisposing cause. In people with temporary high blood pressure, who show extra systoles, I find plenty of healthy exercise in the open air specially beneficial, though until they get trained, the extra systoles may at times become more frequent by the exertion.
This last remark of MacKenzie's is particularly important, for at the beginning of an attempt to relieve the symptoms by insisting on more [{328}] exercise, the patient is almost sure to be disturbed by this symptom of which he will often be conscious, and it takes a good deal of experience on the part of the physician to reassure him that because of the increased subjective symptoms at the beginning of the treatment by increased exertion, he may not be doing harm rather than good. As a rule, however, it is not long before the good results of the exercise treatment of these cases begin to make themselves felt and the patient is reassured. Regulated exercise of body and occupation of mind are the two important factors even in the treatment of organic heart disease. They are extremely important even in the cases with alarming heart symptoms that occur in the very old, once the acute symptoms have subsided. In all the functional heart affections exercise is the most important therapeutic resource we have. It would seem that in the course of muscular exercise some heart tonic was manufactured, which in all but the cases of absolutely failing hearts is the best possible therapeutic resource for the stimulation and steadying of the heart action. Such an internal secretion would not be surprising in the light of all that we have learned of the physiological nexus of organs in recent years.
Many so-called cures for heart disease probably depend for their good effect much more on the graduated exercise that goes with them than on many of the other remedial measures, though it is these latter that are usually vaunted most highly. We all now recognize how little value there is in the Nauheim bath treatment for heart disease away from Nauheim itself. The reason is because the resisted movements of the early part of the cure and, above all, the graduated exercise of walking up the hills around Nauheim, which are such important parts of the treatment there, cannot be so well given with the baths at a distance.
CHAPTER IV
CARDIAC PALPITATION AND GASTRO-INTESTINAL DISTURBANCE
Morgagni, whom Virchow greeted as the Father of Modern Pathology, made a careful study of the pulse and especially of its irregularities. He had learned from the most careful pathological studies that marked intermission and even more decided irregularity of the heart may be present in life, though there may be absolutely no organic affection of the heart itself, either of the valves or of the muscle, discoverable at autopsy. In his opinion the most frequent cause for such irregularity is flatulency and disturbance of digestion generally. He went still farther, however, and seems to have understood very well that constipation was often one of the most important links in the chain of causes leading up to such heart disturbance, itself either a cause or an effect of other digestive symptoms. This idea deserves to be borne in mind when there is question of the significance of heart symptoms. What Morgagni thus determined by precise studies in pathological anatomy had been clinically observed by many of the distinguished old-time practitioners of medicine, who knew the fatal tendencies of organic heart symptoms, yet recognized that many cardiac cases associated with gastric symptoms did not have an unfavorable prognosis.
In spite of the recognition of these conditions by old-time medical investigators, there has always been a tendency to fear that heart symptoms in these cases might be due to a cardiac affection. This has invariably been true for patients themselves to whom the heart disturbance became conscious, but has often made physicians hesitate as to the diagnosis and rendered their prognosis more unfavorable than is justified by actual knowledge.