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

With the strennousness of this era, this disease or condition, which may be regarded as one of the accompaniments of normal old age, has become of grave importance, and nowadays frequently develops in early middle life. If it is diagnosed in its incipiency, and the patient follows the advice given him, the progress of the disease will generally be inhibited, and a premature old age postponed.

In the beginning the symptoms and signs of this disease are generally those of hypertension, and the treatment and management is that advised in hypertension. If the kidneys show irritation, as manifested by the presence of albumini and casts in the urine, or if they show insufficiency in the twenty-four-hour excretion of one or more salts or other excretory product, the diet and life must be more carefully regulated than advised in hypertension, and the treatment becomes practically that of chronic interstitial nephritis.

Sooner or later, in most instances of this disease, whether hypertension, chronic endarteritis or interstitial nephritis or any combination of these conditions is most in evidence, the heart will hypertrophy. As long as the circulation in the heart itself is good and not impaired by coronary sclerosis, and as long as this slowly developing chronic myocarditis has not advanced far, cardiac symptoms will not be in evidence; but if these conditions occur, or if the blood pressure is so greatly increased as to damage the aortic valve or strain and dilate the left ventricle, symptoms rapidly appear, and the heart must be carefully watched. Subsequently, as the disease advances, if the patient does not die of angina pectoris, apoplexy or uremia, the symptoms of cardiac decompensation will develop. As the heart begins to fail, a dilatation of the right ventricle causes passive congestion of the kidneys, and the chronic interstitial nephritis may progress more rapidly. It is often difficult to decide which is more in evidence, heart insufficiency or kidney insufficiency. The more the heart fails, the more albumin will generally appear in the urine, and the lower the blood pressure, especially the diastolic. The more insufficient the kidneys, the higher the blood pressure, especially the diastolic. The location of the edema will aid in deciding which condition is most in evidence. If the edema is pendent in feet, legs and perhaps genitals when the patient is up, with its disappearance at night, and more or less backache and pitting of the back in the morning, it is the heart that is most rapidly failing. If there is more general edema, the hands and face puffing, and there are considerable nausea and vomiting, headache and drowsiness, and perhaps muscular twitchings, with neuralgic pains, the most serious trouble at that particular time lies in the kidney insufficiency. Kisch [Footnote: Kisch: Med. Klin., Feb. 27, 1916.] sums up the procedural symptoms and signs of cerebral hemorrhage. The heart is generally enlarged and hypertrophied. The patient is likely to be overweight or adding weight, and to suffer from intestinal indigestions. Signs of sclerosis of the blood vessels of the brain are evidenced by transient dizziness; headaches; impaired sleep; loss of memory, especially for names and words; slight disturbances of speech, momentary perhaps, and more or less temporary localized numbness of the hands or feet, or arms or legs, with perhaps flushing of some part of the body, or little localized spasms of vessels of other parts of the body, causing chilliness.

There is also a marked hereditary tendency to apoplexy.

Cadwalader, [Footnote: Cadwalader, W. R.: A Comparison of the Onset and Character of the Apoplexy Caused by Cerebral Hemorrhage and by Vascular Occlusion, The Journal A. M. A., May 2, 1914, p. 1385.] after considerable investigation, has come to the conclusion that large hemorrhages into the brain are the rule in apoplexy, and that small hemorrhages are rare, and he is inclined to think that even small, as well as large hemorrhages, are more frequently fatal than supposed. In other words, he thinks that many of the nonfatal hemiplegias are caused by vascular obstruction and softening and not by hemorrhage. He finds that sudden death, or death within a few minutes, does not occur from hemorrhage, even if the hemorrhage is large, though a rapidly developing and persistent coma usually indicates a hemorrhage. If the coma is not profound and is slow in its onset, with symptoms noticed by the patient, and cerebral disturbance, he believes it to be caused generally by softening of the cerebral center, due to some obstruction of the blood flow, and not to hemorrhage. While occasionally a slowly increasing loss of consciousness may be due to hemorrhage, he thinks it is doubtful if real hemorrhage ever occurs without loss of consciousness, while softening of some part of the cerebrum may occur without unconsciousness. He thinks that the size of the hemorrhage is of more importance than its situation in causing the profoundness of the symptoms, but he repeats that nonfatal cases of hemiplegia are generally caused by vascular occlusion and subsequent softening, and not by hemorrhage.

TREATMENT

While it is urged, in preventing the actual development of this disease, and in slowing its progress, that it is advisable to lower a high blood pressure, we must remember that this blood pressure mad be compensatory, and many times should not be much lowered without due consideration of the symptoms and the patient's condition. It is better not to use drugs of any kind in this incipient condition. The hypertension should be regulated by the diet; the purin bases and meat should be reduced to a minimum; tea, coffee and alcohol should be prohibited, and tobacco should be either entirely stopped or reduced to a minimum. Regulated exercise is always advisable, the amount of such exercise depending on the condition of the circulation. Ordinary walking and graduated walking or graduated hill climbing and golfing are good exercise for these patients. Mental and physical strenuosity must be stopped, if the disease is to be slowed. Sleeplessness must be combated, and perhaps actually treated medicinally, and for a time sufficient doses of chloral are perhaps the best treatment. The administration of chloral must always be carefully guarded to avoid the acquirement of dependence on the drug. Mouth and other infections should be sought and removed. Warm baths, Turkish baths, electric light baths or body baking may be advisable, and certainly obesity must always be combated by a regulation of the diet. In obesity, stimulants to the appetite, such as spices, condiments, and even sometimes salt, must be prohibited. Butter, cream, sugar and starches must be reduced to a minimum. A small amount of bread and a small amount of potatoes should be allowed. Liquids with meals should be reduced. Fruits should be given freely. Intestinal indigestion should be corrected, and free daily movements of the bowels should be caused. If the patient is obese, and especially if the blood pressure is high, the administration of thyroid extract is very beneficial. This is particularly true in women suffering from this disease; but the patient should be carefully observed during its administration. It may be advisable to administer small doses of iodid instead of the thyroid treatment, or coincidently with it. Nitrites had better be postponed, if possible, for cardiac emergencies.

White, [Footnote: White: Boston Med. and Surg. Jour., Dec. 2, 1915.] after studying 200 cases of heart disease, finds that men are more subject to auricular fibrillation, auricular flutter, heart block and alternation of the pulse than are women. The greater frequency of syphilis in men than in women should be considered in this difference in frequency.

White finds that hyperthyroidism of long standing is often attended with auricular fibrillation. He does not find that alcohol, tea and coffee play much part in causing these serious disturbances of the heart. His conclusions on this subject are certainly a surprise, and do not coincide with the experience of many others. It would seem that one of the causes of the greater frequency of these disturbances in men would be the amount of alcohol and tobacco used by men.

When the heart begins to fail from a gradually progressing myocarditis, the pulse rate generally increases, especially on the least exertion, and on fast walking may be as high as 120 or 130 a minute, or even higher. It may be found near 100 on the least exertion, even after some minutes of rest. These patients must have more or less absolute bed rest. When this condition occurs in old age, however, prolonged bed rest is inadvisable, for if the heart once loses its energy, in such cases, it is practically impossible to cause a return of normal function. However, in all acute cardiac insufficiency in this disease, due to some heart strain or exertion that was unusual, a bed rest of from one to two weeks and then gradually getting up and returning to normal activity is the proper treatment, and will generally be successful in restoring more or less compensation. These patients may well recline in bed with several pillows or with a back rest. During any cardiac anxiety in this kind of insufficiency the patient breathes better when he is sitting up or reclining with the head and shoulders high. The reason for this is probably because his heart has more space in this position—the same reason that he breathes better when his stomach is empty. Very indicative of the coming cardiac insufficiency is the inability to lie at night on the left side. The pressure of the body, especially if the person is stout, interferes with the heart action and causes dyspnea and distress. Some short, fat patients with cardiac distress caused by this disease must even stand up to relieve the condition, the erect position giving still more space for the action of the heart.