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

It should be remembered that a normal heart may slow to about 60 during sleep, and all nervous acceleration of the pulse may be differentiated during sleep by the fact that if the heart does not markedly slow, there is cardiac weakness or some general disturbance. There is also cardiac weakness if there is a tendency to yawn or to take long breaths after slight exertions or during exertion, or if there is a feeling of suffocation and the person suddenly wants the windows open, or cannot work, even for a few minutes, in a closed room. If these disturbances are purely functional, exercise not only may be endured, but will relieve some nervous heart disturbances, while it will aggravate a real heart disability. If the heart tends to increase in rapidity on lying down, or the person cannot breathe well or feels suffocated with one ordinary pillow, the heart shows more or less weakness. Extrasystoles are due to abnormal irritability of the heart muscle, and may or may not be noted by the patient. If they are noted, and he complains of the condition, the prognosis is better than though he does not note them.

It has long been known that asthma, emphysema, whooping cough, and prolonged bronchitis with hard coughing will dilate the heart. It has not been recognized until recently, as shown by Guthrie, [Footnote: Guthrie, J. B.: Cough Dilatation Time a Measure of Heart Function, The Journal. A. M. A., Jan. 3, 1914, p. 30.] that even one attack of more or less hard coughing will temporarily enlarge the heart. From these slight occurrences, however, the heart quickly returns to its normal size; but if the coughing is frequently repeated, the dilatation is more prolonged. This emphasizes the necessity of supporting the heart in serious pulmonary conditions, and also the necessity of modifying the intensity of the cough by necessary drugs.

In deciding that a heart is enlarged by noting the apex beat, percussion dulness, and by fluoroscopy, it should be remembered that the apex beat may be several centimeters to the left from the actual normal point, and yet the heart not be enlarged.

The necessity of protecting the heart in acute infections, and the seriousness to the heart of infections are emphasized by the present knowledge that tonsillitis, acute or chronic, and mouth and nose infections of all kinds can injure the heart muscle. In probably nearly every case of diphtheria, unless of the mildest type, there is some myocardial involvement, even if not more than 25 percent of such cases show clinical symptoms of such heart injury. Tuberculosis of different parts of the body also, sooner or later, injures the heart; and the effect of syphilis on the heart is now well recognized.

SYMPTOMS AND SIGNS OF CARDIAC DISTURBANCE

It is now recognized that any infection can cause weakness and degeneration of the heart muscle. The Streptococcus rheumaticus found in rheumatic joints is probably the cause of such heart injury in rheumatism. That prolonged fever from any cause injures heart muscle has long been recognized, and cardiac dilatation after severe illness is now more carefully prevented. It is not sufficiently recognized that chronic, slow-going infection can injure the heart. Such infections most frequently occur in the tonsils, in the gums, and in the sinuses around the nose. Tonsillitis, acute or chronic, has been shown to be a menace to the heart. Acute streptococcie tonsillitis is a very frequent disease, and the patient generally, under proper treatment, quickly recovers. Tonsillitis in a more or less acute form, however, sometimes so mild as to be almost unnoticed, probably precedes most attacks of acute inflammatory rheumatism. Chronically diseased tonsils may not cause joint pains or acute fever, but they are certainly often the source of blood infection and later of cardiac inflammations. The probability of chronic inflammation and weakening of the heart muscle from such slow-going and continuous infection must be recognized, and the source of such infection removed.

The determination of the presence of valvular lesions is only a small part of the physical examination of the heart. Furthermore, the heart is too readily eliminated from the cause of the general disturbance because murmurs are not heard. A careful decision as to the size of the heart will often show that it has become slightly dilated and is a cause of the general symptoms of weakness, leg weariness, slight dyspnea, epigastric distress or actual chest pains. Many such cases are treated for gastric disturbance because there are some gastric symptoms. There is no question that gastric flatulence, or hyperacidity, or a large meal causing distention of the stomach may increase the cardiac disturbance, and the cardiac disturbance may be laid entirely to indigestion; but treatment directed toward the stomach, while it may ameliorate some of the symptoms, will not remove the cause of the symptoms.

If the patient complains of pains in any part of the chest or upper abdomen, or of leg aches, or of being weary, or exhausted, or of sleeplessness at night, or of pains in the back of his head, we should investigate the cardiac ability, besides ruling out all of the more frequently recognized causes of these disturbances.

If there is more dyspnea than normally should occur in the individual patient after walking rapidly or climbing a hill or going upstairs, or if after a period of a little excitement one finds that he cannot breathe quite normally, or that something feels tight in his chest, the heart needs resting. If, after one has been driving a motor car or even sitting at rest in one which has been going at speed or has come unpleasantly near to hitting something or to being run into, it is noticed that the little period of cardiac disturbance and chest tension is greater than it should be, the heart needs resting.

If the least excitement or exertion increases the cardiac speed abnormally, it means that for many minutes, if not actually hours during the twenty-four, the heart is contracting too rapidly, and this alone means muscle tire and muscle nutrition lost, even if there is no actual defect in the cardiac muscle or in its own blood supply. If we multiply these extra pulsations or contractions by the number of minutes a day that this extra amount of work is done, it will easily be demonstrable to the physician and the patient what an amount of good a rest, however partial, each twenty-four hours will do to this heart. Of course anything that tends to increase the activity of the disturbance of the heart should be corrected. Overeating, overdrinking (even water), and overuse or perhaps any use of alcohol, tobacco, tea and coffee should all be prevented. In fact, we come right to the discussion of the proper treatment and management of beginning high blood pressure, of the incipiency of arteriosclerosis, of the prevention of chronic interstitial nephritis, and the prevention of cardiovascular-renal disease.