If these hearts are not diagnosed and properly treated, such patients are liable to die suddenly of "heart failure," of acute stomach dilatation, or of angina pectoris. Furthermore, unsuspected dilated hearts are often the cause of sudden deaths during the first forty-eight hours of pneumonia.
Small doses of digitalis are sufficient in these early cases. If more heart pain is caused, the dose of digitalis is too large, or it is contraindicated. Digitalis need not be long given in this condition, especially as Cohen, Fraser and Jamison [Footnote: Cohen, Fraser and Jamison: Jour. Exper. Med., June, 1915.] have shown by the electrocardiograph that its effect on the heart may last twenty- two days, and never lasts a shorter time than five days. They also found that when digitalis is given by the mouth, the electrocardiograph showed that its full activity was not reached until from thirty-six to forty-eight hours after it had been taken. From these scientific findings it will he seen that if it is necessary to give a second course of treatment with digitalis, within two weeks at least from the time the last close of digitalis was given, the dose of this drug should be much smaller than when it was first administered.
Owing to our strenuous life, if persons over 40 would present themselves for a heart and other physical examination once or twice a year there would not be so many sudden deaths of those thought to be in good health. It may be a fact as asserted by many of our best but depressing and pessimistic clinicians, that chronic myocarditis and fatty degeneration of the heart cannot be diagnosed by any special set of symptoms or signs. However, it is a fact that a tolerably accurate estimate of the heart strength can be made by a careful physician, and if danger signals are noted and signs of probable heart weakness are present, life may be long saved by good treatment or management rigorously carried out. The patient must cooperate, and to get him to do this he must be tactfully warned of his condition. Many, such patients, noting their impaired ability, do not seek medical advice, but think all they need is more exercise; hence they walk, golf, and dance to excess and to their cardiac undoing.
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.