In commencing degenerative change the Oertel treatment, consisting of graduated exercise up a gentle slope, limitation of fluids and a special diet, may be indicated.
In cases of slight dilatation after influenza or recent illness, the Schott treatment by baths and exercises as carried out at Nauheim may be sometimes beneficial. The change of air and scene, the enforced rest, the placid life, together with freedom from excitement and worry, are among the most important factors which contribute to success in this class of case.
Disorders of Rhythm of the Heart’s Action.—Under this heading may be grouped a number of conditions to which the name “functional affections of the heart” has sometimes been applied, inasmuch as the disturbances in question cannot usually be attributed to definite organic disease of the heart. We must, of course, exclude from this category the irregularity in the force and frequency of the pulse, which is commonly associated with incompetence of the mitral valve.
The heart is a muscular organ possessing certain properties, rhythmicity, excitability, contractility, conductivity and tonicity, as pointed out by Gaskell, in virtue of which it is able to maintain a regular automatic beat independently of nerve stimulation. It is, however, intimately connected with the brain, blood-vessels and the abdominal and thoracic viscera, by innumerable nerves, through which impulses or messages are being constantly sent to and received from these various portions of the body. Such messages may give rise to disturbances of rhythm with which we are all familiar. For instance, sudden fright or emotion may cause a momentary arrest of the heart’s action, and excitement or apprehension may set up a rapid action of the heart or palpitation. Palpitation, again, is often the result of digestive disorders, the message in this case being received from the stomach, instead of the brain as in emotional disturbances. It may also result from over-indulgence in tobacco and alcohol.
Tachycardia is the name applied to a more or less permanent increase in the rate of the heart-beat. It is usually a prominent feature in the affection known as Graves’ disease or exophthalmic goitre. It may also result from chronic alcoholism. In the condition known as paroxysmal tachycardia there appears to be no adequate explanation for its onset.
Bradycardia or abnormal slowness of the heart-beat, is the converse of tachycardia. An abnormally slow pulse is met with in melancholia, cerebral tumour, jaundice and certain toxic conditions, or may follow an attack of influenza. There is, however, a peculiar affection characterized by abnormal slowness of pulse (often ranging as low as 30), and the onset, from time to time, of epileptiform or syncopal attacks. To this the name “Stokes-Adams disease” has been applied, as it was first called attention to by Adams in 1827, and subsequently fully described by Stokes in 1836. It is usually associated with senile degenerative change of the heart and vascular system, and is held to be due to impairment of conductivity in the muscular fibres (bundle of His) which transmit the wave of contraction from the auricle to the ventricle. It is of serious significance in view of the symptoms associated with it.
Intermittency of the Pulse.—By this is understood a pulse in which a beat is dropped from time to time. The dropping of a beat may occur at regular intervals every two, four or six beats, &c., or occasionally at irregular intervals after a series of normal beats. On examining the heart, it is found, as a rule, that the cause of the intermission at the wrist is not actual omission of a heart-beat, but the occurrence of a hurried imperfect cardiac contraction which does not transmit a pulse-wave to the wrist. It is not characteristic of any special form of heart affection, and is rarely of serious import. It may be due to reflex digestive disturbances, or be associated with conditions of nervous breakdown and irritability, or with an atonic and relaxed condition of the heart muscle. The treatment of these disorders of rhythm of the heart will vary greatly according to the cause and is often a matter of considerable difficulty.
(J. F. H. B.)
Surgery of Heart and Pericardium.—As the result of acute or chronic inflammation of the lining membrane of the fibrous sac which surrounds the heart and the neighbouring parts of the large blood-vessels, a dropsical or a purulent collection may form in it, or the sac may be quietly distended by a thin watery fluid. In either case, but especially in the latter, the heart may be so embarrassed in its work that death seems imminent. The condition is generally due to the cultivation in the pericardium of the germs of rheumatism, influenza or gonorrhoea, or of those of ordinary suppuration. Respiration as well as circulation is embarrassed, and there is a marked fulness and dulness of the front wall of the chest to the left of the breast-bone. In that region also pain and tenderness are complained of. By using the slender, hollow needle of an aspirator great relief may be afforded, but the tapping may have to be repeated from time to time. If the fluid drawn off is found to be purulent, it may be necessary to make a trap-door opening into the chest by cutting across the 4th and 5th ribs, incising and evacuating the pericardium and providing for drainage. In short, an abscess in the pericardium must be treated like an abscess in the pleura.
Wounds of the heart are apt to be quickly fatal. If the probability is that the enfeebled action of the heart is due to pressure from blood which is leaking into, and is locked up in the pericardium, the proper treatment will be to open the pericardium, as described above, and, if possible, to close the opening in the auricle, ventricle or large vessel, by sutures.