DISTURBANCES OF THE HEART

O >> OLIVER T. OSBORNE, A.M., M.D. >> DISTURBANCES OF THE HEART

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The increased muscle tone thus caused raises the blood pressure
somewhat, and the great depression before breakfast is not
experienced. These patients rely oil their morning coffee for
bracing. If they have much indigestion at night which keeps them
awake so that they do not get good comfortable rest, their largest
meals should be the morning and noon meals, and the evening meal
should be very light.

Pendent abdomens or ptosed abdominal organs should be held up by
proper abdominal bandages or corsets.

If the bowels are constipated, only the vegetable laxatives should
be used, if it drug is needed at all. Salines should not be allowed,
or other cathartics which cause profuse watery discharges. If a
brisk purge is required, castor oil is the best.

Plenty of fresh air, and mild exercises in the open air all tend to
increase the pressure. Graded walking, climbing, or other more
interesting exercises are advisable, as all tending to raise the
pressure, provided that at no time are they carried to the point of
exhaustion.

Forced feeding may be useful. Cool sponging in the morning, if there
is proper reaction, is often of benefit. Iron may be indicated;
bitter tonics may be indicated. Digitalis and strychnin are often of
advantage. Caffein may be used as a drug as well as given in coffee
and tea. Atropin may be of value in some forms of hypotension.

At times with a low systolic pressure, but a relatively high
diastolic pressure, nitroglycerin is valuable.

More or less actite hypotension may occur in hot weather or with
overheating, often termed heat exhaustion. Such patients should, if
possible, go to a cooler region, whether to the seashore or to the
mountains is unimportant. The treatment of dangerous sudden low
blood pressure, as shock, will be discussed elsewhere.

PERICARDITIS

ACUTE PERICARDITIS

As this inflammation is generally secondary to some other condition,
its treatment cannot be positively outlined. Furthermore, it is
often a terminal condition, and in such instances the results of
treatment are of necessity nil. The most frequent terminal cause is
nephritis; other terminal causes are pulmonary tuberculosis,
adjacent abscesses, cancer or other growth.

The most frequent infectious cause is rheumatism; other infectious
causes are cerebrospinal fever, typhoid fever, acute miliary
tuberculosis, pneumonia and Sepsis. Accidental causes are traumatism
and an adjacent inflammation of the pleura.

The result of an inflammation of the pericardium may be a fibrous
exudate, or an exudate which is both serous and fibrous, or one in
which pus is present in considerable amount.

The onset of pericarditis may be more or less acute, or it may
commence insidiously. For this reason, during severe illness, and
especially in those diseases which are known to have pericarditis
often as a sequence, frequent examination of the heart should be
made as a routine procedure.

SYMPTOMS AND SIGNS

If there is pain or much aching in the cardiac region, it tends to
disappear with the exudate, if such is to occur, in the same way as
does the pain of pleurisy. If there is much exudate, the pressure on
the heart of course increases, the cardiac dulness enlarges, dyspnea
occurs and even perhaps later cyanosis. As the exudate accumulates,
the patient must lie higher and higher in order that the fluid may
gravitate to the lowest part of the sac and give the heart the
greatest ability to work. Reflex pain may occur from disturbances of
the pneumogastric nerve, or from the weight and pressure of the
enlarged and heavy pericardium. Reflex vomiting may be a troublesome
and distressing symptom.

Acute pericarditis occurring in rheumatism, in acute infections, and
from simple injuries tends to recovery. In dry pericarditis with
serious adhesions, or if adhesions occur as a sequence of acute
pericarditis, the future prognosis is bad, as myocarditis may
develop and sudden death or acute dilatation may occur. As stated
above, if pericarditis develops during the progress of chronic
disease, such as interstitial nephritis, or during sepsis, or from
abscesses or growths in the region of the pericardium, the prognosis
is bad.

TREATMENT OF ACUTE PERICARDITIS

In acute pericarditis, absolute mental as well as physical rest is
essential. Even if the patient does not appear to be seriously ill
and has not much fever, he should not be allowed to have visitors,
to discuss business matters, or to carry on any conversation,
however little exciting. Anything which increases the heart beat
increases the irritation of the inflamed surfaces of the
pericardium. He should not be allowed to sit up, either to eat or to
attend to the calls of Nature. These rules are imperative, and when
they are followed the pain is less, the heart beats less rapidly, is
less hampered by pressure from whatever exudate may be present, and
the adhesions which are liable to form will be less in amount and
less serious for the future work of the heart.

The treatment, of course, depends largely on the cause of the
pericarditis, as, if the cause is one of those just enumerated in
which the prognosis is dire, any treatment directed toward the
pericardial inflammation is almost useless. The periearditis under
these conditions will be more or less benefited, if at all affected,
by the treatment directed toward the cause.

The indications for treatment in all other instances are:

1. To attempt to abort the inflammation.

2. To stop the pain.

3. To limit, if possible, the amount of exudate, and to diminish the
exudate already present.

4. To diminish the rapidity of the heart and to strengthen it.

1. Abortive Treatment.--For many years bloodletting was considered
of the greatest importance in the early treatment of this disease;
but owing to the fact that, except from traumatism, pericarditis
rarely occurs except as a sequela of acute disease after the patient
has been sick along time, or as a terminal condition in a patient
who has long been chronically diseased and therefore has already
lost more or less strength, venesection has been nearly abandoned.
Leeches may be used over the region of the pericardium, and cups are
sometimes used. Dry cupping is more frequently used. These measures
sometimes seem to reduce the inflammation, and certainly often
relieve pain, but the most valuable local treatment is cold, which
may be applied either in the form of an ice bag or by a small coil
through which ice water is caused to flow by siphonage. Cold may be
applied more or less continuously, depending on the sensations of
the patient. The bag or ice cap must not be overfilled and must not
be heavy, as the patient often cannot stand pressure over the
pericardium. Sometimes the relief from pain and the diminution of
the number of the heart beats is marked, and for this reason alone
the cardiac inflammation may be inhibited. If cold applications are
not tolerated by the patient (and they often are not in children)
warm applications may be used, such as an electric pad or cloths
wrung out of hot water and covered with oiled silk, and the pain
will often be relieved thus. While hot applications would not tend
to abort the inflammation, they probably do not tend to promote it.

A diminished diet, of small amount at a time, and such purging as
the patient's strength will allow are essential in attempting to
hasten recovery.

Just what can be done locally or generally to combat the
inflammation actively must depend on the cause. When the
inflammation occurs as a complication of acute rheumatism, it has
been suggested that salicylates, which arc not inhibiting rheumatism
and may be depressant to the heart, should be stopped if they are
being administered; but if the salicylates are apparently improving
the inflammation in the joints, pericarditis would not
contraindicate their continued use. Except in large doses,
salicylates probably do not depress the heart. In pericarditis it is
perhaps well always to administer an alkali in some form unless
otherwise contraindicated, whether or not the cause is rheumatism. A
diminished alkalinity of the blood would always increase the
likelihood of an augmented amount of pericardial or endocardial
inflammation. The blood must be kept strongly alkaline. It is
possible that one of the reasons why pericarditis or endocarditis
occurs so frequently in serious prolonged fevers is that the patient
has not eaten enough cereals or other carbohydrates, and the system
has become more or less endangered by acidosis. Carbohydrate
starvation is inexcusable with our present understanding of the
danger from acideinia, and even from a diminished amount of alkalies
in the blood.

The cause of pericarditis being so varied, any anti-toxin treatment
or any vaccine treatment could be indicated only if the cause of the
inflammation rendered the serum or vaccine advisable.

2. Stopping the Pain.--Nowhere else in the body should pain be so
speedily combated as when it occurs in the region of the heart.
Morphin, with or without atropin, as deemed best, should be
administered hypodermically in the amount and with the frequency
necessary to stop the pain and quiet the restlessness. As stated
above, the frequent need for morphin may be prevented by use of the
ice bag. Morphin might even be considered an abortive treatment, as
nothing tends so much to inhibit this inflammation as the quietude
of the heart caused by the absence of pain, the production of sleep
and the prevention of restlessness, muscle twitching and muscle
movements. The more quiet the patient is, the more quiet is the
heart.

If for any reason morphin is contraindicated, and if pain is not a
symptom, the patient's nerves may be quieted and rest may be given
by sodium bromid, or by veronal-sodium, the dose of the former being
2 gm. (30 grains) two or three times in twenty-four hours, according
to its action and the necessity for it, and the dose of the latter
0.2 gm. (3 grains) once in six hours, if deemed necessary.

Especially if there are cerebral symptoms, as typically presented in
cerebrospinal meningitis, and especially if the arterial tension is
low, the subcutaneous administration of an aseptic ergot will quiet
the central nervous system, increase the blood pressure, quiet the
heart, and prolong the action of a single dose of morphin. It is the
best plan to administer ergot deep into the muscles, with the
deltoid as the place of choice. If the skin is properly cleansed,
the syringe clean and the preparation of the drug aseptic, no
inflammation or abscess will ever occur. If there is any painful
swelling, a wet alcohol dressing to the part will soon relieve it.
The frequence with which ergot should be so administered depends on
the results and the indications. Once in twelve hours for several
doses is generally the best method for its use.

3. The Exudate.--When a fluid exudate into the pericardium has
occurred from inflammation that is, when it is not an exudate from
disturbed kidneys or circulation--it will continue to increase to
some extent in spite of any treatment. Just how much this exudate
may be prevented by the use of small blisters over or around the
heart, and just how much watery stools and diuresis may prevent the
advance of the exudate is difficult to determine. Small blisters,
properly applied, have many times seemed to be the determining
factor in stopping the increase in the fluid, or to have been the
starting cause of the resorption of the exudate.

The amount of purging that should be caused by saline cathartics
such as sodium sulphate (Glauber salt), potassium and sodium
tartrate (Rochelle salt), or the official compound jalap powder
cannot be declared dogmatically. Saline purging should be governed
by the character of the circulation. If the heart is strong, the
pulse not weak, and the blood pressure good, nothing is more
valuable in this condition. Portal depletion is of great advantage,
especially if the amount of liquid ingested is kept as low as
possible, so that the blood vessels may become thirsty and thus tend
to absorb an exudate wherever they find it. Much harm has been done,
however, and death has been caused by saline purgatives in
endeavoring to relieve edemas from a failing heart or to prevent a
uremia from kidney inflammation. The depression following such
purging is often serious. If the circulation is weak, dependence
should be placed on purgation by some of the simple vegetable
cathartics or a small dose of calomel. While it is advisable to give
a saline in concentrated solution, it should not be so strong as to
cause vomiting. With our better understanding of magnesium
absorption and the depressant effect of magnesium on the nervous
system, magnesium salts should not be used in serious conditions.

Diuretics often do not act well when most needed. The simplest
diuretic is potassium citrate, given in wintergreen or peppermint
water, in doses of 2 gm. (30 grains), three or four tunes in twenty-
four hours. One or more of the vegetable, nonirritant diuretics may
be tried if preferred. If the sickness preceding the pericarditis
was not a long fever, and the heart muscle is considered in good
condition, digitalis in small doses may be the best possible
diuretic. Incidentally it will slow the heart, if there is not much
elevation of temperature, and will give some cardiac rest.

Although the patient's diet should be limited in bulk, and
especially in amount of liquids, good nutrition should soon be
given. Systemic weakness certainly tends to increase the exudate;
systemic strength aids in absorption of the exudate.

Iron is early indicated, and nothing is better than 5 drops of the
tincture of chlorid of iron in a little lemonade or orangeade,
administered once in eight hours.

If the exudate tends to decrease, it perhaps may be hastened by the
local application of tincture of iodin over the cardiac region. Also
the administration of small doses of an iodid, as 0.3 gm. (5 grains)
of sodium iodid, given in plenty of water three times a day, is
useful. An iodid circulating in the blood seems to aid absorption.
It has long been believed that iodin in the blood tends to promote
absorption of thickened, left-over material from exudates, and to
prevent the formation of strong fibrous adhesions. Until our
knowledge is more exact in this matter, it is advisable to use iodid
as suggested. If the above-named dose is not tolerated, less should
be given.

If in spite of all the therapeutic measures suggested, the fluid
increases and the pericardium becomes more distended and the heart's
action more labored, paracentesis must be done. The point at which
the aspirating needle should be inserted into the pericardium
depends somewhat on the conditions in each individual case. It is
often best to insert an exploratory needle first. This will
determine the fluidity and character of the exudate. If pus is
found, a more radical surgical procedure than simple paracentesis
must be done immediately. The point of puncture for aspiration most
frequently chosen is in the fourth or fifth intercostal space, about
an inch to the left of the sternal margin. Paracentesis is also
often done in the region of the normal apex beat. The position of
the patient is determined by his dyspnea; he should lie in the
position most comfortable for him. The fluid should be withdrawn
slowly and the pulse carefully watched. The withdrawal of a small
amount of fluid may later seem to be the starting cause of
resorption of the rest of the fluid. On the other hand, it may often
be not of more value than the simple removal of the immediate
pressure, the fluid may again accumulate, and more radical surgery
must be performed.

4. To Strengthen the Heart.--Most of the methods of meeting this
indication have already been stated, namely, absolute rest; absolute
quiet; the use of the bed pan; any movement that must be made should
be deliberate; the nurse and other attendants must be quiet;
necessary conversation must be brief, and every method must be used
to quiet and prevent the heart's action from becoming rapid. The
food taken should be small in amount and nonstimulating; that is, no
tea or coffee should be given, and nothing too hot or too cold.
Movements of the bowels should be caused with the least possible
general disturbance. If the patient does not sleep, he must be made
to sleep. The whole body and the nervous system must have periods of
rest. If the heart is very weak, small closes of morphin may be
used. If the heart is not weak, bromids or chloral may be given. If
the blood pressure is high, such hypnotics will lower it, or if the
heart is strong and the condition does not contraindicate it,
aconite may be used in small doses, for a day or two, unless the
fever is high and it seems advisable to use one of the coal-tar
antipyretics, which reduce the blood tension and the heart activity.

As stated above, pain must not be allowed. Sometimes, when the heart
has not been injured by prolonged fever, digitalis in small doses
may slow the heart and act for good.

Convalescence.--The convalescence should be prolonged as in any
other cardiac inflammation. The patient should be given more and
more nourishing food, and the iron tonic may be changed to a capsule
containing 0.05 gm. of quinin and 0.05 gm. of reduced iron, three
times a day.

It is a question as to when patients convalescent from pericarditis
should be permitted exercise. It has been thought that gentle
movements and possibly exercise, sooner than theoretically
justified, might cause the heart to beat a little more actively and
possibly prevent the formation of tight adhesions between the two
layers of the pericardium. Whether such activity of the heart will
prevent adhesions is something that has not been determined.

The small doses of sodium iodid, perhaps 0.2 gm. (3 grains) two or
three times a day, should be continued for some time. Iodid in this
dosage does no harm and may do a great deal of good.

ADHERENT PERICARDITIS

Following dry pericarditis or pericarditis with an exudate,
especially when the exudate is fibrinous in character, the fibrous
substance which is not absorbed or resorbed may develop into
connective tissue, and the two pericardial surfaces become
permanently grown together, causing the so-called adherent
pericarditis. These adhesions between the two surfaces of the
pericardium may be general throughout the entire pericardial sac, or
they may be limited to some one or more parts of the pericardium.
Perhaps one of the most frequent points of adhesion is the anterior
part of the pericardium, while the apex is the part most likely to
be free, even when other parts of the pericardium have grown
together. This freedom of the apex is probably due to the constant
and more extensive motion of the apical portion of the heart, and is
the reason that it has been suggested, as referred to under acute
pericarditis, that, other conditions not contraindicating, the
patient may be allowed to move about a little during convalescence
to cause the heart to beat more actively. Sometimes the surfaces of
the pericardium are not closely adherent to each other, but bands of
adhesion stretch from one surface to the other.

After adhesions have taken place between the two layers of the
pericardium, the action of the heart is impaired, serious
interference with the cardiac action may develop, and sudden death
may occur. If the heart is given all the rest possible during the
acute phase of the disease, there will be less likelihood of the
surfaces becoming so irritated that adhesions readily form. Anything
which permits complete absorption and resorption of tile exudate
will tend to prevent these hampering adhesions. If the adhesions are
such as to cause irregular heart, recurrent pain and the danger of
sudden death, surgical help has been suggested. This surgical
procedure is to remove a portion of the ribs, perhaps of the third,
fourth and fifth, to allow the heart more freedom of action to
compensate for the impairment of its activity from the adhesions.
Such an operation was first suggested by Brauer of Heidelberg in
1902.

The question of the best method of producing anesthesia in this
condition of the heart is a serious one. A patient might die during
the anesthesia; but he might also die at any time from cardiac
spasm. In certain instances, in adults, local anesthesia might be
sufficient. Pain reflexes, however, would be serious. Such an
operation would be indicated when the apex is fixed so that there is
a constant sensation of hugging of the heart at the fourth and fifth
ribs, with paroxysms of pain and cardiac weakness.

MYOCARDIAL DISTURBANCES

While the myocardium is the most important muscle structure of the
body, it has but recently been studied carefully or well understood
clinically or pathologically. A heart was "hypertrophied" or
"dilated" or perhaps "fatty." It suffered from "pain," "angina
pectoris," from some "serious weakness" or from "coronary disease,"
and that ended the pathology and the clinical diagnosis. This is the
age of heart defects; no one can understand a patient's condition
now, whatever ails him, without studying his heart. No one can treat
a patient properly now without considering the management of the
circulation. No one should administer a drug now without considering
what it will do to the patient's heart.

Although we are scientifically interested in the administration of
specific treatments, antitoxins and vaccines; although we have a
better understanding of food values, and order diets with more
careful consideration of the exact needs of the individual, and
although we are using various physical methods to promote
elimination of toxins, poisons and products of metabolism, we have
until lately forgotten the physical fact that one thirteenth of the
weight of a normal adult is blood. A man who weighs 170 pounds has
13 pounds of blood. This proportion is not true in the obese, and is
not true in children. Whether the person is sick in bed, miserable
though up and about, or beginning to feel the first sensations of
slight incapacity for his life work, his ability properly to
circulate this one thirteenth of his weight through the various
arterial and venous channels and capillary tracts must, with the
increasing tension and speed of our lives, be taken into
consideration.

The more and more frequently repeated statements that the operation
was successfully performed but that the patient died of shock, and
that the typhoid fever and the pneumonia were being successfully
combated, but that the patient died of heart failure, together with
the increase in arteriosclerosis, cardiac disturbances and renal
disease, emphatically present the necessity of more carefully
studying the circulation. A better understanding and the constant
study of the blood pressure shows nothing but the necessity of the
age. The unwillingness of the patient to suffer pain, even for a few
minutes, without some narcotic, generally a cardiac debilitating
drug, means that, if he is a sufferer from chronic or recurrent
pain, he has taken a great deal of medicine which has done his heart
no good. Repeated high tension of life raises the blood pressure and
puts more work on the heart. Therefore the heart is found weary, if
not actually degenerated, when any serious accident, medical or
surgical, happens to the patient.

The requirements of the age have, then, necessitated that the heart
be more carefully studied, and therefore the heart strength and its
disturbances are better understood. The mere determination as to
where the apex beat is located, and as to what murmurs may be
present is not sufficient; we must attempt to determine the probable
condition of the myocardium. The following conditions are
recognized: (1) acute myocarditis, (2) chronic myocarditis
(fibrosis, cardiosclerosis), (3) fatty degeneration, and (4) fatty
heart.

ACUTE MYOCARDITIS

Probably most acute infections cause more or less myocarditis,
depending on their intensity and their prolongation. This
disturbance of the heart is often unrecognized, and has been simply
referred to as "the heart growing weaker from the fever process."
The acute infections most likely to cause a myocarditis are
rheumatism, influenza, sepsis, cerebrospinal meningitis, diphtheria,
typhoid fever, scarlet fever, and mouth and throat infections. It is
probably rare when acute endocarditis occurs that more or less
myocarditis is not present. The acute myocarditis may develop some
fatty degeneration, and with this softening and weakening of the
heart muscle acute dilatation readily occurs, which may be a cause
of sudden death, or, if less serious, may be the cause of prolonged
disability, if the heart ever recovers its original size and
strength.

The symptoms are often indefinite, and the diagnosis of the
condition hardly possible. It may be taken for granted, however,
that hardly any serious illness can long continue without cardiac
muscle disturbance. If endocarditis is present, soft systolic
murmurs soon appear. With the acute myocarditis developing, the apex
beat is less positive, less accentuated, and later it becomes
diffuse and even feeble. The closure of the aortic valve is less
typically sharp, showing that the blood vessels are not so
thoroughly filled. The peripheral circulation is not so active, the
blood pressure falls, and the heart becomes more rapid, especially
on the least exertion. All of these signs indicate myocardial
weakness.

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