MISCELLANEOUS DISTURBANCES

SIMPLE HYPERTROPHY

Like any other muscular tissue, the heart hypertrophies when it has more work to do, provided this work is gradually increased and the heart is not strained by sudden exertion. To hypertrophy properly the heart must go into training. This training is necessary in valvular lesions after acute endocarditis or myocarditis, and is the reason that the return to work must be so carefully graduated. When the heart is hypertrophied sufficiently and compensation is perfect, a reserve power must be developed by such exercise as represented by the Nauheim, Oertel or Schott methods. Anything that increases the peripheral resistance causes the left ventricle to hypertrophy. Anything that increases the resistance in the lungs causes the right ventricle to hypertrophy. The right ventricle hypertrophy caused by mitral lesions has already been sufficiently discussed. The right ventricle also hypertrophies in emphysema, after repeated or prolonged asthma attacks, perhaps generally in neglected pleurisies with effusion, in certain kinds of tuberculosis, and whenever there is increased resistance in the lung tissue or in the chest cavity.

The term "simple hypertrophy" is generally restricted to hypertrophy of the left ventricle without any cardiac excuse—the hypertrophy by hypertension and hard physical labor. It is well recognized that it hypertrophies with hypertension and with chronic interstitial nephritis. It also becomes hypertrophied when the subject drinks largely of liquid—water or beer—and overloads his blood vessels and increases the work the heart must do. This kind of hypertrophy develops slowly because the resistance in the circulation is gradual or intermittent. In athletes and in soldiers who are required to march long distances, hypertrophy generally occurs. This hypertrophy, if slowly developed by gradual, careful training, is normal and compensatory. In effort too long sustained, especially in those untrained in that kind of effort, and even in the trained if the effort is too long continued, the left ventricle will become dilated and the usual symptoms of that condition occur. Such dilatation is always more or less serious. It may be completely recovered from, and it may not be. Therefore it proper understanding of the physics of the circulation by the medical trainer of young men to decide whether or not one should compete in a prolonged effort, as a rowing race, for instance, is essential. It is wrong for any young athlete to have an incurable condition occur from competition.

Sometimes simple hypertrophy of the left ventricle occurs from various kinds of conditions that increase the peripheral circulation. It may occur from oversmoking, from the mertisc of coffee aid tea, from certain kinds of physical labor, or from high tension mental work. It is a part of the story of hypertension. Many times such patients, as well as occasionally trained athletes, and sometimes patients with arteriosclerosis or chronic interstitial nephritis complain of unpleasant throbbing sensations of the heart added to these sensations are a feeling of fulness in the head, flushing of the face, and possibly dizziness—all symptoms not only of hypertension but of too great cardiac activity. Various drugs used to stimulate the heart may cause this condition; when digitalis is given and is not indicated or is given in overdosage, these symptoms occur.

The treatment is simply to lower the diet, cause catharsis, give hot baths, stop the tobacco, tea and coffee, stop the drinking of large amounts of liquid at any one time, and administer bromids and perhaps nitroglycerin, when all the symptoms of simple hypertrophy will, temporarily at least, disappear.

If the heart is enlarged from hypertrophy, if it is the right ventricle that is the most hypertrophied, the apex is not only pushed to the left, but the beat may be rather diffuse, as the enlarged right ventricle will prevent the apex from acting close to the surface of the chest. If the left ventricle is the most hypertrophied, the apex is also to the left, but the impact is very decided and the aortic closure is accentuated.

SIMPLE DILATATION

The term "simple dilatation" may be applied to the dilatation of one or both ventricles when there is no valvular lesion and when the condition may not be called broken compensation. The compensation has been sufficiently discussed. Dilatation of the heart occurs when there is increased resistance to the outflow of the blood front the ventricle, or when the ventricle is overfilled with blood and the muscular wall is unable to compete with the increased work thrown on it. In other words, it may be weakened by myocarditis or fatty degeneration; or it may be a normal heart that has sustained a strain; or it may be a hypertrophied heart that has become weakened. Heart strain is of frequent occurrence. It occurs in young men from severe athletic effort; it occurs in older persons from some severe muscle strain, and it may even occur from so simple an effort as rapid walking by one who is otherwise diseased and whose heart is unable to sustain even this extra work. All of the conditions which have been enumerated as causing simple hypertrophy may have dilatation as a sequence.

Degeneration and disturbance of the heart muscle and cardiac dilatation are found more and more frequently at an earlier age than such conditions should normally occur. Several factors are at work in causing this condition. In the first place, infants and children are now being saved though they may have inherited, or acquired, a diminished withstanding power against disease and against the strain and vicissitudes of adult life. Other very important factors in causing the varied fortes of cardiac disturbances are the rapidity and strenuousness of a business and social life, and competitive athletics in school and college, to say nothing of the oversmoking and excessive dancing of many.

The symptoms of heart strain, if the condition is acute, are those of complete prostration, lowered blood pressure, and a sluggishly, insufficiently acting heart. The heart is found enlarged, the apex beat diffuse and there may be a systolic blow at the mitral or tricuspid valve. Sometimes, although the patient recognizes that he has hurt himself and strained his heart, he is not prostrated, and the full symptoms do not occur for several hours or perhaps several days, although the patient realizes that he is progressively growing weaker and more breathless.

The treatment of this acute or gradual dilatation is absolute rest, with small doses of digitalis gradually but slowly increased, and when the proper dosage is decided on, administered at that dosage but once a day. Cardiac stimulants should not be given, except when faintness or syncope has occurred, and if strychnin is used, it should be in small closes. The heart nay completely recover its usual powers, but subsequently it is more readily strained again by any thoughtless laborious effort. The patient must be warned as carefully as though he had a valvular lesion and had recovered from a broken compensation, and his life should be regulated accordingly, at least for some months. If he is young, and the heart completely and absolutely recovers, the force of the circulation may remain as strong as ever.

Sometimes the heart strain is not so severe, and after a few hours of rest and quiet the patient regains complete cardiac power and is apparently as well as ever; but for some time subsequently his heart more easily suffers strain.

Chronic dilatation of the heart, However, perhaps not sufficient to cause edema, slowly and insidiously develops from persistent strenuosity, or from the insidious irritations caused by absorbed toxins due to intestinal indigestion. A fibrosis of the heart muscle and of the arterioles gradually develops, and the heart muscle sooner or later feels the strain.

It is now very frequent for the physician, in his office, to hear the patient say, "Doctor, I am not sick, but just tired," or, "I get tired on the least exertion." We do not carefully enough note the condition of the heart in our patients who are just "weary," or even when they show beginning cardiovascular-renal trouble.

The primary symptoms of this condition of myocardial weakening are slight dyspnea on least exertion; slight heart pain; slight edema above the ankles; often some increased heart rapidity, sometimes without exertion; after exertion the heart does not immediately return to its normal frequency; slight dyspnea on least exertion after eating; flushing of the face or paleness around the mouth, and more or less dilatation of the veins of the hands. All of these are danger signals which may not be especially noted at first by the individual; but, if he presents himself to his physician, such a story should cause the latter not only to make a thorough physical examination, but also to note particularly the size of the heart.

It a roentgenographic and fluoroscopic examination cannot be made, careful percussion, noting the region of the apex beat, noting the rapidity and action of the heart on sitting, standing and lying, and noting the length of time it takes while resting, after exertion, for the speed of the heart to slacken, will show the heart strength.

Slight dilatation being diagnosed, the treatment is as follows

1. Rest, absolute if needed, and the prohibition of all physical exercise and of all business cares.

2. Reduction in the amount of food, which should be of the simplest. Alcohol should be stopped, and the amount of tea, coffee and tobacco reduced.

3. If medication is needed, strychnin sulphate, 1/40, or 1/30 grain three times a day, acid the tincture of digitalis in from 5 to 10 drop doses twice a day will aid the heart to recover its tone.

Such treatment, when soon applied to a slowly dilating and weakening heart, will establish at least a temporary cure and will greatly- prolong life.

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.

The best treatment of dilatation of the heart in acute disease is its prevention, and to prevent it means to recognize the condition which can cause it. These are

1. Prolonged high temperature. A short-lived temperature, even if high, is not serious. Prolonged temperature of even 103 F. or more is serious, and even that of 101 is serious if too long continued.

2. Exertion and excitement. Every possible means should be inaugurated to prevent muscular exertion and strain of the patient while in bed. Proper help in lifting and turning the patient should be employed, the bed-pan should be used, proper feeding methods should be adopted, and friends should be excluded so that the patient may not be excited by conversation.

3. Bad feeding. The diet should of course be sufficient, for the patient and proper for the disease, but any diet which causes a large amount of gas in the stomach, or tympanites, is harmful to the patient's circulation, to say nothing of any other harm, such as indigestion may do. All of the nutriments needed to keep the body in perfect condition should be given to a patient who is ill; in some manner he should receive the proper amounts of iron, salt, calcium, starch, protein, sugar and water.

4. Intestinal sluggishness. This means not only that tympanites should not be allowed, but also that necessary laxatives should be given. It would be wrong to prostrate a patient with frequent saline purgatives, but the bowels must move at least once every other day, generally better daily; and if the case is one of typhoid fever, they should be moved by some carefully selected laxative, and after the bowels have sufficiently moved, the diarrhea should be stopped by 1/10 grain of morphin, and the next day the bowels properly moved again.

5. Depressant drugs. In this age of cardiac failure, heart depressants of all types, and especially the synthetic products, should be given only with careful judgment, and, never frequently repeated or long continued.

6. Pain. This is one of the most serious depressants a heart has to combat; acute pain must not be allowed, and prolonged subacute pain must be stopped. Even peripheral troublesome irritations must be removed, as tending to wear out a heart which has all of the trouble it can endure.

7. Insomnia. Nothing rests a heart or recuperates a heart more than sleep. Insomnia and acute disease make a combination which will wear a heart out more quickly than any other combination. Sleep, then, must be produced in the best, easiest and safest manner possible.

8. A too speedy return to activity. The convalescence must be prolonged until the heart is able to sustain the work required of it.

The treatment of gradual dilatation in acute disease has been sufficiently discussed under the subject of acute myocarditis. The treatment of acute dilatation is practically the same as the treatment of shock plus whatever treatment must coincidently be given to a patient for the disease with which he is suffering. The treatment of shock will be discussed under a separate heading.

THE HEART IN PNEUMONIA

As pneumonia heads the list of the causes of death in this country, and as the heart fails so quickly, sometimes almost in the beginning in pneumonia, a special discussion of the management of the heart in this disease is justifiable.

Acute lobar pneumonia may kill a patient in twenty-four or forty- eight hours; lie may live for a week and die of heart failure or toxemia, or he may live for several weeks and die of cardiac weakness. If he has double pneumonia be may die almost of suffocation. It is today just as frequent to see a slowly developing and slowly resolving pneumonia as to see one of the sthenic type that attacks one lobe with a rush, has a crisis in a seven, eight or nine days, and then a rapid resolution. In fact the asthenic type, in which different parts of the lung are involved but not necessarily confined to or even equivalent to one lobe, is perhaps the most frequent form of pneumonia.

The serious acute congestion of the lung in sthenic pneumonia in a full-blooded, sturdy person with high tension pulse may be relieved by cardiac sedatives, vasodilators, brisk purging, or by the relaxing effect of antipyretics. Venesection is often the best treatment.

When the sputum almost from the first is tinged with venous blood, or even when the sputum is very bloody, of the prune-juice variety, the heart is in serious trouble, and the right ventricle has generally become weak and possibly dilated. The heart may have been diseased and therefore is unable to overcome the pressure in the lungs during the congestion and consolidation.

There is a great difference in the belief of clinicians as to the best treatment for this condition. It would seem to be a positive indication for digitalis, and good-sized doses of digitalis given correctly, provided always that the preparation of the drug used is active, are good and, many times, efficient treatment. Small doses of strychnin may be of advantage, and camphor may be of value. In the condition described, however, reliance should be placed on digitalis. Later in the disease when the heart begins to fail, perhaps the cause is a myocarditis. In this condition digitalis would not work so well and might do harm. It is quite possible that the difference between digitalis success and digitalis nonsuccess or harm may be as to whether or not a myocarditis is present.

If the expectoration is not of the prune-juice variety and is not more than normally bloody, or in other words, typically pneumonic, and the heart begins to fail, especially if there is no great amount of consolidation, the left ventricle is in trouble as much as the right, if not more. In this case all of the means described above for the prevention of any dilatation of the heart will be means of preventing dilatation from the pneumonia, if possible. The treatment advisable for this gradually failing heart is camphor; strychnin in not too large doses, at the most 1/10 grain hypodermically once in six hours; often ergot intramuscularly once in six hours for two or three doses and then once in twelve hours; plenty of fresh air, or perhaps the inhalation of oxygen. Oxygen does not cure pneumonia, but may relieve a dyspnea and aid a heart until other drugs have time to act.

If there is insomnia, morphin in small doses will not only cause sleep, but also not hurt the heart. In the morning hours of the day the value of caffein as a cardiac stimulant and vasocontractor, either in the form of caffein or as black coffee, should be remembered. Strophanthin may be given intravenously.

One of the greatest cares in the treatment of heart failure in pneumonia should be not to give too many drugs or to do too much.

SHOCK

The treatment of shock will probably always be unsatisfactory as the cause is so varied, and, although circulatory prostration and vasomotor paresis always constitute the acute condition, the physiologic health of the heart and blood vessels is so varied. The patient in shock has low temperature, low blood pressure, and a pulse either rapid or slow, but excessively feeble; the face is pale, the surface of the body cold, and there is more or less clammy perspiration; there may be dyspnea and cardiac anxiety, or the patient may hardly breathe.

An acute cause, as terrible pain or hemorrhage, must of course be stopped immediately. There is more or less anemia of the brain, and therefore the legs and perhaps the lower part of the body should be elevated. It may even be wise to drive the blood from the legs by Esmarch bandages into the rest of the circulation. As there is always more or less paresis and dilatation of the large veins of the splanchnic system, a tight bandage about the abdomen is of great advantage in raising the blood pressure to the safety mark.

Strophanthin, given intravenously, is valuable as a quick restorative of the heart. Digitalis is so slow that it is of little value in an emergency. Camphor hypodermically, and hot liquids (nothing is better than black coffee) given by the mouth, are valuable remedies. The camphor may be repeated frequently. Strychnin, the long-used stimulant, should generally be given, but in not too large doses and not too frequently repeated; 1/30 grain hypodermically is generally a large enough dose; this dose may be repeated in three or four hours, but should ordinarily not be given oftener than once in six hours. An aseptic preparation of ergot given intramuscularly is most efficient in raising the blood pressure and aiding the heart. One dose of brandy or whisky may do no harm. Alcohol, however, should not be pushed.

A most important procedure in all kinds of shock is to surround the patient with dry heat, hot-water bags, and hot flannels; gentle friction of the arms and legs, unless the patient is too exhausted, may be of benefit. A hot-water bag to the heart is always a stimulant. Sometimes friction over the base of the heart in the region of the auricles is of benefit.

If the collapse is not acute and there is gradual profound prostration, or if the patient is improved but still in a serious condition of shock, too energetic measures must not be used; neither should too many drugs be administered, or drugs in too large doses. Absolute quiet and the administration of liquid nourishment in but small amounts at a time are essential.

The hypodermic administration of epinephrin solutions, 1:10,000, or solutions of pituitary extract, 1:10,000, should be considered; they are often valuable.

If the shock occurs in ether or chloroform anesthesia, the vasopressor stimulating effect of inhalations of carbon dioxid gas may be considered, as advised by Henderson."

If the shock is due to hemorrhage and the hemorrhage has ceased, a transfusion of physiologic saline solution is generally indicated. Transfusion of blood under the same conditions is still better. Rarely is transfusion indicated in shock from other causes; it often adds to the difficulty rather than improves it. Occasionally if shock is decided to be due to a toxemia, the toxin may be diluted by the withdrawal of a small amount of blood and the transfusion of an equal amount of saline solution.

ACUTE DILATATION OF THE STOMACH

This condition is not well understood, nor is its frequence known, but not a few instances of shock are due to dilatation of this organ. The shock to the heart may be a reflex one through the pneumogastric nerves.

It perhaps not infrequently occurs after abdominal operations and is more or less serious, the symptoms being persistent vomiting, upper abdominal distention and collapse. The vomiting is of bloody or coffee-ground material.

Sometimes the ordinary treatment of the collapse and washing out the stomach save the patient; at other times the patient with this series of symptoms dies in spite of all treatment.

It has been shown that acute dilatation of the stomach may occur in pneumonia, and may be one of the causes of cardiac collapse in pneumonia.

When the condition is diagnosed, the treatment would be that of shock plus abdominal bandage and washing out the stomach with warm solutions, if the patient is not too collapsed, or at any rate the frequent administration of hot water in small quantities.

Sometimes when the stomach is dilated the pylorus becomes insufficient, and bile regurgitates into the stomach, and is a cause of the profound nausea and vomiting arid the subsequent collapse. In these cases

114. Henderson: Am. Jour. Physiol., February and April, 1909. not infrequently small doses of dilute hydrochloric acid seem to aid the pylorus to maintain its normal contraction, the regurgitation of bile does not take place, and the stomach may soon acquire a more normal muscle tone. Not infrequently when a stomach is in this kind of trouble and all the foods are rejected, and yet the patient seriously needs nourishment, a warm, thin cereal, as oatmeal or gruel or something similar, may be retained. Such patients, as has been repeatedly stated, need starch as soon as possible, lest an acidosis develop.

In these vomiting and collapse cases the hypodermic administration of morphin and atropin will not only stop the vomiting, at least temporarily, but will also give necessary rest. The dose of morphin need not be large, and the atropin may prevent nausea from the drug.

ANESTHESIA IN HEART DISEASE

While no physician likes to give an anesthetic to a patient who has valvular disease of the heart, and no surgeon cares to operate on such a patient unless operation is absolutely necessary, still in valvular disease with good compensation the prognosis of either ether or chloroform narcosis is good.

When there are evidences of chronic myocarditis or a history of broken compensation and the borderline of compensation and dilatation is very narrow, or when there is arteriosclerosis, the danger from an anesthetic and an operation is much greater; it may be serious, in fact, and the decision must be made whether or not the operation is absolutely necessary. Under any circumstances it is understood that the anesthetist must be an expert, as there can be no carelessness and nothing but the best of judgment in causing anesthesia when there is cardiac defect.

The anesthetic to select is a subject for careful decision, as one cannot assert which anesthetic is the best.

While chloroform seems occasionally to cause a fatty degeneration of the heart, or if given too rapidly at first may cause sudden death, especially in cardiac weakness, ether has its disadvantages, owing to the increased tension (especially if there is likely to be much valvular or cerebral excitement), and the greater amount of ether that must be given, with the attendant danger to the kidneys, which may have been disturbed from the cardiac conditions. Generally, however, the better method is perhaps to administer first chloroform to the point of producing sleep and then to change to ether, the first mild chloroform narcosis preventing the ether from causing acute stimulation, and ether being better for the operation, as it is more of a stimulant. Some anesthetists believe that it is better to administer morphin, with perhaps atropin hypodermically before the anesthesia, and then to use ether. Nitrous oxid gas would be contraindicated as tending to increase arterial pressure, and therefore endanger a damaged heart; it is a serious danger to damaged blood vessels.