Part 13 (1/2)
ACUTE CARDIAC SYMPTOMS: ACUTE HEART ATTACK
It is not proposed here to describe the condition of sudden cardiac failure, or acute dilatation during disease, or after a severe heart strain, but to describe the terrible cardiac agony which occurs, sometimes repeatedly, with many patients who have valvular lesions.
These patients may not have the symptoms of loss of compensation.
Probably some one or more chambers of the heart become overdistended and act irregularly, or the blood is suddenly dammed up in the lungs, with the oppression and dyspnea caused by such pa.s.sive congestion, or perhaps it is the right ventricle that is suddenly in serious trouble.
A physician receives an emergency call, and knows, if it is not a patient who has hysteria, that it is his duty to see the patient immediately. The friends of the patient all anxiously await the physician's arrival; front doors are often wide open, and the servants and the whole household are in a great state of excitement and anxiety. The position in which the patient will be found is that which he has learned gives him the greatest comfort. If the physician knows his patient, he will know how he will find him. He may lie sitting up in bed; he may be standing, leaning over a chair; he may be sitting in a chair leaning over a table or leaning over the back of another chair; but he is using every auxiliary muscle he possesses to respire. He is generally bathed in cold perspiration; the extremities are often icy cold; he calls for air, and to stop fanning all in one breath; he wishes the perspiration wiped off his brow, and nearly goes frantic while it is being done; there is agony depicted on his face; his eyes stare; his expirations are often groaning. Sometimes there is even incontinence of urine and feces, often hiccup or short coughs, perhaps vomiting, and possibly sharp pangs of pain in the cardiac region. A patient with these symptoms may die at any moment, and the wonder is that so many times one lives through these paroxysms.
The patient can hardly be questioned, can certainly not be carefully examined; and herein lies the advantage of the family physician who knows the patient and his heart, and in whom the patient has confidence.
In fact, this confidence which such a patient has in the physician who has more or less frequently aided him in weathering these terrible attacks is alone the greatest boon the patient can have.
MANAGEMENT
The immediate conditions to meet are the rapid fluttering heart, the nervous excitation and cardiac anxiety, and perhaps the most important of all, the vasomotor spasm that is often so p.r.o.nounced.
Physically we have, then, a heart with leaking or constricted valves; in either case more blood is entering the chambers of the heart than can be expelled in one contraction, while the peripheral resistance due to the spasm of the blood vessels, because of fear, becomes greater every minute and tends still more to interfere with the peripheral circulation and the complete emptying of the heart of its surplus blood. Owing to the well known stimulus to distention of hollow muscular organs, the heart contracts faster and faster.
Soon, by some disarrangement of the inhibitory apparatus, the pneumogastric nerves, the heart loses its governor, and the beats increase to even 150 a minute, with irregular contractions, the blood being sent through the arteries with irregular force, as evidenced by the varying volume of the pulse. At this time, with or without cardiac pain, which upsets the rhythm of the heart, the patient becomes frightened at the feeling of impending demise, and the cerebral reflexes begin to add to the cardiac difficulty. The breathing becomes nervously rapid, besides that which is due to the rapid heart. The chill of fear is added to the already contracted peripheral vessels, and the surface of the body becomes cold, the extremities sometimes intensely so. Next it seems as if the strongly contracted arterioles begin actually to prevent some of the peripheral circulation, the blood is piled up in the large arteries, and the venous circulation becomes more and more sluggish, while the lips, finger nails and forehead become cyanotic. Respiration becomes more rapid and deep; the inspiration being as strong as possible with every auxiliary muscle taking part, thus making the negative pressure in the chest aid in bringing the blood back through the veins. Part of the extra respiratory stimulus comes from the imperfectly aerated blood reaching the respiratory center.
Two factors may normally, without treatment, stop these paroxysms, and the ”bad heart turn” may be cured spontaneously. The first of these is self-control. If the patient does not lose his head, by an effort of the will he saves himself from becoming nervous or frightened and therefore escapes the result of mental excitement; the increased peripheral blood pressure from fear does not occur, and in a shorter or longer time the heart quiets down. The physician recognizes this power, and gives his patient immediate a.s.surance that he will soon be all right; the patient who knows his physician immediately feels this a.s.surance and is quickly improved.
The second factor in spontaneous cure of the heart attack is relaxation. The exhaustion from the respiratory muscular efforts, together with the drowsy condition caused by the cerebral hyperemia and from the imperfectly aerated blood, causes finally a dulling of the mental acuity, and the nervous excitement abates, which, with the exhaustion, gives a relaxation of peripheral arterioles: the resistance to the flow of the blood is removed, the surface of the body becomes warm, the heart quiets down by the equalization of the circulation, and the paroxysm is over.
DRUGS
The part the nervous system plays in this paroxysm is shown by the good result obtained from injections of morphin, even when there is no pain; hence the action of morphin is directly in line with the natural resolution of the symptoms: it quiets the nervous system, causes drowsiness, relaxes spasm, and thus causes increased peripheral circulation; many times this is the only treatment necessary.
During these heart attacks it is more than useless to administer any drug by the stomach, as in this condition there will be no absorption, even if there is no vomiting.
While morphin is generally indicated, as just suggested, a very large dose should not be given, lest the activity of the respiratory center be impaired (it is already in trouble), and undoubtedly death may easily be caused by an overaction of morphin during these heart attacks. The addition of atropin to the morphin will prevent depression from the morphin. Also, atropin sometimes quiets cardiac pain, but it will not steady the heart, may irritate it, and will increase vasomotor tension, although peripheral nerve irritation may be diminished. Hence a fair dose of morphin hypodermicaly with a small dose of atropin, if respiratory depression is feared, is a physiologic method of bettering the condition. In this kind of heart attack a drug which often acts well is nitroglycerin. It may be given hypodermically in a dose of from 1/200 to 1/100 grain, or a tablet may be dissolved on the tongue, and the dose be repeated once or twice at fifteen-minute intervals, until there is throbbing in the forehead, which shows that a sufficient amount of the drug has been administered. This headache will generally not last long. In the meantime the peripheral blood vessels are relaxed, the surface of the body becomes warm, the heart quiets, and the attack is over.
To hasten the action of nitroglycerin (that is, to equalize the circulation) a hot foot-bath is often valuable. Amyl nitrite may be inhaled with the same object in view, but the action is very intense, the prostration often severe, and unless there is angina pectoris, nitroglycerin is much better.
The symptoms of a heart attack may not be quite those described above; they may be those of sudden dilatation or semiparalysis of the heart, in which the prostration is intense and the patient is unable to sit up, although he may be leaning against several pillows. There is dyspnea, but the patient cannot aid respiration with the auxiliary muscles by holding the arms and shoulders tense or obtaining support from the aruls; in fact, the arms are almost strengthless. The surface of the body may be warm, and the arms may be warm except the hands; the feet, ankles and legs may be cold.
There is generally more or less cyanosis, although the face may be pale. The finger nails often show venous stasis. In these cases the blood pressure is subnormal, the pulse may be hardly perceptible, and there is none of the tension of the body from fear. The patient may be fearful, but lie is completely collapsed. Such an attack may occur suddenly in a heart that is perfectly compensating, or it may accompany general edemas and dropsies.
If the emergency is excessively urgent, the lungs filling up with blood, moist rales beginning to occur, and frothy and blood-tinged sputum being coughed up, venesection may be indicated; combined with proper hypodermic medication it may save life, and does at times. In fact, a patient who shows every sign of fatal cardiac collapse may be saved. (one of the best drugs to administer to such patient is an aseptic ergot, injected intramuscularly.) The drug of all drugs for future action (as it will not act immediately) is digitalis, given hypodermically.
Whether digitalis shall be given at all, or how large the dose shall be depends on whether or not the patient has been taking digitalis in large quant.i.ties.
He may already be overpowered with digitalis. In that case it would be contraindicated.
Stroplianthin, especially when given intravenously, has been found to be a quickly acting circulatory stimulant. The dose of strophanthin, Merck, ranges from 1/500 to l/200 grain. The intravenous dose of strophanthin, Thoms, is about 1/130 grain. It should not be repeated within a day or two, if at all. Ampules of strophanthin in solution for intravenous use are now available.
Atropin in a dose of 1/150 grain, and strychnin in a dose of 1/40 or 1/30 grain are valuable aids in stimulating the circulation under these conditions. The atropin should not be repeated. The strychnin may be repeated in three, four or five hours, depending on the size of the previous close.
Of all quickly acting stimulants, none is better than camphor in saturated solution in sterile oil as may be obtained in ampules.
Alcohol is absolutely contraindicated in the latter condition. In the former kind of heart attack, vasodilation from a large close of whisky or brandy may be of value. The dose should be large to cause immediate increased peripheral circulation, dilation, and even a little stupefaction of the central nervous system, and it may be effectual in a way not dissimilar to the action of morphiti.
TREATMENT OF BROKEN COMPENSATION
The consideration of this subject will include the following topics: A. Hygiene.