Part 23 (1/2)
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 a.s.serted 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 p.r.o.ne 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 alb.u.minous 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, st.u.r.dy 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 b.l.o.o.d.y, 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 b.l.o.o.d.y, 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.