Fresh air, sunlight and anything else that makes the bedroom attractive and cheerful are essential and will aid in the recovery. The kind of nurse that is needed, trained, untrained, or a member of the family, and the amount of company or entertainment allowed must be decided for the individual patient. The patient must be distinctly individualized and the proper measures taken to give mental and physical rest, to prevent excitement, worry, melancholia and depression, and to improve the general nutrition of the body as well as the condition of the heart.
Each occurrence of broken compensation in valvular disease causes another attack of cardiac weakness to occur with less excuse than before, and several serious attacks of broken compensation mean before long the loss of the heart muscle's ability to recover, so that permanent dilatation occurs.
B. DIET
The food given should be just sufficient for the needs of the body; the patient should not be overfed or underfed. Any large bulk of food or liquid should not be given. Pressure on the heart causes discomfort and is therefore inadvisable. Food that causes flatulence should be avoided. Theoretically the patient should receive a little meat, an egg or two, cereal or bread, a small amount of simple vegetables, a little fruit, often milk, a sufficient amount of noneffervescent water, perhaps a cup of chocolate or cocoa, a simple dessert, sometimes ice cream; in other words, a varied, limited diet containing all the elements that are necessary to good nutrition. The diet should be varied from day to day to encourage the appetite.
It has for several years been recognized that a salt-free diet in dropsies due to disease of the kidneys is a valuable aid in causing absorption of such exudates and of preventing greater exudations. For this reason a salt-free diet is often ordered in dropsies occurring in valvular disease. Its value, however, is not so great as in kidney lesions, and if it causes hardship to the patient it should not be continued rigorously. On the other hand, large amounts of salt should of course be interdicted.
A most valuable aid in dropsies due to heart deficiencies is the so- called dry diet, which means that as little liquid as possible should be taken in order that the patient's blood may resorb the exudate in the tissues and not have the blood vessels filled or overfilled with liquid from the gastro-intestinal tract. When dropsy is present, or even when serious pendent edemas are present, the patient should drink as little liquid as possible with his meals, and between meals should sip water rather than drink a large quantity of it. This is one of tile reasons that a large milk diet, even with kidney disturbance due to cardiac lesions, is generally inadvisable. With cardiac or general circulatory weakness, a laige amount of liquid to flush out the kidneys and the whole system, so long ordered for all kidney defects or mistakes in metabolism, is a seribus mistake. The Karel diet is described in the section on cardiovascular-renal disease.
Whether it is better to give three or four small meals a day or to give a small amount of nourishment every three hours during the daytime must again depend on the individual and his ability to digest without fermentation and putrefaction or discomfort. As previously urged, not too much fluid, even milk, though it digest perfectly, should be given, as the greater the amount of fluid the greater the amount of work thrown on the heart.
C. ELIMINATION
A patient who has developed decompensation has always imperfect elimination. The skin, bowels and kidneys do not act sufficiently or well. The circulation in the skin is sluggish. The bowels are generally constipated, or there is diarrhea of the fermentative type. The amount of urine excreted is generally insufficient and likely to be concentrated and show various signs of imperfect kidney elimination. Therefore hot sponge baths, with perhaps warm alcohol rubs, are daily necessary. Gentle massage, generally in the direction to aid the circulation, will benefit the skin. If the skin is dry or in places scaly, oil rubs are of great benefit.
The bowels must be moved daily and sufficiently, but there should be no watery purging allowed or caused. If it seems advisable in the beginning of the treatment to give a calomel purge, it should be done, but such purging should ordinarily not be repeated, although occasionally a grain or two of calomel, combined with the vegetable laxatives needed, may act perfectly and without causing depression. Saline purgatives, or even laxatives, are generally not good treatment when there is cardiac weakness. The bowels should be moved by vegetable laxatives, as aloin, cascara sagrada, or some simple combination of either or both of these drugs.
Diuretics are often not satisfactory in cardiac insufficiency. The cardiac tonics which are given the patient, and the improvement of the heart from the rest in bed generally start the kidneys to secreting properly. A diuretic administered when the kidneys are suffering passive congestion from cardiac insufficiency does not generally act, and is therefore useless. If digitalis is administered, it will act as a diuretic; if caffein is deemed advisable, that will act as a diuretic. Squills may be administered, if it seems best. If for any reason the kidneys secrete less urine and become insufficient, the diet should quickly be reduced to a small amount of milk, cereal and water, and hot baths and local heat to the back should be inaugurated.
D. PHYSICAL MEASURES
Hydrotherapy is often of great value in restoring compensation by improving the surface circulation. Sponging with hot, tepid or cold water, as indicated, will increase the peripheral circulation and the normal secretions of the skin.
When compensation is perfect, in valvular lesions, more or less frequent warm baths are advisable, and often relieve the heart by equalizing the circulation. Cold sponging in the morning may be advisable, but may do harm when there is high tension; warm, not too hot, baths are of value. Anything is of value that improves the peripheral circulation and prevents the extremities from being cold.
The value of the Nauheim or other carbonated baths is perhaps often a question. They have seemed in many instances to aid in improving compensation in such patients as have been able to go abroad for the treatment. On the other hand, so many other regimens are ordered and inaugurated for these patients at these "cures" that it is hard to decide how much benefit the baths have really done. At home the artificial carbonated or carbonic acid baths do not seem to be of great value. Baths and bathing can do harm, and the decision as to which hydrotherapeutic measure shall be used can be made only after careful observation of the patient by the physician.
Gentle massage while the patient is in bed is of undoubted value; more vigorous massage is later often of value, provided there is no arteriosclerosis. As the patient grows stronger and the circulation improves, the muscles are kept in good condition during the enforced rest by massage. When properly applied, it promotes not only the venous return circulation, but also the lymphatic circulation; it often removes muscle aches and muscle tire and restlessness.
While the patient is still in bed, various resistant exercises are of value, and should be begun. These tend to prepare the patient for his later greater activities; the surprise to the heart when the patient begins to sit up and walk is not so great if he has previously taken these exercises. Later, when the patient is ambulatory, he should by gradual gradation walk a little more about the house and take a few steps of the stairs at a time, until gradually he is able to mount the whole flight. Later he should take out-door exercise, and when his heart has become compensated for ordinary work, he should be given gradually graded hill-climbing with the idea of increasing his reserve cardiac power. If it is found that these increased exertions cause him to have pain or a more rapid heart than is excusable, even after persisting for a few days, the attempt to increase this reserve power of the heart should be abandoned. There is probably, at least at that particular time, considerable myocarditis, although the heart may eventually recuperate still more. Pushing it to overexertion, however, will not accomplish improvement. Some of the simple "tests of heart strength" described under that heading may be used with these patients.
Graded exercise was first used scientifically by Oertel and Schott, and has been for years designated by their names. Modifications of their rigid rules are generally advisable.
E. MEDICATION
1. CARDIAC TONICS.-Digitalis: There is no drug that can take the place of digitalis in loss of compensation in chronic valvular disease. It acts specifically for good, and it has its greatest success in the valvular lesions that cause enlargement of the left ventricle, on which it acts the most intensely. It also acts for good on the right ventricle. It has but little action on the auricles. This is simply a question of muscle; the part that has the greatest amount of muscle will receive the greatest benefit from digitalis, and the parts that have the least, the least benefit. The heart muscle is somewhat similar to other muscles; when we attempt athletic improvement in any muscle of the body, we "train" by stimulating it moderately at first, and are careful not to overwork it; the object, then, is to train the heart muscle. For this reason large doses of digitalis should ordinarily not be given to overstimulate suddenly an overworked and weak heart. While in some instances it has been declared that digitalis should be rapidly pushed to the full extent and then dropped for a time, careful experience shows that this method is often not tolerated, sometimes does positive harm, and has at times seemed to hasten death.
Another valuable activity of digitalis is in slowing the heart by action on the pneumogastric nerves. A dilated heart has lost more or less of its regulating mechanism; this is the cause of its irregularity and its increased rapidity. The action of digitalis in slowing the heart, giving it a longer rest, and preventing it from acting irregularly is of great value. This prolonged rest or diastole of the heart allows the circulation in the coronary arteries to become normal, and the nutrition and muscle tone of the heart improves. Digitalis also increases the blood pressure, not only by improving the activity of the heart, but also by causing some contraction of the arterioles. This feature of digitalis action in arteriosclerosis renders its use sometimes a question of careful decision. The dose of digitalis under such a condition should not be large. It may be indicated, however, and may do a great deal of good, and it does not always increase the blood pressure.
If the patient is sufficiently ill to require the best action of digitalis, an active preparation should be obtained. It was long supposed that the infusion presented activities which could not be furnished by the tincture of digitalis. This seems not to be true. The greater value of the infusion is generally because it is freshly made and active; the tincture which had been used previously in a given case was old and useless; furthermore, most physicians give a larger dose of the infusion than they ever do of the tincture. Owing to the uncertainty of the value of the digitalis leaves found in the various drug shops, however, and to variations in the preparation of the infusion, it is generally better to use a tincture of known character. The beginning dose of such a tincture should generally not be more than 5 drops, and it should not be repeated more frequently than once in eight hours. It is generally advisable, in two or three days, to increase this dose to 10 drops once in twelve hours, later perhaps to 15 drops twice a day, and still later to 20 drops once a day. This amount may then be decreased gradually, if the action is satisfactory. Enough should be given to procure results, and then the dose should be brought down to what seems sufficient and best, administered once a day. The frequence advised in the administration of this drug is because it is eliminated slowly. Its greatest action develops a number of hours after it has been taken, and then the action lasts for many hours; the administration of digitalis once in twenty-four hours is perfectly satisfactory for many patients, and more satisfactory than any more frequent administration. On the other hand, some patients do better on a smaller dose once in twelve hours. This frequence is always sufficient.
Digipuratum and digitol, a fat-free tincture, proprietary preparations accepted by the Council on Pharmacy and Chemistry for inclusion in N. N. R., may be employed. They are standardized preparations and may thus be more satisfactory than some pharmacopeial preparations of digitalis, although their claims to lessened emetic action are not borne out by recent experiments of Hatcher and Eggleston.
Digipuratum may be obtained in tubes of twelve tablets. The advice has been given for patients with loss of compensation to receive four tablets the first day, three the second, three the third, and two the fourth day. This, however, is generally an overdosage. The most that should generally be given is one of these tablets in twelve hours. Digipuratum fluid is also a valuable preparation.
Digitol is a fat-free tincture of digitalis which is physiologically standardized and which bears on each package the date of manufacture. The close is from 0.3 to 1 c.c. (5 to 15 mimims).
Digitalinum, one of the active principles of digitalis, is not very satisfactory. It may be given hypodermically, but often causes irritation, and the proper dose and its value are apt to be uncertain.
Digitoxin, another active principle of digitalis, has been declared by some investigators to be harmful, also to be liable to cause serious disturbance of a damaged heart. Other investigators have stated that it acts for good. Digitoxin does not represent the whole value of digitalis, and in broken compensation digitalis itself, or some preparation embodying the majority of its activities, should be given. Digitoxin, however, is often valuable in conditions of cardiac debility or slight weakening in patients who do not have dilated hearts or edemas. The most satisfactory dose of digalen is from 5 to 10 drops once or twice in twenty-four hours.
Digitalis should not be used when there is fatty degeneration of the heart; it should ordinarily not be used when there is arteriosclerosis, and very rarely, if ever, when it is decided that there is coronary disease. Whether digitalis should be used when there is considered to be much myocardial degeneration is a question for individualization. One can never be sure that the heart muscle is so thoroughly degenerated that no part of it would be benefited by digitalis when compensation is lost; therefore, many times, especially if other drugs have failed, small doses of digitalis should be tried, to see if the heart will respond. Large doses or frequent doses would be contraindicated.
The signs of overaction of digitalis are nausea, vomiting, a diminished amount of urine, a tight, band-like feeling around the head, perhaps occipital headache and coldness of the hands and feet, or frequently of one extremity only, combined with a feeling of numbness. The pulse is generally reduced to sixty or less a minute. Such symptoms require that digitalis be immediately stopped. They are the primary signs of cumulative action.
While many patients with ordinary dosage of digitalis may take the drug for months and years without ever showing cumulative action, other patients show this effect quickly. They are apt to be those in whom the kidneys are not perfect. The signs of such undesired action may develop slowly, as suggested by the symptoms just enumerated, or they may develop suddenly. The pulse becomes rapid and irregular, the heart action weak, there is severe backache in the region of the kidneys, a greatly diminished amount of urine, or even partial suppression, severe headache, vomiting, cold extremities and shiverings.
The treatment of such an undesired behavior of digitalis is, of course, to stop the drug immediately, give saline laxatives, hot sponging or hot baths, nitroglycerin and perhaps alcohol.
Strophanthus: Strophanthus cannot be compared with digitalis, except when the glucosid, strophanthin, is administered subcutaneously or intravenously. Strophanthus is given either in the form of the tincture, or as strophanthin. It has been shown that in neither of these forms, when the drug is administered by the stomach, is the muscle of the heart or the blood vessels much acted on. Compensation could not be restored by strophanthus. In emergencies of serious cardiac failure, strophanthin intravenously has been shown apparently to save life. It acts quickly, and its power of stimulating the heart and contracting the blood vessels lasts for many hours. It is rarely, however, that the dose should be repeated, and then not for twenty-four hours, but during that twenty-four hours the patient may be saved until other drugs which act more slowly have been absorbed, or perhaps until the emergency has passed. It probably should not be given if the patient has previously had good dosage of digitalis.
There are many, however, who believe that they obtain considerable value from the tincture of strophanthus, and there seems to be no doubt that although strophanthus, given in the form of the tincture and by the mouth, may not increase the muscle power of the heart, it many times acts as a satisfactory cardiac sedative. Under its action the patient becomes less nervous, the heart often acts more regularly, and the low blood pressure may improve. We should not be quite ready to discard the internal use of the tincture of strophanthus.
The tincture of strophanthus readily deteriorates, and the preparation ordered should be known to be a good one.
Caffein: This should not be given or allowed, even in the form of tea or coffee, to patients who have valvular lesions with perfect compensation, as it is a nervous and cardiac stimulant and may cause a heart to become irritable. It raises the blood pressure slightly, acts as a diuretic, and hence is often of great value when used medicinally. It should be ranked as a stimulotonic to the heart. It increases its activity, but gives it a little more strength. It will rarely slow a rapid heart; it will often stimulate a sluggish, slow heart; it may increase the irritability of an irritable heart. As it is a cerebral stimulant, it should not be given late in the afternoon or evening, as it may prevent sleep.
The most frequent form of caffein used is the citrated caffein. The dose is 0.1 gm. (1 1/2 grains) two or three times in the early part of the day, or 0.2 gm. (3 grains) once or twice during the morning. A few much larger doses may be given if desired. A cup of coffee may be given the patient medicinally: as a substitute for the drug, an ordinary cup of strong coffee containing between 2 and 3 grains. Other preparations of caffein may be selected if desired, or a soluble preparation may be given hypodermically.
Caffein is indicated if digitalis is contraindicated or does not act satisfactorily, and the patient is not nervously excited, but perhaps is stupid or apathetic, and also when diuresis is desired.
Strychnin: This is a valuable stimulator and heart tonic when properly used. It promotes muscular activity of the heart much as it promotes all muscular activities. It awakens nervous stimuli and nervous transmissions to normal in all sluggish nerve functions. If for these reasons the heart acts more perfectly, and the nutrition of the heart muscle improves, it acts as a cardiac tonic. Many times, by improving the action of the heart, and also by the action of the drug on the vasomotor center, the pressure in the peripheral circulation may be increased. On the other hand, strychnin in the low blood pressure of serious illness, such as pneumonia, by no means always raises the blood pressure.
It should not be forgotten that strychnin is a general nervous stimulant, especially of the spinal cord. If it makes a nervous patient more nervous, or a quiet patient restless and irritable, it is acting for harm and should be stopped, just as caffein under the same conditions should be stopped. Strychnin may cause diminished secretion of the skin. This is not frequent, but it does occur. It may prevent the patient from sleeping. If such be the fact, strychnin is not acting for good in a patient who has cardiac weakness.
INDICATIONS FOR STRYCHNIN
Strychnin is a much overused drug. It is now given for almost everything and during almost every disease. It is true that the administration of strychnin is largely due to the evolution of the age in which we are now living. We have ceased to purge and bleed and sweat, and to give large doses of aconite or veratrum viride; have ceased to starve the patient too long; we have ceased to load him with alcohol to the point of circulatory prostration, and we have recognized that he must be braced from start to finish; strychnin is the drug which has been used for this purpose, and, as stated above, overused. Strychnin given too frequently or in too large doses for a laboring heart can prevent its proper rest; the diastole is shortened and the relaxation of the heart is incomplete, its nutrition suffers, or even irregular and fibrillary contractions of a weak heart may apparently be caused. While a large dose of strychnin, even to one-twentieth grain hypodermically, may be used once in serious emergency when it is deemed the drug to use, a dose larger than one-thirtieth grain hypodermically is rarely indicated, the frequency of such a dose should seldom be more than once in six hours, and a smaller close of strychnin may act more satisfactorily.
Strychnin is indicated when the heart is acting sluggishly and the contractions seem incomplete, and when digitalis either is not indicated or is not acting perfectly. Small doses of strychnin may aid such a heart during the administration of digitalis. In many instances in which digitalis is contraindicated, strychnin is of marked value. This is typically true in fatty hearts, and may be true in arteriosclerosis, in which it often does not increase the blood pressure at all.
2. Cardiac Stimulants.—A cardiac stimulant is a drug which makes the heart beat more strongly and the frequence more nearly normal. The drugs named as cardiac stimulants, however, camphor, alcohol and ammonia, do not leave a heart better than they found it—they are not cardiac tonics.
Camphor: This is one of the best cardiac stimulants that we possess. It is a quickly acting nervous and circulatory stimulant, acting principally on the cerebrum and causing a dilation of the peripheral blood vessels. No subsequent weakness follows after a dose of camphor. Too much will make a patient wakeful, a little often quiets nervous irritability. It should be used as a cardiac stimulant during serious illness more frequently than it has been; and during the endeavor to make a noncompensating heart again compensatory camphor will often act for good. The dose is 2 teaspoonfuls of the camphor-water every three or four hours, as deemed advisable. Each teaspoonful represents a little more than one-fourth grain of camphor. The spirits of camphor, of course, may be used, if preferred.
For cardiac emergencies, ampules of sterile saturated solutions in oil are now obtainable and are valuable. Such hypodermic stimulation acts quickly, and may be repeated every half hour for several times, if the patient does not respond. The solution should be injected slowly, and as a rule intramuscularly.
Many times while other measures are being used to repair a broken compensation, camphor makes a splendid circulatory and nervous bracer. Camphor has long been used as a so-called antispasmodic in hysteric or other nervously irritable persons. It really acts as a stimulant to the highest centers of the brain, promoting more or less nervous control. Perhaps its ability to increase the peripheral circulation may be one of the reasons that it seems at times to be almost a nervous sedative by relieving internal congestion. As just stated, after the camphor action is over there is no depression. This is not true of alcohol.
Alcohol: It is of course now generally understood that alcohol is not a cardiac stimulant in the sense of its being more than momentarily helpful to a weak heart. If alcohol is pushed when a heart is in trouble, the secondary vasodilatation and more or less nerve prostration and muscle debility will cause greater circulatory weakness than before it was administered.
To obtain cardiac stimulation from alcohol it must be given in strong solutions, generally in the form of whisky or brandy, for local irritation of the mouth, esophagus and stomach; reflexly the heart is stimulated and the blood pressure rises. As soon as complete absorption has taken place, the blood pressure falls. For continuous stimulation, another dose of alcohol must be given before this depression occurs. This may be in from one to three hours. To continue such stimulation, the dose of alcohol must be increased. The future of such treatment means an alcoholic sleep with depression, alcoholic excitement which is not desired, or profound nausea and vomiting, with peripheral relaxation and cold perspiration.
Obviously none of these conditions is desirable; but in arteriosclerosis, or when the blood pressure is high and the heart labors tinder the disadvantage of contracting against an abnormal circulatory resistance, alcohol may act perfectly to relieve this kind of circulatory disturbance. In this condition the alcohol should not be given concentrated, and as soon as it is thoroughly absorbed vasodilatation occurs, peripheral circulation and therefore warmth are increased, and the heart is relieved of its extra load. In such instances, in proper doses not too frequently repeated, rarely more than 1 or 2 teaspoonfuls every three hours, alcohol is a valuable drug. Such good action of alcohol is often seen when the surface of the body is cold from chilling, or the extremities are cold from vasomotor spasm. A good-sized dose of alcohol, best given hot, equalizes the circulation and acts for good. On the contrary, it is obvious that, if the patient is cold from collapse and there is cold perspiration and very low blood pressure, alcohol is not the drug indicated, although one dose may be of benefit while other more slowly acting cardiac tonics or stimulants are being administered.
During serious prolonged illness and when the patient has not had sufficient food and is not taking sufficient food, alcohol in the form of whisky or brandy, not more than a teaspoonful every three hours, acts as a necessary food, and will more or less prevent acidosis from starvation.
It will be seen that alcohol, except possibly in a single dose occasionally, or for some special reason, is rarely indicated in decompensation.
When alcohol is administered regularly, whether during a fever process or for any other reason, if it causes a dry tongue, cerebral excitement, flushed face and a bounding pulse or if there is the odor of alcohol on the breath, the dose is too large, and alcohol is contraindicated.
Ammonia: In the form of ammonium carbonate or the aromatic spirits of ammonia, this has long been used with clinical satisfaction as a cardiac stimulant. Probably, however, it is seldom wise to use ammonium carbonate. It is exceedingly irritant, and constantly causes nausea, perhaps vomiting, and often heartburn or other gastric disturbance. It has no value over the pleasanter aromatic spirits of ammonia, which is essentially a solution of ammonium carbonate. The dose of the aromatic spirits is anywhere from a few drops to half a teaspoonful, given with plenty of water. It is thought to be a quickly acting stimulant, with an effect much like alcohol, followed by very little or no depression. It is more of a cerebral irritant than alcohol, and probably has few, if any, advantages over camphor.
When but little nutriment has been taken for some days, it may be a chemical question, since ammonium compounds so readily form and become cerebral irritants, whether any more ammonium radicals should be given the patient. This is especially true with defective kidneys. In these conditions camphor is better.
3. Vasodilators.—In various conditions of high blood pressure, arteriosclerosis and even during the sthenic stage of a fever, vasodilators may be indicated. The most important are nitrites, iodids and thyroid extracts. Alcohol, as stated above, may act as a vasodilator. Aconite and veratrum viride are now rarely indicated, although possibly aconite should be used when there is high tension and the heart is acting irritably and stormily.
If the nitrites, no preparation seems to act more satisfactorily than nitroglycerin (trinitrin, glyceryl nitratis, glonoin). Its action may not be so prolonged as other forms of nitrite, such as sodium nitrite or erythrol tetranitrate, but it is not irritant, and only a little less rapid than amyl nitrite, and although the marked dilation lasts but a short time, often apparently only for minutes, still, when frequently repeated or given a few times (from four to six) in twenty-four hours, it frequently keeps the blood pressure lower than it would be without the drug. In diseases of the heart the sudden vasodilation caused by amyl nitrite inhalations is indicated only in angina pectoris. "Then the surface of the body tends to be cold, however, when the peripheral blood pressure is increased and the heart is laboring, nitroglycerin in small doses is valuable. The dose may be from 1/400 to 1/100 grain, dissolved on the tongue or given hypodermically for quick action, or given by the mouth for more prolonged action. In sudden cardiac dyspnea nitroglycerin sometimes acts specifically, especially when there is asthma. When a drop or two of the official spirits, which is a 1 percent solution, is given on the tongue, or a soluble tablet of 1/100 grain is dissolved on the tongue, the action is almost as rapid as though the dose had been administered hypodermically. Many times when such increased peripheral circulation is desired and alcohol seems indicated, nitroglycerin in small doses will act as well. It cannot be termed a cardiac stimulant, although many times a heart acts better and the pulse is fuller and stronger after nitroglycerin than before. It should not be used, except if specially indicated, in broken compensation or in other myocardial weakness.
Iodids: These have no immediate action. The vasorelaxation that often occurs from iodid is quite likely due to the stimulation of the thyroid gland by the iodin, and the thyroid gland secretes a vasodilating substance. Small doses of iodid, however, when indicated in various kinds of sclerosis, have seemed to lower blood pressure. While large doses may have more of this actioli, they are not now under consideration, and large doses are rarely indicated. Too mach iodid has been given for many conditions. If the indications for an iodid are present, such as sclerosis anywhere, or unabsorbed inflammatory products, exudation in or around the heart, or an apparent insufficiency of the thyroid, from 0.1 to 0.2 gm. (1 1/2 to 3 grains) once or twice in twenty-four hours, after meals, is all that is required to give the action desired, and the circulation is benefited. It is sometimes a question whether small doses of iodid are not actually stimulant to the heart, possibly through the action on the thyroid gland.
Thyroid Extract: In slow hearts and in sluggish circulation, often in old age, quite frequently in arteriosclerosis and in every condition of insufficient thyroid secretion (these instances are frequent), small doses of thyroid extract will benefit the circulation. Its satisfactory action is to increase the cardiac activity, slightly lower the blood pressure, and increase the peripheral circulation and the health of the skin. If it causes tachycardia, nervous excitement, sleeplessness or loss of weight, it is doing harm and the dose is too large, or it is not indicated. The dose for the cardiac action desired is a tablet representing from 1/2 to 1 grain of the active substalice of the thyroid gland, given once a day, continued for a long period.
When an improved peripheral circulation is desired, and especially when a reduction of the pressure in the heart is desired and a diminished amount of blood in overfilled arteries is indicated, the value of the sitzbath, hot foot-baths, warm liquids (not hot) in the stomach, and warm, moist applications to the abdomen should all be remembered.
4. Cardiac Nutritives.—Iron: Nothing is of more value to a weakened heart muscle, when the nutrition is low, the patient anemic, and the iron of the food not properly metabolized, than tonic doses of some iron salt. It has frequently been repeated, but should constantly be reiterated, that there is no physiologic reason or therapeutic excuse for the patient to pay a large amount of money for some organic iron preparation.
Small doses of an inorganic salt act perfectly, and nothing will act better. As previously suggested, a drop or two of the tincture of iron, a grain or two of the reduced iron, or 2 or 3 grains of saccharated ferric oxid, given once or twice in twenty-four hours, is all the iron the body needs from the points of view of the blood and the heart.
Calcium: It has lately been learned that calcium is an element which a heart needs for perfect activity. Many patients who are ill lose their calcium, and they may not receive a sufficient amount of it unless milk is given them. Even if such patients are taking milk, the heart and the whole general condition sometimes such; to improve when calcium is added to the diet. It may be given either in the form of lime water, calcium lactate or calcium glycerophosphate. If a medium-sized dose is given three or four times in twenty-four hours, it is sufficient and will often act for good.
Whether calcium can do harm in a chronic endocarditis or an arteriosclerosis to offset the value that it seems to have in quieting the nervous system and in being of value to a weak or nervously irritable heart is a question which has not been decided. Theoretically lime should not be given when there is a tendency to calcification, or when a patient is past middle age. Lime seems to be essential to youth, and to the welfare of nervous patients.
EMERGENCIES
5. Cardiac Emergency Drugs.—Besides some of the drugs already mentioned (such as camphor hypodermically, nitroglycerin when indicated, strophanthin hypodermically or intravenously, caffein and strychnin), often ergot, suprarenal vasopressor principle, pituitary vasopressor principle, atropin and morphin should be considered.
When there is low blood pressure, venous stasis, pulmonary congestion, cyanosis and a laboring, failing heart, intramuscular injections of ergot, with or without coincident venesection, may be the most valuable method of combating the condition. Life has been saved in this kind of sudden acute cardiac failure in valvular disease. When venesection is not indicated in certain conditions of low blood pressure and heart failure, ergot has saved life. It causes contraction of the blood vessels and seems to tone the heart. Incidentally it quiets the central nervous system. If the blood pressure is much increased by it, the ergot should not be repeated, as too much work should not be thrown on the heart muscle. Often, however, it may be administered intramuscularly with advantage in aseptic preparation as offered in ampules, at the rate of one ampule every three hours for two or three times, and then once in six hours for a few times, the future frequency depending on the indications.
Epinephrin and Pituitary Extract: The blood pressure-raising substance of the suprarenals or of the pituitary gland (hypophysis cerebri) has been much used in heart failure. These substances certainly would not be indicated in high blood pressure; they are indicated in low blood pressure. They have been given intravenously; they are frequently given hypodermically. They often act rapidly when a solution in proper dose is dropped on the tongue. The blood pressure rise from epinephrin is quickly over; that from the pituitary extract lasts longer. In large doses, or when it is too frequently repeated, epinephrin depresses the respiration. Pituitary extract acts as a diuretic. Sterilized solutions of both, put up in ampules ready for hypodermic medication, are obtainable, the strength offered generally being 1 part of the active principle to 10,000 of the solution. Hypodermic tablets of epinephrin may also be obtained. Stronger solutions of 1 part to 1,000 may be dropped on the tongue, or tablets may be dissolved on the tongue. The blood pressure is temporarily raised and the heart stimulated by these treatments, but epinephrin is not used so often for cardiac failure as it was a short time ago.
The most satisfactory action, especially from the epinephrin, is from small doses frequently repeated. Sometimes in serious emergencies it has been found to be of value when given intravenously in physiologic saline solution. The close, of course, should be very small. In circulatory weakness in acute illness, epinephrin has been given regularly, a few drops (perhaps the most frequent dose is 5) of a 1: 1,000 solution, on the tongue, once in six hours. Such a dosage may be of value, and certainly is better than the administration of too much strychnin. Much larger or more frequent doses are likely, as just stated, to depress the respiration.
Besides the small amount of blood pressure-raising substance secreted by the hypophysis cerebri. it has not been shown that any other gland of the body furnishes vasopressor substance except the suprarenals.
Atropin: When there is great cardiac weakness, atropin may be used to advantage. The dose is from 1/200 to 1/150 grain hypodermically, not repeated in many hours. It will whip up a flagging heart, more or less increase the blood pressure, cause cerebral awakening, and may often be of value. If there is any idiosyncrasy against atropin, if the throat and mouth are made intensely dry, or if there is serious flushing or cerebral excitement, the dose should not be repeated.
Morphin: This would rarely be considered as an emergency drug in cardiac weakness. A small dose of it, not more than one-eighth grain, especially if combined with atropin, will often quiet and brace a weak heart, especially when there is cardiac pain. Just which drug or drugs should be used and just which are not indicated can never be specifically outlined in a textbook, a lecture or a paper. The decision can be made only at the bedside, and then mistakes, many times unavoidable, are often made.
In all conditions of shock with cardiac failure, the blood vessels of the abdomen and splauclinic system are dilated, and more or less of the blood of the body is lost in these large veins, and the peripheral and cerebral blood pressure fails. The advantage in such a condition of firm abdominal bandages, and of raising the foot of the bed or of raising the feet and legs, need only be mentioned to be understood.
It is a pretty good working rule, in cardiac failure, not to do too much. On the other hand, life is frequently saved by proper treatment, and the physician repeatedly saves life as surely as does the surgeon with his knife.
CONVALESCENCE
When compensation has been restored, the patient may be allowed gradually to resume his usual habits and work, provided these habits are sensible, and the work is not one requiring severe muscular exertion. Careful rules and regulations must be laid down for him, depending on his age and the condition of his arteries, kidneys and heart muscle. It should be remembered that a patient over 40, who has had broken compensation, is always in more dancer of a recurrence of this weakness than one who is younger, as after 40 the blood pressure normally increases in all persons, and this normal increase may be just too much for a compensating heart which is overcoming all of the handicap that it can withstand. Such patients, then, should be more carefully restricted in their habits of life, and also should have longer and more frequent periods of rest.
The avoidance of all sudden exertion in any instance in which compensation has just been restored is too important not to be frequently repeated. The child must be prevented from hard playing, even running with other children, to say nothing of bicycle riding, tennis playing, baseball, football, rowing, etc. The older boy and girl may need to be restricted in their athletic pleasures, and dancing should often be prohibited. Young adults may generally, little by little, assume most of their ordinary habits of life; but carrying heavy weights upstairs, going up more than one flight of stairs rapidly, hastening or running on the street for any purpose, and exertion, especially after eating a large meal, must all be prohibited. Graded physical exercise or athletic work, however, is essential for the patients' future health, and first walking and later more energetic exercise may be advisable.
These patients must not become chilled, as they are liable to catch cold, and a cold with them must not be neglected, as coughing or lung congestions are always more serious in valvular disease. Their feet and hands, which are often cold, should be properly clothed to keep them warm. Chilling of the extremities drives the blood to the interior of the body, increases congestion there, and by peripheral contraction raises the general blood pressure. A weak heart generally needs the blood pressure strengthened, but a compensating heart rarely needs an increase in peripheral blood pressure, and any great increase from any reason is a disadvantage to such a heart. The patient should sleep in a well ventilated room, but should not suffer the severe exposures that are advocated for pulmonary tuberculosis, as severe chilling of the body must absolutely be avoided.
The peripheral circulation is improved, the skin is kept healthy, the general circulation is equalized, and the heart is relieved by a proper frequency of warm baths. Cold baths are generally inadvisable, whether the plunge, shower or sponging; very hot baths are inadvisable on account of causing a great deal of faintness; while warm baths are not stimulating and are sedative. The Turkish and Russian bath should be prohibited. They are never advisable in cardiac disease. With kidney insufficiency, body hot-air treatment (body-baking), carefully supervised, may greatly benefit a patient who has no dilatation of the heart and who has no serious broken compensation. Surfbathing, and, generally, sea-bathing and lake- bathing are not advisable. The artificial sea-salt baths and carbon dioxid baths may do some good, but they do not lower the general blood pressure so surely as has been advocated, and probably no great advantage is apt to be derived from such baths. If a patient cannot properly exercise, massage should be given him intermittently.
Any systemic need should be supplied. If the patient is anemic, he should receive iron. If he has no appetite, he should be encouraged by bitter tonics. If sleep does not come naturally, it must be induced by such means as do not injure the heart.
Perhaps there is no better place in this series on diseases of the heart to discuss the diet in general and the resort treatment than at this point, as the question is one of moment after convalescence from a broken compensation, at which time every means must be inaugurated to establish a reserve heart strength to overcome the daily emergencies of life.
DIET AND BATHS IN HEART DISEASE
The diet in cardiac diseases has already incidentally been referred to. The decision as to what a patient ought to eat or drink must often be modified by just what the patient will do, and, as we all know, it is absolutely necessary to make some concessions in order for him to aid us in hastening his own recovery or in preventing him from having relapses. Consequently, we cannot be dogmatic with most patients with chronic heart disease. Parents should be prohibited from allowing children or adolescents with heart disease to drink tea, coffee or any alcoholic stimulant. The young boy and young man must absolutely be prohibited from indulging in tobacco at all. There is no excuse for allowing these stimulants or foods in such cases. If the patient is older and has been accustomed to tea and coffee, one cup of coffee in the morning may be allowed, provided a decaffeinated coffee is not found satisfactory. Whether a small cup of coffee or a cup of tea is allowed at noon is again a matter for individualization; they should rarely be allowed after the noon meal. In a patient who has been accustomed to alcohol regularly (generally an older patient), careful judgment should be used in deciding whether or not a small amount of alcohol daily should be allowed. It should never be in large amounts, even of a dilute alcohol like beer; it may be a weak wine; it may be a small amount of diluted whisky, if seems best. Ordinarily the patient is better without it. If he is used to smoking and a small amount does not raise the blood pressure much, it may do him no harm to smoke a small mild cigar once or twice a clay. On the other hand, if a hard smoker suddenly has heart failure, whether from exertion, from chronic disease or from acute illness, a small amount of smoking is of advantage as it tends to remove cardiac irritability, to raise the blood pressure, and actually to quiet and improve the circulation. It is unwise during acute circulatory failure to take tobacco away entirely from a chronic tobacco user.
The character of the food which each patient should receive depends on his blood pressure and his age. The older person with a tendency to high blood pressure should have the protein (especially meat) reduced in amount, as any putrefaction in the intestine with absorption of products of such maldigestion irritates the blood vessels, raises the blood pressure, and injuries the kidneys. On the other hand, a young patient should receive a sufficient meat diet rather than be overloaded with vegetables and starches, to the easy production of fermentation and gas. Flatulence from any cause must be avoided. It dilates the stomach and intestines, causing them to press on the diaphragm, so that the heart and respiration are interfered with. Also, an increased abdominal pressure, especially if there is any edema or dropsy, is bad for the circulation. A distended, tense abdomen is serious in cardiac failure. On the other hand, a flaccid, flabby, lax abdomen should be well bandaged in cardiac failure with low blood pressure.
Children do well on a milk diet, but it should be remembered that excessive amounts of any liquid, even milk and water, are inadvisable, if the circulation is poor and there is a tendency to dropsy. It has been recommended at times to limit a patient's diet for a week or so to a small amount of milk, not more than a quart in twenty-four hours. If such a patient is in bed and does not require carbohydrates, sugars or stronger proteins or more fat, such a restricted diet may aid in establishing circulatory equilibrium, although he will lose in nutrition. The excretory organs are relieved by the decreased amount of excretory product, the digestive system is rested and the circulation is improved. Such a limited diet should not be tried longer than a week, but it may be the turning point of circulatory improvement.
The ordinary diet for a convalescing heart patient should be small in bulk, of good nutritive value, and should represent all the different elements for nutrition. This means a small amount of meat, once a day to older patients, twice a day to those who work hard or for young patients; such vegetables as do not cause indigestion with the particular patient, and these must be individualized; such fruits as are readily digested, especially cooked fruits; generally plenty of butter, cream, olive oil if the nutrition is low, and milk, depending on the age of the patient or the ease with which it is digested. Soups, on account of their bulk and low nutritive value, should be avoided. Anything that causes indigestion, such as fried foods, hot bread, oatmeal or any other gummy, sticky, gelatinous cereal should be avoided; also spices, sauces and strong condiments. Anything that is recognized as especially loaded with nuclein and xanthin bodies, such as liver, sweetbreads and kidneys, should be prohibited, as tending to cause uric acid disturbance; and the more tendency to gout or uric acid malmetabolism the more irritated are the arteries and the more disturbed the blood pressure. Sugars should be used moderately unless the patient is thin and feels cold, in which case more may be given, provided there are no signs of gout or disturbed sugar metabolism. Sugar is at times a good stimulant food. Very cold and very hot drinks or food should be avoided.
Many times these patients have a diminished hydrochloric acid secretion, and such patients thrive on 5 drops of dilute hydrochloric acid in water, three times a day, after meals. When their nutrition has improved and the digestion becomes perfect, hydrochloric acid will generally be sufficiently secreted and the medication may be stopped.
If the patient is overweight, this obesity must be reduced, as nothing more interferes with the welfare of the heart than overweight and overfat. In these cases the diet should be that required for the condition. If there are edemas, or a tendency to edemas, the decision should be made whether salt (sodium chlorid) should be removed from the diet. Unless there is kidney defect, probably it need not be omitted, and a long salt-free diet is certainly not advisable. This salt-free diet has been recommended not only in nephritis and heart disease, but also in diabetes insipidus and in epilepsy. It is of value if there is edema in nephritis; it is of doubtful value in heart disease; it is rarely of value in diabetes insipidus; and in epilepsy its value consists probably in allowing the bromid that may be administered to have better activity in smaller doses, the bromin salt being substituted in the metabolism for the chlorin salt.
THE RESORT TREATMENT OF CHRONIC HEART DISEASE
In line with the continued growing popularity of special resorts and special cures for different types of disease, resort or sanatorium treatment for chronic heart disease has grown to considerable popularity during the last twenty years or more. The most popular of these resorts owe their success to the personality of the physicians, who have made heart disease a life study.
Perhaps the most noted of these resorts for the cure of heart disease is that at Bad Nauheim, Germany, which was inaugurated by Dr. August Schott and Prof. Theodore Schott, and is now conducted by the latter, Dr. August Schott having died about fifteen years ago. Hundreds of patients and many physicians have testified to the value and benefit of the treatment carried out at this institution.
The method of treatment largely employed at these heart resorts is to withdraw all, or nearly all, of the active drugs that the patient may be taking, and to substitute physical and physiologic methods of therapy. These include bathing, regulation of the diet, and exercise. This exercise consists of two varieties: exercise of the muscles against the resistance of an attendant, and exercise by walking on inclined planes or up hills. The treatment is aimed at chronic heart disease, to develop a greater cardiac reserve strength; the whole object of the treatment is to strengthen the myocardium, either in conditions of its debility or in conditions of diminished compensation in valvular disease. Any treatment that will develop a reserve heart strength to be called on in emergencies, more or less similar to the reserve strength of a normal heart, tends to prolong the patient's life and health.
Patients with acute heart failure or acute loss of compensation, with more or less serious edemas, should rarely take the risk of traveling any distance to be treated at an institution. As a general rule they are better treated for a few weeks or months at home. After the broken compensation is repaired, a reserve strength of the heart may well be developed by a visit to one of these institutions, if the patient can afford it.
The Oertel treatment consists chiefly in diminishing the fluids taken into the body, and in graduated mountain climbing. By diminishing the fluids taken, the work of the heart is diminished, as the blood vessels are not overfilled and may be even underfilled. The diet is carefully regulated with the object of removing all superfluous fat from the body. The third leg of the tripod of the Oertel treatment is the gradually increasing hill and mountain climbing to educate the heart by graded muscular training to become strong, perfectly compensatory, and later to develop a reserve strength. This particular cure is especially adapted to the obese, who have weakened heart muscles.
NAUHEIM BATHS
At Nauheim, under the direction of Dr. Theodore Schott, baths form an important part of the treatment. These baths are of two kinds, the saline and the carbonic acid. The medicinal constituents of the saline bath are sodium chlorid and calcium chlorid, the strength of each varying from 2 to 3 percent The baths at first arc given at a temperature of 95 F., and as the patient becomes used to them and can take them without discomfort, the temperature is gradually reduced. The patient remains in the bath from five to ten minutes. After the bath he is dried with towels and rubbed until the cutaneous circulation becomes active. He must then lie down for an hour. These baths are repeated for two or three days, and are omitted on the third and fourth days, to be resumed on the following day. After a few baths have been taken, the carbon dioxid baths are commenced, beginning with a small quantity of the gas which is later gradually increased. This course of baths should be continued from four to eight weeks. Unless there is some special reason for taking them at some other period of the year, they are taken more advantageously during the warm months.
Besides the baths, all important part of the treatment at Nauheim consists in the exercises against resistance. These are usually given an hour or more after a bath, and are taken with great deliberation; their effect is carefully watched by an intelligent attendant so that no harm may be done by the exercise.
During this treatment the food is, of course, carefully regulated with the aim of giving a mixed, sufficient, easily digestible and easily assimilated diet. All highly seasoned dishes, all effervescent drinks and anything that tends to cause gas in the stomach and intestines are prohibited. Coffee and tea are not allowed, except coffee without caffein; and it may be noted that it has recently been shown that caffein is one of the surest of drugs to raise the blood pressure, and is therefore generally not desirable when the heart muscle requires strengthening. Because of its tendency to raise blood pressure and weaken cardiac muscle, tobacco is entirely forbidden at Nauheim, except in a few individual instances, and then the amount allowed is a minimum one. Large amounts of liquid are not allowed because they distend the stomach, raise the blood pressure and increase the pumping work of the heart.
One of the greatest advantages of the treatment at an institution like Nauheim is the general hopeful spirit instilled into the patients, who are so many times seriously depressed by the knowledge of a heart weakness and the realization of their physical inability to do what other persons are able to do. Also, it is of great value to send a patient to a resort where the climate is good and the scenery is lovely and soothing. No disease, perhaps, needs cheerfulness and pleasantness and lack of anxiety, or frets more than does cardiac weakness. A tuberculous patient may sit on a mountain top with snow blowing about him, and recover; a heart patient must have sunshine and comfort.
The results of such sanatorium treatment of heart disease are often evident not only to the patient by an increase of general muscle strength, the ability to do ordinary things and perhaps even sustain muscular effort without dyspnea and cardiac discomfort, but also to the physician by the physical signs. The contraction of the heart becomes stronger and the normal sounds more decided; murmurs which were entirely due to dilated ventricles and insufficiency disappear, while the permanent murmurs may become louder from a more forceful, normal action of the heart muscle. The pulse becomes slower, and the blood pressure, from being too low, becomes normal for the age of the individual. The heart will often also actually decrease in size, and the apex beat become localized rather than diffuse, The liver becomes reduced in size; the urine is less concentrated, and if there were traces of albumin after exertion, these disappear.
It should perhaps be emphasized that not a little benefit from these resort treatments may be due to the withdrawal of unnecessary drugs. Many heart patients are overdrugged.
This sort of treatment is contraindicated in some kinds of heart disease, as heart weakness due to arteriosclerosis with high blood pressure, to aneurysm of the thoracic or abdominal aorta, and to nephritis.
So many heart patients have been improved by the Nauheim treatment that the question arises as to whether the treatment can be conducted at home or in a sanatorium near home, when the patient is unable to go to this resort; that is to say, Can we establish this treatment for the majority of patients who have chronic heart disease? Of course, even at home, the sodium chlorid and calcium chlorid baths may be given, and one may obtain the salts all prepared to make the carbon dioxid bath; the exercises may be given, and walking on various ascending grades may be inaugurated. All patients will be more or less benefited, provided they will carry out the treatment. Unfortunately, the surroundings at a patient's home are generally adverse to perpetuating these treatments long enough to develop the muscular strength of the heart to the reserve desired. If a patient appears pretty well, especially if he is stimulated by his family to believe that he is well, he thinks the continuation of the treatment entirely unnecessary, and unless he goes to a resort where he sees other patients with similar conditions able to do what he is not able to do, and therefore is stimulated to acquire their ability by the treatment outlined, he will not follow his physician's directions. There are several sanatoriums in this country where the diet, hydrotherapy and exercise necessary for developing heart strength are carried out, and patients are sent to some of them with great advantage.
It has been found that these stimulant baths do not act well in mitral stenosis, if the left ventricle is small. If the left ventricle is unable to receive and therefore send out into the systemic circulation sufficient blood to dilate the peripheral capillaries under the irritation of the baths or the vasodilator effects of the baths, the bath treatment does harm instead of good. A patient who has mitral stenosis and also a small left ventricle will be found to be poorly developed, badly nourished, and to have poor peripheral circulation.
As elsewhere stated, the improvised carbon dioxid bath, to stimulate the skin so as to reduce the blood pressure, is not satisfactory. Other methods of reducing blood pressure, when it is too high, are much more effective.
HEART DISEASE IN CHILDREN AND DURING PREGNANCY
A common characteristic in a large proportion of middle-aged or old patients with heart disease is the presence of degenerative changes in the myocardium, the valves, or the arteries of the heart. In children, on the other hand, the most common disturbances of the heart are acute inflammations affecting its different structures, and due in most instances to acute infections. Myocarditis and endocarditis occur frequently, and pericarditis occasionally. As in adults, rheumatism is the most common cause of inflammation of the structures of the heart, but rheumatism causes inflammation of the heart much more frequently in children than in adults. Besides this infection, the most frequent causes of inflammation of the heart in children are diphtheria, scarlet fever, typhoid fever, measles and influenza, with the frequency, perhaps, in the order named. Diphtheria frequently gives rise to myocarditis, which results in dilatation of the heart. This may occur in the second or third week of the course of the disease, and even up to the eighth and tenth week from the beginning of the disease. The myocarditis due to diphtheria is not always the cause of sudden death occurring during the disease, as such a fatal result may be due to paralysis of nervous origin. In scarlet fever, inflammation of the heart may be due directly to the poison of the disease, or it may be secondary to a nephritis which is so frequent a complication of scarlet fever. It is probable that the inflammation of the skin in scarlet fever, preventing normal secretion, may be a cause of a sometimes increased blood pressure and also of the nephritis, both of which conditions may predispose to the cardiac complication. Erysipelas may cause acute inflammation of the heart, perhaps for the same reason.
A certain proportion of cardiac diseases in children, especially endocarditis, seems to be due to a general septic infection which results in the so-called septic, infectious or malignant endocarditis. There is sometimes a tendency in certain children, and perhaps in certain families, for the heart to become readily infected during an infectious disease, more than in other children who suffer from the same disease. Sometimes the heart becomes inflamed in rheumatic children without any joint affection occurring; the inflammation in the heart may be the only manifestation of the disease.
This etiology of cardiac affections of children indicates the directions in which therapeutic efforts should be aimed. In children who are under the more or less constant care of the family physician, the possibility of the occurrence of some cardiac affection should be borne in mind, especially in children in families which are known to be affected with what may be called a rheumatic diathesis—families in which several members have suffered from rheumatism. It is reasonable to suppose that children who are delicate and feeble, who do not have sufficient fresh air, who do not take sufficient exercise, and who are not properly fed are more liable to be affected with cardiac complications in the presence of infectious diseases than children who have had plenty of fresh air, an abundance of exercise and a sufficient amount of proper food.
At the present day it is hardly necessary to insist on the importance of giving every child an adequate amount of fresh air. It is possible, however, that this gospel has been overworked, and it is not infrequently necessary to caution some parents that there is danger of impairing their children's health by too much exposure. The old ideas of the influence of exposure to cold and dampness in the production of rheumatism have not yet been so far abandoned that we can entirely neglect the possibility of rheumatism being developed, at least, by the exposure to cold winds and dampness of children who are otherwise predisposed to this disease. It is possible that the enormously increasing number of children with adenoids and enlarged tonsils, who need operative measures for their removal, may have these conditions aggravated by too much exposure to the inclemency of variable, harsh weather.
It is not necessary to state that proper exercise develops the heart, as it does all the other muscles; but at the same time it is necessary to caution parents against allowing their children to indulge in too violent and too prolonged exercise. Young children probably stop often enough in their play not to overwork their hearts. Older boys and girls, especially boys, are inclined to take too severe athletics, such as long-distance running, competitive rowing, violent football and rapid cycling. It should be emphasized to school-masters, gymnasium teachers and athletic trainers that a boy who is larger than he should be at his age has not the circulatory ability that the older boy of the same size has. The overgrown boy has all he can do to carry his bulk around at the speed of his age and youth. The addition of competitive labor overreaches his reserve heart power, and he readily acquires a strained, injured heart. On the other hand, moderate indulgence in walking, baseball, swimming, rowing and golf should be commended. It is not exactly the exercise that does him the harm, it is the competitive element in it. Until a boy is well developed in his internal reserve strength, he should not compete with other boys who are better developed. His pride makes him do himself injury.
Dietetic fads are so prevalent today that there is danger that many children will not receive an adequate amount of nutriment, that they will be fed an excess of such foods as are likely to produce damage to their constitutions, or that they will be given food which does not contain all the different elements of nutrition to satisfy their economy and their growth. While it is now generally acknowledged that an excess of meat is not beneficial to any one, on the other hand a moderate amount is necessary for individuals who are working or are mentally active, especially for growing children. Also a too great limitation of the child's diet to farinaceous foods, and especially the allowance of too much sugar and sugar-producing food, is liable to encourage the development of rheumatism. A mixed diet, not excessive in amount, and prepared so that it will be digested without difficulty, is most useful, and it should include in suitable proportions meat, milk, eggs, vegetables, starches and fruit. These should all be taken at regular intervals, thoroughly chewed, and should not be taken in excess.
If a child has had an attack of heart inflammation, a myocarditis or an endocarditis, greater care should be taken of him not only when he is well but especially when he becomes ill of any other disease. If the child has had a rheumatic inflammation of the heart, or has had rheumatism without such a complication, it is considered by some clinicians wise to give a week's treatment with salicylates at intervals of three or four months, for two or three years, perhaps. It is hard to determine how much value this prophylactic treatment has. If the child's surroundings cannot be changed and lie is subjected to the same conditions of possible reinfection, it may be a wise precaution, much like the prophylactic administration of quinin in malarial regions. If a child has developed a cardiac inflammation during any disease, the treatment is that previously outlined.
An important part of prophylaxis and treatment of a cardiac affection during the course of any disease is the prevention of serious anemia. During sickness the patient is liable to become more or less anemic, but the administration of iron, in the manner previously suggested, during the course of the disease, and especially during rheumatism, will prevent the anemia becoming rapid or severe.
CARDIAC DISEASE IN PREGNANCY
It is so serious a thing for a woman with valvular lesion or other cardiac defect to become pregnant that no young woman with heart disease should be allowed to marry. Perhaps every normal heart during pregnancy hypertrophies somewhat to do the extra work thrown on it, but it may easily become weakened and show serious disturbance as its work grows harder and the distention of the abdomen and the upward pressure on the diaphragm increase. This pressure perhaps generally displaces the apex of the heart to the left and causes the heart to lie a little more horizontal. If the patient is normal, there may be a gradually increasing blood pressure all through the months of pregnancy, and if the kidneys are at all disturbed this pressure is increased, and there is, of course, much increased resistance to the circulation during labor. The better the heart acts, the less likely are edemas of the legs during pregnancy. It is thus readily seen that pregnancy is a serious thing for a damaged heart. The reserve strength of the heart muscle, as has been previously stated, is much less in valvular compensation than that of the normal heart, and this reserve force is easily overcome by the pregnancy, and loss of compensation occurs with all of its usual symptoms.
The most serious lesion a woman may have, as far as pregnancy is concerned, is mitral stenosis. An increased abdnominal pressure interferes with her lung capacity, and her lungs are already overcongested. The left ventricle may be small with mitral stenosis, and therefore her general systemic circulation poor. For those two reasons mitral stenosis should absolutely prohibit pregnancy. While many women with well compensated valvular disease go through pregnancy without serious trouble, still, as stated above, they should be advised never to marry. If they do marry, or if the lesion develops after marriage, warning should be given of the seriousness of pregnancies.
If a woman becomes pregnant while there are symptoms or signs of broken compensation, there can be no question, medically or morally, of the advisability of evacuating the uterus. The same ruling is true if during pregnancy the heart fails, compensation is broken, and the usual symptoms of such heart weakness develop, provided a period of rest in bed, with proper treatment, has shown that the heart will not again compensate. Under such a condition delay should not be too long, as the heart may become permanently disabled. If, during pregnancy in a patient with a damaged heart, albuminuria develops and the blood pressure is increased, showing kidney insufficiency, there can be no question of delay, from every point of view, and labor must be precipitated; the uterus must be emptied to save the mother's life.
If a pregnant woman is known to have a degenerative condition of the myocardium, or arteriosclerosis, the danger from the pregnancy is serious, and the pregnancy should rarely be allowed to continue.
Even if no serious symptoms occur during the term of the pregnancy, and the heart continues to compensate sufficiently for its defect, labor should never be allowed to be prolonged. The tension thrown on the heart during labor is always severe, and has not infrequently caused acute heart failure by causing acute dilatation, and in these damaged hearts tediousness and severe, intense exertion should not be allowed. Proper anesthetics and proper instrumentation should be inaugurated early.
Patients who have successfully passed through the danger of pregnancy with cardiac lesions, possibly relieved by radical treatments, should be warned against ever again becoming pregnant. If this warning does not prevent future pregnancies, the family physician and his consultant must decide just what it is proper to do. It is to be understood that no uterus should ever be emptied until one or more consultants have approved of such treatment.
Sometimes serious heart weakness develops during the later weeks of pregnancy, requiring the patient to remain in bed and receive every advantage which rest, proper care and well judged medicinal treatment will give the circulation.
If the heart is weak and there have been signs of myocardial weakness or loss of compensation, the sudden loss of abdominal pressure after delivery may allow the blood vessels of the abdomen to become so overfilled as to cause serious cerebral anemia and cardiac paralysis. Therefore in such cases a tight bandage must immediately be applied, and it has even been suggested that a weight, as a bag of sand weighing several pounds, be placed temporarily on the abdomen. The greatest possible care should be given these women during and after labor.
Acute dilatation is not an infrequent cause of death during ordinary labor, and is more apt to occur in these cardiac patients. If signs of acute dilatation of the heart occur, with associated pulmonary edema, venesection (especially if there has not been much uterine hemorrhage), with the coincident intramuscular injection of one or two syringefuls of aseptic ergot, will often be found to be life- saving treatment. Septic infections after parturition are prone to cause endocarditis and myocarditis, and a malignant endocarditis may develop from uterine infection or uterine putridity.