CHAPTER XII

THE CIRCULATORY SYSTEM-Continued

MUSCULAR AND VALVULAR INSUFFICIENCY OF THE HEART AND HEART NEUROSES

SYNOPSIS: Weak and Flabby Heart.-Fat Laden Heart.-Degeneration of the Heart Muscle without Valvular Defects: Senile, Gouty, Syphilitic, Fatty, Fibroid Heart, Myocarditis with Constant Arrhythmia.-Valvular Heart Disease and Muscular Insufficiency-Heart Neuroses.

WEAK HEART; CONGENITALLY SMALL HEART; FLABBY HEART MUSCLE Ir is a well known clinical fact that some individuals have a small heart; thus, most people with tuberculosis or tuberculous tendencies have small hearts. It goes without saying that persons not afflicted with tuberculosis may have a small heart. Such persons look anæmic, are easily tired, and have palpitation on slight exertion, particularly if they increase in weight. These patients present all the clinical evidence of moderate heart insufficiency, and may show a slight puffiness at the ankles.

The diagnosis is made by exclusion. So called "neurasthenic "heart weakness with its long train of symptoms is often nothing more than motor weakness.

Treatment. An insufficient heart which will stand a strain will improve by reason of such strain and increase in motor force; therefore it is the duty of the physician to overrule the laziness and indolence of that class of patients whose heart symptoms are not due to degenerative processes by ordering active exercise. It must be explained to the patient that palpitation and moderate dyspnoea do not contraindicate active exercise. This must be particularly impressed upon corpulent women who feel faint, dizzy, and languid after exertion and are very prone to accept rest instead of motion. It is in this class of cases that graded climbing, outdoor and indoor exercise and gymnastics, and a judicious dietary will work wonders. The details of such management will be discussed under Fat Laden Heart. Weak heart from cardioptosis is described as a relaxation of the elastic tissue of the large vessels which allows the heart to prolapse, that is, hang much lower in the thorax than normal. This prolapse causes the apex beat to appear beyond the nipple line, and makes the lower part of the area of relative and absolute heart dulness much wider than normal. The pathognomonic sign of the existence of this anomalous condition is the absence of heart dulness at the ordinary upper limit of the organ. As the result of the cardioptosis such symptoms as respiratory anguish, painful

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dyspnoea, and præcordial discomfort develop. Some of the cases of angina. pectoris are said to be due to this condition. The cause is always an hereditary tendency to relaxation of tissues and seems to be a family trait. Apart from general tonic management there is no special treatment for such a condition.

THE FAT LADEN HEART (COR ADIPOSUM)

Fat people frequently present the clinical evidence of heart weakness, and in the absence of a murmur, we are apt to diagnosticate "fatty heart." In all such cases we must endeavor to distinguish between fatty degeneration and the fat laden heart of obesity. In obesity and fat laden heart much can be done by rational management. Corpulent individuals are sluggish in their movements. They have dyspepsia from mechanical interference with respiration, later on from true fatty infiltration of the heart muscle; the liver becomes large and fatty. Edema, intertrigo, and eczema increase the suffering of the patient.

Treatment. The indications for treatment are reduction of the amount of food and oxidation of the fat already stored. Persons who have a tendency to corpulency should be warned in time. To reduce weight we have the Banting, Ebstein, Schwenninger, and Oertel systems (see Nutrition and Diet). The latter regulates diet and gives attention to the heart and circulation by systematic exercise, and is as follows:

Oertel recognizes two classes of cases: 1. Corpulency without respiratory and circulatory disturbance. 2. Corpulency with respiratory and circulatory disturbance. The oxidation of fat in the body is accomplished by massage, exercise in a gymnasium or in the open air, walking, mountain climbing, cycling, horseback riding, rowing, using the punching bag, playing tennis, etc. Turkish baths may be used, also the purgative waters of Carlsbad, Marienbad, Vichy, and Kissengen or their salts. Liquids should be restricted and none taken with a meal. Turkish baths and violent exercise are contraindicated when the heart is damaged, as in the second class of cases. Walking is the best exercise, and climbing must be done gradually (terrain cure of Oertel).

Thyreoid treatment, probably by increasing oxidation, has given good results in a number of cases of obesity. From 3 to 5 grains of the dry powdered gland may be given three times a day. Should palpitation and disturbance of the cardiac rhythm supervene, its use must be stopped, but dieting and exercise should be continued.

SPECIMEN DIET IN OBESITY

A. M.-Six ounces of coffee or tea, 3 ounces of bread.

Noon.-Eight ounces of meat or fish of any kind, salad, vegetables, 2 ounces, fruit, 3 to 6 ounces, bread or pudding, 3 ounces; wine for those who are accustomed to it, but no beer.

Evening. Two eggs, 4 ounces of ham or raw meat, bread, cheese, salad, fruit, tea or coffee.

Water is to be taken between meals. The diet should be generous as to variation. The menu should be liberal in quality, but the quantity

should not exceed 2,000 calories. One should eat one third less than under ordinary circumstances and not attempt to reduce fat by a special kind of food. The same rule holds good for children. In corpulency with the muscles or valves damaged, and as the consequence, congestion in various organs or arteriosclerotic changes, the greatest care must be taken in advising exercise. The physician must feel his way, so to say, and not force the patient into a regimen which may bring him into danger from bursting of a capillary vessel or from acute dilatation of the heart. Good common sense will direct the management, which can only be outlined in the absence of a specific case.

The total daily amount of water should be limited to from 36 to 48 ounces (including tea, coffee, and wine), except in very hot weather, when more can be taken. Sweets of all kinds are to be avoided as much as possible.

CHRONIC DEGENERATION OF THE HEART MUSCLE NOT DUE TO

VALVULAR DEFECTS

Various terms are used to designate such condition, viz.: Senile heart, gouty heart, syphilitic heart, myocarditis with constant arrhythmia, fatty degeneration, fibroid heart, etc.

Any acute infection, such as diphtheria, typhoid or rheumatic fever, scarlatina, etc., may be the starting point of the chronic inflammatory process in the heart muscle. Chronic infections, such as syphilis and malaria, are causative factors; and gout, diabetes, atheroma, alcoholism, pernicious anæmia, chronic intestinal putrefaction, toxæmia, and overwork are frequent causes. In fact, any nutritional change which blocks up the blood supply of the heart may result in softening and degeneration of the heart walls. The chronic form generally supervenes upon sclerosis of the coronary arteries. They are terminal arteries, and become blocked with a gradual onset.

Anatomically we observe induration, softening, calcareous, hyaline, fatty, and amyloid degeneration with general or localized dilatation. Clinically we cannot distinguish one form of degeneration from the other, their symptoms being alike.

Symptoms of Muscular Degeneration of Whatever Nature.-Dyspepsia; palpitation; præcordial distress; arrhythmia; anginoid, syncopal, apoplectic, or epileptoid attacks; a short, unsustained, rapid, or regular or irregular pulse; cold extremities; dropsy; and great weakness. The heart eventually dilates, and a murmur may be heard, due to ventricular dilatation. Sudden death after a full meal is not infrequent.

The area of the heart dulness may be normal unless degeneration has affected a hypertrophic heart. Attacks of aphasia often present themselves when sclerosis is present.

Prognosis. We cannot cure this condition, but by careful management we may prolong life for an indefinite time. A person with myocarditis. may drop dead suddenly or live for many years.

THE SENILE HEART AND ARTERIOSCLEROSIS

In late life and without any history of previous disease the heart is often found enlarged, and an active or relative weakness of the myocar

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dium is the origin of the symptoms of the senile heart, such as præcordial anxiety, unstable action, weak impulse, intermission of the beat, subjective throbbing (which may be physical or emotional), cardiac asthma with and without exertion, tremor cordis, fluttering, loss of appetite, fainting, a feeling of weakness, albuminuria, and a feeling of insecurity.

Senile diseases are always degenerative and tend to abridge the natural term of life, and our object is to relieve symptoms and check decadence. Senile cardiac failure is based upon impaired metabolism.

cure.

Heart Insufficiency due to Syphilis belongs to the group. There are no special pathognomonic symptoms in heart syphilis; early symptoms. are not pronounced. Its prevention is more readily accomplished than its When the usual subjective symptoms bring the patient to the physician and anamnestic data point to an underlying syphilis as a causative factor of myocardial weakness, an antiluetic regimen must be instituted. It is in this class of cases that potassium iodide is powerful for good. As the heart's action is increased and depressed by nervous influence, it is unwise to worry the patient by keeping him constantly under strict supervision.

Principles of Treatment of the Various Forms of Chronic Muscular Degeneration.—The patient must be moderate in eating, drinking, and exercis

ing.

No special diet is necessary (except in obesity). The food should be plain and whatever the patient may like, except Swiss cheese, pork (lean) ham allowed), roast goose and duck, fatty sausage, pastry, rich dishes, hard vegetables, cabbage, sauerkraut, peas, white beans, string beans, and lentils. Beer should be forbidden as apt to produce flatulence and indigestion. There should be five hours between meals, and the main meal should be in the middle of the day. Fluids should be taken sparingly between meals. A little whiskey in water is rather beneficial. Ginger ale is a good drink. Five to ten drops of dilute hydrochloric acid in water after meals will aid digestion. The patient may rest before and after eating. A mild smoke is not objectionable. The bowels should move daily. General massage is advisable. Venesection is often of great value. A warm, cleansing bath may be taken as often as necessary. Iodide of potassium is indicated in syphilitic myocarditis. The indications for heart drugs are discussed under Valvular Heart Disease.

VALVULAR HEART DISEASE

The heart is liable to functional and structural derangements, many of which can be recognized clinically, and among the latter the valvular defects play an important rôle.

A valvular defect is of accommodative importance. A derangement in the mechanism of the cardiac valves places an obstacle in the way of the outward flow of blood. To maintain the circulation under these conditions, the heart necessarily enlarges by hypertrophy of the myocardium. As a sequel and correction of valvular insufficiency or obstruction Nature furnishes us with compensatory hypertrophy of the heart muscle, but muscular degeneration and dilatation manifest themselves earlier in the damaged heart than in the strong heart, and shorten the tenure of life. The action of the

heart is increased and depressed by nervous influence; worry and anxiety act unfavorably upon the heart and particularly upon a damaged heart; therefore, don't worry the patient by keeping him continually under strict supervision and treatment.

The various valvular defects do not influence or disturb the circulation in a like manner, but clinically this is more of prognostic than therapeutic import. We have no separate treatment for the individual sets of valves, and an exact valve diagnosis cannot always be made, nor is it absolutely necessary as regards treatment. Treatment really begins when the hypertrophic heart muscle becomes insufficient and the heart is unable to empty itself.

The estimation of valvular insufficiency or obstruction as a problem. of hydrostatics is easier than the estimation of the loss of elasticity of muscle or the reserve power of the heart. The prognosis as to tenure of life in cardiac disease is therefore somewhat uncertain.

Signs and Symptoms of Valvular Lesions

Aortic Stenosis.-Systolic murmur in the aortic area at the right edge of the sternum, in the second or third space, is transmitted upward to the right sternoclavicular articulation or may be heard along the right edge of the sternum lower down; occasionally it is accompanied by a thrill, particularly if it follows rheumatic fever. Functional systolic murmurs in this region are also heard in anæmia, in anamic individuals convalescent from acute illness; in impaired flexibility of a valve without stenosis in middle age, and in dilatation of the aorta just above the valves.

The DIAGNOSIS will depend upon the history, the aspect, the age, and the absence or presence of concomitant symptoms. A loud murmur indicates strong ventricular action. In actual obstruction we observe cardiac hypertrophy and deranged circulation, and a low and forcible apex beat, the pulse wave being long and slow and the pulse small. In actual obstruction of the aortic valve the mitral valve may suffer severe strain and become incompetent, which is a downward step in the evolution of the disease.

The PROGNOSIS is not so serious as in aortic incompetence, but more serious than in mitral incompetence. Sudden death from it is improbable.

Aortic Incompetence.-A diastolic murmur in the aortic area is sometimes heard in the third left space and may be conducted downward to the apex. There is violent arterial pulsation, particularly in the carotid and brachial arteries. Pulsatile reddening of the skin is noticed when a red patch on the skin is brought out by friction. Capillary pulsation is also noticed from various causes, producing a low tension pulse. The pulse is a collapsing water hammer pulse (Corrigan), and has a peculiar double beat. In advanced cases the pulse is irregular and the aortic second sound, if looked for over the carotid in the neck, is absent. Concomitant stenosis modifies the pulse signs. There will be in addition to hypertrophy, dilatation of the left ventricle, with a marked apex beat displaced downward and to the left and lifting of the chest wall. Other symptoms are breathlessness, syncopal attacks, anginal attacks, and præcordial pain. Sudden death is apt to occur. Mitral regurgitation may coexist.