Simple Dilatation


Categories: Uncategorized
Sources: Disturbances Of The Heart

The term "simple dilatation" may be applied to the dilatation of one

or both ventricles when there is no valvular lesion and when the

condition may not be called broken compensation. The compensation

has been sufficiently discussed. Dilatation of the heart occurs when

there is increased resistance to the outflow of the blood front the

ventricle, or when the ventricle is overfilled with blood and the

muscular wall is unable to compete with the increased work thrown on

it. In other words, it may be weakened by myocarditis or fatty

degeneration; or it may be a normal heart that has sustained a

strain; or it may be a hypertrophied heart that has become weakened.

Heart strain is of frequent occurrence. It occurs in young men from

severe athletic effort; it occurs in older persons from some severe

muscle strain, and it may even occur from so simple an effort as

rapid walking by one who is otherwise diseased and whose heart is

unable to sustain even this extra work. All of the conditions which

have been enumerated as causing simple hypertrophy may have

dilatation as a sequence.



Degeneration and disturbance of the heart muscle and cardiac

dilatation are found more and more frequently at an earlier age than

such conditions should normally occur. Several factors are at work

in causing this condition. In the first place, infants and children

are now being saved though they may have inherited, or acquired, a

diminished withstanding power against disease and against the strain

and vicissitudes of adult life. Other very important factors in

causing the varied fortes of cardiac disturbances are the rapidity

and strenuousness of a business and social life, and competitive

athletics in school and college, to say nothing of the oversmoking

and excessive dancing of many.



The symptoms of heart strain, if the condition is acute, are those

of complete prostration, lowered blood pressure, and a sluggishly,

insufficiently acting heart. The heart is found enlarged, the apex

beat diffuse and there may be a systolic blow at the mitral or

tricuspid valve. Sometimes, although the patient recognizes that he

has hurt himself and strained his heart, he is not prostrated, and

the full symptoms do not occur for several hours or perhaps several

days, although the patient realizes that he is progressively growing

weaker and more breathless.



The treatment of this acute or gradual dilatation is absolute rest,

with small doses of digitalis gradually but slowly increased, and

when the proper dosage is decided on, administered at that dosage

but once a day. Cardiac stimulants should not be given, except when

faintness or syncope has occurred, and if strychnin is used, it

should be in small closes. The heart nay completely recover its

usual powers, but subsequently it is more readily strained again by

any thoughtless laborious effort. The patient must be warned as

carefully as though he had a valvular lesion and had recovered from

a broken compensation, and his life should be regulated accordingly,

at least for some months. If he is young, and the heart completely

and absolutely recovers, the force of the circulation may remain as

strong as ever.



Sometimes the heart strain is not so severe, and after a few hours

of rest and quiet the patient regains complete cardiac power and is

apparently as well as ever; but for some time subsequently his heart

more easily suffers strain.



Chronic dilatation of the heart, However, perhaps not sufficient to

cause edema, slowly and insidiously develops from persistent

strenuosity, or from the insidious irritations caused by absorbed

toxins due to intestinal indigestion. A fibrosis of the heart muscle

and of the arterioles gradually develops, and the heart muscle

sooner or later feels the strain.



It is now very frequent for the physician, in his office, to hear

the patient say, "Doctor, I am not sick, but just tired," or, "I get

tired on the least exertion." We do not carefully enough note the

condition of the heart in our patients who are just "weary," or even

when they show beginning cardiovascular-renal trouble.



The primary symptoms of this condition of myocardial weakening are

slight dyspnea on least exertion; slight heart pain; slight edema

above the ankles; often some increased heart rapidity, sometimes

without exertion; after exertion the heart does not immediately

return to its normal frequency; slight dyspnea on least exertion

after eating; flushing of the face or paleness around the mouth, and

more or less dilatation of the veins of the hands. All of these are

danger signals which may not be especially noted at first by the

individual; but, if he presents himself to his physician, such a

story should cause the latter not only to make a thorough physical

examination, but also to note particularly the size of the heart.



It a roentgenographic and fluoroscopic examination cannot be made,

careful percussion, noting the region of the apex beat, noting the

rapidity and action of the heart on sitting, standing and lying, and

noting the length of time it takes while resting, after exertion,

for the speed of the heart to slacken, will show the heart strength.



Slight dilatation being diagnosed, the treatment is as follows



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

exercise and of all business cares.



2. Reduction in the amount of food, which should be of the simplest.

Alcohol should be stopped, and the amount of tea, coffee and tobacco

reduced.



3. If medication is needed, strychnin sulphate, 1/40, or 1/30 grain

three times a day, acid the tincture of digitalis in from 5 to 10

drop doses twice a day will aid the heart to recover its tone.



Such treatment, when soon applied to a slowly dilating and weakening

heart, will establish at least a temporary cure and will greatly-

prolong life.



If these hearts are not diagnosed and properly treated, such

patients are liable to die suddenly of "heart failure," of acute

stomach dilatation, or of angina pectoris. Furthermore, unsuspected

dilated hearts are often the cause of sudden deaths during the first

forty-eight hours of pneumonia.



Small doses of digitalis are sufficient in these early cases. If

more heart pain is caused, the dose of digitalis is too large, or it

is contraindicated. Digitalis need not be long given in this

condition, especially as Cohen, Fraser and Jamison [Footnote: Cohen,

Fraser and Jamison: Jour. Exper. Med., June, 1915.] have shown by

the electrocardiograph that its effect on the heart may last twenty-

two days, and never lasts a shorter time than five days. They also

found that when digitalis is given by the mouth, the

electrocardiograph showed that its full activity was not reached

until from thirty-six to forty-eight hours after it had been taken.

From these scientific findings it will he seen that if it is

necessary to give a second course of treatment with digitalis,

within two weeks at least from the time the last close of digitalis

was given, the dose of this drug should be much smaller than when it

was first administered.



Owing to our strenuous life, if persons over 40 would present

themselves for a heart and other physical examination once or twice

a year there would not be so many sudden deaths of those thought to

be in good health. It may be a fact as asserted by many of our best

but depressing and pessimistic clinicians, that chronic myocarditis

and fatty degeneration of the heart cannot be diagnosed by any

special set of symptoms or signs. However, it is a fact that a

tolerably accurate estimate of the heart strength can be made by a

careful physician, and if danger signals are noted and signs of

probable heart weakness are present, life may be long saved by good

treatment or management rigorously carried out. The patient must

cooperate, and to get him to do this he must be tactfully warned of

his condition. Many, such patients, noting their impaired ability,

do not seek medical advice, but think all they need is more

exercise; hence they walk, golf, and dance to excess and to their

cardiac undoing.





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