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
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-
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