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The first sign of such an illness is a brief and slight attack...
Auricular Fibrillation Pathology
Schoenberg [Footnote: Schoenberg: Frankfurt. Ztschr. f. Patho...
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Water In The Head
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Symptoms And Signs Of Cardiac Disturbance
Source: Disturbances Of The Heart
It is now recognized that any infection can cause weakness and
degeneration of the heart muscle. The Streptococcus rheumaticus
found in rheumatic joints is probably the cause of such heart injury
in rheumatism. That prolonged fever from any cause injures heart
muscle has long been recognized, and cardiac dilatation after severe
illness is now more carefully prevented. It is not sufficiently
recognized that chronic, slow-going infection can injure the heart.
Such infections most frequently occur in the tonsils, in the gums,
and in the sinuses around the nose. Tonsillitis, acute or chronic,
has been shown to be a menace to the heart. Acute streptococcie
tonsillitis is a very frequent disease, and the patient generally,
under proper treatment, quickly recovers. Tonsillitis in a more or
less acute form, however, sometimes so mild as to be almost
unnoticed, probably precedes most attacks of acute inflammatory
rheumatism. Chronically diseased tonsils may not cause joint pains
or acute fever, but they are certainly often the source of blood
infection and later of cardiac inflammations. The probability of
chronic inflammation and weakening of the heart muscle from such
slow-going and continuous infection must be recognized, and the
source of such infection removed.
The determination of the presence of valvular lesions is only a
small part of the physical examination of the heart. Furthermore,
the heart is too readily eliminated from the cause of the general
disturbance because murmurs are not heard. A careful decision as to
the size of the heart will often show that it has become slightly
dilated and is a cause of the general symptoms of weakness, leg
weariness, slight dyspnea, epigastric distress or actual chest
pains. Many such cases are treated for gastric disturbance because
there are some gastric symptoms. There is no question that gastric
flatulence, or hyperacidity, or a large meal causing distention of
the stomach may increase the cardiac disturbance, and the cardiac
disturbance may be laid entirely to indigestion; but treatment
directed toward the stomach, while it may ameliorate some of the
symptoms, will not remove the cause of the symptoms.
If the patient complains of pains in any part of the chest or upper
abdomen, or of leg aches, or of being weary, or exhausted, or of
sleeplessness at night, or of pains in the back of his head, we
should investigate the cardiac ability, besides ruling out all of
the more frequently recognized causes of these disturbances.
If there is more dyspnea than normally should occur in the
individual patient after walking rapidly or climbing a hill or going
upstairs, or if after a period of a little excitement one finds that
he cannot breathe quite normally, or that something feels tight in
his chest, the heart needs resting. If, after one has been driving a
motor car or even sitting at rest in one which has been going at
speed or has come unpleasantly near to hitting something or to being
run into, it is noticed that the little period of cardiac
disturbance and chest tension is greater than it should be, the
heart needs resting.
If the least excitement or exertion increases the cardiac speed
abnormally, it means that for many minutes, if not actually hours
during the twenty-four, the heart is contracting too rapidly, and
this alone means muscle tire and muscle nutrition lost, even if
there is no actual defect in the cardiac muscle or in its own blood
supply. If we multiply these extra pulsations or contractions by the
number of minutes a day that this extra amount of work is done, it
will easily be demonstrable to the physician and the patient what an
amount of good a rest, however partial, each twenty-four hours will
do to this heart. Of course anything that tends to increase the
activity of the disturbance of the heart should be corrected.
Overeating, overdrinking (even water), and overuse or perhaps any
use of alcohol, tobacco, tea and coffee should all be prevented. In
fact, we come right to the discussion of the proper treatment and
management of beginning high blood pressure, of the incipiency of
arteriosclerosis, of the prevention of chronic interstitial
nephritis, and the prevention of cardiovascular-renal disease.
When an otherwise apparently well person begins to complain of
weariness, or perhaps drowsiness in the daytime and sleeplessness at
night, or his sleep is disturbed, or be has feelings of mental
depression, or he says that he "senses" his heart, perhaps for the
first time in his life, with or without edema of the feet and legs,
or pains referred to the heart or heart region, we should presuppose
that there is weakening of the heart muscle until, by perfect
examination, we have excluded the heart as being the cause of such
Although constantly repeated by all books on the heart and by many
articles on cardiac pain, it still is often forgotten that pain due
to cardiac disturbance may be referred to the shoulders, to the
upper part of the chest, to the axillae, to the arms, and even to
the wrists, to the neck, into the head, and into the upper abdomen.
It is perhaps generally auricular disturbance that causes pain to
ascend, but disturbances of the ventricles can cause pain in the
arms and in the region of the stomach. Not infrequently disturbances
of the aorta cause pain over the right side of the chest as well as
tip into the neck. Real heart pains frequently occur without any
valvular lesion, and also when necropsies have shown that there has
been no sclerosis of the coronary vessels.
While angina pectoris is a distinct, well recognized condition,
pains in the regions mentioned, especially if they occur after
exertion or after mental excitement or even after eating (provided a
real gastric excuse has been eliminated), are due to a disturbance
of the heart, generally to an overstrained heart muscle or to a
slight dilatation. Too much or too little blood in the cavity of the
heart may cause distress and pain; or an imperfect circulation
through the coronary arteries and the vessels of the heart,
impairing its nutrition or causing it to tire more readily, may be
the cause of these cardiac pains, distress or discomfort.
Palpating the radial artery is not absolutely reliable in all cases
of auricular fibrillation, or in another form of arrhythmia called
auricular flutter or tachysystole. James and Hart [Footnote: James
and Hart: Am. Jour. Med. Sc., 1914, cxlvii, 63.] have found that the
pulse is not a true criterion of the condition Of the circulation.
There is always a certain amount of heart block associated with
auricular fibrillation so that not all of the auricular stimuli pass
through the bundle of His. James and Hart determine the heart rate
both at the radial pulse and at the apex, the difference being
called the pulse deficit. They use this deficit as an aid in
deciding when to stop the administration of digitalis. When the
pulse deficit is zero, the digitalis is stopped. In this connection
they also find that, even though the pulse deficit may be zero,
there may be a difference in force and size of the waves at the
radial artery. This can be demonstrated by the use of a cuff around
the brachial artery and by varying the pressure. It will be found
that the greater the pressure, the fewer the number of beats coming
Besides the instruments of precision referred to above, more careful
percussion, more careful auscultation, more careful measurements,
roentgenoscopy and fluoroscopic examination of the heart, and a
study of the circulation with the patient standing, sitting, lying
and after exercise make the determination of circulatory ability a
specialty, and the physician who becomes an expert a specialist. It
is a specialization needed today almost more than in any other line
of medical science.
So frequently is the cause of these pains, disturbances and weakness
overlooked and the stomach or the intestines treated, or treatment
aimed at neuralgias, rheumatisms or rheumatic conditions, that a
careful examination of the patient, and a consideration of the part
the heart is playing in the causation of these symptoms are always
The treatment required for such a heart, unless there is some
complication, as a kidney complication or a too high blood pressure,
or arteriosclerosis (and none of these causes necessarily prohibits
energetic cardiac treatment), is digitalis. If there is doubt as to
the condition of the cardiac arteries, digitalis should be given in
small doses. If it causes distinct cardiac pain, it is not indicated
and should be stopped. If, on the other hand, improvement occurs, as
it generally does, the dose can be regulated by the results. The
minimum dose which improves the condition is the proper one. Enough
should be given; too much should not be given. Before deciding that
digitalis does not improve the condition (provided it does not cause
cardiac pain) the physician should know that a good and efficient
preparation of digitalis is being taken. Strychnin will sometimes
whip up a tired heart and tide it over periods of depression, but it
is a whip and not a cardiac tonic. While overeating, all
overexertion, and alcohol should be stopped, and the amount of
tobacco should be modified, there is no treatment so successful as
mental and physical rest and a change of climate and scene, with
good clean air.
Many persons with these symptoms of cardiac tire think that they are
house-tired, shop-tired, or office-tired, and take on a physical
exercise, such as walking, climbing, tennis playing or golf playing,
to their injury. Such tired hearts are not ready yet for added
physical exercise; they should be rested first.
The treatment of this cardiac tire is not complete until the
tonsils, gums, teeth and the nose and its accessory sinuses are in
good condition. Various other sources of chronic poisoning from
chronic infection should of course be eliminated, whether an uncured
gonorrhea, prostatitis, some chronic inflammation of the female
pelvic organs, or a chronic appendicitis.
Longcope [Footnote: Longcope, W. T.: The Effect of Repeated
Injections of Foreign Protein on the Heart Muscle, Arch. Int. Med.,
June, 1915, p. 1079.] has recently shown that repeated, and even at
times one protein poisoning can cause degeneration of the heart
muscle in rabbits. Hence it is quite possible that repeated
absorption of protein poisons from the intestines may injure the
heart muscle as well as the kidney structure; consequently, in heart
weakness, besides removing all evident sources of infection, we
should also give such food and cause such intestinal activity as to
preclude the absorption of protein poison from the bowels.
Next: Classification Of Cardiac Disturbances
Previous: Signs Of Heart Weakness