Symptoms And Signs Of Cardiac Disturbance


Categories: Uncategorized
Sources: 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

disturbance.



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

through.



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

necessary.



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.





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