Digitized by the Internet Archive in 2008 with funding from IVIicrosoft Corporation http://www.archive.org/details/causesofheartfaiOOroberich HARVARD HEALTH TALKS THE CARE OF CHILDREN BY JOHN LOVETT MORSE PRESERVATIVES AND OTHER CHEMICALS IN FOODS: THEIR USE AND ABUSE BY OTTO FOLIN THE CARE OF THE SKIN BY CHARLES JAMES WHITE THE CARE OF THE SICK ROOM BY ELBRIDGE GERRY CUTLER THE CARE OF THE TEETH BY CHARLES ALBERT BRACKETT ADENOIDS AND TONSILS BY ALGERNON COOLIDGE AN ADEQUATE DIET BY PERCY GOLDTHWAIT STILES HOW TO AVOID INFECTION BY CHARLES VALUE CHAPIN PNEUMONIA BY FREDERICK TAYLOR LORD NEW GROWTHS AND CANCER BY SIMEON BURT WOLBACH THE CAUSES OF HEART FAILURE BY WILLIAM HENRY ROBEY HARVARD HEALTH TALKS HARVAED HEAL'te'tALK^ ••••''•' THE CAUSES OF HEART FAILURE BY WILLIAM HENRY ROBEY ASSISTANT PB0FES80B OP MEDICINE IN HABVABD UNIVEBSITT VISITING PHYSICIAN TO THE BOSTON CITY HOSPITAL ^ CAMBRIDGE HARVARD UNFS^ERSITY PRESS LONDON: HTJMPHBEY MILFORD OXrOBD UNIYKBaiTY PBSBS 19^^ ^^" .^^^ COPYRIGHT, 1922 HABVABD tJNIVERSITT PRESS HARVARD HEALTH TALKS PRESENTING the substance of some -*• of the public lectures delivered at the Medical School of Harvard Univer- sity, this series aims to provide in easily accessible form modern and authorita- tive information on medical subjects of general importance. The following committee, composed of members of the Faculty of Medicine, has editorial supervision of the volumes published: EDWARD HICKLING BRADFORD, A.M., M.D., Dean of the Faculty of Medicine, and Professor of Orthopedic Surgery, Emeritus. HAROLD CLARENCE ERNST, A.M., M.D., Professor of Bacteriology. WALTER BRADFORD CANNON, A.M., M.D., George Higginson Professor of Physiology. 4H0i!? THE CAUSES OF HEART FAILURE THE CAUSES OF HEART FAILURE SEVERAL years ago newspapers throughout the country amused themselves with jests about deaths from heart failure. They were not untimely, for it was obvious to the layman that in the last analysis the patient had died of heart failure. It was clear that if a man's heart stopped beating his life would cease, no matter what the underlying cause might be. It is, and always has been, quite unscientific for physicians to give "heart failure" as a cause of death. Many years ago registrars refused to ac- cept from physicians a death certificate in which "heart failure " was given as the cause. In 1910 the Federal Government issued the Physicians' Pocket Reference to the International List of Causes of Deaths on the flyleaf of which was the following HARVARD HEALTH TALKS quotation from Dr. Charles V. Chapin, superintendent of health in Providence, Rhode Island: ''The registration of vital statistics is the firm basis on which the whole structure of sanitary science and practice must rest. In order to learn the laws of disease, to devise remedies and test them, we must have approxi- mately accurate knowledge of the move- ment of population and of the causes of death." In signing a death certificate the best trained physicians have not within the lifetime of many of us given such a meaningless cause. Notwithstanding all this, the term "heart failure" has re- mained in medical parlance where it has a perfectly good place if its significance is understood. To the mind of the intelli- gent physician the expression "heart failure" never means the death of the heart — that is too obvious. It means that the heart is failing to do its work and that brings us to the consideration of our subject — the causes which make 10 CAUSES OF HEART FAILURE the heart fail. That is what Dr. Chapin meant when he said that in order to learn the laws of disease and to devise remedies we must have an approximately accurate knowledge of the causes of disease. If we are to prevent heart disease we must be alive to its causes and so greatly lessen the affections of this vital organ. Structure and Mechanism OF THE Heart Let us look for a moment at the heart and consider its structure and work. It is a somewhat conical body placed in the anterior portion of the thorax behind the sternum or breast bo;ne, lying almost in the median line, rather more to the left than the right. Its apex hangs down- ward and backward and rests upon the diaphragm, the large muscular division which separates the thoracic from the abdominal cavity. Its base is at the third rib where it is held firmly in place and where the great veins enter and the 11 HARVARD HEALTH TALKS aorta is given ojff. The heart may be said to be in two main divisions which we speak of for convenience as the right and left heart. Each side is again divided into two parts, the auricle and ventricle. The right auricle receives the blood from the great veins, passes it through the right auricular-ventricular opening into the right ventricle from which its back- ward flow is prevented by the tricuspid valve. The right ventricle contracts and drives the blood through the pulmonary artery into the lungs and thence through the pulmonary veins into the left auricle from which it passes through the left auricular-ventricular opening into the left ventricle. When the left ventricle contracts, the blood is forced into the aorta and thence through the body. Its backward flow into the auricle, when the ventricle contracts, is prevented by the closure of the mitral valve. After the blood has entered the aorta, it is prevented from returning to the left ven- 10 CAUSES OF HEART FAILURE tricle by the immediate closure of the aortic valves. This wonderfully adjusted piece of mechanism works in health with perfect regularity, the auricles contract- ing on the average 72 times per minute to be immediately followed by 72 contrac- tions of the ventricles. Each auricular contraction is followed by a ventricular contraction in rhythmic sequence. The ^ heart is a muscular organ and the thick- ness and strength of the walls of its chambers vary with the work required of them. Because it takes much more force to drive the blood through the body than through the lungs, the thickness and strength of the left ventricular wall is about four times greater than the right. Since it is a muscle, it must, like all other muscles, be nourished with blood and this is accomplished by the coronary or crown artery which is given off from the aorta and divides into two branches, one to the right and the other to the left. The two main branches again divide into 13 HARVARD HEALTH TALKS many smaller branches, the whole struc- ture resembling a great tree. The heart is enclosed in a serous sack, the pericar- dium, the surfaces of which lie in appo- sition with about an ounce and a half of serum quite evenly distributed between the surfaces to act as a lubricant. All of the structures of the heart may be the seat of disease, singly or in varying com- binations, the muscle {myocarditis), the valve and valve openings {endocarditis) , the pericardium {pericarditis) and the cor- onary arteries {coronary disease; arterio- sclerosis). The heart muscle supplies the force which maintains the flow of blood through the lungs and through the body. In the normal circulatory mechanism all parts are so adjusted that the work of the heart is facilitated and any disturbance in any part of the heart or in other or- gans increases the work of efficiently maintaining the circulation and eventu- ally leads to overwork and failure of the 14 CAUSES OF HEART FAILURE heart. So long as the heart can over- come the effects of disease and maintain the circulation normally no symptoms are evoked, but when too great a strain is put upon it signs of fatigue and failure appear. No matter what the cause, the result is always embarrassment and fi- nally exhaustion of the heart. The Commonest Forms of Heart Disease 1. The Arteriosclerotic Heart The arterio-sclerotic heart is some- times spoken of as the ''old-age heart." With hardening of the arteries through- out the body, the coronary arteries gen- erally become involved, the circulation of the heart is impeded and the muscle undernourished. The person becomes breathless with any slight exertion, fa- tigues easily and may have pain in the region of the heart or a sensation of pres- sure about the root of the neck as though 15 HARVARD HEALTH TALKS the throat was compressed. The pain may shoot down the arm into the fingers or there may be tender points on pres- sure over the heart area. The occlusion of a large branch of the coronary artery is a frequent cause of sudden death in an ojd person. An old gentleman who had always been vigorous noticed that he be- came breathless with exertion and often had attacks of acute indigestion. He was treated by a physician for "stomach trouble" without relief. Upon examina- tion evidences of a moderate degree of arterio-sclerosis were found with some increase in blood pressure. By limiting his activities and requiring him to take frequent rest periods his indigestion ceased and he felt as well as before. As chaplain of a Grand Army Post, he was impelled to conduct the funeral services of a comrade but the effort was too great, he collapsed and was carried home. A few days of rest made him feel as well as ever and he was advised to avoid emo- 16 CAUSES OF HEART FAILURE tional as well as physical strain. Some two weeks later he became involved in an altercation with a man on his place, fell to the ground and died before the phy- sician who was summoned could reach him. It should be remembered that emotional strain is often as great a factor in overtaxing the heart as physical work. The physician realizes this when he treats the overworried business man with an- gina pectoris. The physician may be misled by the absence of any marked abnormal signs in the heart and circulation of a middle- aged or elderly individual. There will, however, usually be some found if the search is thorough. The history is of great importance. Pain about the heart in the elderly should always be taken seriously and the patient's response to effort carefully studied. Persons of all ages may have pain which may or may not be due to cardiac disease. Children sometimes 17 HARVARD HEALTH TALKS suffer from pain in the cardiac area caused by overeating, indigestion or con- stipation. It may be due to valvular disease of the heart, such as mitral ste- nosis or aortic regurgitation. In the first instance a correction of the digestion and habits of eating will remove the symp- tom, while in the latter the physician recognizes it as one of the signs of struc- tural damage resulting from some infec- tious disease. Certain nervous condi- tions such as neurocirculatory asthenia (effort syndrome; soldier's heart) cause heart pain. In this condition there is no organic disease of the heart. The exces- sive use of tobacco is another cause of pain known as "tobacco angina." Why it occurs in one person and not in an- other is unknown unless the theory that it attacks those with some underlying or- ganic basis be tenable. Usually the ces- sation of tobacco for a few weeks will remove the pain. 18 CAUSES OF HEART FAILURE Breathlessness coming on with any slight exertion is very important, espe- cially if it occurs when the individual is sitting quietly or is awakened at night with a smothering sensation. Fatigue in a person who states that his usual walk can no longer be taken with- out undue weariness should not be over- looked. We do not ask the physician to take towards his patient the attitude of the illiterate police magistrate who summed up each case in this wise: "When I look at the prisoner in the dock, I says to my- self, well, if he hadn't done something he wouldn't be there, so I finds him guilty," — but we do ask the physician to weigh the evidence carefully before beginning treatment. He must answer the ques- tion — can the patient "carry on" .^ Let me give two examples of what we mean by failure to "carry on." A pa- tient, for thirty years a railroad engi- 19 HARVARD HEALTH TALKS neer, was accused by the legal depart- ment of sleeping in his cab between sta- tions. He was taken from his engine immediately to the office of the medical examiner who found a very high blood pressure but practically no other signs. In three days of rest his pressure dropped to normal and in two or three weeks he was allowed to resume work but with the same result. Another and longer rest period was taken and he was then given a freight engine, possibly with the idea of greater safety, but all to no purpose. The man was highly indignant when de- moted to a yard job, but three months later when entering the yard gate he fell dead. The heart and circulation could no longer stand the nervous strain of en- gine driving. Fortunately, the regular examination of engineers greatly elim- inates this danger. A well nourished middle-aged business man had carried out the same routine for nearly thirty years. Every morning he walked about 20 CAUSES OF HEART FAILURE two blocks up an incline to the street- car, but for two years had noticed that he could not do it without breathless- ness. One morning he ran for his car, collapsed and was in his bed when he recovered consciousness. His physician could find very few signs of heart dis- ease, but because of his history had urged a change in his mode of life. The patient absolutely refused to heed the warning and two weeks later had an- other collapse in which he died. This was the result of undue physical strain on a damaged heart. 2. The Rheumatic Heart The rheumatic heart includes damage by rheumatic fever, chorea, tonsillitis, and scarlet fever. These diseases have the power of attacking all or any one of the structures of the heart. It is impor- tant for the physician to inspect the heart carefully during the course of the disease to discover the onset of lesions 21 HARVARD HEALTH TALKS which will later, if not guarded against, cause impairment. After an acute infec- tion has ceased, it is necessary for the patient to be seen at regular intervals because there are some lesions which do not appear immediately. The heart may seem to be normal for a time, but later the evidence of damage presents itself. This is particularly true of the condi- tion known as mitral stenosis — one of the greatest dangers of acute rheumatic fever in young people. Chorea or Saint Vitus Dance has often been classed and treated as an entity, but is, in the opin- ion of some of us, merely a part of the symptom complex of acute rheumatism. When present, even if unaccompanied by other signs, it should not be dismissed without a thorough sea^rch for foci of infection. Since acute articular rheumatism (rheu- matic fever) often causes heart disease and tonsillitis is frequently followed by rheumatism and cardiac disease, the im- 22 CAUSES OF HEART FAILURE portance of removing diseased tonsils is evident. Not every person with enlarged tonsils requires tonsillectomy (removal by operation), but an operation should be performed if there are repeated attacks. Persons with rheumatism or rheumatic heart disease should have their tonsils thoroughly inspected by a competent laryngologist. In this way only can re- currences be prevented, the heart saved or additional damage avoided. The small "buried" tonsil is often more danger- ous than the large one. Recently a new method of destroying the lymphoid tissue of the tonsil by the application of radium or the X-ray has come into use. The shrinking of the tonsil is quite marvelous even with one treatment, but time alone wfU prove the value of the procedure. Unless the method absolutely prevents re-infection it is useless and waiting is sometimes very dangerous. Dr. Alexander Lambert of New York states that the number of cases of acute 23 HARVARD HEALTH TALKS rheumatism in the Bellevue Hospital has diminished in recent years and attributes this improvement to the care of the noses, throats, and teeth of the school chil- dren. In Boston, acute rheumatism is not the common disease it was twenty- five years ago. Potential Heart Disease Potential Heart Disease is a term which has been used recently and means that a person who has recurrences of any infection (tonsils, teeth, sore throats, rheumatism, etc.) is in danger of cardiac involvement. His heart may escape during the first and second infections, but with the third it may be involved. Hence the importance of removing the sources of danger before it is too late. A young girl has had two rather severe attacks of tonsillitis and as far as we can see the heart has not been affected. We have strongly urged the removal of the tonsils, but operation has been refused. 24 CAUSES OF HEART FAILURE At any time a third attack may come and if heart disease should result we would all be regretful, but it would then be too late. Pericarditis Sometimes only the valves are af- fected, but often the valves, muscle, and pericardial sack are involved giving what is called a pancarditis. The recognition by the physician of the appearance of pericarditis during the course of an acute infection is of great importance, since it may be the only evidence at the time of a pancarditis and may warn the phy- sician to search for other lesions then and later. 3. The Syphilitic Heart The late Sir WiUiam Osier said, ''It is to be remembered that syphilis is common in the community and there are probably more families with a luetic than a tubercular taint." This 25 HARVARD HEALTH TALKS is a sad commentary knowing as we do that syphilis is a preventable dis- ease. Its effect upon the heart may be acute or chronic and its progress insidi- ous. The parasite of syphilis attacks the heart muscle and more particularly the aorta and aortic valve. Regurgi- tation of blood through the aortic valve in a child is often the result of rheumatic infection, but in a middle-aged man it is frequently due to syphilis. Ten to twenty years after the initial lesion the syphilitic heart gives its first sign of distress, incapacitates the sufferer, and closes a life which should halve seen twenty to thirty years more of useful- ness. Much has been done to prevent syphilitic cardiac disease by early diag- nosis of the initial lesion and prompt, thorough, and repeated treatments but, notwithstanding, some do not escape. Is it any wonder that the United States Public Health Service and other organi- zations are doing all in their power to 26 CAUSES OP HEART FAILURE stamp but this menace by various educa- tional methods ? Jf.. Other Infections Pneumonia, typhoid fever, tubercu- losis and certain obscure infections affect the cardiac structures, but this is chiefly a medical problem of interest during and immediately after the course of the dis- ease. 5. Nervous Influences Certain nervous disorders increase the cardiac rate as hyperthyroidism (goitre) and neurocirculatory asthenia (soldier's heart). This becomes important when the condition persists for a considerable period of time by fatiguing the over- worked heart muscle. 6. Blood Pressure Any condition which produces a con- stantly high blood pressure as in kidney disease or arterio-sclerosis. 27 HAHVARD HEALTH TALKS 7. The Athlete's Heart We are often asked by anxious parents if school and college games injure the heart. The experience of those who have seen large numbers of college athletes is that even strenuous exercise rarely injures the heart, provided the athlete begins with a normal heart and is grad- ually trained. The collapse at the end of a contest is more often nervous than muscular. Irregularities of Heart Action Children often have normally an ir- regular action of the heart known as ** sinus arrhythmia." It will be noticed when the child breathes deeply or cries that the pulse becomes irregular yet he can play without undue fatigue. There is no lack of cardiac response to ef- fort. All other irregularities have, with certain exceptions, some pathological significance and should be thoroughly 28 CAUSES OF HEART FAILURE investigated. Extra beats of the heart may occur at all ages and are not always important if inconstant. In old persons in apparently good health they are quite common. Prevalence of Heart Disease Heart disease has become a greater cause of death than tuberculosis. In New York for ten years it has been re- sponsible for 200 deaths in every 100,Q00 of the population, while in 1920 tubercu- losis caused 126 deaths in every 100,000. In 1919 the death rate from organic heart disease was 181 per 100,000 of the popu- lation of Massachusetts. It is not a rapidly fatal condition as many people suppose, but one which usually means years of suffering and dis- ability. Most of the sudden deaths occur in old i>eople. Even when the end is un- expected, premonitory signs have fre- quently been present waiting for recog- nition. The economic waste from heart 29 HARVARD HEALTH TALKS disease in the United States is tremen- dous and therefore the great problem of prevention, early diagnosis, and relief appeals not only to physicians but to the general public. The crusade which has been going on for years against tuber- culosis by various organizations, the in- struction of patients in sanatoria and the appreciation of early diagnosis and proper protection against infection by physicians has made the disease so fa- miliar to the country at large that the dreaded '* Great White Plague" has steadily diminished. When the public realizes that [heart disease is prevent- able by early recognition of its causes, a great step will have been taken in ad- vance. The stress of modern life will continue to tax the circulatory system and old age will probably close in many instances with coronary disease, but this result can be greatly delayed by proper living and freedom from infectious dis- eases in early life. Our greatest hope is so CAUSES OF HEART FAILURE for the children. Much has been written about treatment but more must be said and written about prevention. One of the largest fields today for preventive medicine is the instruction of the public in the importance of thoroughly under- standing the causes of infections which involve the heart. For this purpose sev- eral large cities now have associations of physicians and laymen. Their meetings are open to all interested people and their transactions are reported in the daily press. In Boston there is the Association of Cardiac Clinics which holds meetings four times a year. The public schools have the throats and teeth of their pupils inspected. There is now an organized movement to carry instruction to all parts of the country. Diagnosis The diagnosis of heart disease can be made only after all methods of examina- tion have been employed. The examina- 81 f HARVARD HEALTH TALKS tion must be thorough and frequently re- peated. The stethoscope, X-ray, blood pressure apparatus, polygraph, and elec- trocardiograph all contribute findings of varying importance in arriving at a final interpretation of the physical signs. No instrument of precision will give all the necessary information. A normal elec- trocardiogram, for example, would not convince the experienced physician of the absence of disease if other striking physical signs were present. In old peo- ple there may be very few objective symptoms but a history of pain, breath- lessness, and undue fatigue will often aid in diagnosis. Some years ago a great deal of atten- tion was paid to heart murmurs, but later it was found that to be significant they must be associated with other physical findings. Children sometimes had mur- murs which were unimportant, but as Sir James Mackenzie pointed out several years ago their activities were needlessly 82 CAUSES OP HEART FAILURE limited. A career has been ruined be- cause too much has been made of a mean- ingless murmur. A healthy child who can play as hard as his fellows without abnormal fatigue may generally have his murmur disregarded if other physi- cal signs are absent. We have all seen people who have gone about for years in fear because at some period in their lives a murmur had been discovered. So the physician must be able to distinguish be- tween functional and organic heart dis- ease. Some forms of heart affections, as regurgitation at the aortic valve, may exist for years without giving subjective symptoms. Near the close of the World War the British Medical Journal reported the case of a captain of infantry who had seen active service at the front for three and a half years and was, in addition, the director of athletics in his area. This offi- cer carried on during all that time with aortic regurgitation which was not dis- covered until his heart failed suddenly 33 HARVARD HEALTH TALKS and he was sent to the rear. Probably in the haste of mobilization his lesion was overlooked by the examining board. Treatment It is clear that prophylaxis and the recognition of potential heart disease come first by the removal of foci of infec- tion such as diseased tonsils, the care and possible extraction of carious teeth, the X-ray examination by an exj>ert of the teeth in doubtful cases especially the sealed or crowned tooth, the prevention of acute rheumatism and thorough pro- tection against infectious diseases, the establishment of a proper diet with good digestion, and the best hygienic meas- ures. While of the utmost importance in prevention their danger is not les- sened by the detection of a heart lesion, because foci of infection if allowed to continue add to the damage. The prev- alence of syphilis should be borne in mind and its detection in adults should 34 CAUSES OF HEART FAILURE be made by the Wassermann test. The recognition of unsusj>ected syphiKs may save a man from its serious cardiac se- quelae in after years. Thorough routine physical examinations of apparently healthy people should be made at rea- sonable intervals. In this way latent causes and early circulatory diseases will be detected. We have our watches and automobiles regularly overhauled, but we allow our bodies to go until they break. The dentists have outstripped the physicians in this respect by insisting on regular inspection of the teeth. The dental patient receives notice of an ap- pointment twice a year which he keeps knowing that the early recognition of decay will save his teeth, health, and mqney. Why do not all physicians have such an arrangement with their regular patients? Fortunately, the public is learning the importance of these pre- cautionary examinations and is more and more demanding them. Some per- 35 HARVARD HEALTH TALKS sons derive great comfort by belonging to companies which examine the urine at stated intervals. Such an examina- tion may or may not reveal the presence of kidney disease; it will very rarely dis- close a damaged heart. An examination of the heart, however, will, if such exist, reveal cardiac abnormalities and may in- dicate the possibility of kidney involve- ment. An intelligent business man once told me with a good deal of satisfaction that he sent his urine twice a year to a laboratory and received reports for which he paid ten dollars. A young colleague thought well of the idea and they formed the plan of combining their urines in the same container and, inci- dentally, sharing the expense. When I asked him what he would do in the case of a positive finding, he blandly replied that each would seek his own physician to discover the source. Nothing can replace the complete physical examina- tion. Recently the medical director of a so CAUSES OF HEART FAILURE large insurance company informed me that 80 per cent of the rejected appli- cants have the causes of rejection dis- covered first by the medical examiner and not by their physicians as should be the case. We have shown quite conclusively that the best method of treatment is to remove the cause of heart infection in the young and to delay circulatory de- generation in the old, but if disease is detected the medical treatment varies with the cause and degree of involve- ment. Rest is the most important agent in the care of all forms of heart disease and satisfying sleep must be secured. In acute heart disease absolute rest in bed is imperative during and for a consider- able period after the attack. Children are frequently kept in bed for weeks and months until the infection has com- pletely subsided and the heart muscle has recovered its power. In the acute 87 HARVARD HEALTH TALKS stage the patient should not be allowed to make any exertion and should be assisted even when turning in bed. Straining at stool should be avoided by the use of suitable cathartics. The diet should be light and easily digestible. In the febrile stage the farinaceous diet is best. Enough water should be given to relieve thirst and insure a reasonable urinary output. An icebag over the precordia, while it probably has no effect upon the disease, often gives comfort. It should be very light otherwise a bur- den is added to a laboring chest. The patient is assisted in breathing by re- clining upon several pillows. Drugs in the acute stage are indicated by the character of the infection. Sleep may be secured by various hypnotics such as the bromides and veronal. Co- deine and morphia are perhaps the best for quieting the heart and giving sleep in the more severe cases. 88 CAUSES OF HEART FAILURE Chronic Heart Disease Certain forms and conditions of chronic heart disease do not require medication but merely a sensible direction of the patient's life. All sources of possible local infection should be treated such as diseased tonsils, adenoids, pyorrhea, and infected teeth. Discretion must be used, however, in estimating the importance of these conditions. Cardiac patients must be careful about head colds and attacks of bronchitis, and such intercurrent af- fections should be treated with dispatch and thoroughness since they tend to throw added work on the heart. If the physician has assured himself that the patient has organic heart dis- ease he should secure his cooperation by a simple and tactful explanation of the true nature of the condition. The pa- tient may be temporarily disturbed by the information, but he will quickly ad- 39 HARVARD HEALTH TALKS just himself to it and will thereby add greatly to his life and comfort. Exercise. Muscular work increases the heart rate and raises the blood pres- sure, but it also improves the circula- tion. Moderate physical exercise gives a greater supply of fresh air, increases the pulmonary expansion, benefits the diges- tion, and causes a healthier action of the skin, thereby improving the circulation and the general health. It is diflScult to control the activity of children, but by watching the effect of reasonable exer- cise and not exaggerating the dangers of occasional excesses they will be in better condition physically than those who be- come nervous and apprehensive by con- stant repression. Games which require hard physical work should not be al- lowed. In adult life the same rules obtain. Walking, riding, and light games may all be indulged in provided they do not produce the signs of cardiac overwork. 40 CAUSES OF HEART FAILURE Occupations which give ordinary exer- cise need not be changed. A sedentary life results in poor pulmonary expansion and defective digestion. Rough manual labor or work producing great fatigue should be abandoned. Diet, The diet should be plain and composed of articles which are known to be easily digested. The meals should be taken regularly and eating between meals avoided. The weight should be watched and the diet regulated accord- ingly. Overweight, especially when due to fat, throws more work on the heart muscle. Moderation in all things must be the rule in cardiac disease. Consti- pation should be carefully avoided. Drugs. In chronic cardiac affections, digitalis in its various forms is our greatest aid. In many early cases it is unnecessary. When, in suitable cases, digitalis fails it may be due to a poor preparation, insufficient dosage or a too 41 HARVARD HEALTH TALKS advanced stage of the disease. In recent years much effort has been made to se- cure potent digitalis and the physician should be careful to obtain a reliable preparation. He must watch its action and regulate the amount accordingly. It acts by slowing and strengthening the heart. The circulation is improved and dropsy, when present, relieved. Several years ago it was discovered that quinin could occasionally abolish an absolute irregularity of the heart action, and its use in the form of quinidin sulphate has added an important drug to the list of cardiac remedies. It cannot be used with the same ease as digitalis but only in carefully selected cases under close and competent observation. Since gross ir- regularity of the heart is a common sequel of several of its diseased condi- tions, it is obvious that any drug which will restore normal rhythm is of great value. It is necessary, however, that further study should be given by physi- 42 CAUSES OF HEART FAILURE cians before the drug passes into com- mon use, and it is quite possible that this stage will never be reached, but will be limited to certain cases which the cardi- ologist considers favorable. The various hypnotics are useful as already stated, and morphia is of great help to the chronic cardiac patient with marked failure of the heart muscle. In the anginal type of heart disease nitroglycerin and sodium nitrite are valu- able agents. Pearls of amyl nitrite should be carried by the patient to relieve an attack of angina pectoris. The patient with any form of recog- nized heart disease should not attempt to regulate the management of his case, but should consult his physician at regu- lar intervals. The appearance of any symptom which he does not under- stand should be the signal for medical advice. In conclusion let me emphasize the following points: > 48 HARVARD HEALTH TALKS 1. Since disease is best managed in its incipiency, the value of routine physi- . cal examinations is obvious. Even when the individual supposes that he is in perfect health, signs of disease may be evident to the physician and the proper treatment instituted. 2. Early recognition means early treat- ment in which the proper manage- ment of the patient's mode of living is of more value than drugs. Further- more, the removal of other diseased conditions will often prevent added injury to the heart. 3. Many cases of heart disease begin in childhood and youth due to foci of infection and the early eradication of these causes will save many lives. Thorough protection against infec- tious diseases is very essential. 4. The public should fully reaUze the important part which venereal dis- ease, especially syphilis, plays in the causation of cardiac disease. 44 CAUSES OF HEART FAILURE In the majority of cases heart disease does not cause sudden death but means years of inactivity and suffer- ing. Apart from this the economic waste is tremendous. The responsibiHty for the diffusion of knowledge concerning the causes and prevention of heart disease rests with physicians and other qualified per- sons who by individual instruction and public lectures should awaken the community to the means of de- creasing unnecessary suffering and disability. 45 PBINTED AT THE HARVARD UNIVEBSITT PRESS CAMBRIDGE, MASS., U. S. A. RETURN BIOLOGY TO— #> 3503 LIBRARY Life Sciences BIdg. 642-253 LOAN PERIOD 1 ALL BOOKS MAY BE RECALLED AFTER 7 DAYS Renewed books ore subject to immediate recall DUE AS STAMPED BELOW 0y€ — Subject t o Recal l iDfflediate! i I 1C37 UNIVERSITY OF CALIFORN FORM NO. 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