(A) Errors In Diet

Errors In Diet are as frequent causes of heart symptoms as dyspepsia itself, and although such errors usually cause dyspepsia this is by no means always the case, and heart troubles may be caused by such errors without there being any obvious dyspepsia. It is only necessary to indicate the various ways in which patients do err in order to make the treatment obvious. What has been said above as to hurry, worry, irregularity, etc., should be repeated here, as they are, perhaps, the most common errors. We have also the taking of meals, or drinks, which are too large, too indigestible, too hot or too cold (iced); too much or too little fluid taken, or too great a frequency in meals. Of course, the majority of such errors cause cardiac symptoms by causing dyspepsia, but not all. A stomach which is simply acutely or chronically over-distended will cause some or other of the cardiac symptoms mentioned above : and we have seen very serious symptoms occur as the result of swallowing very hot food, and another case of syncope from taking a big iced drink; both occurring in people with perfectly healthy hearts and without a symptom of dyspepsia. In both these cases the effects were probably reflex, through the nervous system.

The treatment consists wholly in removing the cause and in regulating the diet to suit the particular case.

(B) Abuse Of Drinks And Drugs

We must here consider the treatment of abuse of tea, coffee, alcohol, tobacco, morphia and other drugs.

Tea and coffee can conveniently be taken together. Nothing is commoner than to find some functional disorder resulting from abuse of one or both of these beverages, occurring either with or without dyspepsia. The symptoms are sometimes immediate or may be delayed until some hours after the ingestion. It is quite easy to forbid their use altogether, but such an order is frequently not obeyed, and although it may be necessary in some instances, it is well to try and find a middle course between abuse and abstinence. Tea, taken once a day, can sometimes be borne, when, used more frequently, it causes heart trouble. Similarly very weak tea, or China tea, can often be tolerated when stronger, or Indian, tea causes symptoms. Coffee usually causes less trouble than tea, but some people have a peculiar susceptibility to it. Much the same may be said with regard to its limited use as has been said of tea. In the case of both tea and coffee, they sometimes only cause cardiac trouble when taken alone, whilst they can be borne if taken with food. Wherever they have caused symptoms, they should be used, in future, more as flavourings than taken as beverages in the ordinary way. It is important to remember that tea frequently causes dyspepsia and heart symptoms if taken with a meat meal.

Tobacco

Perhaps there is no more alarming condition with reference to the heart than acute or chronic nicotine poisoning. It has long been recognized that the dose likely to produce harm differs in individuals : that some are very sensitive to even small doses, while others seem practically immune to even large doses of the poison.

Some of these cases are purely functional, entirely due to the abuse of tobacco, whilst others are a combination of old morbus cordis and abuse of alcohol in addition to the nicotine poisoning; for it is not uncommon to find the abuse of tobacco one of the chief hindrances to the establishment of proper compensation in cases of true heart disease. In such cases the heart will be found with irregular and feeble action, often dilated, whilst the patient will complain of many of the symptoms of heart failure, though there is rarely oedema unless the abuse is complicating true heart disease.

Here again we have only to discontinue the use of tobacco to get rid of the symptoms altogether if they are entirely due to tobacco, and to get a marked improvement if the condition is one in which tobacco plays a part only. In most of the cases dyspepsia has also resulted from the abuse, and care will be needed in the management of the diet, with treatment, as well as abstinence from the tobacco.

Alcohol

Abuse of alcohol is a most frequent cause of heart trouble, with or without its usual attendant, dyspepsia. Palpitation, faintness, pain over the precordium, shortness of breath are frequently complained of. Sometimes the patient describes sudden attacks of oppression and distress of breathing, waking him in the night, very much resembling cardiac asthma or even angina pectoris; whilst in the morning he is sick and faint and the pulse is often small, weak and occasionally irregular and rapid. In cases of long standing abuse, myocardial degeneration results with dilatation and cardiac failure with all the signs and symptoms pertaining thereto. There are few cases which are so difficult and unsatisfactory to treat. In many of them the digestion is ruined, the liver diseased and the general health undermined. The question between total abstinence and moderation will have to be considered, but in the majority of such cases nothing short of total abstinence will be of any permanent good. It is not always possible to attain this at once, but it is the goal to be aimed at. There is usually loss of appetite, occasionally sickness and a loathing of food, and one of the great difficulties is gradually to substitute food for the alcohol as it is diminished.

In the worst cases it is far the best course to put them to bed under skilled nursing, because, first, they are often so weak and feeble that they are unable to digest even small quantities of nourishment while up and about and, second, it is the only way of insuring that alcohol is diminished or abstained from as desired. In such cases it will frequently be found that milk, soups, broths or meat extracts are the only forms of nourishment that can be borne, and it may be necessary even to peptonize the milk for a time.

The diminution or total withdrawal of the alcohol habitually taken often necessitates the use of some cardiac stimulant in the shape of strychnine or digitalis - preferably the former - or small, and ever diminishing, quantities of alcohol may have to be returned to for a time. As the power to take food returns these stimulants can be discontinued. In these cases sleep is all important, because it soothes the mental excitement so common in such patients, but also because it gives the heart a much needed rest. It will be necessary, however, to use great care in the exhibition of hypnotics, especially morphia, because of the frequency of the presence of renal disease in such cases. It will generally be found that systematic and good feeding will insure the necessary rest, and it is here that the skilled nurse is so helpful, always being able to do so much more than relations or untrained servants. Later, when the patient has sufficiently recovered, and from the first in those who have never been so ill, exercise and open air are important in order to increase the appetite and general vitality. Finally will come the question " What am I to drink? " The abnormal craving for some "nip," or stimulant between meals has sometimes to be catered for, at any rate for some time, and if tea and coffee can be borne, they are often the best substitutes though, as we have seen, their immoderate use may be attended by cardiac symptoms; and although they constitute a lesser evil, their habitual and prolonged use is not to be advised. With meals, water, milk, barley-water, lemonade and ginger beer are the best, or a light claret, or lager beer, may be allowed in some cases. Highly spiced foods, strong sauces and an excess of meat will often be found useful stepping stones between alcoholic abuse and a more healthy-appetite, and although their habitual use cannot be recommended, they may be found very useful for a time.

Morphia, Chloral And Other Hypnotics, Antipyrin, Etc

The abuse - and in some cases even the use - of these and other drugs may be attended by symptoms of cardiac failure. When the cardiac failure is acutely manifest, appropriate treatment for the poisonous effects of the drug (morphia, e.g.), with the exhibition of stimulants, will be necessary. This is not a question of dietetics; but in mentioning the cardiac symptoms frequently presented by such patients, one must emphasize, from the point of view of treatment, the great importance of food. In most of these cases the taking of proper nourishment has been neglected, and frequently the digestion is wofully deranged by the abuse of the drug. They are often wasted and feeble, and the heart symptoms complained of are often caused as much by the dyspepsia and debility present, as by the drug taken. What has been said in speaking of alcoholic abuse may be repeated here. Such cases should be put to bed under skilled nursing, and while their particular drug is gradually diminished, food should be carefully and systematically increased. The importance of skilful feeding cannot be ranked too highly.