In persons past middle life the heart may become enfeebled from a variety of causes independent of inflammatory conditions or valvular lesions. Fatty degeneration is a very common cause of such weakness, and in other cases the heart muscle may gradually lose its normal strength and " tone " from strain, or a disturbance of balance between its power and the peripheral resistance to be overcome. In the aged the arterial walls become less and less resilient, if not actually rigid, from fibrosis or calcareous deposit, and, moreover, the heart suffers no less than other organs from impaired nutrition. In such cases the prolongation of the patient's life as well as the maintenance of his comfort may be fostered by attention to dietetics.

A weak heart implies impaired circulation in the gastric vessels, and hence the gastric juice becomes poor in quality and lessened in quantity. Digestion is consequently retarded, and absorption of food products is less active than it should be. The heart and the stomach being both supplied by branches of the vagus nerve, it is easy to understand how gastric irritation, caused by products of malfermentation, organic acids, accumulated undigested food, or gaseous distention, may affect the heart through reflex action. Mechanically, too, a stomach distended by gas presses upon and irritates the heart. Balfour (The Senile Heart) says: "If the heart is weak the discomfort induced by such irregularities is after middle life more apt to be felt in connection with that organ than in the stomach itself." The result is intermission in the pulse rate, unevenness in force and frequency of the heart beat, its " fluttering " action, and sensations of palpitation, precordial distress, fulness or constriction, and dyspnoea. In order to avoid these symptoms as far as possible, the patient must have his diet carefully supervised.

A sufficient interval - fully five hours - must always elapse for the complete digestion of one meal before a second is taken, and because the gastric juice is feeble it is best not to allow more than four or five ounces of fluid of any kind to be taken with the meals. While sufficient variety of food may be allowed to maintain a fair appetite, it should never be so great as to entice the patient to eat too freely.

Balfour summarises excellent rules for dieting to be followed by patients whose cardiac action is enfeebled by any cause, but especially for the condition described as " the senile heart".

Balfour's Rules For Dieting For Weak Hearts

"1. There must never be less than five-hour intervals between meals.

"2. No solid food is ever to be taken between meals.

"3. All those with weak hearts should have their principal meal in the middle of the day.

"4. All those with weak hearts should have their food as dry as possible".

A good typical menu is given by the writer above quoted:

Balfour's Diet For The Senile Heart

Breakfast, 8.30 A. M

Dry toast, one small piece - one or one and a half ounce - with butter; one soft, boiled egg, a small piece of whitefish; three to five ounces of tea or coffee with cream and sugar, or an infusion of cocoa nibs, or milk and hot water, or cream and Seltzer. Sometimes oatmeal porridge is permissible, but not over three or four ounces should be taken.

Principal Meal, 1.30 Or 2 P. M

Fish, such as haddock or sole, or meat and pudding. Two courses only are allowed. No soups, pickles, pastry, or cheese. Whitefish and short-fibred meat only are allowable. The fish may be boiled in milk. A little spinach or one potato may sometimes be eaten, or a half pound of fruit, such as pears, apples, or grapes. Four to five ounces of hot water may be drunk with each meal, but no more.

5to6 P. M

Three to four ounces of tea (one teacupful) infused for four minutes may be drunk, but absolutely no solid food is to be taken with it. If desirable, a teaspoonful of Liebig's extract of meat may be stirred in with the tea.

Supper, 7 P. M

Whitefish and a potato or toast and pudding, or milk pudding, or bread and milk, or revalenta made with milk or Liebig's extract.

Bedtime

Four to five ounces of very hot water, sipped, helps the patient to fall asleep".

Upon this very limited regimen the patient, if heavy and waterlogged, at first loses weight by absorption of "cedematous soakage," or if much wasted he may gain in weight. In this manner the natural equilibrium of the body is re-established.

In not too critical cases a little more latitude is permitted, and such vegetables may be occasionally eaten as asparagus, onions, leeks, tomatoes, lettuce, cress. The heavier, coarser vegetables (like cabbage, sprouts, turnips, parsnips, carrots, beets, legumes), pastry, nuts, dried fruits, and sweets of all kinds are forbidden.

Equal care mut be given to the selection of proper beverages. If there is much palpitation, tea, coffee, and chocolate must be pro-33 scribed. In many cases Balfour allows a little weak tea, made by infusing a teaspoonful (about one hundred grains) in four or five ounces of water for only three or four minutes. Alcathrepta may be drunk. The two latter beverages may be taken at 5 p. m. or on retiring, when the stomach is empty. They must not be made too sweet.

No champagne or effervescing drinks are allowed, and all alcoholic beverages should be given only in moderation. If more than twp ounces (a claret-glassful) of one of the stronger wines is taken, it excites acid dyspepsia, and claret, Burgundy, or hock should not be allowed in greater measure. A small glass of port or sherry may be drunk twice a day; but, as Balfour observes, there is so much idiosyncrasy in the digestibility of wines that in general plain liquor is better for these cases and in the small quantity recommended in the menu given above. Alcohol is by no means a necessity, and many patients are better without any. He has great faith in the stimulating properties of hot water, slowly sipped, and says: "This will be found to have quite as good an immediate effect upon the heart as alcohol".

It has been elsewhere shown that the frequent acts of deglutition performed in sipping any fluid tend to increase the pulse rate slightly through reflex stimulation of the vagus branches which are concerned in the act.

As the heart becomes more and more feeble, the inactive circulation, perhaps aided by alteration in the composition of the blood or by albuminuria, results in the production of localised oedema or general anasarca.

In referring to the use of dry diet for these conditions as occurring in connection with the senile heart, Balfour says: "When there is anasarca, or any evidence of soakage in any dependent part of the body, it is of the greatest importance to place the patient, for a time at least, on the driest possible diet, and not too much of it.... I have seen a considerable amount of oedema of the lower limbs disappear within twenty-four hours before there had been time for any change in the heart, which was feeble and dilated." His dry diet is as follows:

Breakfast

A single slice of dry toast, without butter. A cup of tea (infused only four minutes).

Dinner

Two lean chops, or their equivalent in chicken or fish. No vegetables. Dry toast ad libitum. Half an ounce of brandy, whisky, or Hollands in three ounces of water.

Supper

As much dry toast as desired. Half an ounce of liquor, as at dinner.

Nothing else is allowed; but if the patient is thirsty, very hot water may be sipped between meals. This, Balfour maintains, is an excellent cardiac tonic.