Too mach iodid has been given for many conditions. If the indications for an iodid are present, such as sclerosis anywhere, or unabsorbed inflammatory products, exudation in or around the heart, or an apparent insufficiency of the thyroid, from 0.1 to 0.2 gm. (1 1/2 to 3 grains) once or twice in twenty-four hours, after meals, is all that is required to give the action desired, and the circulation is benefited. It is sometimes a question whether small doses of iodid are not actually stimulant to the heart, possibly through the action on the thyroid gland.
Thyroid Extract: In slow hearts and in sluggish circulation, often in old age, quite frequently in arteriosclerosis and in every condition of insufficient thyroid secretion (these instances are frequent), small doses of thyroid extract will benefit the circulation. Its satisfactory action is to increase the cardiac activity, slightly lower the blood pressure, and increase the peripheral circulation and the health of the skin. If it causes tachycardia, nervous excitement, sleeplessness or loss of weight, it is doing harm and the dose is too large, or it is not indicated. The dose for the cardiac action desired is a tablet representing from 1/2 to 1 grain of the active substalice of the thyroid gland, given once a day, continued for a long period.
When an improved peripheral circulation is desired, and especially when a reduction of the pressure in the heart is desired and a diminished amount of blood in overfilled arteries is indicated, the value of the sitzbath, hot foot-baths, warm liquids (not hot) in the stomach, and warm, moist applications to the abdomen should all be remembered.
4. Cardiac Nutritives.--Iron: Nothing is of more value to a weakened heart muscle, when the nutrition is low, the patient anemic, and the iron of the food not properly metabolized, than tonic doses of some iron salt. It has frequently been repeated, but should constantly be reiterated, that there is no physiologic reason or therapeutic excuse for the patient to pay a large amount of money for some organic iron preparation.
Small doses of an inorganic salt act perfectly, and nothing will act better. As previously suggested, a drop or two of the tincture of iron, a grain or two of the reduced iron, or 2 or 3 grains of saccharated ferric oxid, given once or twice in twenty-four hours, is all the iron the body needs from the points of view of the blood and the heart.
Calcium: It has lately been learned that calcium is an element which a heart needs for perfect activity. Many patients who are ill lose their calcium, and they may not receive a sufficient amount of it unless milk is given them. Even if such patients are taking milk, the heart and the whole general condition sometimes such; to improve when calcium is added to the diet. It may be given either in the form of lime water, calcium lactate or calcium glycerophosphate. If a medium-sized dose is given three or four times in twenty-four hours, it is sufficient and will often act for good.
Whether calcium can do harm in a chronic endocarditis or an arteriosclerosis to offset the value that it seems to have in quieting the nervous system and in being of value to a weak or nervously irritable heart is a question which has not been decided.
Theoretically lime should not be given when there is a tendency to calcification, or when a patient is past middle age. Lime seems to be essential to youth, and to the welfare of nervous patients.
EMERGENCIES
5. Cardiac Emergency Drugs.--Besides some of the drugs already mentioned (such as camphor hypodermically, nitroglycerin when indicated, strophanthin hypodermically or intravenously, caffein and strychnin), often ergot, suprarenal vasopressor principle, pituitary vasopressor principle, atropin and morphin should be considered.
When there is low blood pressure, venous stasis, pulmonary congestion, cyanosis and a laboring, failing heart, intramuscular injections of ergot, with or without coincident venesection, may be the most valuable method of combating the condition. Life has been saved in this kind of sudden acute cardiac failure in valvular disease. When venesection is not indicated in certain conditions of low blood pressure and heart failure, ergot has saved life. It causes contraction of the blood vessels and seems to tone the heart.
Incidentally it quiets the central nervous system. If the blood pressure is much increased by it, the ergot should not be repeated, as too much work should not be thrown on the heart muscle. Often, however, it may be administered intramuscularly with advantage in aseptic preparation as offered in ampules, at the rate of one ampule every three hours for two or three times, and then once in six hours for a few times, the future frequency depending on the indications.
Epinephrin and Pituitary Extract: The blood pressure-raising substance of the suprarenals or of the pituitary gland (hypophysis cerebri) has been much used in heart failure. These substances certainly would not be indicated in high blood pressure; they are indicated in low blood pressure. They have been given intravenously; they are frequently given hypodermically. They often act rapidly when a solution in proper dose is dropped on the tongue. The blood pressure rise from epinephrin is quickly over; that from the pituitary extract lasts longer. In large doses, or when it is too frequently repeated, epinephrin depresses the respiration. Pituitary extract acts as a diuretic. Sterilized solutions of both, put up in ampules ready for hypodermic medication, are obtainable, the strength offered generally being 1 part of the active principle to 10,000 of the solution. Hypodermic tablets of epinephrin may also be obtained. Stronger solutions of 1 part to 1,000 may be dropped on the tongue, or tablets may be dissolved on the tongue. The blood pressure is temporarily raised and the heart stimulated by these treatments, but epinephrin is not used so often for cardiac failure as it was a short time ago.
The most satisfactory action, especially from the epinephrin, is from small doses frequently repeated. Sometimes in serious emergencies it has been found to be of value when given intravenously in physiologic saline solution. The close, of course, should be very small. In circulatory weakness in acute illness, epinephrin has been given regularly, a few drops (perhaps the most frequent dose is 5) of a 1: 1,000 solution, on the tongue, once in six hours. Such a dosage may be of value, and certainly is better than the administration of too much strychnin. Much larger or more frequent doses are likely, as just stated, to depress the respiration.
Besides the small amount of blood pressure-raising substance secreted by the hypophysis cerebri. it has not been shown that any other gland of the body furnishes vasopressor substance except the suprarenals.
Atropin: When there is great cardiac weakness, atropin may be used to advantage. The dose is from 1/200 to 1/150 grain hypodermically, not repeated in many hours. It will whip up a flagging heart, more or less increase the blood pressure, cause cerebral awakening, and may often be of value. If there is any idiosyncrasy against atropin, if the throat and mouth are made intensely dry, or if there is serious flushing or cerebral excitement, the dose should not be repeated.
Morphin: This would rarely be considered as an emergency drug in cardiac weakness. A small dose of it, not more than one-eighth grain, especially if combined with atropin, will often quiet and brace a weak heart, especially when there is cardiac pain. Just which drug or drugs should be used and just which are not indicated can never be specifically outlined in a textbook, a lecture or a paper. The decision can be made only at the bedside, and then mistakes, many times unavoidable, are often made.
In all conditions of shock with cardiac failure, the blood vessels of the abdomen and splauclinic system are dilated, and more or less of the blood of the body is lost in these large veins, and the peripheral and cerebral blood pressure fails. The advantage in such a condition of firm abdominal bandages, and of raising the foot of the bed or of raising the feet and legs, need only be mentioned to be understood.
It is a pretty good working rule, in cardiac failure, not to do too much. On the other hand, life is frequently saved by proper treatment, and the physician repeatedly saves life as surely as does the surgeon with his knife.
CONVALESCENCE
When compensation has been restored, the patient may be allowed gradually to resume his usual habits and work, provided these habits are sensible, and the work is not one requiring severe muscular exertion. Careful rules and regulations must be laid down for him, depending on his age and the condition of his arteries, kidneys and heart muscle. It should be remembered that a patient over 40, who has had broken compensation, is always in more dancer of a recurrence of this weakness than one who is younger, as after 40 the blood pressure normally increases in all persons, and this normal increase may be just too much for a compensating heart which is overcoming all of the handicap that it can withstand. Such patients, then, should be more carefully restricted in their habits of life, and also should have longer and more frequent periods of rest.
The avoidance of all sudden exertion in any instance in which compensation has just been restored is too important not to be frequently repeated. The child must be prevented from hard playing, even running with other children, to say nothing of bicycle riding, tennis playing, baseball, football, rowing, etc. The older boy and girl may need to be restricted in their athletic pleasures, and dancing should often be prohibited. Young adults may generally, little by little, a.s.sume most of their ordinary habits of life; but carrying heavy weights upstairs, going up more than one flight of stairs rapidly, hastening or running on the street for any purpose, and exertion, especially after eating a large meal, must all be prohibited. Graded physical exercise or athletic work, however, is essential for the patients" future health, and first walking and later more energetic exercise may be advisable.
These patients must not become chilled, as they are liable to catch cold, and a cold with them must not be neglected, as coughing or lung congestions are always more serious in valvular disease. Their feet and hands, which are often cold, should be properly clothed to keep them warm. Chilling of the extremities drives the blood to the interior of the body, increases congestion there, and by peripheral contraction raises the general blood pressure. A weak heart generally needs the blood pressure strengthened, but a compensating heart rarely needs an increase in peripheral blood pressure, and any great increase from any reason is a disadvantage to such a heart.
The patient should sleep in a well ventilated room, but should not suffer the severe exposures that are advocated for pulmonary tuberculosis, as severe chilling of the body must absolutely be avoided.
The peripheral circulation is improved, the skin is kept healthy, the general circulation is equalized, and the heart is relieved by a proper frequency of warm baths. Cold baths are generally inadvisable, whether the plunge, shower or sponging; very hot baths are inadvisable on account of causing a great deal of faintness; while warm baths are not stimulating and are sedative. The Turkish and Russian bath should be prohibited. They are never advisable in cardiac disease. With kidney insufficiency, body hot-air treatment (body-baking), carefully supervised, may greatly benefit a patient who has no dilatation of the heart and who has no serious broken compensation. Surfbathing, and, generally, sea-bathing and lake- bathing are not advisable. The artificial sea-salt baths and carbon dioxid baths may do some good, but they do not lower the general blood pressure so surely as has been advocated, and probably no great advantage is apt to be derived from such baths. If a patient cannot properly exercise, ma.s.sage should be given him intermittently.
Any systemic need should be supplied. If the patient is anemic, he should receive iron. If he has no appet.i.te, he should be encouraged by bitter tonics. If sleep does not come naturally, it must be induced by such means as do not injure the heart.
Perhaps there is no better place in this series on diseases of the heart to discuss the diet in general and the resort treatment than at this point, as the question is one of moment after convalescence from a broken compensation, at which time every means must be inaugurated to establish a reserve heart strength to overcome the daily emergencies of life.
DIET AND BATHS IN HEART DISEASE
The diet in cardiac diseases has already incidentally been referred to. The decision as to what a patient ought to eat or drink must often be modified by just what the patient will do, and, as we all know, it is absolutely necessary to make some concessions in order for him to aid us in hastening his own recovery or in preventing him from having relapses. Consequently, we cannot be dogmatic with most patients with chronic heart disease. Parents should be prohibited from allowing children or adolescents with heart disease to drink tea, coffee or any alcoholic stimulant. The young boy and young man must absolutely be prohibited from indulging in tobacco at all.
There is no excuse for allowing these stimulants or foods in such cases. If the patient is older and has been accustomed to tea and coffee, one cup of coffee in the morning may be allowed, provided a decaffeinated coffee is not found satisfactory. Whether a small cup of coffee or a cup of tea is allowed at noon is again a matter for individualization; they should rarely be allowed after the noon meal. In a patient who has been accustomed to alcohol regularly (generally an older patient), careful judgment should be used in deciding whether or not a small amount of alcohol daily should be allowed. It should never be in large amounts, even of a dilute alcohol like beer; it may be a weak wine; it may be a small amount of diluted whisky, if seems best. Ordinarily the patient is better without it. If he is used to smoking and a small amount does not raise the blood pressure much, it may do him no harm to smoke a small mild cigar once or twice a clay. On the other hand, if a hard smoker suddenly has heart failure, whether from exertion, from chronic disease or from acute illness, a small amount of smoking is of advantage as it tends to remove cardiac irritability, to raise the blood pressure, and actually to quiet and improve the circulation. It is unwise during acute circulatory failure to take tobacco away entirely from a chronic tobacco user.
The character of the food which each patient should receive depends on his blood pressure and his age. The older person with a tendency to high blood pressure should have the protein (especially meat) reduced in amount, as any putrefaction in the intestine with absorption of products of such maldigestion irritates the blood vessels, raises the blood pressure, and injuries the kidneys. On the other hand, a young patient should receive a sufficient meat diet rather than be overloaded with vegetables and starches, to the easy production of fermentation and gas. Flatulence from any cause must be avoided. It dilates the stomach and intestines, causing them to press on the diaphragm, so that the heart and respiration are interfered with. Also, an increased abdominal pressure, especially if there is any edema or dropsy, is bad for the circulation. A distended, tense abdomen is serious in cardiac failure. On the other hand, a flaccid, flabby, lax abdomen should be well bandaged in cardiac failure with low blood pressure.
Children do well on a milk diet, but it should be remembered that excessive amounts of any liquid, even milk and water, are inadvisable, if the circulation is poor and there is a tendency to dropsy. It has been recommended at times to limit a patient"s diet for a week or so to a small amount of milk, not more than a quart in twenty-four hours. If such a patient is in bed and does not require carbohydrates, sugars or stronger proteins or more fat, such a restricted diet may aid in establishing circulatory equilibrium, although he will lose in nutrition. The excretory organs are relieved by the decreased amount of excretory product, the digestive system is rested and the circulation is improved. Such a limited diet should not be tried longer than a week, but it may be the turning point of circulatory improvement.
The ordinary diet for a convalescing heart patient should be small in bulk, of good nutritive value, and should represent all the different elements for nutrition. This means a small amount of meat, once a day to older patients, twice a day to those who work hard or for young patients; such vegetables as do not cause indigestion with the particular patient, and these must be individualized; such fruits as are readily digested, especially cooked fruits; generally plenty of b.u.t.ter, cream, olive oil if the nutrition is low, and milk, depending on the age of the patient or the ease with which it is digested. Soups, on account of their bulk and low nutritive value, should be avoided. Anything that causes indigestion, such as fried foods, hot bread, oatmeal or any other gummy, sticky, gelatinous cereal should be avoided; also spices, sauces and strong condiments. Anything that is recognized as especially loaded with nuclein and xanthin bodies, such as liver, sweetbreads and kidneys, should be prohibited, as tending to cause uric acid disturbance; and the more tendency to gout or uric acid malmetabolism the more irritated are the arteries and the more disturbed the blood pressure. Sugars should be used moderately unless the patient is thin and feels cold, in which case more may be given, provided there are no signs of gout or disturbed sugar metabolism. Sugar is at times a good stimulant food. Very cold and very hot drinks or food should be avoided.
Many times these patients have a diminished hydrochloric acid secretion, and such patients thrive on 5 drops of dilute hydrochloric acid in water, three times a day, after meals. When their nutrition has improved and the digestion becomes perfect, hydrochloric acid will generally be sufficiently secreted and the medication may be stopped.
If the patient is overweight, this obesity must be reduced, as nothing more interferes with the welfare of the heart than overweight and overfat. In these cases the diet should be that required for the condition. If there are edemas, or a tendency to edemas, the decision should be made whether salt (sodium chlorid) should be removed from the diet. Unless there is kidney defect, probably it need not be omitted, and a long salt-free diet is certainly not advisable. This salt-free diet has been recommended not only in nephritis and heart disease, but also in diabetes insipidus and in epilepsy. It is of value if there is edema in nephritis; it is of doubtful value in heart disease; it is rarely of value in diabetes insipidus; and in epilepsy its value consists probably in allowing the bromid that may be administered to have better activity in smaller doses, the bromin salt being subst.i.tuted in the metabolism for the chlorin salt.
THE RESORT TREATMENT OF CHRONIC HEART DISEASE
In line with the continued growing popularity of special resorts and special cures for different types of disease, resort or sanatorium treatment for chronic heart disease has grown to considerable popularity during the last twenty years or more. The most popular of these resorts owe their success to the personality of the physicians, who have made heart disease a life study.
Perhaps the most noted of these resorts for the cure of heart disease is that at Bad Nauheim, Germany, which was inaugurated by Dr. August Schott and Prof. Theodore Schott, and is now conducted by the latter, Dr. August Schott having died about fifteen years ago.
Hundreds of patients and many physicians have testified to the value and benefit of the treatment carried out at this inst.i.tution.
The method of treatment largely employed at these heart resorts is to withdraw all, or nearly all, of the active drugs that the patient may be taking, and to subst.i.tute physical and physiologic methods of therapy. These include bathing, regulation of the diet, and exercise. This exercise consists of two varieties: exercise of the muscles against the resistance of an attendant, and exercise by walking on inclined planes or up hills. The treatment is aimed at chronic heart disease, to develop a greater cardiac reserve strength; the whole object of the treatment is to strengthen the myocardium, either in conditions of its debility or in conditions of diminished compensation in valvular disease. Any treatment that will develop a reserve heart strength to be called on in emergencies, more or less similar to the reserve strength of a normal heart, tends to prolong the patient"s life and health.
Patients with acute heart failure or acute loss of compensation, with more or less serious edemas, should rarely take the risk of traveling any distance to be treated at an inst.i.tution. As a general rule they are better treated for a few weeks or months at home.
After the broken compensation is repaired, a reserve strength of the heart may well be developed by a visit to one of these inst.i.tutions, if the patient can afford it.
The Oertel treatment consists chiefly in diminishing the fluids taken into the body, and in graduated mountain climbing. By diminishing the fluids taken, the work of the heart is diminished, as the blood vessels are not overfilled and may be even underfilled.
The diet is carefully regulated with the object of removing all superfluous fat from the body. The third leg of the tripod of the Oertel treatment is the gradually increasing hill and mountain climbing to educate the heart by graded muscular training to become strong, perfectly compensatory, and later to develop a reserve strength. This particular cure is especially adapted to the obese, who have weakened heart muscles.
NAUHEIM BATHS
At Nauheim, under the direction of Dr. Theodore Schott, baths form an important part of the treatment. These baths are of two kinds, the saline and the carbonic acid. The medicinal const.i.tuents of the saline bath are sodium chlorid and calcium chlorid, the strength of each varying from 2 to 3 percent The baths at first arc given at a temperature of 95 F., and as the patient becomes used to them and can take them without discomfort, the temperature is gradually reduced. The patient remains in the bath from five to ten minutes.
After the bath he is dried with towels and rubbed until the cutaneous circulation becomes active. He must then lie down for an hour. These baths are repeated for two or three days, and are omitted on the third and fourth days, to be resumed on the following day. After a few baths have been taken, the carbon dioxid baths are commenced, beginning with a small quant.i.ty of the gas which is later gradually increased. This course of baths should be continued from four to eight weeks. Unless there is some special reason for taking them at some other period of the year, they are taken more advantageously during the warm months.
Besides the baths, all important part of the treatment at Nauheim consists in the exercises against resistance. These are usually given an hour or more after a bath, and are taken with great deliberation; their effect is carefully watched by an intelligent attendant so that no harm may be done by the exercise.
During this treatment the food is, of course, carefully regulated with the aim of giving a mixed, sufficient, easily digestible and easily a.s.similated diet. All highly seasoned dishes, all effervescent drinks and anything that tends to cause gas in the stomach and intestines are prohibited. Coffee and tea are not allowed, except coffee without caffein; and it may be noted that it has recently been shown that caffein is one of the surest of drugs to raise the blood pressure, and is therefore generally not desirable when the heart muscle requires strengthening. Because of its tendency to raise blood pressure and weaken cardiac muscle, tobacco is entirely forbidden at Nauheim, except in a few individual instances, and then the amount allowed is a minimum one. Large amounts of liquid are not allowed because they distend the stomach, raise the blood pressure and increase the pumping work of the heart.
One of the greatest advantages of the treatment at an inst.i.tution like Nauheim is the general hopeful spirit instilled into the patients, who are so many times seriously depressed by the knowledge of a heart weakness and the realization of their physical inability to do what other persons are able to do. Also, it is of great value to send a patient to a resort where the climate is good and the scenery is lovely and soothing. No disease, perhaps, needs cheerfulness and pleasantness and lack of anxiety, or frets more than does cardiac weakness. A tuberculous patient may sit on a mountain top with snow blowing about him, and recover; a heart patient must have sunshine and comfort.