Chapter D: Physical Measures (1)

Hydrotherapy is often of great value in restoring compensation by improving the surface circulation. Sponging with hot, tepid or cold water, as indicated, will increase the peripheral circulation and the normal secretions of the skin.

When compensation is perfect, in valvular lesions, more or less frequent warm baths are advisable, and often relieve the heart by equalizing the circulation. Cold sponging in the morning may be advisable, but may do harm when there is high tension; warm, not too hot, baths are of value. Anything is of value that improves the peripheral circulation and prevents the extremities from being cold.

The value of the Nauheim or other carbonated baths is perhaps often a question. They have seemed in many instances to aid in improving compensation in such patients as have been able to go abroad for the treatment. On the other hand, so many other regimens are ordered and inaugurated for these patients at these "cures" that it is hard to decide how much benefit the baths have really done. At home the artificial carbonated or carbonic acid baths do not seem to be of great value. Baths and bathing can do harm, and the decision as to which hydrotherapeutic measure shall be used can be made only after careful observation of the patient by the physician.

Gentle massage while the patient is in bed is of undoubted value; more vigorous massage is later often of value, provided there is no arteriosclerosis. As the patient grows stronger and the circulation improves, the muscles are kept in good condition during the enforced rest by massage. When properly applied, it promotes not only the venous return circulation, but also the lymphatic circulation; it often removes muscle aches and muscle tire and restlessness.

While the patient is still in bed, various resistant exercises are of value, and should be begun. These tend to prepare the patient for his later greater activities; the surprise to the heart when the patient begins to sit up and walk is not so great if he has previously taken these exercises. Later, when the patient is ambulatory, he should by gradual gradation walk a little more about the house and take a few steps of the stairs at a time, until gradually he is able to mount the whole flight. Later he should take out-door exercise, and when his heart has become compensated for ordinary work, he should be given gradually graded hill-climbing with the idea of increasing his reserve cardiac power. If it is found that these increased exertions cause him to have pain or a more rapid heart than is excusable, even after persisting for a few days, the attempt to increase this reserve power of the heart should be abandoned. There is probably, at least at that particular time, considerable myocarditis, although the heart may eventually recuperate still more. Pushing it to overexertion, however, will not accomplish improvement. Some of the simple "tests of heart strength" described under that heading may be used with these patients.

Graded exercise was first used scientifically by Oertel and Schott, and has been for years designated by their names. Modifications of their rigid rules are generally advisable.

E. MEDICATION

1. CARDIAC TONICS.-Digitalis: There is no drug that can take the place of digitalis in loss of compensation in chronic valvular disease. It acts specifically for good, and it has its greatest success in the valvular lesions that cause enlargement of the left ventricle, on which it acts the most intensely. It also acts for good on the right ventricle. It has but little action on the auricles. This is simply a question of muscle; the part that has the greatest amount of muscle will receive the greatest benefit from digitalis, and the parts that have the least, the least benefit. The heart muscle is somewhat similar to other muscles; when we attempt athletic improvement in any muscle of the body, we "train" by stimulating it moderately at first, and are careful not to overwork it; the object, then, is to train the heart muscle. For this reason large doses of digitalis should ordinarily not be given to overstimulate suddenly an overworked and weak heart. While in some instances it has been declared that digitalis should be rapidly pushed to the full extent and then dropped for a time, careful experience shows that this method is often not tolerated, sometimes does positive harm, and has at times seemed to hasten death.

Another valuable activity of digitalis is in slowing the heart by action on the pneumogastric nerves. A dilated heart has lost more or less of its regulating mechanism; this is the cause of its irregularity and its increased rapidity. The action of digitalis in slowing the heart, giving it a longer rest, and preventing it from acting irregularly is of great value. This prolonged rest or diastole of the heart allows the circulation in the coronary arteries to become normal, and the nutrition and muscle tone of the heart improves. Digitalis also increases the blood pressure, not only by improving the activity of the heart, but also by causing some contraction of the arterioles. This feature of digitalis action in arteriosclerosis renders its use sometimes a question of careful decision. The dose of digitalis under such a condition should not be large. It may be indicated, however, and may do a great deal of good, and it does not always increase the blood pressure.

If the patient is sufficiently ill to require the best action of digitalis, an active preparation should be obtained. It was long supposed that the infusion presented activities which could not be furnished by the tincture of digitalis. This seems not to be true. The greater value of the infusion is generally because it is freshly made and active; the tincture which had been used previously in a given case was old and useless; furthermore, most physicians give a larger dose of the infusion than they ever do of the tincture. Owing to the uncertainty of the value of the digitalis leaves found in the various drug shops, however, and to variations in the preparation of the infusion, it is generally better to use a tincture of known character. The beginning dose of such a tincture should generally not be more than 5 drops, and it should not be repeated more frequently than once in eight hours. It is generally advisable, in two or three days, to increase this dose to 10 drops once in twelve hours, later perhaps to 15 drops twice a day, and still later to 20 drops once a day. This amount may then be decreased gradually, if the action is satisfactory. Enough should be given to procure results, and then the dose should be brought down to what seems sufficient and best, administered once a day. The frequence advised in the administration of this drug is because it is eliminated slowly. Its greatest action develops a number of hours after it has been taken, and then the action lasts for many hours; the administration of digitalis once in twenty-four hours is perfectly satisfactory for many patients, and more satisfactory than any more frequent administration. On the other hand, some patients do better on a smaller dose once in twelve hours. This frequence is always sufficient.

Digipuratum and digitol, a fat-free tincture, proprietary preparations accepted by the Council on Pharmacy and Chemistry for inclusion in N. N. R., may be employed. They are standardized preparations and may thus be more satisfactory than some pharmacopeial preparations of digitalis, although their claims to lessened emetic action are not borne out by recent experiments of Hatcher and Eggleston.

Digipuratum may be obtained in tubes of twelve tablets. The advice has been given for patients with loss of compensation to receive four tablets the first day, three the second, three the third, and two the fourth day. This, however, is generally an overdosage. The most that should generally be given is one of these tablets in twelve hours. Digipuratum fluid is also a valuable preparation.

Digitol is a fat-free tincture of digitalis which is physiologically standardized and which bears on each package the date of manufacture. The close is from 0.3 to 1 c.c. (5 to 15 mimims).

Digitalinum, one of the active principles of digitalis, is not very satisfactory. It may be given hypodermically, but often causes irritation, and the proper dose and its value are apt to be uncertain.

Digitoxin, another active principle of digitalis, has been declared by some investigators to be harmful, also to be liable to cause serious disturbance of a damaged heart. Other investigators have stated that it acts for good. Digitoxin does not represent the whole value of digitalis, and in broken compensation digitalis itself, or some preparation embodying the majority of its activities, should be given. Digitoxin, however, is often valuable in conditions of cardiac debility or slight weakening in patients who do not have dilated hearts or edemas. The most satisfactory dose of digalen is from 5 to 10 drops once or twice in twenty-four hours.

Digitalis should not be used when there is fatty degeneration of the heart; it should ordinarily not be used when there is arteriosclerosis, and very rarely, if ever, when it is decided that there is coronary disease. Whether digitalis should be used when there is considered to be much myocardial degeneration is a question for individualization. One can never be sure that the heart muscle is so thoroughly degenerated that no part of it would be benefited by digitalis when compensation is lost; therefore, many times, especially if other drugs have failed, small doses of digitalis should be tried, to see if the heart will respond. Large doses or frequent doses would be contraindicated.

The signs of overaction of digitalis are nausea, vomiting, a diminished amount of urine, a tight, band-like feeling around the head, perhaps occipital headache and coldness of the hands and feet, or frequently of one extremity only, combined with a feeling of numbness. The pulse is generally reduced to sixty or less a minute. Such symptoms require that digitalis be immediately stopped. They are the primary signs of cumulative action.

While many patients with ordinary dosage of digitalis may take the drug for months and years without ever showing cumulative action, other patients show this effect quickly. They are apt to be those in whom the kidneys are not perfect. The signs of such undesired action may develop slowly, as suggested by the symptoms just enumerated, or they may develop suddenly. The pulse becomes rapid and irregular, the heart action weak, there is severe backache in the region of the kidneys, a greatly diminished amount of urine, or even partial suppression, severe headache, vomiting, cold extremities and shiverings.

The treatment of such an undesired behavior of digitalis is, of course, to stop the drug immediately, give saline laxatives, hot sponging or hot baths, nitroglycerin and perhaps alcohol.

Strophanthus: Strophanthus cannot be compared with digitalis, except when the glucosid, strophanthin, is administered subcutaneously or intravenously. Strophanthus is given either in the form of the tincture, or as strophanthin. It has been shown that in neither of these forms, when the drug is administered by the stomach, is the muscle of the heart or the blood vessels much acted on. Compensation could not be restored by strophanthus. In emergencies of serious cardiac failure, strophanthin intravenously has been shown apparently to save life. It acts quickly, and its power of stimulating the heart and contracting the blood vessels lasts for many hours. It is rarely, however, that the dose should be repeated, and then not for twenty-four hours, but during that twenty-four hours the patient may be saved until other drugs which act more slowly have been absorbed, or perhaps until the emergency has passed. It probably should not be given if the patient has previously had good dosage of digitalis.

There are many, however, who believe that they obtain considerable value from the tincture of strophanthus, and there seems to be no doubt that although strophanthus, given in the form of the tincture and by the mouth, may not increase the muscle power of the heart, it many times acts as a satisfactory cardiac sedative. Under its action the patient becomes less nervous, the heart often acts more regularly, and the low blood pressure may improve. We should not be quite ready to discard the internal use of the tincture of strophanthus.

The tincture of strophanthus readily deteriorates, and the preparation ordered should be known to be a good one.

Caffein: This should not be given or allowed, even in the form of tea or coffee, to patients who have valvular lesions with perfect compensation, as it is a nervous and cardiac stimulant and may cause a heart to become irritable. It raises the blood pressure slightly, acts as a diuretic, and hence is often of great value when used medicinally. It should be ranked as a stimulotonic to the heart. It increases its activity, but gives it a little more strength. It will rarely slow a rapid heart; it will often stimulate a sluggish, slow heart; it may increase the irritability of an irritable heart. As it is a cerebral stimulant, it should not be given late in the afternoon or evening, as it may prevent sleep.

The most frequent form of caffein used is the citrated caffein. The dose is 0.1 gm. (1 1/2 grains) two or three times in the early part of the day, or 0.2 gm. (3 grains) once or twice during the morning. A few much larger doses may be given if desired. A cup of coffee may be given the patient medicinally: as a substitute for the drug, an ordinary cup of strong coffee containing between 2 and 3 grains. Other preparations of caffein may be selected if desired, or a soluble preparation may be given hypodermically.

Caffein is indicated if digitalis is contraindicated or does not act satisfactorily, and the patient is not nervously excited, but perhaps is stupid or apathetic, and also when diuresis is desired.

Strychnin: This is a valuable stimulator and heart tonic when properly used. It promotes muscular activity of the heart much as it promotes all muscular activities. It awakens nervous stimuli and nervous transmissions to normal in all sluggish nerve functions. If for these reasons the heart acts more perfectly, and the nutrition of the heart muscle improves, it acts as a cardiac tonic. Many times, by improving the action of the heart, and also by the action of the drug on the vasomotor center, the pressure in the peripheral circulation may be increased. On the other hand, strychnin in the low blood pressure of serious illness, such as pneumonia, by no means always raises the blood pressure.

It should not be forgotten that strychnin is a general nervous stimulant, especially of the spinal cord. If it makes a nervous patient more nervous, or a quiet patient restless and irritable, it is acting for harm and should be stopped, just as caffein under the same conditions should be stopped. Strychnin may cause diminished secretion of the skin. This is not frequent, but it does occur. It may prevent the patient from sleeping. If such be the fact, strychnin is not acting for good in a patient who has cardiac weakness.

INDICATIONS FOR STRYCHNIN

Strychnin is a much overused drug. It is now given for almost everything and during almost every disease. It is true that the administration of strychnin is largely due to the evolution of the age in which we are now living. We have ceased to purge and bleed and sweat, and to give large doses of aconite or veratrum viride; have ceased to starve the patient too long; we have ceased to load him with alcohol to the point of circulatory prostration, and we have recognized that he must be braced from start to finish; strychnin is the drug which has been used for this purpose, and, as stated above, overused. Strychnin given too frequently or in too large doses for a laboring heart can prevent its proper rest; the diastole is shortened and the relaxation of the heart is incomplete, its nutrition suffers, or even irregular and fibrillary contractions of a weak heart may apparently be caused. While a large dose of strychnin, even to one-twentieth grain hypodermically, may be used once in serious emergency when it is deemed the drug to use, a dose larger than one-thirtieth grain hypodermically is rarely indicated, the frequency of such a dose should seldom be more than once in six hours, and a smaller close of strychnin may act more satisfactorily.

Strychnin is indicated when the heart is acting sluggishly and the contractions seem incomplete, and when digitalis either is not indicated or is not acting perfectly. Small doses of strychnin may aid such a heart during the administration of digitalis. In many instances in which digitalis is contraindicated, strychnin is of marked value. This is typically true in fatty hearts, and may be true in arteriosclerosis, in which it often does not increase the blood pressure at all.

2. Cardiac Stimulants.--A cardiac stimulant is a drug which makes the heart beat more strongly and the frequence more nearly normal. The drugs named as cardiac stimulants, however, camphor, alcohol and ammonia, do not leave a heart better than they found it--they are not cardiac tonics.

Camphor: This is one of the best cardiac stimulants that we possess. It is a quickly acting nervous and circulatory stimulant, acting principally on the cerebrum and causing a dilation of the peripheral blood vessels. No subsequent weakness follows after a dose of camphor. Too much will make a patient wakeful, a little often quiets nervous irritability. It should be used as a cardiac stimulant during serious illness more frequently than it has been; and during the endeavor to make a noncompensating heart again compensatory camphor will often act for good. The dose is 2 teaspoonfuls of the camphor-water every three or four hours, as deemed advisable. Each teaspoonful represents a little more than one-fourth grain of camphor. The spirits of camphor, of course, may be used, if preferred.

For cardiac emergencies, ampules of sterile saturated solutions in oil are now obtainable and are valuable. Such hypodermic stimulation acts quickly, and may be repeated every half hour for several times, if the patient does not respond. The solution should be injected slowly, and as a rule intramuscularly.

Many times while other measures are being used to repair a broken compensation, camphor makes a splendid circulatory and nervous bracer. Camphor has long been used as a so-called antispasmodic in hysteric or other nervously irritable persons. It really acts as a stimulant to the highest centers of the brain, promoting more or less nervous control. Perhaps its ability to increase the peripheral circulation may be one of the reasons that it seems at times to be almost a nervous sedative by relieving internal congestion. As just stated, after the camphor action is over there is no depression. This is not true of alcohol.

Alcohol: It is of course now generally understood that alcohol is not a cardiac stimulant in the sense of its being more than momentarily helpful to a weak heart. If alcohol is pushed when a heart is in trouble, the secondary vasodilatation and more or less nerve prostration and muscle debility will cause greater circulatory weakness than before it was administered.

To obtain cardiac stimulation from alcohol it must be given in strong solutions, generally in the form of whisky or brandy, for local irritation of the mouth, esophagus and stomach; reflexly the heart is stimulated and the blood pressure rises. As soon as complete absorption has taken place, the blood pressure falls. For continuous stimulation, another dose of alcohol must be given before this depression occurs. This may be in from one to three hours. To continue such stimulation, the dose of alcohol must be increased. The future of such treatment means an alcoholic sleep with depression, alcoholic excitement which is not desired, or profound nausea and vomiting, with peripheral relaxation and cold perspiration.

Obviously none of these conditions is desirable; but in arteriosclerosis, or when the blood pressure is high and the heart labors tinder the disadvantage of contracting against an abnormal circulatory resistance, alcohol may act perfectly to relieve this kind of circulatory disturbance. In this condition the alcohol should not be given concentrated, and as soon as it is thoroughly absorbed vasodilatation occurs, peripheral circulation and therefore warmth are increased, and the heart is relieved of its extra load. In such instances, in proper doses not too frequently repeated, rarely more than 1 or 2 teaspoonfuls every three hours, alcohol is a valuable drug. Such good action of alcohol is often seen when the surface of the body is cold from chilling, or the extremities are cold from vasomotor spasm. A good-sized dose of alcohol, best given hot, equalizes the circulation and acts for good. On the contrary, it is obvious that, if the patient is cold from collapse and there is cold perspiration and very low blood pressure, alcohol is not the drug indicated, although one dose may be of benefit while other more slowly acting cardiac tonics or stimulants are being administered.

During serious prolonged illness and when the patient has not had sufficient food and is not taking sufficient food, alcohol in the form of whisky or brandy, not more than a teaspoonful every three hours, acts as a necessary food, and will more or less prevent acidosis from starvation.

It will be seen that alcohol, except possibly in a single dose occasionally, or for some special reason, is rarely indicated in decompensation.

When alcohol is administered regularly, whether during a fever process or for any other reason, if it causes a dry tongue, cerebral excitement, flushed face and a bounding pulse or if there is the odor of alcohol on the breath, the dose is too large, and alcohol is contraindicated.

Ammonia: In the form of ammonium carbonate or the aromatic spirits of ammonia, this has long been used with clinical satisfaction as a cardiac stimulant. Probably, however, it is seldom wise to use ammonium carbonate. It is exceedingly irritant, and constantly causes nausea, perhaps vomiting, and often heartburn or other gastric disturbance. It has no value over the pleasanter aromatic spirits of ammonia, which is essentially a solution of ammonium carbonate. The dose of the aromatic spirits is anywhere from a few drops to half a teaspoonful, given with plenty of water. It is thought to be a quickly acting stimulant, with an effect much like alcohol, followed by very little or no depression. It is more of a cerebral irritant than alcohol, and probably has few, if any, advantages over camphor.

When but little nutriment has been taken for some days, it may be a chemical question, since ammonium compounds so readily form and become cerebral irritants, whether any more ammonium radicals should be given the patient. This is especially true with defective kidneys. In these conditions camphor is better.

3. Vasodilators.--In various conditions of high blood pressure, arteriosclerosis and even during the sthenic stage of a fever, vasodilators may be indicated. The most important are nitrites, iodids and thyroid extracts. Alcohol, as stated above, may act as a vasodilator. Aconite and veratrum viride are now rarely indicated, although possibly aconite should be used when there is high tension and the heart is acting irritably and stormily.

If the nitrites, no preparation seems to act more satisfactorily than nitroglycerin (trinitrin, glyceryl nitratis, glonoin). Its action may not be so prolonged as other forms of nitrite, such as sodium nitrite or erythrol tetranitrate, but it is not irritant, and only a little less rapid than amyl nitrite, and although the marked dilation lasts but a short time, often apparently only for minutes, still, when frequently repeated or given a few times (from four to six) in twenty-four hours, it frequently keeps the blood pressure lower than it would be without the drug. In diseases of the heart the sudden vasodilation caused by amyl nitrite inhalations is indicated only in angina pectoris. "Then the surface of the body tends to be cold, however, when the peripheral blood pressure is increased and the heart is laboring, nitroglycerin in small doses is valuable. The dose may be from 1/400 to 1/100 grain, dissolved on the tongue or given hypodermically for quick action, or given by the mouth for more prolonged action. In sudden cardiac dyspnea nitroglycerin sometimes acts specifically, especially when there is asthma. When a drop or two of the official spirits, which is a 1 percent solution, is given on the tongue, or a soluble tablet of 1/100 grain is dissolved on the tongue, the action is almost as rapid as though the dose had been administered hypodermically. Many times when such increased peripheral circulation is desired and alcohol seems indicated, nitroglycerin in small doses will act as well. It cannot be termed a cardiac stimulant, although many times a heart acts better and the pulse is fuller and stronger after nitroglycerin than before. It should not be used, except if specially indicated, in broken compensation or in other myocardial weakness.

Iodids: These have no immediate action. The vasorelaxation that often occurs from iodid is quite likely due to the stimulation of the thyroid gland by the iodin, and the thyroid gland secretes a vasodilating substance. Small doses of iodid, however, when indicated in various kinds of sclerosis, have seemed to lower blood pressure. While large doses may have more of this actioli, they are not now under consideration, and large doses are rarely indicated. 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, assume 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, massage should be given him intermittently.

Any systemic need should be supplied. If the patient is anemic, he should receive iron. If he has no appetite, 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 butter, 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 substituted 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 institution.

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 substitute 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 institution. 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 institutions, 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 constituents 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 quantity 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 assimilated 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 institution 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.

The results of such sanatorium treatment of heart disease are often evident not only to the patient by an increase of general muscle strength, the ability to do ordinary things and perhaps even sustain muscular effort without dyspnea and cardiac discomfort, but also to the physician by the physical signs. The contraction of the heart becomes stronger and the normal sounds more decided; murmurs which were entirely due to dilated ventricles and insufficiency disappear, while the permanent murmurs may become louder from a more forceful, normal action of the heart muscle. The pulse becomes slower, and the blood pressure, from being too low, becomes normal for the age of the individual. The heart will often also actually decrease in size, and the apex beat become localized rather than diffuse, The liver becomes reduced in size; the urine is less concentrated, and if there were traces of albumin after exertion, these disappear.

It should perhaps be emphasized that not a little benefit from these resort treatments may be due to the withdrawal of unnecessary drugs. Many heart patients are overdrugged.

This sort of treatment is contraindicated in some kinds of heart disease, as heart weakness due to arteriosclerosis with high blood pressure, to aneurysm of the thoracic or abdominal aorta, and to nephritis.