Cardiovascular Renal Disease Treatment


Categories: Uncategorized
Sources: Disturbances Of The Heart

While it is urged, in preventing the actual development of this

disease, and in slowing its progress, that it is advisable to lower

a high blood pressure, we must remember that this blood pressure mad

be compensatory, and many times should not be much lowered without

due consideration of the symptoms and the patient's condition. It is

better not to use drugs of any kind in this incipient condition. The

hypertension should be regulated by the diet; the purin bases and

meat should be reduced to a minimum; tea, coffee and alcohol should

be prohibited, and tobacco should be either entirely stopped or

reduced to a minimum. Regulated exercise is always advisable, the

amount of such exercise depending on the condition of the

circulation. Ordinary walking and graduated walking or graduated

hill climbing and golfing are good exercise for these patients.

Mental and physical strenuosity must be stopped, if the disease is

to be slowed. Sleeplessness must be combated, and perhaps actually

treated medicinally, and for a time sufficient doses of chloral are

perhaps the best treatment. The administration of chloral must

always be carefully guarded to avoid the acquirement of dependence

on the drug. Mouth and other infections should be sought and

removed. Warm baths, Turkish baths, electric light baths or body

baking may be advisable, and certainly obesity must always be

combated by a regulation of the diet. In obesity, stimulants to the

appetite, such as spices, condiments, and even sometimes salt, must

be prohibited. Butter, cream, sugar and starches must be reduced to

a minimum. A small amount of bread and a small amount of potatoes

should be allowed. Liquids with meals should be reduced. Fruits

should be given freely. Intestinal indigestion should be corrected,

and free daily movements of the bowels should be caused. If the

patient is obese, and especially if the blood pressure is high, the

administration of thyroid extract is very beneficial. This is

particularly true in women suffering from this disease; but the

patient should be carefully observed during its administration. It

may be advisable to administer small doses of iodid instead of the

thyroid treatment, or coincidently with it. Nitrites had better be

postponed, if possible, for cardiac emergencies.



White, [Footnote: White: Boston Med. and Surg. Jour., Dec. 2, 1915.]

after studying 200 cases of heart disease, finds that men are more

subject to auricular fibrillation, auricular flutter, heart block

and alternation of the pulse than are women. The greater frequency

of syphilis in men than in women should be considered in this

difference in frequency.



White finds that hyperthyroidism of long standing is often attended

with auricular fibrillation. He does not find that alcohol, tea and

coffee play much part in causing these serious disturbances of the

heart. His conclusions on this subject are certainly a surprise, and

do not coincide with the experience of many others. It would seem

that one of the causes of the greater frequency of these

disturbances in men would be the amount of alcohol and tobacco used

by men.



When the heart begins to fail from a gradually progressing

myocarditis, the pulse rate generally increases, especially on the

least exertion, and on fast walking may be as high as 120 or 130 a

minute, or even higher. It may be found near 100 on the least

exertion, even after some minutes of rest. These patients must have

more or less absolute bed rest. When this condition occurs in old

age, however, prolonged bed rest is inadvisable, for if the heart

once loses its energy, in such cases, it is practically impossible

to cause a return of normal function. However, in all acute cardiac

insufficiency in this disease, due to some heart strain or exertion

that was unusual, a bed rest of from one to two weeks and then

gradually getting up and returning to normal activity is the proper

treatment, and will generally be successful in restoring more or

less compensation. These patients may well recline in bed with

several pillows or with a back rest. During any cardiac anxiety in

this kind of insufficiency the patient breathes better when he is

sitting up or reclining with the head and shoulders high. The reason

for this is probably because his heart has more space in this

position--the same reason that he breathes better when his stomach

is empty. Very indicative of the coming cardiac insufficiency is the

inability to lie at night on the left side. The pressure of the

body, especially if the person is stout, interferes with the heart

action and causes dyspnea and distress. Some short, fat patients

with cardiac distress caused by this disease must even stand up to

relieve the condition, the erect position giving still more space

for the action of the heart.



Before these patients get up, after a period of bed rest, slight

exercises should be done, perhaps resistant exercises, to see what

the effect is on the heart, and also gradually to cause increase in

cardiac strength, much as any other training exercise. Whatever

exercise increases the heart rate more than twenty-five beats is too

strenuous at that particular period. The exercise should then be

still more carefully graduated. If the systolic blood pressure is

altogether too low for the age of the person or for the previous

history, it should be allowed to become higher, if possible, before

much exercise is begun.



The diet should be nutritious, but, of course, modified by the

condition of the stomach, intestines and kidneys, and whether or not

the patient is obese. The bulk of the meal should be small, and

nutriment should be given at three or four hour intervals during the

daytime.



The Karell milk diet or so-called "cure" was first presented in 1865

by Phillippe Karell, physician to the Czar of Russia. This treatment

was more or less forgotten until lately, when it has been more

frequently used in kidney, liver and heart insufficiency. Its main

object in kidney and heart disease is to remove dropsies. In cardiac

dropsy it is advised to give 200 c.c. of milk for four doses at four

hour intervals, beginning at 8 o'clock in the morning. Whether the

milk is taken hot or cold depends on the desire of the patient. This

treatment is supposed to be kept up for six days, and during this

time no other fluid is given and no solid food allowed. During the

next two days an egg is added to this treatment, given about 10

o'clock in the morning, and a slice of dry toast, or zwieback, at 6

p. m. Then up to the twelfth day the food is gradually increased,

first to two eggs a day, then more bread, then a little chopped

meat, then rice or some cereal, and by the end of two weeks the

patient is about back to his ordinary diet. During this period the

bowels are moved by enema or by some vegetable cathartic, or even

castor oil. If thirst is excessive, the patient must have a little

water, and if the desire for solid food is excessive, even Karell

allowed a little white bread and at times a little salt. He

sometimes even prolonged the period of treatment to five or six

weeks.



Various modifications of this treatment have been suggested, such as

skimmed milk, and more in quantity, or a cereal is added more or

less from the beginning, and perhaps cream. The diuretic action of

this treatment is not always successful. Also, sometimes the

treatment is even dangerous, the heart and circulation becoming

weaker than before such treatment was begun. Certainly the treatment

should be used in cardiac insufficiency with a great deal of care,

although it is often very valuable treatment. It should be

emphasized that most patients with cardiac dropsy receiving the

Karell treatment or a modification of it should also receive

digitalis in full doses, and should have daily free movement of the

bowels. It should be urged, however, that too free catharsis in

cardiac weakness is to be avoided, and the prolonged use of salines,

and sometimes even one administration is contraindicated. Before

cardiac failure has occurred in this disease, once a week a dose of

calomel or a brisk saline purge is advisable, and is good treatment;

but when cardiac weakness has developed, free catharsis is rarely

indicated, although the bowels should be daily moved, and vegetable

laxatives are the best treatment. The upper intestine and the liver

and kidneys may be relieved by a more or less abrupt modification of

the diet, or even a starvation period, and the bowels will generally

become cleaned; but frequent profuse purging with salines or some

drastic cathartic puts the final touch on a cardiac failure.



Recently Goodman [Footnote: Goodman, E. H.: The Use of the "Karell

Cure" in the Treatment of Cardiac, Renal and Hepatic Dropsies, Arch.

Int. Med., June, 1916, p. 809.] presented a report of his studies of

the Karell treatment in cardiac, renal and hepatic dropsies. He

finds that patients with uremia ordinarily should not be subjected

to the Karell cure, such patients needing more fluid.



As long as the patient remains in bed, and as long as his ability to

exercise is at a minimum, gentle massage is advisable.



In these cases of cardiac weakness, with or without dropsy, unless

the diastolic pressure is very high, digitalis is valuable. If there

is no cardiac dropsy, but other symptoms of heart tire are manifest

and the blood pressure is high, the nitrites are valuable. The

amount should be sufficient to lower the blood pressure. Sometimes

the diastolic pressure is high and the systolic low and the pressure

pulse small because of heart insufficiency; such a condition is

often improved by digitalis. In other words, with a failing heart

digitalis may not make a blood pressure higher, and often does not;

it may even lower a diastolic pressure, and the moment that the

pressure pulse becomes sufficient, the patient improves. Under this

treatment of digitalis, rest and regulated diet, a dilated left

ventricle with a systolic mitral blow often becomes contracted and

this regurgitation disappears.



The amount of digitalis that is advisable has been frequently

discussed. It should be given in the best preparation obtainable,

and should be pushed gradually (not suddenly) to the point of full

physiologic activity. While it may be given at first three times a

day in smaller doses, it later should be given but twice a day, and

still later once a day, in a dose sufficient to cause the results.

As soon as the full activity has been reached it may be intermitted

for a short time; or it may be given a longer time in smaller

dosage. In renal insufficiency associated with cardiac

insufficiency, its action is subject to careful watching. If there

is marked advanced interstitial nephritis, digitalis may not work

satisfactorily and must be used with caution. If, on the other hand,

a large part of the kidney trouble is due to the passive congestion

caused by circulatory weakness, digitalis will be valuable.



In sudden cardiac insufficiency, provided digitalis has not been

given in large doses a short time before, strophanthin may be given

intravenously once or at most twice at twenty-four-hour intervals.



If, in this more or less serious condition of the heart weakness,

there is great sleeplessness, a hypnotic must sometimes be given,

and the safest hypnotic is perhaps 3 / 10 grain of morphin. One of

the synthetic hypnotics, where the dose required is small, may be

used a few times and even a small dose of chloral should not be

feared when sleep is a necessity and large doses of synthetics are

inadvisable on account of the condition of the kidneys.



The value of the Nauheim baths with sodium chlorid and carbonic acid

gas still depends on the individual and the way that they are

applied. If the blood pressure is low and the circulation at the

periphery is poor, they bring the blood to the surface, dilating the

peripheral vessels, and relieving the congestion of the inner organs

and abdominal vessels, and they often will slow the pulse and the

patient feels improved. If they are used warm, a high blood pressure

may not be raised; if the baths are cool, the blood pressure will

ordinarily be raised. Provided the patient is not greatly disturbed

or exhausted by getting into and out of the bath, even a patient

with cardiac dilatation may get some benefit f rom such a bath, as

there is no question, in such a condition, that anything which

brings the blood to the muscles and skin relieves the passive

internal congestion. Sometimes these baths increase the kidney

excretion. At other times these, or any tub baths, are

contraindicated by the exertion and exhaustion they cause the

patient; and cool Nauheim baths, or any other kind of baths, are

inadvisable with high blood pressure.





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