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Cardiovascular Renal Disease Treatment
Source: 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
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
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
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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