Treatment Of Broken Compensation


Categories: Uncategorized
Sources: Disturbances Of The Heart

The consideration of this subject will include the following topics:

A. Hygiene.

B. Diet.

C. Elimination.

D. Physical measures.

E. Medication.

1. Cardiac Tonics: Digiralis, strophanthus, caffein, strychnin.

2. Cardiac Stimulants: Camphor, alcohol, ammonia.

3. Vasodilators: Nitrites, iodids, thyroid extract.

4. Cardiac Nutritives: Iron, calcium.

5. Cardiac Emergency Drugs: Ergot, suprarenal active principle,

pituitary active principle, atropin, morphin, and also some

of the drugs already mentioned.





A. HYGIENE



Of all treatment for broken compensation or dilated heart, nothing

equals rest in bed. Sometimes it is the only treatment that is

needed. The rigidness of this rest, the length of time that it

should endure, and the period at which relaxation of such rest

should be allowed depend entirely on the individual patient; no rule

can be established. Most of the symptoms must disappear before

exercise is allowed. Perhaps a not infrequent exception to the rule

is when cardiac weakness, generally a inyocarditis, develops in a

patient after 50. It is not always wise to keep such a patient in

bed; he may be rested and his exercise greatly restricted, but

sometimes it is difficult to get him out of bed if he is kept there

any length of time.



Fresh air, sunlight and anything else that makes the bedroom

attractive and cheerful are essential and will aid in the recovery.

The kind of nurse that is needed, trained, untrained, or a member of

the family, and the amount of company or entertainment allowed must

be decided for the individual patient. The patient must be

distinctly individualized and the proper measures taken to give

mental and physical rest, to prevent excitement, worry, melancholia

and depression, and to improve the general nutrition of the body as

well as the condition of the heart.



Each occurrence of broken compensation in valvular disease causes

another attack of cardiac weakness to occur with less excuse than

before, and several serious attacks of broken compensation mean

before long the loss of the heart muscle's ability to recover, so

that permanent dilatation occurs.



B. DIET



The food given should be just sufficient for the needs of the body;

the patient should not be overfed or underfed. Any large bulk of

food or liquid should not be given. Pressure on the heart causes

discomfort and is therefore inadvisable. Food that causes flatulence

should be avoided. Theoretically the patient should receive a little

meat, an egg or two, cereal or bread, a small amount of simple

vegetables, a little fruit, often milk, a sufficient amount of

noneffervescent water, perhaps a cup of chocolate or cocoa, a simple

dessert, sometimes ice cream; in other words, a varied, limited diet

containing all the elements that are necessary to good nutrition.

The diet should be varied from day to day to encourage the appetite.



It has for several years been recognized that a salt-free diet in

dropsies due to disease of the kidneys is a valuable aid in causing

absorption of such exudates and of preventing greater exudations.

For this reason a salt-free diet is often ordered in dropsies

occurring in valvular disease. Its value, however, is not so great

as in kidney lesions, and if it causes hardship to the patient it

should not be continued rigorously. On the other hand, large amounts

of salt should of course be interdicted.



A most valuable aid in dropsies due to heart deficiencies is the so-

called dry diet, which means that as little liquid as possible

should be taken in order that the patient's blood may resorb the

exudate in the tissues and not have the blood vessels filled or

overfilled with liquid from the gastro-intestinal tract. When dropsy

is present, or even when serious pendent edemas are present, the

patient should drink as little liquid as possible with his meals,

and between meals should sip water rather than drink a large

quantity of it. This is one of tile reasons that a large milk diet,

even with kidney disturbance due to cardiac lesions, is generally

inadvisable. With cardiac or general circulatory weakness, a laige

amount of liquid to flush out the kidneys and the whole system, so

long ordered for all kidney defects or mistakes in metabolism, is a

seribus mistake. The Karel diet is described in the section on

cardiovascular-renal disease.



Whether it is better to give three or four small meals a day or to

give a small amount of nourishment every three hours during the

daytime must again depend on the individual and his ability to

digest without fermentation and putrefaction or discomfort. As

previously urged, not too much fluid, even milk, though it digest

perfectly, should be given, as the greater the amount of fluid the

greater the amount of work thrown on the heart.



C. ELIMINATION



A patient who has developed decompensation has always imperfect

elimination. The skin, bowels and kidneys do not act sufficiently or

well. The circulation in the skin is sluggish. The bowels are

generally constipated, or there is diarrhea of the fermentative

type. The amount of urine excreted is generally insufficient and

likely to be concentrated and show various signs of imperfect kidney

elimination. Therefore hot sponge baths, with perhaps warm alcohol

rubs, are daily necessary. Gentle massage, generally in the

direction to aid the circulation, will benefit the skin. If the skin

is dry or in places scaly, oil rubs are of great benefit.



The bowels must be moved daily and sufficiently, but there should be

no watery purging allowed or caused. If it seems advisable in the

beginning of the treatment to give a calomel purge, it should be

done, but such purging should ordinarily not be repeated, although

occasionally a grain or two of calomel, combined with the vegetable

laxatives needed, may act perfectly and without causing depression.

Saline purgatives, or even laxatives, are generally not good

treatment when there is cardiac weakness. The bowels should be moved

by vegetable laxatives, as aloin, cascara sagrada, or some simple

combination of either or both of these drugs.



Diuretics are often not satisfactory in cardiac insufficiency. The

cardiac tonics which are given the patient, and the improvement of

the heart from the rest in bed generally start the kidneys to

secreting properly. A diuretic administered when the kidneys are

suffering passive congestion from cardiac insufficiency does not

generally act, and is therefore useless. If digitalis is

administered, it will act as a diuretic; if caffein is deemed

advisable, that will act as a diuretic. Squills may be administered,

if it seems best. If for any reason the kidneys secrete less urine

and become insufficient, the diet should quickly be reduced to a

small amount of milk, cereal and water, and hot baths and local heat

to the back should be inaugurated.



D. PHYSICAL MEASURES



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.





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