4. Intestinal sluggishness. This means not only that tympanites should not be allowed, but also that necessary laxatives should be given. It would be wrong to prostrate a patient with frequent saline purgatives, but the bowels must move at least once every other day, generally better daily; and if the case is one of typhoid fever, they should be moved by some carefully selected laxative, and after the bowels have sufficiently moved, the diarrhea should be stopped by 1/10 grain of morphin, and the next day the bowels properly moved again.
5. Depressant drugs. In this age of cardiac failure, heart depressants of all types, and especially the synthetic products, should be given only with careful judgment, and, never frequently repeated or long continued.
6. Pain. This is one of the most serious depressants a heart has to combat; acute pain must not be allowed, and prolonged subacute pain must be stopped. Even peripheral troublesome irritations must be removed, as tending to wear out a heart which has all of the trouble it can endure.
7. Insomnia. Nothing rests a heart or recuperates a heart more than sleep. Insomnia and acute disease make a combination which will wear a heart out more quickly than any other combination. Sleep, then, must be produced in the best, easiest and safest manner possible.
8. A too speedy return to activity. The convalescence must be prolonged until the heart is able to sustain the work required of it.
The treatment of gradual dilatation in acute disease has been sufficiently discussed under the subject of acute myocarditis. The treatment of acute dilatation is practically the same as the treatment of shock plus whatever treatment must coincidently be given to a patient for the disease with which he is suffering. The treatment of shock will be discussed under a separate heading.
As pneumonia heads the list of the causes of death in this country, and as the heart fails so quickly, sometimes almost in the beginning in pneumonia, a special discussion of the management of the heart in this disease is justifiable.
Acute lobar pneumonia may kill a patient in twenty-four or forty- eight hours; lie may live for a week and die of heart failure or toxemia, or he may live for several weeks and die of cardiac weakness. If he has double pneumonia be may die almost of suffocation. It is today just as frequent to see a slowly developing and slowly resolving pneumonia as to see one of the sthenic type that attacks one lobe with a rush, has a crisis in a seven, eight or nine days, and then a rapid resolution. In fact the asthenic type, in which different parts of the lung are involved but not necessarily confined to or even equivalent to one lobe, is perhaps the most frequent form of pneumonia.
The serious acute congestion of the lung in sthenic pneumonia in a full-blooded, sturdy person with high tension pulse may be relieved by cardiac sedatives, vasodilators, brisk purging, or by the relaxing effect of antipyretics. Venesection is often the best treatment.
When the sputum almost from the first is tinged with venous blood, or even when the sputum is very bloody, of the prune-juice variety, the heart is in serious trouble, and the right ventricle has generally become weak and possibly dilated. The heart may have been diseased and therefore is unable to overcome the pressure in the lungs during the congestion and consolidation.
There is a great difference in the belief of clinicians as to the best treatment for this condition. It would seem to be a positive indication for digitalis, and good-sized doses of digitalis given correctly, provided always that the preparation of the drug used is active, are good and, many times, efficient treatment. Small doses of strychnin may be of advantage, and camphor may be of value. In the condition described, however, reliance should be placed on digitalis. Later in the disease when the heart begins to fail, perhaps the cause is a myocarditis. In this condition digitalis would not work so well and might do harm. It is quite possible that the difference between digitalis success and digitalis nonsuccess or harm may be as to whether or not a myocarditis is present.
If the expectoration is not of the prune-juice variety and is not more than normally bloody, or in other words, typically pneumonic, and the heart begins to fail, especially if there is no great amount of consolidation, the left ventricle is in trouble as much as the right, if not more. In this case all of the means described above for the prevention of any dilatation of the heart will be means of preventing dilatation from the pneumonia, if possible. The treatment advisable for this gradually failing heart is camphor; strychnin in not too large doses, at the most 1/10 grain hypodermically once in six hours; often ergot intramuscularly once in six hours for two or three doses and then once in twelve hours; plenty of fresh air, or perhaps the inhalation of oxygen. Oxygen does not cure pneumonia, but may relieve a dyspnea and aid a heart until other drugs have time to act.
If there is insomnia, morphin in small doses will not only cause sleep, but also not hurt the heart. In the morning hours of the day the value of caffein as a cardiac stimulant and vasocontractor, either in the form of caffein or as black coffee, should be remembered. Strophanthin may be given intravenously.
One of the greatest cares in the treatment of heart failure in pneumonia should be not to give too many drugs or to do too much.
The treatment of shock will probably always be unsatisfactory as the cause is so varied, and, although circulatory prostration and vasomotor paresis always constitute the acute condition, the physiologic health of the heart and blood vessels is so varied. The patient in shock has low temperature, low blood pressure, and a pulse either rapid or slow, but excessively feeble; the face is pale, the surface of the body cold, and there is more or less clammy perspiration; there may be dyspnea and cardiac anxiety, or the patient may hardly breathe.
An acute cause, as terrible pain or hemorrhage, must of course be stopped immediately. There is more or less anemia of the brain, and therefore the legs and perhaps the lower part of the body should be elevated. It may even be wise to drive the blood from the legs by Esmarch bandages into the rest of the circulation. As there is always more or less paresis and dilatation of the large veins of the splanchnic system, a tight bandage about the abdomen is of great advantage in raising the blood pressure to the safety mark.
Strophanthin, given intravenously, is valuable as a quick restorative of the heart. Digitalis is so slow that it is of little value in an emergency. Camphor hypodermically, and hot liquids (nothing is better than black coffee) given by the mouth, are valuable remedies. The camphor may be repeated frequently. Strychnin, the long-used stimulant, should generally be given, but in not too large doses and not too frequently repeated; 1/30 grain hypodermically is generally a large enough dose; this dose may be repeated in three or four hours, but should ordinarily not be given oftener than once in six hours. An aseptic preparation of ergot given intramuscularly is most efficient in raising the blood pressure and aiding the heart. One dose of brandy or whisky may do no harm. Alcohol, however, should not be pushed.
A most important procedure in all kinds of shock is to surround the patient with dry heat, hot-water bags, and hot flannels; gentle friction of the arms and legs, unless the patient is too exhausted, may be of benefit. A hot-water bag to the heart is always a stimulant. Sometimes friction over the base of the heart in the region of the auricles is of benefit.
If the collapse is not acute and there is gradual profound prostration, or if the patient is improved but still in a serious condition of shock, too energetic measures must not be used; neither should too many drugs be administered, or drugs in too large doses. Absolute quiet and the administration of liquid nourishment in but small amounts at a time are essential.
The hypodermic administration of epinephrin solutions, 1:10,000, or solutions of pituitary extract, 1:10,000, should be considered; they are often valuable.
If the shock occurs in ether or chloroform anesthesia, the vasopressor stimulating effect of inhalations of carbon dioxid gas may be considered, as advised by Henderson."
If the shock is due to hemorrhage and the hemorrhage has ceased, a transfusion of physiologic saline solution is generally indicated. Transfusion of blood under the same conditions is still better. Rarely is transfusion indicated in shock from other causes; it often adds to the difficulty rather than improves it. Occasionally if shock is decided to be due to a toxemia, the toxin may be diluted by the withdrawal of a small amount of blood and the transfusion of an equal amount of saline solution.
This condition is not well understood, nor is its frequence known, but not a few instances of shock are due to dilatation of this organ. The shock to the heart may be a reflex one through the pneumogastric nerves.
It perhaps not infrequently occurs after abdominal operations and is more or less serious, the symptoms being persistent vomiting, upper abdominal distention and collapse. The vomiting is of bloody or coffee-ground material.
Sometimes the ordinary treatment of the collapse and washing out the stomach save the patient; at other times the patient with this series of symptoms dies in spite of all treatment.
It has been shown that acute dilatation of the stomach may occur in pneumonia, and may be one of the causes of cardiac collapse in pneumonia.
When the condition is diagnosed, the treatment would be that of shock plus abdominal bandage and washing out the stomach with warm solutions, if the patient is not too collapsed, or at any rate the frequent administration of hot water in small quantities.
Sometimes when the stomach is dilated the pylorus becomes insufficient, and bile regurgitates into the stomach, and is a cause of the profound nausea and vomiting arid the subsequent collapse. In these cases
114. Henderson: Am. Jour. Physiol., February and April, 1909. not infrequently small doses of dilute hydrochloric acid seem to aid the pylorus to maintain its normal contraction, the regurgitation of bile does not take place, and the stomach may soon acquire a more normal muscle tone. Not infrequently when a stomach is in this kind of trouble and all the foods are rejected, and yet the patient seriously needs nourishment, a warm, thin cereal, as oatmeal or gruel or something similar, may be retained. Such patients, as has been repeatedly stated, need starch as soon as possible, lest an acidosis develop.
In these vomiting and collapse cases the hypodermic administration of morphin and atropin will not only stop the vomiting, at least temporarily, but will also give necessary rest. The dose of morphin need not be large, and the atropin may prevent nausea from the drug.
While no physician likes to give an anesthetic to a patient who has valvular disease of the heart, and no surgeon cares to operate on such a patient unless operation is absolutely necessary, still in valvular disease with good compensation the prognosis of either ether or chloroform narcosis is good.
When there are evidences of chronic myocarditis or a history of broken compensation and the borderline of compensation and dilatation is very narrow, or when there is arteriosclerosis, the danger from an anesthetic and an operation is much greater; it may be serious, in fact, and the decision must be made whether or not the operation is absolutely necessary. Under any circumstances it is understood that the anesthetist must be an expert, as there can be no carelessness and nothing but the best of judgment in causing anesthesia when there is cardiac defect.
The anesthetic to select is a subject for careful decision, as one cannot assert which anesthetic is the best.
While chloroform seems occasionally to cause a fatty degeneration of the heart, or if given too rapidly at first may cause sudden death, especially in cardiac weakness, ether has its disadvantages, owing to the increased tension (especially if there is likely to be much valvular or cerebral excitement), and the greater amount of ether that must be given, with the attendant danger to the kidneys, which may have been disturbed from the cardiac conditions. Generally, however, the better method is perhaps to administer first chloroform to the point of producing sleep and then to change to ether, the first mild chloroform narcosis preventing the ether from causing acute stimulation, and ether being better for the operation, as it is more of a stimulant. Some anesthetists believe that it is better to administer morphin, with perhaps atropin hypodermically before the anesthesia, and then to use ether. Nitrous oxid gas would be contraindicated as tending to increase arterial pressure, and therefore endanger a damaged heart; it is a serious danger to damaged blood vessels.