IT WAS, I believe, Herophilus who in 300 B.C. said that the best physician is the one who can distinguish between what is possible and what is impossible. Sigerist, Henry E.: “The Great Doctors,” New York, W.W. Norton. 1933, p. 45. In the treatment of congestive heart failure we must realize that only certain things are possible and they are made possible only by medication which is physiologic in nature. If we fail to face that fact our patient will fail to improve.
The treatment of congestive heart failure can be divided into several general divisions and I shall go over them briefly, with the chief object in view of being practical.
The first need is rest. Complete rest is essential. It acts by lessening mental and physical strain and also by lowering the metabolic demands. The cardiac patient usually rests more comfortably sitting up in an erect or almost erect position. The exact reason for this is not clear but I occasionally encounter patients who are lying flat, warned not to move because of the erroneous idea that a change in position might be dangerous. The patient should not sit up by his own effort but can easily be raised not sit up by his own effort but can easily be raised to a sitting position and his breathing will then be much freer.
Complete rest should be prolonged, first, until there are no signs of congestive failure: no leg edema; and then beyond that until, by carefully testing him out, you determine that he can be active without sending the heart rate much above 90 for any length of time. Activities should be resumed very gradually but in the absence of signs and symptoms you are safe in letting the patient do what he may be able to accomplish without accelerating the hart rate above 90. It will do no harm to send the heart rate above this level if it returns to normal within a minute or two. Tachycardia which indicates that this type of patient has attempted too much will usually persist much longer than a few minutes.
The second factor in treatment is diet. A low-calorie diet apparently has some advantages as it tends to lower to basal metabolic rate. In congestion heart failure it tends to be somewhat above normal in many cases. On the other hand, adequate nutrition must be provided in a form permitting assimilation with the minimum of digestive work. For this purpose sugar is desirable, but cane sugar often aggravates digestive disturbances. Lactose is preferable and may be given with fruit juices. The various dextri-maltose foods used for infants are very helpful during the early period of treatment.
Gradually the diet can be enlarged in the direction of a standard bland diet. This eliminates raw foods, foods rich in roughage, salty foods and in general those that tend to produce gas. As the diet is enlarged we must keep in mind the following rules: avoid dilatation of the stomach, take fluids between meals rather than with meals. Take soup in great moderation if at all, and avoid watery dishes such as stewed tomatoes, squash, etc. The intake of fluids must be controlled to prevent gastric dilatation but there is a more important reason which we shall now consider.
Then diet must include the prophylactic treatment of edema. The patient accumulates edema because he takes in more water than he excretes. We get rid of water in three ways: by the water vapor in respiration, by evaporation from the skin, and by the kidneys. The kidneys eliminate approximately 75 per cent of the fluid output. As they are the chief factor, we cannot safely restrict fluids until we are certain that he kidneys are competent.
A simple concentration test will answer the question as far as the kidneys are concerned. The two-hour renal test is cumbersome and tedious and I have used a much simpler one described originally by Fishberg. 2 Fishberg, Arthur M.: “Hypertension and Nephritis,” Phila., Lea & Febiger, 1930, p.45. The patient is given a dry protein dinner in the evening with six ounces of fluid and nothing further to ear or drink until the following morning. The first morning specimen collected under these circumstances should reach a specific gravity of 1.022 or higher.
It is does, the kidney can concentrate well and fluids may be safely restricted. If the specific gravity is lower, confirmed by repeating the test, the kidney concentrating power is probably impaired and the practical conclusion is twofold: determine the blood urea nitrogen and meanwhile permit two quarts of fluid as uremia is worse for the patient than edema.
Thus we can check up on kidney concentrating power by a simple clinical test which does not require technical laboratory assistance and then we must decide how much fluid to give per day. We can restrict fluids absolutely to 1,000 cc. or possibly to 800 cc., which is the maximum reduction you can usually make for a week or ten days at a time. On the long run you usually have to permit a liter or a quart a day. Another method of determining the amount of fluid that is desirable in chronic cases has the advantage of playing a game with the patient.
He may be told that he can have as much no drink as he has put in ounces of urine the day before. If he has voided thirty ounces of urine he has also eliminated ten or twelve ounces more by respiration and perspiration. If the amount taken in is equivalent to the urine output be will therefore bail himself out to the extent of 25 per cent more than he is given. In limiting fluids it is important to count liquids in other foods. Fruit should be counted as 50 per cent liquid and it is wise to avoid watery vegetables as already noted.
In the prevention of edema it is important to reduce the salt intake. An absolutely salt-free diet cannot be attained and it would have the disadvantage of producing a complete loss of appetite. Unless edema is increasing, food many be cooked with the ordinary amount of slat but none should be added when served. In general I am not in favor of the substitutes for salt which contain sodium mallate or the like.
These cannot be cooked, as they decompose in cooking and the taste is not satisfactory. Moreover, as far as we know it is the sodium ion which tends to hold fluid and not the chlorine ion, so that other salts of sodium are equally undesirable.3Loeb: “Medicine,” vol. 2,p. 171, 1923. For other references see Fishberg, Arthur M.: “Hypertension and Nephritis,” Phila., Lea & Febiger, 1930, p.45. p.85.
With the patient at complete rest on a low-calorie diet made upon food that is easily assimilated, with care to limit the fluid and salt intake, a certain degree of improvement will follow. Medication must do the rest.
As a typical case, I shall consider the patient with auricular fibrillation, as the onset of this arrythmia is responsible for the occurrences of chronic congestive failure in many cases. The mainstay of drug treatment here is digitalis.
The clinical pharmacology of digitalis may be explained by a very homely comparison, which is not strictly true but which is near enough to the truth to serve as a practical guide. If we desire a therapeutic effect from digitalis we must bring about a certain degree of saturation of the myocardium. The art of administering digitalis in these cases consists in producing a useful degree of saturation without exceeding it.
The comparison which I have referred to is this: let us suppose we have a quart pail with a small hole in the bottom of it. We shall assume for the same of argument that the hole permits one ounce of fluid to leak out daily. Let us suppose further that we put an ounce of water in the pail each day.
At the end of the first day the ounce of fluid has leaked out and at the second day the second ounce out and at the end of the second day the second ounce of fluid has leaked out and if you go on putting an ounce a day into this pail, it will remain empty at the end of each day. This corresponds to the physician who gives his patient five drops of the tincture of digitalis three times a day. He will not reach any useful degree of saturation and may conclude that the drug is ineffective.
To return to our comparison, let us suppose that we now put in the pail two ounces a day. At the end of the first day one ounce will have leaked out but one ounce is left in it; at the end of the second day another ounce has leaked out but a second ounce remains and thus at the end of thirty-two days, the thirty-two-ounce pail will be full. If now on the thirty-third day we add two ounces, the pail will run over. This corresponds again to the physician who was given his patient thirty to forty minims of digitalis twice a day.
He observes the patient improve steadily until the second, third or fourth week, and then sudrabbits suffering from some type of endocrine imbalance which prevents them from reacting to the test. She believes that steinization looked for, as it is possible for certain non pregnant conditions to give haemorrhagic follicle formation within the heart and thereafter give a daily maintenance dose to maintain the useful degree of drug effect.
In a large number of clinic cases we have found that the daily maintenance dose is approximately two eat units which corresponds to three grains of the powdered leaf or thirty minims (sixty drops) of a good tincture. To produce saturation, therefore, we must give more than this maintenance dose at first. If the common 12 grain tables of a standard preparation are used, at least three a day will be required at first and it is often desirable to give four a day, two in the morning and two in the evening.
As you approach saturation the best guide is the heart rate and this must be determined in fibrillators by listening at the apex. When the rate begins to approach normal, 80 to 70, stop the digitalis for a day or two (stop it completely and do not simply reduce the dose) and the then give three grains a day. If the rate creeps up, it will indicate that the maintenance dosage in this particular patient is more than three grains a day.
If the rate falls below 60, it will indicate that the maintenance dosage is less than three grains a day. Thus you can experiment by giving one tablet one day and two the next or give two tablets as a dose five or six times a week. The slow method of digitalization which has just been outlined is usually the best.
The rapid method is more dramatic but is not often needed. In an urgent case with a very rapid ventricular rate, of 140 or more, with great discomfort a nd rapidly increasing passive congestion, the rapid method may be used. One simple form is to order a dram of tincture of digitalis every six hours until the apex rate is 90 or less. One, two or at most three doses will accomplish this result. Another method assumes that ten can units or ten tablets of 12 grains each will saturate or nearly saturate your patient.
Space the doses six hours apart, counting the heart rate at the apex before each dose and give five tablets for the first dose, three for the second and two thereafter every six hours until the heart rate has been reduced to 90. Then stop the drug and you will find in twelve hours that the rate will probably be 70 or less. In this way patients can be digitalized within eighteen or twenty-four hours very safely. After waiting another day the maintenance dosage will have to be started, beginning with three grains a day until the exact individual requirement can be determined by trial and error.
In using the rapid method it is simpler to follow a general rule rather than to attempt any calculation based upon the patient s weight. Such calculations give a false sense of security because the individual differences in susceptibility of patients will always; defy calculation. In all these methods we follow the counsel of Withering. Withering, Wm.: “An Account of the Foxglove and Some of Its Medicinal Uses: with Practical Remarks on Dropsy and Other Diseases,” Birmingham, M. Swinney, 1785. to give the drug until we get the effect desired, pushing it consistently until we get that effect.
The common errors in digitalis dosage have already been mentioned. Insufficient dosage without ever securing an adequate effect is the first. The second mistake is to continue large doses which are necessary for saturation but which produce toxic symptoms if they are continued beyond the point of useful saturation of the heart muscle.
We know that many cases of heart disease will secure benefit from moderate or even small doses of digitalis without even approaching complete myocardial saturation but these cases are not the ones that you encounter in bed will swollen legs, large liver or moist Rales at the lung bases.
When digitalis has done all that it can without bringing about the relief we have hoped for, we must go a step further by the use of diuretics. It is not logical to attempt a direct attack before digitalis has brought the circulation up to its optimum efficiency as the kidneys cannot get rid of fluid that is not brought to them. On the other hand the peripheral edema as well as the stasis in the kidney seems to acts as a peripheral block so that digitalis may not be able to exert all its effects without the assistance of diuretics. Digitalis has no direct diuretic action upon the kidney in therapeutic doses.
It produces an increase in the output of urine by its action on the circulation, by bringing more fluid to the kidneys. In this sense it is an indirect diuretic but cannot properly be called a diuretic drug. It is wise to give digitalis for two or three days at least before considered diuretic medication, and, if improvement is evident, the use of diuretics may be postponed.
The most effective diuretic which can be given by mouth is theocin. It may be ordered in capsules containing four or five grains to be taken three time a day immediately after food. Irritation of the stomach is an occasional effect of theocin and therefore it is important to give it after meals. It should not be continued for more than three to five days at a time so as to avoid renal irritation and it is wise to watch the urine for showers of red cells during treatment. If a course of theocin lasting four or five days has not had any effect, stop the drug and avoid diuretic measures for at least forty-hours, so as to give the kidneys a rest.
If theocin by mouth is not effective, we must turn to one of the diuretics used intravenously or intramuscularly: Salyrgan or Mercupurin. These may be given by deep intramuscular injection, but an eschar is always a possibility. If the veins are readily accessible, intravenous use is to be preferred. A dose of 2 cc. should be given first, followed in twenty-four or forty-eight hours by 1 cc. A dose of 1 or 2 cc. may then be given every second or third day. If is possible to keep chronic cases in comfort by a weekly injection over long periods. I have had several patients with irreducible congestive failure who have had their edema kept within comfortable limits by this medication.
The effect of these strong diuretics will be enhanced by preparatory treatment: ammonium nitrate or ammonium chloride in doses of at least fifteen grains three times a day for a few days before the intravenous injection. Enteric coated tablets containing 72 grains of either of these salts are available and the patients should receive two or more tablets per dose. If well tolerated he may take three or four tablets three times a day over long periods.
When the diuretic effect has been secured i t can often be maintained by the use of urea in 50 per cent solution, one to two ounces or more per day. For psychologic reasons the nature of the drug should not be revealed to the patient. The taste can best be disguised in sarsaparilla, in my experience, although orange juice and beer can be used as vehicles. I have observed that patients maybe disturbed at night by the need to urinate when area is given in the afternoon or evening. As a rule, therefore, I divide the daily ration of urea, which may be as much as four or six ounces of the 50 per cent solution, into two doses, one to be taken with breakfast and the second after lunch.
The daily use of urea may be necessary in some cases in order to control edema.
The term irreducible congestive heart failure which I have just used is a confession that all these methods of treatment (rest, limitation of fluids and salt, digitalis and diuretics) may be ineffective. Even than the outlook is not necessarily hopeless as we have another method in reserve. Blumgart and his associates in Boston deserve credit for the pioneer work on this problem. They have attempted to control congestive heart failure by reducing the basal metabolic rate. To accomplish this, total thyroidectomy has been successful in a large series of cases. Bulgmart, H.L., Riseman, J.E.F., Davis, D., and Berlin,.
A low basal metabolic rate from our present point of view means practically that the tissues are content with an amount of oxygen which is less than they would demand if the metabolic rate were higher. The speed of the blood flow determines the rate of oxygen supply tot he tissues. If the rate is low the tissues may be satisfied by the reduced amount of oxygen furnished by an impaired circulation. Thus removal of the thyroid gland by reducing the metabolic rate will bring the demands of the tissues within the capacity of the circulation when it is impossible to raise the efficiency of the circulation beyond a certain subnormal limit.
This is a new and novel attack on the problem of heart failure and has proven to be effective in a fair percentage of cases. In two cases which I have observed the patients were bed-ridden, one for nine months, the other for over a year. After total thyroidectomy they are both up now, able to carry on moderate activities without excessive dyspnea or other distress. The fear of undesirable effects following the operation is apparently unfounded. These patients do not become mentally sluggish if the basal metabolic rate is kept at about minus 25 per cent. A small daily dose of thyroid suffices for this.
The growth of hair is slower and men who have had to shave daily may only have to shave once or twice a week after a total thyroidectomy. These side effects are never troublesome and cannot weigh in the balance against the advantages. These must be considered from the point of view of the bed-ridden patient who up to this time had had irreducible or constantly recurring heart failure, and who has had nothing to look forward to except invalidism, a progressive downhill course and a fatal termination. Removal of the thyroid does not produce a cure but it does bring about a balance between the demands upon the circulation and the ability of the heart to supply these demands so that something approaching relative health is made possible.
The problem of congestive heart failure can never be solved completely. The first need is rest with limitation of fluids and salt. In addition, digitalis frequently suffices; if not, diuretic medication is in order. If, in spite of all these measures, failure recurs or persist, total thyroidectomy demands careful consideration.