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.
