Acute Heart Attack : Diet, Elimination, Physical Measures

Disturbances of the Heart
by Oliver T. Osborne, M.D.

(Page 11 of 24)

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.