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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.

Shock

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.

Tags: Heart Disease