Before these patients get up, after a period of bed rest, slight exercises should be done, perhaps resistant exercises, to see what the effect is on the heart, and also gradually to cause increase in cardiac strength, much as any other training exercise. Whatever exercise increases the heart rate more than twenty-five beats is too strenuous at that particular period. The exercise should then be still more carefully graduated. If the systolic blood pressure is altogether too low for the age of the person or for the previous history, it should be allowed to become higher, if possible, before much exercise is begun.
The diet should be nutritious, but, of course, modified by the condition of the stomach, intestines and kidneys, and whether or not the patient is obese. The bulk of the meal should be small, and nutriment should be given at three or four hour intervals during the daytime.
The Karell milk diet or so-called "cure" was first presented in 1865 by Phillippe Karell, physician to the Czar of Russia. This treatment was more or less forgotten until lately, when it has been more frequently used in kidney, liver and heart insufficiency. Its main object in kidney and heart disease is to remove dropsies. In cardiac dropsy it is advised to give 200 c.c. of milk for four doses at four hour intervals, beginning at 8 o'clock in the morning. Whether the milk is taken hot or cold depends on the desire of the patient. This treatment is supposed to be kept up for six days, and during this time no other fluid is given and no solid food allowed. During the next two days an egg is added to this treatment, given about 10 o'clock in the morning, and a slice of dry toast, or zwieback, at 6 p. m. Then up to the twelfth day the food is gradually increased, first to two eggs a day, then more bread, then a little chopped meat, then rice or some cereal, and by the end of two weeks the patient is about back to his ordinary diet. During this period the bowels are moved by enema or by some vegetable cathartic, or even castor oil. If thirst is excessive, the patient must have a little water, and if the desire for solid food is excessive, even Karell allowed a little white bread and at times a little salt. He sometimes even prolonged the period of treatment to five or six weeks.
Various modifications of this treatment have been suggested, such as skimmed milk, and more in quantity, or a cereal is added more or less from the beginning, and perhaps cream. The diuretic action of this treatment is not always successful. Also, sometimes the treatment is even dangerous, the heart and circulation becoming weaker than before such treatment was begun. Certainly the treatment should be used in cardiac insufficiency with a great deal of care, although it is often very valuable treatment. It should be emphasized that most patients with cardiac dropsy receiving the Karell treatment or a modification of it should also receive digitalis in full doses, and should have daily free movement of the bowels. It should be urged, however, that too free catharsis in cardiac weakness is to be avoided, and the prolonged use of salines, and sometimes even one administration is contraindicated. Before cardiac failure has occurred in this disease, once a week a dose of calomel or a brisk saline purge is advisable, and is good treatment; but when cardiac weakness has developed, free catharsis is rarely indicated, although the bowels should be daily moved, and vegetable laxatives are the best treatment. The upper intestine and the liver and kidneys may be relieved by a more or less abrupt modification of the diet, or even a starvation period, and the bowels will generally become cleaned; but frequent profuse purging with salines or some drastic cathartic puts the final touch on a cardiac failure.
Recently Goodman [Footnote: Goodman, E. H.: The Use of the "Karell Cure" in the Treatment of Cardiac, Renal and Hepatic Dropsies, Arch. Int. Med., June, 1916, p. 809.] presented a report of his studies of the Karell treatment in cardiac, renal and hepatic dropsies. He finds that patients with uremia ordinarily should not be subjected to the Karell cure, such patients needing more fluid.
As long as the patient remains in bed, and as long as his ability to exercise is at a minimum, gentle massage is advisable.
In these cases of cardiac weakness, with or without dropsy, unless the diastolic pressure is very high, digitalis is valuable. If there is no cardiac dropsy, but other symptoms of heart tire are manifest and the blood pressure is high, the nitrites are valuable. The amount should be sufficient to lower the blood pressure. Sometimes the diastolic pressure is high and the systolic low and the pressure pulse small because of heart insufficiency; such a condition is often improved by digitalis. In other words, with a failing heart digitalis may not make a blood pressure higher, and often does not; it may even lower a diastolic pressure, and the moment that the pressure pulse becomes sufficient, the patient improves. Under this treatment of digitalis, rest and regulated diet, a dilated left ventricle with a systolic mitral blow often becomes contracted and this regurgitation disappears.
The amount of digitalis that is advisable has been frequently discussed. It should be given in the best preparation obtainable, and should be pushed gradually (not suddenly) to the point of full physiologic activity. While it may be given at first three times a day in smaller doses, it later should be given but twice a day, and still later once a day, in a dose sufficient to cause the results. As soon as the full activity has been reached it may be intermitted for a short time; or it may be given a longer time in smaller dosage. In renal insufficiency associated with cardiac insufficiency, its action is subject to careful watching. If there is marked advanced interstitial nephritis, digitalis may not work satisfactorily and must be used with caution. If, on the other hand, a large part of the kidney trouble is due to the passive congestion caused by circulatory weakness, digitalis will be valuable.
In sudden cardiac insufficiency, provided digitalis has not been given in large doses a short time before, strophanthin may be given intravenously once or at most twice at twenty-four-hour intervals.
If, in this more or less serious condition of the heart weakness, there is great sleeplessness, a hypnotic must sometimes be given, and the safest hypnotic is perhaps 3 / 10 grain of morphin. One of the synthetic hypnotics, where the dose required is small, may be used a few times and even a small dose of chloral should not be feared when sleep is a necessity and large doses of synthetics are inadvisable on account of the condition of the kidneys.