Part 7 (1/2)

The increased muscle tone thus caused raises the blood pressure somewhat, and the great depression before breakfast is not experienced. These patients rely oil their morning coffee for bracing. If they have much indigestion at night which keeps them awake so that they do not get good comfortable rest, their largest meals should be the morning and noon meals, and the evening meal should be very light.

Pendent abdomens or ptosed abdominal organs should be held up by proper abdominal bandages or corsets.

If the bowels are constipated, only the vegetable laxatives should be used, if it drug is needed at all. Salines should not be allowed, or other cathartics which cause profuse watery discharges. If a brisk purge is required, castor oil is the best.

Plenty of fresh air, and mild exercises in the open air all tend to increase the pressure. Graded walking, climbing, or other more interesting exercises are advisable, as all tending to raise the pressure, provided that at no time are they carried to the point of exhaustion.

Forced feeding may be useful. Cool sponging in the morning, if there is proper reaction, is often of benefit. Iron may be indicated; bitter tonics may be indicated. Digitalis and strychnin are often of advantage. Caffein may be used as a drug as well as given in coffee and tea. Atropin may be of value in some forms of hypotension.

At times with a low systolic pressure, but a relatively high diastolic pressure, nitroglycerin is valuable.

More or less act.i.te hypotension may occur in hot weather or with overheating, often termed heat exhaustion. Such patients should, if possible, go to a cooler region, whether to the seash.o.r.e or to the mountains is unimportant. The treatment of dangerous sudden low blood pressure, as shock, will be discussed elsewhere.

PERICARDITIS

ACUTE PERICARDITIS

As this inflammation is generally secondary to some other condition, its treatment cannot be positively outlined. Furthermore, it is often a terminal condition, and in such instances the results of treatment are of necessity nil. The most frequent terminal cause is nephritis; other terminal causes are pulmonary tuberculosis, adjacent abscesses, cancer or other growth.

The most frequent infectious cause is rheumatism; other infectious causes are cerebrospinal fever, typhoid fever, acute miliary tuberculosis, pneumonia and Sepsis. Accidental causes are traumatism and an adjacent inflammation of the pleura.

The result of an inflammation of the pericardium may be a fibrous exudate, or an exudate which is both serous and fibrous, or one in which pus is present in considerable amount.

The onset of pericarditis may be more or less acute, or it may commence insidiously. For this reason, during severe illness, and especially in those diseases which are known to have pericarditis often as a sequence, frequent examination of the heart should be made as a routine procedure.

SYMPTOMS AND SIGNS

If there is pain or much aching in the cardiac region, it tends to disappear with the exudate, if such is to occur, in the same way as does the pain of pleurisy. If there is much exudate, the pressure on the heart of course increases, the cardiac dulness enlarges, dyspnea occurs and even perhaps later cyanosis. As the exudate acc.u.mulates, the patient must lie higher and higher in order that the fluid may gravitate to the lowest part of the sac and give the heart the greatest ability to work. Reflex pain may occur from disturbances of the pneumogastric nerve, or from the weight and pressure of the enlarged and heavy pericardium. Reflex vomiting may be a troublesome and distressing symptom.

Acute pericarditis occurring in rheumatism, in acute infections, and from simple injuries tends to recovery. In dry pericarditis with serious adhesions, or if adhesions occur as a sequence of acute pericarditis, the future prognosis is bad, as myocarditis may develop and sudden death or acute dilatation may occur. As stated above, if pericarditis develops during the progress of chronic disease, such as interst.i.tial nephritis, or during sepsis, or from abscesses or growths in the region of the pericardium, the prognosis is bad.

TREATMENT OF ACUTE PERICARDITIS

In acute pericarditis, absolute mental as well as physical rest is essential. Even if the patient does not appear to be seriously ill and has not much fever, he should not be allowed to have visitors, to discuss business matters, or to carry on any conversation, however little exciting. Anything which increases the heart beat increases the irritation of the inflamed surfaces of the pericardium. He should not be allowed to sit up, either to eat or to attend to the calls of Nature. These rules are imperative, and when they are followed the pain is less, the heart beats less rapidly, is less hampered by pressure from whatever exudate may be present, and the adhesions which are liable to form will be less in amount and less serious for the future work of the heart.

The treatment, of course, depends largely on the cause of the pericarditis, as, if the cause is one of those just enumerated in which the prognosis is dire, any treatment directed toward the pericardial inflammation is almost useless. The periearditis under these conditions will be more or less benefited, if at all affected, by the treatment directed toward the cause.

The indications for treatment in all other instances are:

1. To attempt to abort the inflammation.

2. To stop the pain.

3. To limit, if possible, the amount of exudate, and to diminish the exudate already present.

4. To diminish the rapidity of the heart and to strengthen it.

1. Abortive Treatment.--For many years bloodletting was considered of the greatest importance in the early treatment of this disease; but owing to the fact that, except from traumatism, pericarditis rarely occurs except as a sequela of acute disease after the patient has been sick along time, or as a terminal condition in a patient who has long been chronically diseased and therefore has already lost more or less strength, venesection has been nearly abandoned.