(A) Perfect Compensation

Under these circumstances the patients are well, living an ordinary life, more or less, and in some of them no special care in diet seems necessary. It is always wise, of course, to avoid excess in either eating or drinking, and what has been said when speaking of the regulation of the diet according to the cause of the heart lesion is applicable to those whose hearts, although diseased, are causing no symptoms. In many compensated cases, however, probably in most, rather special care in matters of diet becomes necessary. Even where there are no symptoms, or when they are so slight as not to interfere seriously with the daily life, there is sufficient backpressure to cause a chronic engorgement of the stomach, intestines and liver. Catarrh, arising from various causes, is very apt to occur under such conditions. It is, therefore, important to insist upon special attention being paid to the care of the teeth, prevention of oral sepsis, regularity and digestibility of food and to the avoidance of excess in eating or drinking, as well as the avoidance of mental or physical work in close connexion with a meal.

(B) Disturbed Compensation

It constantly happens that indigestion is one of the first signs to warn us that failure of compensation is imminent, or may first draw attention to the true state of the heart. All that has been said with regard to care in dietary becomes more important under these circumstances. In some cases there is intolerance of food, or such an amount of dyspepsia that the diet has to be chiefly fluid for a time. The continued use of irritating drugs, such as digitalis, may have made matters worse and it may be necessary to discontinue their administration by the mouth in order to get the stomach into a condition fit to digest food. As soon as possible solid, easily digestible food should be given in place of fluids, as better nourishment is needed, and it is often necessary to limit the amount of fluid taken. What has been said with regard to distension of the stomach and intestines with wind must be remembered here; and if fluid food, especially milk, is found to be causing it, measures must be taken to render it more easily assimilable by the addition of lime-water, bicarbonate or citrate of soda, peptonizing it, or it may be necessary to discontinue its use altogether for a time. However careful we may be with the diet, the symptoms will not be relieved unless, and until, the back pressure congestion is relieved by returning compensation aided by free purgation, so that the whole of the portal circulation may be eased by copious evacuations.

(C) Extreme Failure

There are no heart cases so difficult to feed as some of those in which there is complete failure of compensation, though fortunately this is not always so. The need for nourishment in order to promote returning strength is great; but such is the state of the digestive tract that the greatest care must be used so as to prevent complete intolerance of food. The tongue is frequently thickly coated, reflecting the condition of the stomach, and in some cases there may be vomiting or even haema-temesis. It is well not to pay too much attention to the state of the tongue, as it will often be found that patients are able to take and digest their feeds well, although the tongue is very coated. Attention has already been drawn to the wisdom of feeding acute cases in young subjects liberally and rather early in the convalescence. Similarly in some instances of complete failure of compensation, where the state of the digestive tract would seem to contra indicate food, nevertheless it will be found that food is well borne and that improvement results from an increased amount of it. Where, however, there is definite intolerance of food, it is best, for the time, to stop all food and drugs by the mouth and to resort to hypodermic medication and rectal feeding. Later predigested food (peptonized milk and beef-tea) may be tried, but the return to ordinary food must be attempted very gradually indeed.

Alcohol

It is in these cases of failing heart that we have the greatest need for alcohol. Many will prefer to use such drugs as digitalis, strychnine, aether and ammonia before resorting to its use, but most of us must admit that there are a good many cases which will not respond to the drugs mentioned above, and in which we are forced to have recourse to alcohol in some form or another.

Its advantages may be summarized as follows :

1. It will sometimes raise the force and quiet the tumultuous action of a failing heart when drugs have failed.

2. It frequently eases pain and distress as nothing else will.

3. In many cases it promotes sleep better and more safely than hypnotics.

4. Although it cannot be counted as a food, it often takes the place of and, temporarily at any rate, does away with the necessity for food.

Its dangers are these : -

1. It sometimes irritates the stomach and causes intolerance of food, at the same time engorging the liver.

2. It occasionally produces an exciting rather than a soothing effect on the nervous system.

3. Its prolonged use instead, or at the expense, of food will eventually precipitate and intensify complete cardiac failure.

It must not be understood that the indiscriminate use of alcohol is here advocated, but it is attempted to put it in its proper place as a most useful drug, to be used with discretion under circumstances where nothing that we know of answers quite the same purpose.