STUBBORNNESS IS THE BACK SIDE OF A VIRTUE (Congestive Heart Failure)
This insight arose decades ago from a farm patient with congestive heart failure. She was a widow who had been running the farm herself for some years. Her heart failure was severe and demanded hospitalization, which she stubbornly refused. Her situation was complicated by rapid irregular heart action, probably of recent onset that had set the stage for her dropsy, the old name for congestive heart failure. When we doctors realized that modern diuretics were quite successful as a treatment, we started calling it congestive heart failure to avoid consternation of old timers who remembered dropsy as a death sentence.
Out of respect for her autonomy, and realizing that no other physician was going to persuade her to accept the hospital, I immediately gave her long, detailed oral and written instructions which she followed stubbornly. Her rapid irregular heart action called auricular fibrillation was treated with digitalis in those days before cardioversion. To avoid overloading her mental circuits, I didn’t try to explain loading dose used with long acting medications such as digitalis when a prompt effect is essential. So I gave the loading dose as a “separate” treatment using different colored pills from the maintenance dose of digitalis. But she mastered the concept of using diuretics (water pills) depending on “dry weight”. Dry weight is what daily weighings settle down to as the swelling of the legs subsides. At that point, she reduced the dose of diuretics to avoid overdose effects. With continued daily weighings to guide her, the perfect dose was achieved in a few weeks. Later on, she learned just how much extra diuretic to take for a restaurant meal or a church potluck because there, she got much more salt than at home where she was following instructions about low salt. The benefits of low salt were discovered when I was a medical student in the 1940's. This was the beginning of the modern treatment of dropsy.
When I ask older folks for their recollection of which of their classmates were sent to the principal’s office for misbehavior, they can scarcely remember a girl being sent. This, I explain, is because girls have more respect for authority than boys. But this respect has it’s backlash when it comes to the printed word in the recipe book versus the doctor’s instructions. I have found that the vast majority of the ladies make the same compromise: half the salt specified in the recipe. I usually get my way when I explain that only sauerkraut and pickles demand salt and it can be left out of all other recipes. Salt free bread is hard to obtain unless you make it yourself. Don’t write to me to explain that the yeast won’t rise without salt because I make the bread in our family with and without salt and it rises just the same.
Congestive heart failure starts with reduced blood flow (cardiac output). In the kidneys, the result is reduced salt and water elimination leading to the accumulating swelling. In recent years, we have found that some of the new blood pressure medications increase cardiac output even when given in the absence of high blood pressure thus getting at underlying causes better than diuretics do.
Now back to stubbornness and digitalis. Because of it’s prolonged action, missing a dose or two or three is not a test of whether it is still needed. In this lady’s case, a few weeks after stopping digitalis, the rapid heart action would have recurred. Digitalis merely controls the rate, and the irregularity from auricular fibrillation persists. Her stubbornness also prevented this hazard. She returned for annual checkups and refills and died of old age many years later. Ever since meeting her, I have enjoyed defending stubborness. I have decided that I might be called an honorary farmer but that is another story.
John A. Frantz
Chairman, Monroe Board of Health
March 30, 2001