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Alfred Vogl, M.D.; Paul Esserman, M.D.
JAMA. 1951;147(7):625-630. doi:10.1001/jama.1951.03670240009003.
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Management of the persistently edematous patient in an advanced stage of congestive heart failure presents a serious problem frequently encountered in medical practice. Such a patient is commonly considered refractory to treatment when he no longer responds to the combined use of bed rest, low salt diet, adequate digitalization and repeated mercurial injections. In particular, the lack of an adequate response to mercurial diuretics is generally regarded as an ominous sign,1 indicating that the terminal stage of heart failure has been reached. Since all other measures are generally regarded as auxiliary to digitalis therapy, the most rigid criteria of full digitalization must be fulfilled before a therapeutic regimen can be called a failure.

Whenever it can be established that inadequate digitalization is not at fault, different therapeutic approaches must be considered. There are on record cases in which serum sodium reached abnormally low levels as a result of repeated


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