Disturbances of the Heart Part 14

Hydrotherapy is often of great value in restoring compensation by improving the surface circulation. Sponging with hot, tepid or cold water, as indicated, will increase the peripheral circulation and the normal secretions of the skin.

When compensation is perfect, in valvular lesions, more or less frequent warm baths are advisable, and often relieve the heart by equalizing the circulation. Cold sponging in the morning may be advisable, but may do harm when there is high tension; warm, not too hot, baths are of value. Anything is of value that improves the peripheral circulation and prevents the extremities from being cold.

The value of the Nauheim or other carbonated baths is perhaps often a question. They have seemed in many instances to aid in improving compensation in such patients as have been able to go abroad for the treatment. On the other hand, so many other regimens are ordered and inaugurated for these patients at these "cures" that it is hard to decide how much benefit the baths have really done. At home the artificial carbonated or carbonic acid baths do not seem to be of great value. Baths and bathing can do harm, and the decision as to which hydrotherapeutic measure shall be used can be made only after careful observation of the patient by the physician.

Gentle ma.s.sage while the patient is in bed is of undoubted value; more vigorous ma.s.sage is later often of value, provided there is no arteriosclerosis. As the patient grows stronger and the circulation improves, the muscles are kept in good condition during the enforced rest by ma.s.sage. When properly applied, it promotes not only the venous return circulation, but also the lymphatic circulation; it often removes muscle aches and muscle tire and restlessness.

While the patient is still in bed, various resistant exercises are of value, and should be begun. These tend to prepare the patient for his later greater activities; the surprise to the heart when the patient begins to sit up and walk is not so great if he has previously taken these exercises. Later, when the patient is ambulatory, he should by gradual gradation walk a little more about the house and take a few steps of the stairs at a time, until gradually he is able to mount the whole flight. Later he should take out-door exercise, and when his heart has become compensated for ordinary work, he should be given gradually graded hill-climbing with the idea of increasing his reserve cardiac power. If it is found that these increased exertions cause him to have pain or a more rapid heart than is excusable, even after persisting for a few days, the attempt to increase this reserve power of the heart should be abandoned. There is probably, at least at that particular time, considerable myocarditis, although the heart may eventually recuperate still more. Pushing it to overexertion, however, will not accomplish improvement. Some of the simple "tests of heart strength"

described under that heading may be used with these patients.

Graded exercise was first used scientifically by Oertel and Schott, and has been for years designated by their names. Modifications of their rigid rules are generally advisable.

E. MEDICATION

1. CARDIAC TONICS.-Digitalis: There is no drug that can take the place of digitalis in loss of compensation in chronic valvular disease. It acts specifically for good, and it has its greatest success in the valvular lesions that cause enlargement of the left ventricle, on which it acts the most intensely. It also acts for good on the right ventricle. It has but little action on the auricles. This is simply a question of muscle; the part that has the greatest amount of muscle will receive the greatest benefit from digitalis, and the parts that have the least, the least benefit. The heart muscle is somewhat similar to other muscles; when we attempt athletic improvement in any muscle of the body, we "train" by stimulating it moderately at first, and are careful not to overwork it; the object, then, is to train the heart muscle. For this reason large doses of digitalis should ordinarily not be given to overstimulate suddenly an overworked and weak heart. While in some instances it has been declared that digitalis should be rapidly pushed to the full extent and then dropped for a time, careful experience shows that this method is often not tolerated, sometimes does positive harm, and has at times seemed to hasten death.

Another valuable activity of digitalis is in slowing the heart by action on the pneumogastric nerves. A dilated heart has lost more or less of its regulating mechanism; this is the cause of its irregularity and its increased rapidity. The action of digitalis in slowing the heart, giving it a longer rest, and preventing it from acting irregularly is of great value. This prolonged rest or diastole of the heart allows the circulation in the coronary arteries to become normal, and the nutrition and muscle tone of the heart improves. Digitalis also increases the blood pressure, not only by improving the activity of the heart, but also by causing some contraction of the arterioles. This feature of digitalis action in arteriosclerosis renders its use sometimes a question of careful decision. The dose of digitalis under such a condition should not be large. It may be indicated, however, and may do a great deal of good, and it does not always increase the blood pressure.

If the patient is sufficiently ill to require the best action of digitalis, an active preparation should be obtained. It was long supposed that the infusion presented activities which could not be furnished by the tincture of digitalis. This seems not to be true.

The greater value of the infusion is generally because it is freshly made and active; the tincture which had been used previously in a given case was old and useless; furthermore, most physicians give a larger dose of the infusion than they ever do of the tincture. Owing to the uncertainty of the value of the digitalis leaves found in the various drug shops, however, and to variations in the preparation of the infusion, it is generally better to use a tincture of known character. The beginning dose of such a tincture should generally not be more than 5 drops, and it should not be repeated more frequently than once in eight hours. It is generally advisable, in two or three days, to increase this dose to 10 drops once in twelve hours, later perhaps to 15 drops twice a day, and still later to 20 drops once a day. This amount may then be decreased gradually, if the action is satisfactory. Enough should be given to procure results, and then the dose should be brought down to what seems sufficient and best, administered once a day. The frequence advised in the administration of this drug is because it is eliminated slowly. Its greatest action develops a number of hours after it has been taken, and then the action lasts for many hours; the administration of digitalis once in twenty-four hours is perfectly satisfactory for many patients, and more satisfactory than any more frequent administration. On the other hand, some patients do better on a smaller dose once in twelve hours. This frequence is always sufficient.

Digipuratum and digitol, a fat-free tincture, proprietary preparations accepted by the Council on Pharmacy and Chemistry for inclusion in N. N. R., may be employed. They are standardized preparations and may thus be more satisfactory than some pharmacopeial preparations of digitalis, although their claims to lessened emetic action are not borne out by recent experiments of Hatcher and Eggleston.

Digipuratum may be obtained in tubes of twelve tablets. The advice has been given for patients with loss of compensation to receive four tablets the first day, three the second, three the third, and two the fourth day. This, however, is generally an overdosage. The most that should generally be given is one of these tablets in twelve hours. Digipuratum fluid is also a valuable preparation.

Digitol is a fat-free tincture of digitalis which is physiologically standardized and which bears on each package the date of manufacture. The close is from 0.3 to 1 c.c. (5 to 15 mimims).

Digitalinum, one of the active principles of digitalis, is not very satisfactory. It may be given hypodermically, but often causes irritation, and the proper dose and its value are apt to be uncertain.

Digitoxin, another active principle of digitalis, has been declared by some investigators to be harmful, also to be liable to cause serious disturbance of a damaged heart. Other investigators have stated that it acts for good. Digitoxin does not represent the whole value of digitalis, and in broken compensation digitalis itself, or some preparation embodying the majority of its activities, should be given. Digitoxin, however, is often valuable in conditions of cardiac debility or slight weakening in patients who do not have dilated hearts or edemas. The most satisfactory dose of digalen is from 5 to 10 drops once or twice in twenty-four hours.

Digitalis should not be used when there is fatty degeneration of the heart; it should ordinarily not be used when there is arteriosclerosis, and very rarely, if ever, when it is decided that there is coronary disease. Whether digitalis should be used when there is considered to be much myocardial degeneration is a question for individualization. One can never be sure that the heart muscle is so thoroughly degenerated that no part of it would be benefited by digitalis when compensation is lost; therefore, many times, especially if other drugs have failed, small doses of digitalis should be tried, to see if the heart will respond. Large doses or frequent doses would be contraindicated.

The signs of overaction of digitalis are nausea, vomiting, a diminished amount of urine, a tight, band-like feeling around the head, perhaps occipital headache and coldness of the hands and feet, or frequently of one extremity only, combined with a feeling of numbness. The pulse is generally reduced to sixty or less a minute.

Such symptoms require that digitalis be immediately stopped. They are the primary signs of c.u.mulative action.

While many patients with ordinary dosage of digitalis may take the drug for months and years without ever showing c.u.mulative action, other patients show this effect quickly. They are apt to be those in whom the kidneys are not perfect. The signs of such undesired action may develop slowly, as suggested by the symptoms just enumerated, or they may develop suddenly. The pulse becomes rapid and irregular, the heart action weak, there is severe backache in the region of the kidneys, a greatly diminished amount of urine, or even partial suppression, severe headache, vomiting, cold extremities and shiverings.

The treatment of such an undesired behavior of digitalis is, of course, to stop the drug immediately, give saline laxatives, hot sponging or hot baths, nitroglycerin and perhaps alcohol.

Strophanthus: Strophanthus cannot be compared with digitalis, except when the glucosid, strophanthin, is administered subcutaneously or intravenously. Strophanthus is given either in the form of the tincture, or as strophanthin. It has been shown that in neither of these forms, when the drug is administered by the stomach, is the muscle of the heart or the blood vessels much acted on. Compensation could not be restored by strophanthus. In emergencies of serious cardiac failure, strophanthin intravenously has been shown apparently to save life. It acts quickly, and its power of stimulating the heart and contracting the blood vessels lasts for many hours. It is rarely, however, that the dose should be repeated, and then not for twenty-four hours, but during that twenty-four hours the patient may be saved until other drugs which act more slowly have been absorbed, or perhaps until the emergency has pa.s.sed. It probably should not be given if the patient has previously had good dosage of digitalis.

There are many, however, who believe that they obtain considerable value from the tincture of strophanthus, and there seems to be no doubt that although strophanthus, given in the form of the tincture and by the mouth, may not increase the muscle power of the heart, it many times acts as a satisfactory cardiac sedative. Under its action the patient becomes less nervous, the heart often acts more regularly, and the low blood pressure may improve. We should not be quite ready to discard the internal use of the tincture of strophanthus.

The tincture of strophanthus readily deteriorates, and the preparation ordered should be known to be a good one.

Caffein: This should not be given or allowed, even in the form of tea or coffee, to patients who have valvular lesions with perfect compensation, as it is a nervous and cardiac stimulant and may cause a heart to become irritable. It raises the blood pressure slightly, acts as a diuretic, and hence is often of great value when used medicinally. It should be ranked as a stimulotonic to the heart. It increases its activity, but gives it a little more strength. It will rarely slow a rapid heart; it will often stimulate a sluggish, slow heart; it may increase the irritability of an irritable heart. As it is a cerebral stimulant, it should not be given late in the afternoon or evening, as it may prevent sleep.

The most frequent form of caffein used is the citrated caffein. The dose is 0.1 gm. (1 1/2 grains) two or three times in the early part of the day, or 0.2 gm. (3 grains) once or twice during the morning.

A few much larger doses may be given if desired. A cup of coffee may be given the patient medicinally: as a subst.i.tute for the drug, an ordinary cup of strong coffee containing between 2 and 3 grains.

Other preparations of caffein may be selected if desired, or a soluble preparation may be given hypodermically.

Caffein is indicated if digitalis is contraindicated or does not act satisfactorily, and the patient is not nervously excited, but perhaps is stupid or apathetic, and also when diuresis is desired.

Strychnin: This is a valuable stimulator and heart tonic when properly used. It promotes muscular activity of the heart much as it promotes all muscular activities. It awakens nervous stimuli and nervous transmissions to normal in all sluggish nerve functions. If for these reasons the heart acts more perfectly, and the nutrition of the heart muscle improves, it acts as a cardiac tonic. Many times, by improving the action of the heart, and also by the action of the drug on the vasomotor center, the pressure in the peripheral circulation may be increased. On the other hand, strychnin in the low blood pressure of serious illness, such as pneumonia, by no means always raises the blood pressure.

It should not be forgotten that strychnin is a general nervous stimulant, especially of the spinal cord. If it makes a nervous patient more nervous, or a quiet patient restless and irritable, it is acting for harm and should be stopped, just as caffein under the same conditions should be stopped. Strychnin may cause diminished secretion of the skin. This is not frequent, but it does occur. It may prevent the patient from sleeping. If such be the fact, strychnin is not acting for good in a patient who has cardiac weakness.

INDICATIONS FOR STRYCHNIN

Strychnin is a much overused drug. It is now given for almost everything and during almost every disease. It is true that the administration of strychnin is largely due to the evolution of the age in which we are now living. We have ceased to purge and bleed and sweat, and to give large doses of aconite or veratrum viride; have ceased to starve the patient too long; we have ceased to load him with alcohol to the point of circulatory prostration, and we have recognized that he must be braced from start to finish; strychnin is the drug which has been used for this purpose, and, as stated above, overused. Strychnin given too frequently or in too large doses for a laboring heart can prevent its proper rest; the diastole is shortened and the relaxation of the heart is incomplete, its nutrition suffers, or even irregular and fibrillary contractions of a weak heart may apparently be caused. While a large dose of strychnin, even to one-twentieth grain hypodermically, may be used once in serious emergency when it is deemed the drug to use, a dose larger than one-thirtieth grain hypodermically is rarely indicated, the frequency of such a dose should seldom be more than once in six hours, and a smaller close of strychnin may act more satisfactorily.

Strychnin is indicated when the heart is acting sluggishly and the contractions seem incomplete, and when digitalis either is not indicated or is not acting perfectly. Small doses of strychnin may aid such a heart during the administration of digitalis. In many instances in which digitalis is contraindicated, strychnin is of marked value. This is typically true in fatty hearts, and may be true in arteriosclerosis, in which it often does not increase the blood pressure at all.

2. Cardiac Stimulants.--A cardiac stimulant is a drug which makes the heart beat more strongly and the frequence more nearly normal.

The drugs named as cardiac stimulants, however, camphor, alcohol and ammonia, do not leave a heart better than they found it--they are not cardiac tonics.

Camphor: This is one of the best cardiac stimulants that we possess.

It is a quickly acting nervous and circulatory stimulant, acting princ.i.p.ally on the cerebrum and causing a dilation of the peripheral blood vessels. No subsequent weakness follows after a dose of camphor. Too much will make a patient wakeful, a little often quiets nervous irritability. It should be used as a cardiac stimulant during serious illness more frequently than it has been; and during the endeavor to make a noncompensating heart again compensatory camphor will often act for good. The dose is 2 teaspoonfuls of the camphor-water every three or four hours, as deemed advisable. Each teaspoonful represents a little more than one-fourth grain of camphor. The spirits of camphor, of course, may be used, if preferred.

For cardiac emergencies, ampules of sterile saturated solutions in oil are now obtainable and are valuable. Such hypodermic stimulation acts quickly, and may be repeated every half hour for several times, if the patient does not respond. The solution should be injected slowly, and as a rule intramuscularly.

Many times while other measures are being used to repair a broken compensation, camphor makes a splendid circulatory and nervous bracer. Camphor has long been used as a so-called antispasmodic in hysteric or other nervously irritable persons. It really acts as a stimulant to the highest centers of the brain, promoting more or less nervous control. Perhaps its ability to increase the peripheral circulation may be one of the reasons that it seems at times to be almost a nervous sedative by relieving internal congestion. As just stated, after the camphor action is over there is no depression.

This is not true of alcohol.

Alcohol: It is of course now generally understood that alcohol is not a cardiac stimulant in the sense of its being more than momentarily helpful to a weak heart. If alcohol is pushed when a heart is in trouble, the secondary vasodilatation and more or less nerve prostration and muscle debility will cause greater circulatory weakness than before it was administered.

To obtain cardiac stimulation from alcohol it must be given in strong solutions, generally in the form of whisky or brandy, for local irritation of the mouth, esophagus and stomach; reflexly the heart is stimulated and the blood pressure rises. As soon as complete absorption has taken place, the blood pressure falls. For continuous stimulation, another dose of alcohol must be given before this depression occurs. This may be in from one to three hours. To continue such stimulation, the dose of alcohol must be increased.

The future of such treatment means an alcoholic sleep with depression, alcoholic excitement which is not desired, or profound nausea and vomiting, with peripheral relaxation and cold perspiration.

Obviously none of these conditions is desirable; but in arteriosclerosis, or when the blood pressure is high and the heart labors tinder the disadvantage of contracting against an abnormal circulatory resistance, alcohol may act perfectly to relieve this kind of circulatory disturbance. In this condition the alcohol should not be given concentrated, and as soon as it is thoroughly absorbed vasodilatation occurs, peripheral circulation and therefore warmth are increased, and the heart is relieved of its extra load.

In such instances, in proper doses not too frequently repeated, rarely more than 1 or 2 teaspoonfuls every three hours, alcohol is a valuable drug. Such good action of alcohol is often seen when the surface of the body is cold from chilling, or the extremities are cold from vasomotor spasm. A good-sized dose of alcohol, best given hot, equalizes the circulation and acts for good. On the contrary, it is obvious that, if the patient is cold from collapse and there is cold perspiration and very low blood pressure, alcohol is not the drug indicated, although one dose may be of benefit while other more slowly acting cardiac tonics or stimulants are being administered.

During serious prolonged illness and when the patient has not had sufficient food and is not taking sufficient food, alcohol in the form of whisky or brandy, not more than a teaspoonful every three hours, acts as a necessary food, and will more or less prevent acidosis from starvation.

It will be seen that alcohol, except possibly in a single dose occasionally, or for some special reason, is rarely indicated in decompensation.

When alcohol is administered regularly, whether during a fever process or for any other reason, if it causes a dry tongue, cerebral excitement, flushed face and a bounding pulse or if there is the odor of alcohol on the breath, the dose is too large, and alcohol is contraindicated.

Ammonia: In the form of ammonium carbonate or the aromatic spirits of ammonia, this has long been used with clinical satisfaction as a cardiac stimulant. Probably, however, it is seldom wise to use ammonium carbonate. It is exceedingly irritant, and constantly causes nausea, perhaps vomiting, and often heartburn or other gastric disturbance. It has no value over the pleasanter aromatic spirits of ammonia, which is essentially a solution of ammonium carbonate. The dose of the aromatic spirits is anywhere from a few drops to half a teaspoonful, given with plenty of water. It is thought to be a quickly acting stimulant, with an effect much like alcohol, followed by very little or no depression. It is more of a cerebral irritant than alcohol, and probably has few, if any, advantages over camphor.

When but little nutriment has been taken for some days, it may be a chemical question, since ammonium compounds so readily form and become cerebral irritants, whether any more ammonium radicals should be given the patient. This is especially true with defective kidneys. In these conditions camphor is better.

3. Vasodilators.--In various conditions of high blood pressure, arteriosclerosis and even during the sthenic stage of a fever, vasodilators may be indicated. The most important are nitrites, iodids and thyroid extracts. Alcohol, as stated above, may act as a vasodilator. Aconite and veratrum viride are now rarely indicated, although possibly aconite should be used when there is high tension and the heart is acting irritably and stormily.

If the nitrites, no preparation seems to act more satisfactorily than nitroglycerin (trinitrin, glyceryl nitratis, glonoin). Its action may not be so prolonged as other forms of nitrite, such as sodium nitrite or erythrol tetranitrate, but it is not irritant, and only a little less rapid than amyl nitrite, and although the marked dilation lasts but a short time, often apparently only for minutes, still, when frequently repeated or given a few times (from four to six) in twenty-four hours, it frequently keeps the blood pressure lower than it would be without the drug. In diseases of the heart the sudden vasodilation caused by amyl nitrite inhalations is indicated only in angina pectoris. "Then the surface of the body tends to be cold, however, when the peripheral blood pressure is increased and the heart is laboring, nitroglycerin in small doses is valuable. The dose may be from 1/400 to 1/100 grain, dissolved on the tongue or given hypodermically for quick action, or given by the mouth for more prolonged action. In sudden cardiac dyspnea nitroglycerin sometimes acts specifically, especially when there is asthma. When a drop or two of the official spirits, which is a 1 percent solution, is given on the tongue, or a soluble tablet of 1/100 grain is dissolved on the tongue, the action is almost as rapid as though the dose had been administered hypodermically. Many times when such increased peripheral circulation is desired and alcohol seems indicated, nitroglycerin in small doses will act as well. It cannot be termed a cardiac stimulant, although many times a heart acts better and the pulse is fuller and stronger after nitroglycerin than before. It should not be used, except if specially indicated, in broken compensation or in other myocardial weakness.

Iodids: These have no immediate action. The vasorelaxation that often occurs from iodid is quite likely due to the stimulation of the thyroid gland by the iodin, and the thyroid gland secretes a vasodilating substance. Small doses of iodid, however, when indicated in various kinds of sclerosis, have seemed to lower blood pressure. While large doses may have more of this actioli, they are not now under consideration, and large doses are rarely indicated.