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nutrition. It may be given as arsenious acid in tablet form, or in solu-
tion, as we have it in Pearson's or Fowler's preparations. Moderate
doses only should be given daily, and after a few weeks this medicine
should be interrupted, either to resume it later, or else to try some other
medicine, with a view to giving tone to the patient who shows indica-
tions of impaired vigor.

Many occurrences, doubtless, of one's ordinary life, help disturb car-
diac compensation when it exists, and it is difficult with the wear and
tear of pressing occupation or interests, which can neither be ignored
nor gotten rid of by many persons thus affected, to follow out the strict
medical indications in each and every case that is brought to our atten-
tion. Yet when we insist emphatically how important it is in order to
retain a fair degree of bodily comfort to banish, as far as may be from
our ordinary vocations, mental worry and bodily strain, we have done
much toward carrying home the importance of the pernicious influ-



ences when they are allowed to exert themselves. It is also true that
pure air, good food, gentle exercise, hygienic surroundings in what per-
tains to plumbing, drainage, and ventilation, are all important adjuncts
to continuous well-being of very many persons similarly affected.

The compensation in organic heart disease is sometimes broken sud-
denly, and in that case alarming symptoms may instantly arise. These
instances are not infrequent after great exertions in lifting heavy
weights, or after severe contests in athletics, where the muscular and
nervous system has been put on a severe strain for several hours, or
even days' duration. After such accidental occurrences we are often
called to witness and care for the evidences of acute dilatation of the
heart, grafted on previous existing disease. In many instances the
effort or strain, whether it be interrupted or continuous, may seem in-
sufficient almost to account for the distressing sequelse which follow.
Yet when we bear in mind the fact of the pre-existing state, we have
less reason to be surprised than we otherwise would. Under like circum
stances, or even when the patient was doing nothing unusual but merely
taking his ordinary exercise, plugging of the coronary artery has oc-
curred and brought on a rapidly fatal termination.

The lack of compensatory power in the heart may not be of necessity
rapid in its occurrence. Very frequently it comes on little by little, and
in such a manner that its precise initial period is doubtful. The first
symptoms of moment may be cardiac palpitations, more or less distress-
ing in character, and lasting at first but a short time, which manifests
itself even after slight exertion. These patients often get along very
comfortably when they walk on level ground, but let them try to go up
a flight of stairs, or a steep declivity of any kind, and immediately they
suffer extremely from irregular and throbbing heart pulsations. Over-
fatigue, a high wind, late hours, emotional strain will cause similar un-
pleasant cardiac fluttering, with choking sensations in the throat and
chest, and a thirst for air, which is so distressing at times. One of the
most unpleasant forms of this cardiac incompetency is that in which
nocturnal dyspnoea is the acute evidence of it. The patient goes to bed
comfortably and falls asleep. For several hours he is obviously at ease,
and his slumber is restful, when suddenly he awakens with a start, in
great mental agitation, and his heart beats are rapid, irregular, and
lacking in force. An alcoholic and ethereal stimulant internally with
warmth to the chest by means of a hot- water bag or poultice will in a
brief period relieve the situation immensely and restore the patient to
relative ease and comfort. Of course, one must be on guard in any
condition which seems at first to show cardiac incompetency ; not to be
deceived as to the cause of it.

An acute attack of stomachal dyspepsia after a late supper, flatus with
distention of the colon from persistent irregularities of dietary, may


cause a flatulent distention of these organs which may interfere very
much with the proper action of the heart through pressure or displace-
ment thus occasioned, and very great and immediate relief may be
afforded with aromatic stimulants.

In affections of the mitral orifice mere irregularity of the pulse is so
frequent a sign of this lesion that little importance should be attributed
to its presence, unless it be allied with other rational symptoms, such as
dyspnoea, or precordial pain — of cardiac insufficiency.

If there be a constipated condition of the bowels, a dose of licorice
powder at bedtime, or a saline purge with some carminative added, in
the morning on rising, may be all that is needed to re-establish perfect
comfort. If the symptoms of cardiac inadequacy continue despite the
rational treatment just indicated, and without further trials of other
medication, absolute rest in bed must be enjoined. In a very short
time, from this enforced quiet alone, great benefit results very often.
The compensatory power of the heart is rapidly re-established, and car-
diac irregularity may soon completely disappear. Even in those cases
where percussion shows pronounced dilatation with enlargement of all
the cardiac cavities, and there are evidences of cellular infiltration in
the lower limbs, the advantages of rest are unmistakable. The rest in
bed is of service mainly because the heart has much less work to do
when a patient is in repose than when he is moving about actively
Many thousand cardiac beats are thus prevented each day, and the car-
diac ganglia have an opportunity to regain their former power. Thus,
the heart muscle is restored from its fatigued or exhausted condition and
proper rhythmic explosions are developed.

Just as rest is important, so is more sleep to be induced, and in this
way a passing condition of incompetency is prevented from becoming
permanent. Of course, if any complicating condition exists which
evidently interferes with the patient's rapid recuperation, this should be
properly attended to. Among these we would mention mal-assimila-
tion of food, leucorrhoea, diarrhoea, bleeding piles. The mere fact of
arresting a weakening discharge by administering proper medicinal
remedies, in connection with an appropriate dietary, may be of great
service in promoting the cure, or great relief of the case, so far as all
functional disturbance is concerned. Such remarkable effects are so
frequently obtained by attention to the foregoing indications that patients
are apt to become reckless and the physician careless. The result is
that frequently the patients go back too soon to the mode of life which
has been the direct occasion of their bad symptoms, and very soon we
have a return of the latter in an aggravated form.

Whenever the case is that of a workingman or woman, they should
be particularly warned against the evil effects of sudden strains on the
heart, and should be told to seek, if necessary, occupations in which the


hours of work may, perhaps, be longer, but the danger of frequent or
occasional occurrence of great efforts will be wholly avoided. If the
patient be a professional man accustomed to great mental toil he should
be brought to consider the necessity of an out-door life, longer hours of
sleep, and soothing mental distractions as far as is practicable. If the
patient be a lady addicted to the pleasures of fashionable entertain-
ments, where late suppers, dancing, and the great stress of this mode of
life in lessening nerve force be the custom, she must be told emphatically
that it is only by abandoning these pleasures that she can be restored to
health, and that the heart can recover healthy action in proportion as
the structural failure may be lessened or cured — i. e., cardiac dilatation.

In many cases, however, progress of organic disease, although pre-
vented for a longer or shorter period, is steadily worse. Onward and
downward is the march of events. Under these circumstances we are
obliged to depend upon drugs or other medication systematically used
from time to time, or continuously, to obtain an arrest of the troublous
effects of disease.

The remedies employed are, first, those which stimulate the heart-
action ; and second, those which are directly tonic or corroborant in their
effects, not only to the heart, but also to the blood and general system
as well. Digitalis easily ranks first among the former in the estima-
tion of the great number of clinicians, and must be given without regard
to the nature of the lesion whenever the heart begins to fail and is
unrelieved by the means previously referred to. Digitalis unquestion-
ably, in the great majority of cases, leads other remedies by the certainty
of its power and action. Whenever digitalis in small or moderate doses
remains without apparent good effect, and the patient is evidently ansemic
and has not yet reached middle life, some iron salt may be combined
with it. There are some instances in which the iron and digitalis once
begun, in order to restore the compensatory balance in the heart muscle,
have to be continued long periods of time and almost continuously.
In other instances the treatment by digitalis alone or digitalis and iron
combined are only required occasionally and for a few weeks on any
occasion to bring back the circulation to healthy activity. The effect
of digitalis in small doses persistently and constantly given for a while
is to diminish markedly cardiac dilatation, whether there be or not in-
sufficiency at the mitral orifice. Sometimes, as an aid to the digitalis,
strychnine may be advantageously combined with it. Strychnine, besides
stimulating the heart, is also a stimulant to the respiratory centres, and
this action is often valuable in view of the relations between the circu-
lation and respiration, independently of what is simply mechanical.

It is sometimes wise if there be a chronic lung affection, as cirrhosis
or emphysema, at the same time that there is notable cardiac asthenia,
to add carbonate of ammonia to the previous combination of strychnine


and digitalis. Instances are not rare in which some combination of two
or more of these drugs has been taken for years, and when at any time
they were interrupted almost immediately the patient began again to
suffer from palpitations or cardiac distress.

No doubt in many of these cases where regurgitation at the mitral
orifice results mainly from mere weakness of the cardiac muscle, and
very little from the valvular changes, which are very slight, the depend-
ence of the heart upon stimulation from these drugs is very great. Evi-
dently, as has been shown, the mechanism for closing the mitral orifice
does not reside in the valve alone, but much power is present in the
muscular walls of the left ventricle, not only to lift the valve itself, but
also to diminish the mitral orifice.

As a rule, however, digitalis should be intermitted from time to time,
in order to obtain its best effects. Once, indeed, its bad effects produced,
such as nausea and vomiting, it is frequently with some difficulty that
we again obtain tolerance for the use of the drug.

One of the observations of Withering, who wrote about the use of
digitalis at the end of the last century, was that it acted particularly
well with dropsical patients, and when the pulse was low, feeble, irregular,
or intermittent ; on the contrary, when there was a tense pulse with
evident thickening of the arterial coats, its action was not so beneficial
or its diuretic action at all pronounced. This view of Withering is
practically somewhat our own estimate of digitalis to-day. It is gener-
ally admitted that it increases and lends force to the systole of the heart ;
at the same time, digitalis unquestionably contracts the arterioles, and it
is in this manner that arterial tension is increased. This double effect
is, as a rule, very useful in mitral regurgitation, particularly at the
commencement of this disease and when both effects of digitalis are
desirable. Later on, the action of digitalis on the arterioles is not so
satisfactory, especially when dropsy has set in, because this effect mili-
tates against its diuretic action, which is so essential at this period of the
disease. In order to obviate as far as possible this untoward action of
digitalis, we should exhibit concomitantly with it moderate doses of

By the use of these drugs combined with one another we can fre-
quently accomplish effects at the terminal stage of a mitral lesion which
we can obtain in no other manner. The action of the nitroglycerin is
doubly useful under these circumstances. It adds to the power of the
heart's contractions; it dilates peripheral vessels, and thus renders these
contractions more effective, and thus the diuretic action of the digitalis
is notably increased. The amount of either one of these drug3 which
may be given advantageously in the condition of obstinate or increasing
dropsy cannot easily be determined in advance. My plan is to give,
say one drachm of the infusion of digitalis and ^^ gr. of nitroglycerin


every two hours, and progressively increase both of them, if need be, up
to two or three drachms of the infusion of digitalis every two hours, and
-5*5- gr., or even more, of the nitroglycerin at similar intervals, before we
can obtain the most desirable effects. Everything depends upon the
case and the effects of the drugs. If digitalis apparently causes nausea
or vomiting, if the pulse under its influence, instead of becoming stronger
and more regular, becomes weaker, intermittent, and very slow, it is
time to diminish, or it may be, interrupt its use for several hours or days.
These indications are even more formal whenever the quantity of urine
remains the same and its density is unaltered. As regards the nitro-
glycerin, if the head throbs and pains in a notable manner, whilst the
pulse remains small, feeble, and uncertain, to increase its dose would be
of questionable utility.

It is most important in the use of these drugs to know that their
quality and preparation can be relied on. The tablets of nitroglycerin
as purchased in many drug stores are frequently unreliable, and we can
at times use very large doses of the drug in this form without obtaining
the effects we should expect from it ordinarily. It is preferable, there-
fore, to make use of a freshly prepared solution, graduated so as to
exhibit in every teaspoonful a given amount of the active ingredient.
The best preparation of digitalis cannot always be stated. Personally,
I favor the fresh infusion of the leaves in cases where I desire particu-
larly to procure its diuretic action. In cases where the tonic effect on
the heart is most important, I prefer the tincture. Moreover, the tincture
is such an available preparation, which we can always obtain and keep
ready for immediate use, that this very convenience makes us, perhaps,
somewhat over-i'ate its value. The fluid extract is, of course, given in
smaller bulk on account of its greater strength. Further than this I
do not believe it has* any appreciable different value from the tincture,
as I do not think the addition of alcohol in the tincture makes any
essential change in its action unless the doses given be unusually

I am confident that the action of hydragogue purgatives is very im-
portant to relieve dropsy, and particularly in those cases where digitalis
in moderate doses and by itself has not notably increased the bulk of
urine. Compound jalap powder, with or without calomel, has always
seemed to me the most reliable among the purgatives, and I give it
invariably almost the preference over other means in this line when
treatment is begun.

Elaterium and croton oil never appear to me desirable if they can be
properly avoided, or if the compound jalap or scammony powders prove
active and beneficial. After repeated movements from the bowels, which
follow the use of these purgatives, the diuretic action of the digitalis
and nitroglycerin is shown frequently in a remarkable manner, and


the bulk of urine is increased from a few ounces to several pints in a
few days.

I have no doubt that it is important in these instances not to attempt
giving any solid food by the mouth, for the patient will be quite unable
to digest it, and the only consequence of allowing it to be taken is to
bring on nausea or vomiting, besides causing stomachal distress, and, it
may be, further injuring the condition of the patient by the toxins which
are produced and absorbed. The diet should be a strictly fluid one,
and even the quantity of the fluid must be limited. It would not do to
allow a patient where dropsy is very considerable to take large draughts
of milk or water. The milk should be limited to two or three ounces
every two hours, and given preferably peptonized.

Unless the patient be unusually prostrated he should not be awakened
if he is asleep to give him his dose of milk. Of course, this severity in
regard to the quantity of fluids allowed should only last while the drop-
sical condition is very threatening. As soon as the vessels are able to
take up the effused serum in the tissues and cavities, owing to the drugs
employed and the dietary just insisted upon, the latter may be increased
or made somewhat more liberal.

It is especially important whenever the serous cavity contains fluid,
either of the chest or the abdomen, to let it out by paracentesis, or
otherwise the patient's chances of even temporary recovery are greatly
diminished. It is sometimes these repeated tappings which keep such
patients alive for long periods and enable them to get about once more,
when without them they would surely die, and that, too, very rapidly.
I can recall instances where withdrawal of chest-fluid on repeated occa-
sions had helped restore the patient, with the other agents and care
insisted upon, to a state of relative strength and comfort which has
lasted a considerable period. The same statement is true in regard to
abdominal puncture with withdrawal of intra-peritoneal effusion.

Of course, if there be dropsy in connection with aortic disease the
same treatment holds good ; but it is a well-known fact that this com-
plication is then infrequent, and it is far more probable to encounter it
with advanced mitral lesions.

Whenever the tricuspid valves have lost their ability to close the
right auriculo ventricular orifice, and the cavity of the ventricle is dis-
tended, while the muscular walls have lost compensatory power, we have
to do with those very bad cases in which the prognosis is gravest. With
pulsating, enormously distended, over-charged jugulars, with markedly
pronounced epigastric pulsations, and the soft blowing murmur distinctly
marked over the right heart, in addition to numerous other signs inci-
dent to this state, we have one other means besides the foregoing which
will help us sometimes relieve our patient, at least temporarily. This
final expedient is blood-letting. The vein at the bend of the elbow must


be opened and the blood allowed to escape. A few ounces thus taken
will sometimes give notable relief and enable the right heart to continue
its beats, when without this help it would soon cease to combat the
increasing pressure from within from the quantity of its contained

It will not answer in an advanced state of incompetency, where dis-
tress and lack of power are marked with such intense features, to do
more than afford some relief in this way. If we attempt it we are apt
to weaken the patient too much, and the heart soon ceases to contract
altogether, and stops in diastole. Of course, in those cases where there
is acute dilatation of the right cavities in a heart as yet undegenerated,
and which is but the result of over-strain, the quantity of blood which
can be advantageously taken by venesection is sometimes very consider-
able, and even as much as a pint or more will, be a loss soon completely
replaced. Moreover, the patient's condition seems lighter and better in
every way from getting rid of an excess of blood, which was the greatest
obstacle which stood in the way of possible recovery from animmineutly
threatening condition.

This indication for relief of the right heart by venesection in acute
dilatation is not changed by the fact that there may be old bronchial
imflammation with emphysema ; on the contrary, in just such cases this
means may be our most potent one of saving life, and all other meaus
without it appear at times to be insufficient or unavailing.

Although the usefulness of digitalis has not been doubted in later
years, at least, as to its power to combat, when properly managed and
helped in its action by the other means which I have mentioned, the
dropsical condition dependent on organic heart disease, such is not the
invariable opinion held about the value of this drug in aortic lesions
where dropsy is present. Theoretically it has been considered injurious,
because the diastole of the heart was lengthened, and thus the disten-
tion of the left ventricle was said to be increased. Practically, however,
this judgment cannot be regarded simply because after the continuous
use of digitalis for some time, even in this condition, we shall note in-
crease in the vigor of cardiac contractions. Moreover, the pulse becomes
stronger and more regular, the dropsy decreases, and the bulk of the
urine notably augments. It is wise, however, with an aortic lesion
present, never to give large doses of digitalis in the beginning, and to
increase even a very moderate dose of the drug with great care and
circumspection. Upon any indication of its failing to be beneficial it
is only prudent to withdraw the use of the drug and substitute some
other cardiac stimulant in its place.

Whenever the oedema of the lower limbs continues, with other evidences
of dropsical effusion, and is not influenced by all previous remedies, we
are compelled to resort to the use of Southey's tubes or to repeated scari-


fications, with proper antiseptic precautions to relieve their great disten-
tion. Without such means of relief, painful ulcers may occur, which it
is almost impossible to heal, and they render the patient's condition even
more deplorable.

A red blush over the thickened and tense skin, not unlike an erysipe-
latous inflammation, may occur and give additional anxiety in our
patient's behalf. After scarification or punctures, and when the fluid
has pretty well drained from the lower limbs, they should be wrapped
in canton-flannel bandages, which are frequently renewed, so as to keep
down the recurrence of the great swelling and distention. These means
are but temporary expedients and fail to afford more than passing relief.

According to some writers, caffein is very little to be relied upon in
the treatment of any form of organic heart disease. This opinion,
fortunately, is not general, and certainly does not correspond with my
own experience. In doses of one to three grains by the mouth, espe-
cially in the form of the citrate, by reason of its solubility, I regard it
as being a very excellent heart stimulant. In my judgment, as in that
of others, it is especially adapted to certain cases of mitral stenosis in
which dyspnoea is excessive and where digitalis does not seem to act
well. It is also very desirable to make use of citrate of caffein in com-
bination with strychnine in cases of aortic incompetence which do not
respond favorably to the action of digitalis. Caffein not only agrees
with the stomach very well when digitalis disturbs it given in any form,
but it likewise has a very marked diuretic action, particularly if the
kidneys are not much diseased, which may be shown, although digitalis
has remained inactive in this regard.

Some writers have regarded the citrate of caffein as inert when given
as a salt already prepared, but in this opinion I am inclined to believe
they are greatly mistaken. Even in the last stages of chronic heart
disease, this drug when given in one-grain doses hourly has been of
great service after digitalis has failed to produce the slightest favorable
impression upon the patient, and, indeed, has been followed by many
evidences of intoxication from retention of the drug in the economy.

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Online LibraryBeverley RobinsonEssays on clinical medicine → online text (page 5 of 20)