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Whenever the powers of assimilation are very imperfect, the salicylate
or benzoate of caffein should be employed hypodermically by reason of
their perfect solubility and their non-irritant local effects.

The two objections to the employment of caffein continuously in large
or frequently repeated doses, are first, its action in causing insomnia,
which, of course, is a great drawback when a patient's nervous system
seems to call imperatively for the influence of this great restorer of
bodily comfort. Again, I have known patients to become restless and
mentally agitated to a high degree when I have persistently used caffein
for several days continuously with but short intervals of rest between
doses. Hallucinations and delirium have occurred when a nearly poison-



50 ORGANIC DISEASE OF THE HEART.

ous dose has been taken by mistake rather than premeditation. The
objectionable fact of these occurrences has been insisted upon by some
writers.

There is another remedy for failing heart about whose value there
seems to be just as much difference of opinion as there is in regard to
caffein, and that is convallaria majalis. The Russians and some distin-
guished observers in France and England consider it to be eminently
valuable. It has been said to produce evident regularity of the pulse
and increased force of heart-beats, with great diuretic power in cases
even where there was marked tricuspid regurgitation. And this action
may be noted after digitalis fails. Like caffein, convallaria does not
impair stomachal digestion, but is easily tolerated ; associated or not
with caffein, it seems well adapted to cases of mitral stenosis. It may
be given as the tincture or fluid extract. I have prescribed the drug
repeatedly for many years, and have been much pleased with its action
on several occasions when I was really despairing as to what could be
done to afford relief to a water-logged patient.

In mitral stenosis, the difficulty against which we are obliged to con-
tend is not the dilated left ventricle, to which we wish to give strength
and tenacity, but it is the tendency to pulmonary congestion, which throws
more work on the right heart. If we attempt to increase the vigor of
the right-heart contractions with the use of digitalis, while the lungs re-
main congested owing to the fact of the non-passage of a sufficient quan-
tity of blood through a much narrowed mitral orifice in a certain length
of time, the patient's distress is not relieved, but the dyspnoea from
which he is suffering is frequently much increased. Aconite in small
repeated doses is said occasionally to be of service under these conditions.
I have never believed this observation to be correct, at least among
adults ; but, on the contrary, am of the opinion that the use of this drug
merely aggravates the preceding condition by increasing vascular par-
alysis in the lungs. A far better method is to use repeated doses of
nitroglycerin in all urgent cases and whenever the patient has been un-
relieved by caffein and convallaria, and afterward to follow up the use
of nitroglycerin by the long-continued exhibition of strychnine or nux
vomica.

^It has always appeared to me highly injudicious to make use of aconite
in any appreciable dose in the treatment of any condition of failing
heart strength, acute or chronic, particularly among adults. With
children I am occasionally of a different opinion ; but even such instances
are rare in practice, and unless a child has a febrile state concomitant
with the intracardiac condition, and which is apparently of ephemeral
nature and without evident localization, I am loath even with them to
give aconite, except in very small doses.

In certain cases of cardiac hypertrophy connected with or indepen-



ORGANIC DISEASE OF THE HEART, 51

dent of a valvular lesion, aconite has been used by many practitioners
with, as they believe, obvious benefit. The cases where this action seems
most desirable are those in which the cardiac impulse is excessive and
the patient is annoyed with the throbbing and pulsation in the chest,
which apparently indicate excessive cardiac action. It is probable that
this excessive action rarely occurs, and we should be very careful, in my
judgment, of toning down the heart. If we must give a cardiac seda-
tive, I attach far more value to the use of the mixed bromides than I
do to aconite.

Of the bromides, I regard the salt of sodium as least likely to do
harm, and I am sure that I have often given this remedy in large doses,
3SS-3J, several times in the twenty-four hours, without occasioning any
cardiac depression. On the contrary, it has seemed to exercise a gentle,
soothing, and quieting effect, which diminished the turbulent action of
the heart without lessening its strength.

What is true of the bromides is also true of the valerianates — and
valerianate of ammonia in pill form is a most valuable adjunct to our
treatment in these cases. The excessive cardiac action may be attended
with feelings of fulness or uncertainty in the head, and the tinnitus
aurium from which such patients occasionally suffer is extremely annoy-
ing and objectionable. I have known these unpleasant sensations to be
greatly diminished by salicylate of soda, with a small addition of phe-
nacetine. Of course, the use of the latter prescription should simply be
made while the aural and head symptoms are actually a source of great
discomfort. As soon as they are dissipated we should interrupt their use.

In cardiac hypertrophy, as long as tension is kept up in the arteries,
the prognosis is good, because we know that the general and cardiac
nutrition are being sustained. Whenever this tension fails, by reason of
the rupture or of the insufficiency of one of the coronary cups, we know
that the prognosis has become serious, and that the case will progress
rapidly downward. Even under these conditions, we have tumultuous
intrathoracic throbbings, but they show not strength but weakness, and
that weakness is of secondary degeneration, against which we should fight,
not with depressant agents like aconite and veratrum viride, but rather
with heart tonics, like strychnine and iron, which in restoring vigor to
the heart-muscle, lessen its impotent struggle, as shown by the dissipation
of painful symptoms, which from a narrow and limited observation, ap-
pear to indicate nerve sedatives.

Whenever cardiac power is defective there is an insufficient quantity
of blood sent out by its pulsations to the arteries which distribute them-
selves throughout the body. Owing to this insufficient distribution of
arterial blood there is a marked tendency to venous engorgement every-
where. In the kidneys we have it, and albuminuria follows ; in the
stomach it is evident, and gastric catarrh results ; in the liver the venous



52 ORGANIC DISEASE OF THE HEART.

portal circulation is clogged, and soon the sclerotics are yellow, the
tongue coated, and nausea and inappetence present themselves. With
this marked, recurring, or almost constant venous engorgement of the
viscera, fibrous changes occur in all these organs, and these permanent
changes weaken and cripple them in their functional power to that degree
finally that no remedies can ultimately afford relief, even to symptomatic
disturbance.

Whenever in the conditions alluded to we have called to our help
the power of digitalis, and instead of giving notable relief, it merely
diminishes the pulse-rate so as to make it abnormally slow, we should
abandon its use and recur to that of the other cardiac stimulants. When
we are assured that we have obtained good results we note easily a
stronger heart-beat, an increased pulse tension, and a real compensatory
hypertrophy. Doubtless, at the same time, the coronary arteries are
filled with blood, the nutrition of the heart is improved, and the arterial
recoil accentuated.

One of the bugbears of many practitioners relates to the so-called
cumulative action of digitalis. As a fact, there is no more danger of this
with digitalis than there would be in the case of many other heart tonics,
if they were injudiciously managed, as is true whenever digitalis is followed
by sudden poisonous effects of marked severity. Digitalis does not elimi-
nate itself from the economy rapidly ; and, of course, if we give large
dose3 of it in short periods of time we may get untoward effects, just as
we might if we gave arsenic or belladonna frequently, and without allow-
ing time enough for their physiological elimination from the body. I
must protest, however, against the notion still common with some prac-
titioners, that digitalis has a way of its own of lying dormant for a while,
and afterward appearing suddenly, and springing, as it were, upon the
poor victim, who will show signs of poisoning from its use. This idea is
very erroneous, and should be combated forcibly whenever it appears.
Of course, in certain forms of heart disease but for mechanical reasons,
as in hypertrophy, we should be very temperate in our use of digitalis,
or else we would do great damage. On the other hand, in cardiac dila-
tation it is more than doubtful whether we could really poison an indi-
vidual with this drug unless we gave excessive, almost unjustifiable, doses.
Even in cardiac dilatation, however, the use of digitalis must be inter-
mitted when we have obtained desirable effects, or else we may occasion
a return of cardiac palpitation and irregularity of the heart. Sometimes,
with the presence of cardiac dilatation, we may have a cardiac systolic
murmur at the apex, and after digitalis has been taken for a while the
murmur disappears. This simply means that the cardiac ostium has
become smaller through ventricular contraction so as to permit the
valve to be competent once more. Again, sometimes, a murmur which
did not exist at first, with evidences of cardiac dilatation, may become



ORGANIC DISEASE OF THE HEART. 53

distinct after the continuous use of moderate doses of digitalis, and yet
all the rational symptoms of cardiac incompetence previously observed
by the patient have greatly improved or entirely disappeared. This
means merely that the heart has obtained renewed power, that the mus-
cular contraction of the heart-walls is greater, and that the blood when
thrown through the enlarged or diseased orifice gives a murmur which
was not noticed previously, because the heart had not force sufficient to
produce it. The ventricle in the latter case also may show signs of
diminution as to volume as well as increased force in its dynamic
function.

There are many states of cardiac asthenia, as those resulting from
effort or great and sudden shock, in which it is nearly impossible to
recognize at once, or indeed, until the patient has been carefully ob-
served for several days or weeks, what amount of disturbance is purely
functional and what amount is occasioned by organic heart changes.
Murmurs, intermittences, cardiac irregularities, combined with weakness
of heart action, afford, at least, sufficient reasons to be doubtful as to the
r6le each may play in the condition presented to us. Careful physical
examination will not invariably enable us accurately to determine the
size or precise state of the heart, owing perhaps to the corpulency of the
individual, to intra-pulmonary conditions, to natural conformations of
the chest- walls, to organic or functional disease of one or more of the
abdominal viscera. When we are in reasonable doubt as to our diag-
nosis we should treat the case very much as we would if we were quite
confident we had to do with cardiac insufficiency depending solely on
organic heart disease. In fatty degeneration of the heart the cardiac
stimulants are often necessary in order to increase rhythmic action
through their influence on the intra-cardiac ganglia. Let us bear in
mind, however, two considerations, both of which have their value : First,
we can only help a fatty heart materially by stimulating its healthy
fibres. Now we should not do this to an excessive degree, because we
wish to save those which are degenerated from over-action, or increased
pressure from within the cardiac cavity, or else we run great risk of in-
creasing cardiac dilatation, or else producing rupture, it may be, which
would have a fatal result. In the second place, we are aware that it is
not merely the heart which is implicated in fatty cardiac degeneration,
the arteries are also affected with morbid alterations, usually of athero-
matous nature. These changes may also occasion bad consequences if
undue arterial tension is produced, as rupture in some of them — particu-
larly the cerebral ones — is not uncommon.

These objections may be considered by some as more theoretical than
practical, and as in no degree militating against the employment of
cardiac stimulants when their use for other reasons seems advisable. In
some cases of distended cardiac cavity through a vaso-inhibitory action



54 ORGANIC DISEASE OF THE HEART.

upon the vessels, the arteries are somewhat distended. Digitalis by its
power over the peripheral circulation appears to restore these vessels to
their normal calibre, and hence its action under these conditions should
be regarded as really injurious.

In cases where the heart seems rapidly to fail, as it frequently does
where organic disease exists and an acute disease like pneumonia or
typhoid fever is grafted upon it, digitalis appears at times to have con-
siderable power in lowering the temperature and thus benefiting the
patient. Clinically, the lowering of the temperature as well as the
better condition of the patient seem to be accompanied by retained or
increased arterial tension. When the arterial tension fails, not only is
the condition of the patient, as a rule, unimproved, but the temperature
does not appreciably fall. Perhaps this action of digitalis may serve to
explain some remarkable effects occasionally obtained in the treatment
of pneumonia and typhoid fever, which without this explanation would
seem to be doubtful or mysterious. Of course, in considering such
action we should have in view the effect of heart stimulants, not merely
on one factor of cardiac power, but upon alb — many of which are com-
bined.

The heart, it is true, is a muscle, and upon this muscle digitalis,
strychnine, convallaria, caffein, etc., all act probably to a certain degree.
But the heart muscle is controlled by the regular rhythmic discharges
from its intrinsic ganglia, and these are probably even more effectively
stimulated to action in fevers or disease of microbic origin by the car-
diac stimulant than the muscle itself.

Belladonna is to-day often forgotten as to its beneficial action when-
ever neurosal difficulty is present in any condition of heart depression,
without regard to the precise organic disease which prevails. Not many
years ago belladonna was much lauded not merely for its valuable as-
sistance in helping all cases of chronic heart disease where arterial ten-
sion was low and the quantity of urine daily voided quite insufficient ;
it was also admitted to be a very powerful agent for the relief of the
effects of shock and when the patient was in a state of collapse which
threatened immediate death. Let us not forget, therefore, that, perhaps
in many instances where we fail to obtain relief from other drugs,
belladonna may afford us very valuable assistance. Fothergill insisted
in his work on heart diseases upon the use to which belladonna might be
referred, and, with what seems to be very clear insight, recommended it
highly.

Not infrequently I have had good reasons to believe that our ordinary
estimate of the value of belladonna is too low, and am convinced that
if it were more frequently prescribed in connection with strychnine we
should obtain very excellent results from it. In combination with iodide
of potassium, it certainly gives marked relief to many cases of aortic



ORGANIC DISEASE OF THE HEART. 55

disease in which part at least of the pain is apparently connected with a
lack of synchronous rhythmic contractions between the two sides of the
heart, connected with an insufficient or badly co-ordinated nervous con-
trol. Possibly, its stimulating effect upon the nervous centres controlling
respiration may have also great value in the re-establishment of heart
power and more perfect rhythmic action.

Few authors have insisted upon the value of electric currents as a
means of restoring heart power. Reasoning from analogy, I am con-
fident that we neglect too much this means of relief. I have seen such
notable good effects both of faradic and galvanic currents in Graves'
disease; it has been of such evident and great use to patients in whom
the acute asthenia grafted on the previous cardiac changes was of immi-
nent gravity, that I feel as if I have often neglected a means that would
surely be helpful, if properly applied, when compensation is temporarily
lessened or gravely impaired. One pole should be placed in the region
of the neck, and the other over the cardiac region, and mild currents
should be daily applied for a limited time. I trust that others besides
myself will see the utility of electricity, and, it may be, obtain results
from it in the treatment of organic heart disease which have not hitherto
been secured.

The dyspnoea from which patients affected with chronic cardiac dis-
ease suffer, either continuously or spasmodically, is most distressing ;
sometimes it comes on in a sudden manner, perhaps in the middle of the
night, with or without a sufficient apparent accidental cause to produce
it. Frequently, however, these attacks follow imprudences in eating or
drinking. Indigestible, rich food taken late at night, and after any un-
usual nervous strain is a frequent cause of similar attacks in the begin-
ning of cardiac asthenia. During the attack the heart is unable to
expel its contents, and the right heart particularly seems to be specially
involved. The patients are anxious, distressed, panting for breath ; the
lips, face, and extremities are cyanosed ; the hands are cold and clammy ;
there is often free perspiration from the face and neck ; the pulse is
feeble and irregular ; they are often restless and uneasy and seek dif-
ferent postures to relieve their breathing ; sometimes they sit up straight ;
often they bend over on a chair or head-rest, and fix their arms and
shoulders so as to give them additional support, and thus enable them
to use the accessory muscles of respiration. The heart's action is inter-
fered with frequently by the bulging upward of the diaphragm, which
cannot descend in the abdominal cavity, owing to gaseous distention of
the stomach or colon. When the stomach is full of food and gas, nothing
gives more immediate relief, at times, than to have it emptied by an
attack of vomiting. On other occasions, the diffusible stimulants given
internally, i. e., alcohol, ammonia, chloric ether, in frequently repeated
doses, will be of almost immediate and great use. If the extremities



56 ORGANIC DISEASE OF THE HEART.

are cold, hot-water bags or mustard poultices applied to them will help
restore the circulation. When the attack is severe and the position of
the patient imminently threatening, hypodermics of brandy, nitro-
glycerin, strychnine, or digitalis should be given and repeated several
times until the patient notably revives. The quantities of these drugs
which can be given to these patients with evident relief is often very
large. Of course, such attacks vary greatly as to their gravity, and in
some instances life itself hangs upon a thread. I have seen patients
more than once remain in a semi- collapsed condition several hours and
only revive thoroughly after I and others had expended all our efforts in
their behalf.

In dyspnoea of more chronic nature we find that pulmonary conges-
tion, bronchitis, cardiac dilatation or effusion into the pleural cavities are
frequent causes of it. Any of these thoracic complications may be ac-
companied also by a renal affection which renders the treatment more
difficult and the prognosis graver — sometimes the patient cannot lie down
at all for many nights. This position, often so painful to the patient, is
measurably relieved by a good bed-rest, with arms at the side to prevent
the patient's head or body from falling over or taking a position which
greatly increases the difficult breathing. Hypodermics of morphine
with atropine will sometimes quiet and subdue these attacks very
rapidly. When these drugs fail to relieve in appropriate doses, nitro-
glycerin is available and most reliable. This is particularly true if the
tension of the radial pulse is high and there is clearly present a state of
advanced arterio capillary fibrosis.

Whenever there is a moderate or large amount of fluid in one of the
pleural cavities, thoracentesis repeated one or more times gives great
relief to the breathing, and prolongs life many months in some instances.
Warm poultices, with the addition of mustard in moderate proportion to
the chest walls, is a very excellent means to give relief to distressed
breathing. Repeated applications of dry cups to the chest or over the
renal region are of great value.

As soon as the acute dyspnoea is relieved a free purgative dose with
calomel and compound jalap powder will carry off considerable fluid
from the economy, and thus afford sensible relief. Hoffman's anodyne
in full doses will often quiet extreme restlessness and promote sleep, be-
sides being of great service in lessening dyspnoea of functional character
and nervous origin, although connected with organic heart disease. If
there is much venous engorgement we can obtain more relief by blood-
letting than in any other way. Leeches, wet cups, venesection, may all
be used in certain cases with great advantage to the patient.

I have also known oxygen inhalation to be successfully employed.
Again, even when there is much bronchial engorgement, oxygen will
fail to produce any amelioration in the patient's condition. We are,



ORGANIC DISEASE OF THE HEART. 67

indeed, compelled to abandon its use at times on account of increased
distress which it evidently occasions in the breathing. Inhalations of
nitrite of amyl, the internal use of the bromides and chloral are resorted
to by me with evident great resulting benefit in some instances. In the
use of chloral one must be guarded whenever there is danger of heart-
failure from organic cardiac disease, as the heart may suddenly be
arrested in diastole. Cardiac dyspnoea is frequently aggravated by an
underlying gouty condition, by hysteria, or emotional excitement, and
may be greatly relieved by appropriate medication addressed to these
diverse causative conditions.

The condition of the stomach and liver is also very important, and a
vomitive or purgative given at the proper time is able to afford much
relief, when otherwise the patient's distress would continue. It is wise
in many such cases to be cautious is rendering too grave a prognosis, as
the occasion does not 'always warrant it, and with judicious treatment
the patient may rapidly improve.



ETIOLOGY AND TREATMENT OF CERTAIN KINDS

OF COUGH. 1



Cough is one of those symptoms we are called upon constantly to
treat. At times the diagnosis of its cause is relatively easy, and our
treatment satisfactory. It may last, it is true, for some days despite our
efforts to relieve, and during this time cause moderate annoyance, or
even considerable distress. Still, after a fair trial of remedies judiciously
employed, a measure of benefit is obtained, and both patient and physi-
cian are hopeful as to a speedy cure, and both are tolerably satisfied
with the amount of success accomplished in a given period. Again,
there are cases in which we know from the first that whatever treatment
may be followed the obstinate cough, in the nature of things, must per-
sist, and arrest, except from increasing doses of anodynes, can rarely be
effected. Such cases we are familiar with in certain forms of pulmonary
and laryngeal phthisis.

There are other kinds of cough which are also met with quite fre-
quently ; yet their diagnosis is made with difficulty, and their treatment
despite repeated changes, fails to accomplish much in the way of abate-
ment and cure. This is true not only of the patients who go first to the
family physician in search of help, but also of those who in the begin-
ning of their trouble gravitate toward some prominent specialist.

In the class of cases where the general practitioner is usually at fault
I would place the cough which is under dependence of an engorged


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Online LibraryBeverley RobinsonEssays on clinical medicine → online text (page 6 of 20)