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finally she was interested In the poets ; then in work. As soon as she began
to do basket work and worked in the flower garden she improved markedly.
She soon became a different girl ; was happy and gay and wanted to work all
the time. Five miles a day was her usual walk. After a stay of eleven
months here, having gained thirty-five pounds, she left apparently well, and a
recent report from Clifton Springs, New York, where her father has a cottage
for her, states that she is working outdoors right along and is better than she
has been in many years, if not in her whole life.

Case VI : Miss L. B. was a professor for twenty years in one of the leading
schools of the South for women, and was a woman of unusual mentality, hav-
ing spent several years in Germany in preparation for her work. She had a
complete mental breakdown, due largely to overwork, and on admission was
terribly run down physically and possessed of the most distressing and vile
delusions and hallucinations. For quite a while it was impossible to get her
to work, but by constant persistence she was persuaded to start on a basket.
Her first work was done very slowly and was exceedingly poor and rough ;



MATERIA MEDICA AND THERAPEUTICS. " 101

gradually, however, she became interested ; her work improved ; she began to
talk less about herself and her delusions and hallucinations. Although her
progress was exceedingly slow, she gained steadily. As she improved, she
said that when she was occupied the voices did not trouble her nearly so
much. Her physical condition improved as her mental condition improved,
and she gained a great deal in weight. After eighteen months she went home
absolutely well and now has taken up cooking and housekeeping, something
she had never done before, in addition to her basket work which she continues.
She also continues taking a five-mile walk each day, and stated in a recent
letter that she felt better than she had in many, many years. This case for
months seemed absolutely hoi^eless, and the patient herself attributes her
recovery largely to the fact that she worked with her hands and was kept
almost constantly employed.

Many cases might be reported, but I tliink I have given enough to
show the vaUie of employment in mental and nervous troubles. All of us
would be better off if we could do something with our hands ; chop wood,
as did Gladstone, or dig in the ground. Outdoor exercise, and, if possi-
ble, real w^ork, is the best of all remedies for poor digestion, insomnia,
and many of the nervous ills to which Americans especially are so prone.

The best of all work, however, is that which is done with a purpose,
and this should always be striven for, i. e., w^ork which makes flow^ers and
vegetables grow, or work which beautifies and accomplishes some useful
purpose, or brings forth some completed useful or beautiful object. The
accomplishing of any task which produces a completed result which can
be seen always gives pleasure.

Mr. Kipling expresses the gist of the matter when he tells us what will
happen when we come to the end of things, and, although he expresses
the desire to rest a while first, which all of us feel, yet he does not wish
to rest always ; and this, too, is true of all of us. Quoting him :

When Earth's last picture is painted and the tubes are twisted and dried,
When the oldest colors have faded, and the youngest critic has died.
We shall rest, and, faith, we shall need it — lie down for an ?eon or two,
Till the Master of All Good Workmen shall put us to work anew.

And those that were good shall be happy : they shall sit in a golden chair ;
They shall splash at a ten-league canvas with brushes of comets' hair ;
They shall find real saints to draw from — Magdalene, Peter, and Paul ;
They shall work for an age at a sitting, and never be tired at all !

And only the Master shall praise us, and only the Master shall blame ;
And no one shall work for money, and no one shall work for fame.
But each for the joy of the working, and each, in his separate star.
Shall draw the Thing as he sees It for the God of Things as They are !



102 NORTH CAROLINA MEDICAL SOCIETY.



HEART STIMULANTS AND TONICS.



Dr. W. p. Beall, Greensboro, N. C.



The heart is one of the most remarkable organs of the body. It is the
only striped muscle entirely automatic and independent of the will. It
maintains its action steadily and tirelessly through our allotted span of
life, and ceases to beat only when its inherent reserve force is exhausted.

The most essential functions of the heart from the clinical point of
view are contractility and tonicity, and underlying these, and controlling
both, is that property of all striped muscle which enables it to respond to
all reasonable calls made upon it, known as Reserve Force.

Dr. James MacKenzie says :

"Reserve force is the essential principle upon which diagnosis, prognosis,
and treatment sliould be based. It is the premature exhaustion of this reserve
which constitutes heart failure, and it is the heart's power to regain this
reserve force on which recovery from heart failure depends."

The drugs used in treating a diseased or disordered heart are classed
as tonics and stimulants, though there is no hard and fast line dividing
them. First among the tonic drugs digitalis stands preeminent. Mac-
Kenzie says that when digitalis fails, he has never been able to find any-
thing to take its place.

In proper doses digitalis causes the ventricle to beat more slowlj^, to
dilate more completely in diastole, and to contract more forcibly and
completely in systole. This causes the heart to empty itself more per-
fectly, thus improving the circulation. As the heart can rest only in
diastole, the slowing of the heart rate permits more prolonged rest, and
as the coronary arteries are filled during diastole, the heart must neces-
sarily be nourished more efficiently by its increased blood supply.

It has been generally held that digitalis contracts the arterioles and
raises blood pressure, but very recent experiments seem to throw doubt
on this theory. It has been shown that digitalis leaves the blood stream
within a very few minutes after its intravenous injection, and that it
acts on the vessels only while it is in the circulating blood; in the next
place, it is never present in the blood of patients in the concentration in
which it was used in the experiments. From this it is claimed with
some reasonable assurance that digitalis exerts no direct vascular action
of any importance unless through the general improvement in the circu-
lation.



MATERIA MEDICA AND THERAPEUTICS. 103

Digitalis is absorbed slowly by the skin or mucous membrane, and still
more slowly when given bypodermically, and its so-called cumulative
action is probably only the accumulated effects of several doses.

Digitalis is indicated in almost all cases in which the tonicity of the
heart is impaired, but is especially useful in acute affections of the organ.
Opinions as to dosage vary greatly. While most authorities advise cau-
tion in its use, beginning with the minimum dose, a writer in a recent
number of the Journal of A. M. A. says that in acute cardiac insuffi-
ciency the initial dose should be 1 drachm of a standardized tincture
(which would represent about 6 grains of the leaf), and continued in
15 m. doses every four hours until some signs of its therapeutic action
are obtained. This seems to be very heroic dosage, and not unattended
with danger.

The symptoms of overaction of the drug are nausea and vomiting,
diminished amount of urine, a tight band-like feeling around the head,
occipital headache, with numbness and coldness of the extremities. The
pulse drops to sixty or less per minute. After giving digitalis for some
time do not allow patient to rise suddenly from the recumbent position,
as sudden death might occur from heart paralysis.

Stroj)hanthiu was greatly lauded a few years ago as a heart tonic, but
extended experience does not sustain the claims made for it. The prepa-
rations of the drug vary greatly in strength.

Houghton states that in testing four samples of tinctures physiologi-
cally, he found one ninety times as strong as the weakest, and more than
twice as strong as either of the other specimens.

Given a reliable tincture, it acts well in cases of irritable heart with
irregular beats, and under its use low blood pressure will improve.

It is said that in emergencies of serious cardiac failure strophanthin
intravenously or intramuscularly has apparently saved life, as it acts
very quickly. It cannot be safely repeated for twenty-four hours, but
in that time much may be done in other ways to hold the patient safe.

Sparteine is also a member of the digitalis group, and is a valuable
drug. It is useful because of its rapid action as compared with other
members of this group. A half-hour after administration the pulse is
markedly slower, in another half-hour arterial tension rises, and its
effects last five or six hours. It gives greater force to the cardiac con-
tractions, and increases the circulation in skin and kidneys. It is well
suited for hypodermic use, being very soluble.

The dose should be from 1 to 3 grains every four to six hours, and as
it has no cumulative action this dosage can be continued as long as
required. Personally I have found it especially useful in typhoid fever
and in the so-called typhoid conditions.



104 NOKTH CAROLIlSrA MEDICAL SOCIETY.

Caffeine is grouped with the heart tonics, though it is i-eally more of
a stimulant. It increases the frequency of the pulse, and seems to give
a little more strength also. It does not slow a rapid heart, but will often
stimulate a slow and sluggish heart. It should not be given in the even-
ing, as it is likely to prevent sleep. The usual dose of the alkaloid is
1^ grain to 1 grain, and of citrated caffeine l^/^ grains to 3 grains.

It sometimes acts well where digitalis fails, especially when patient is
stupid or apathetic.

Strychnine is used probably more than any other drug in heart affec-
tions, and with little discrimination. The claims for and against it are
most conflicting. It is vaunted by many as the best emergency stimulant,
and by many others it is constantly used as a cardiac tonic, and it is held
in high repute. Other very competent clinicians hold that its effect upon
the heart is only incidental.

Dr. MacKenzie says :

"I have carefully sought for its special effect upon the heart, and found
none. I found that the evidence for its good effect was practically all clinical,
and clinical evidence endows the drug with the most diverse properties. It
is recommended as a cardiac stimulant in slow-acting hearts, and even in
heart block is said to quicken the beat. It is said to be beneficial in cases of
low blood pressure, and equally beneficial in cases of high tension, and even
in Angina Pectoris. The evidence that can show a drug to possess the prop-
erty of exciting the sluggish and of soothing the excited heart, of raising the
low pressure and relieving the high, speaks more for unreasoning faith in the
drug than for the beneficial properties of the drug itself."

Prof. W. E. Dixon, in an address before a section of the British Medi-
cal Association in 1909, said :

"Strychnine is still employed on the supposition that it excites the heart to
increased activity. It has no direct stimulant action on the heart ; by exciting
the vaso-motor center it may slightly increase vaso-motor activity indirectly,
but it should never be put in the same categoi-y with digitalis and other cardiac
drugs."

Professor Osborne of Yale says :

"Strychnine is a much overused drug. It is now given for almost every-
thing, and during almost every disease. It is true that the administration of
strychnine is largely due to the evolution of the age in which we are now
living. We have ceased to bleed and purge and sweat ; we have ceased to
starve the patient too long ; we have ceased to load him with alcohol to the
point of circulatory prostration, but brace him from start to finish. Strych-
nine is the drug that is being used for this purpose, and overused."

Nevertheless, strychnine seems to be indicated when the heart is acting
sluggishly and the contractions seem incomplete, especially when digi-



MATERIA MEDIGA AXD THERAPEUTICS. 105

talis is contra-indicated, or is not acting jDerfectly. In the latter con-
dition small doses of strychnine will aid the action of digitalis. It is
said to be especially useful in fatty heart.

Iron is valuable as a heart tonic, not because of any direct action on
the organ, but by improving the condition of the blood the heart muscle
is better nourished and strengthened.

HEART STIMULANTS.

A cardiac stimulant is a drug that makes the heart beat more strongly,
and renders the pulse more normal in frequency. But it does not leave
the heart any better than it found it ; it is not a cardiac tonic.

The principal heart stimulants are camphor, alcohol, and ammonia,
and of these camphor is probably the best. It acts quickly, stimulating
the brain centers and dilating the arterioles. No depression follows its
use in carefully regulated doses, though excessive doses will cause sleep-
lessness. It can be given by stomach in solution, or hypodermic ally dis-
solved in sterile oil. It is advised not to give it to children, as it is not
well borne.

Alcohol is a vaso-dilator, and in cases of high blood pressure with
laboring heart it gives relief by lessening the labor of the heart, but its
effect in safe dosage is transient and it must be repeated at short
intervals. Its value in diseases of the heart is limited.

Ammonia, preferably in the form of the aromatic spirits, is a quickly
acting stimulant, with little after depression, and is valuable as an emer-
gency remedy ; for 'continued stimulation camphor is preferable.

The nitrites are also vaso-dilators, and under appropriate conditions
are valuable cardiac stimulants. iJs'othing can take the place of Amyl
I^^itrite in Angina Pectoris, and when the skin is cold and pallid, and
the heart is laboring, nitroglycerin in solution is very useful, flushing
the face and making the pulse fuller and stronger. It is eliminated
rapidly, and must be given every hour or two to maintain its effects. It
is dangerous in broken compensation or myocardial degeneration.

There are a few other drugs that may be classed as emergency stimu-
lants. Such are ergot, adrenalin, pituitrin, atropin, and morphine.

Ergot hypodermically is said to be very valuable in cases of low blood
pressure with venous stasis, pulmonary congestion, and a laboring, fail-
ing heart. It causes contraction of the blood vessels, and seems to give
tone to the heart.

The caution is given not to overdo administration, as there is danger
of throwing too much strain on the heart muscle.



106 NORTH CAROLINA MEDICAL SOCIETY.

Adrenalin and pituitrin raise blood pressure, and are useful when
pressure is low. Adrenalin is best given hypodennically or by absorp-
tion under the tongue; do not give by the stomach. Pituitrin is given
hypodermically. The dose of either should be small, and should not be
repeated oftener than every four to six hours.

Atropin may sometimes be used to advantage in case of great cardiac
weakness. Like strychnine, it will whip up a flagging heart, but it soon
ceases to be of value. It is best given hypodermically in small doses, not
repeated for several hours, and if it causes excessive dryness of mouth
and throat, much flushing or cerebral excitement, do not continue its use.
Morphine in a small dose, as Y^o grain to i/s grain, combined with atro-
pin, seems to assist in quieting and bracing a weak heart, especially when
there is cardiac pain and sleeplessness.

But by far the most valuable of all heart tonics is rest. If exhaustion
of reserve force is the essential factor in heart failure, then its restora-
tion must be the aim of all treatment. We cannot expect to restore a
crippled valve, a calcareous artery, or a diseased heart muscle to a nor-
mal condition by any treatment whatever; and we can only make the
best of what is left. If we can put the heart into position to regain its
reserve force, we have adopted the only rational treatment. If the con-
dition is acute or severe, prolonged rest in bed is imperative.

As the heart is more nearly at rest during sleep than at any other
time, see that the patient gets plenty of sleep. A warm sponge bath, or
a glass of hot milk, at bedtime may be sufficient. If not, try veronal, or
a small dose of chloral hydrate combined with bromides, or a small dose
of morphine with atropin.

As the patient improves try to impress upon him the urgent necessity
of continued rest and freedom from excitement. In other words, have
him continue the use of the best heart tonic.

I have tried, as briefly as possible, to epitomize our present knowledge
of heart stimulants and tonics ; not to give the results of personal expe-
rience, which is negligible, but the opinions of teachers and specialists
who have earned the right to be heard.

My excuse for selecting this time-worn subject is that whether we are
surgeons, specialists, or general practitioners, we must all watch the
heart of every patient, and respond promptly to its call for help if we
would keep our mortality rate within a creditable limit.

Solomon, the wisest man who has written, advises us to "Keep the
heart with all diligence, for out of it are the issues of life," and who of
us can gainsay his advice ?



MATERIA MEDICA AXD THERAPEUTICS. 107



HAVE ALCOHOLICS A PLACE IN" MEDICAL
THERAPEUTICS?



Dr. J. F. McKay, Buie's Creek, N. C.



In selecting this subject for a paper before this society, the writer did
so with some misgivings. It is a question about which many honest
medical men disagree, nor is the subject always approached with a calm
and dispassionate mind or charity for the opinions of others. In express-
ing my convictions on this subject at a time when hysteria on the subject
of alcohol, both in the profession and among the laity, is so rampant, the
writer, although he has neither the zeal and fanaticism of a crusader,
nor the courage of a gladiator, feels like exclaiming, ''We about to die,
salute you."

At the meeting of the Xorth Carolina Medical Society in Raleigh last
year our retiring president in his address took a very radical position on
the prescribing of alcoholics. The society also passed resolutions against
the prescribing of alcoholics, copies of which have doubtless been fur-
nished you all by the North Carolina Board of Health. In view of the
wide publicity which has been given by the press of the State to the
address and the resolutions passed by the Medical Society, and as the
Board of Health has seen fit to circulate them, I think a word on the
other side not amiss.

The first resolution reads :

"That the Medical Society of tlie State of Nortli Carolina will use its best
efforts to discourage the use of alcohol in any form as a beverage."

Against this resolution the writer has nothing to say. That the habit-
ual use of alcohol in its various forms as a beverage by persons in health
is an unmitigated evil, I admit. That its eifect both on the individual
and posterity are bad and far-reaching the writer also admits. That it
is one of the causes of idiocy, insanity, epilepsy, crime, poverty, and
degeneracy all thoughtful men concede.

The second resolution reads :

"That it is the sense of this society that any member of the profession who
does promiscuous or unnecessary prescribing of whiskey, either to patients or
nonpatients, is violating one of the principles of our profession, and is deserv-
ing of censure."



108 NORTH CAROLINA MEDICAL SOCIETY.

The writer is sure that every member of this society and every true
physician in this State Avill most heartily indorse this resolution. That
alcohol as a drug is being and may be abused by some medical men I
think is true. The same may be said of such common and everyday
drugs as calomel and quinine. There may be a few physicians Avho pre-
scribe alcohol as a routine measure, without any clear idea as to its
action, or the indications to be met, but the number is small. There may
even be a few who so far forget their high calling as to prostitute it for
gain, but the number must be very, very small.

The third and last resolution reads as follows :

"Tbat alcohol as a drug can be eliminated from the Pharmacopeia without
in any degree crippling the efficiency of the doctor's armamentarium."

Against this resolution the writer in all sincerity is compelled to pro-
test. Against our president's views as a citizen or individual, or of those
of the gentlemen who introduced the resolutions, I have nothing to say.
But when the attempt is made to commit the Medical Society of the
great State of iN^orth Carolina to any man's hobby or personal views, I
must demur. That this third resolution represents the views of the great
mass of the medical profession in I^orth Carolina the writer does not
believe. To take this question, with which pharmacologists and clini-
cians have been wrestling for the last fifty years, and settle it once for all
by a resolution passed with very little or no consideration seems to be
running amuck both as to science and experience. The writer does not
believe that the Medical Society in passing this resolution regarded it
any more seriously than they did the joke of our former president, that
physicians be reexamined every five years. By passing this resolution
one of the by-laws of the society was disregarded, as this society does not
stand as sponsor for the views or opinions of any one. The injection of
this more or less political subject into this society was a mistake. It
places the medical profession in the hypocritical position of saying that
alcoholics have no place in medicine, and then stultifying themselves by
prescribing them.

We are living in an age when everything must be regulated, and we
have societies organized to promote everything from antivaccination,
vegetarianism, and temperance to eugenics and trial marriages. If
science and the experience of the world seem to controvert the conclusions
of these fanatics, so much the worse for science and experience. Do these
numerous societies do harm? I think not. So long as they do not
attempt to put their theories into practice, they are harmless. Every
one obsessed with one idea, or affected with a fixed delusion, can find one



MATERIA MEDICA AND THERAPEUTICS. 109

that appeals to him, and it aft'ords a safety valve for his surplus energy
and a medium through which he can ventilate his theories.

This whole thing recalls to my mind a story that I read many years
ago that happened out West. It was at the time when a certain political
party set out to regulate the affairs of the universe. At a great political
convention, when a long set of resolutions reciting many grievances and
demands was about to be passed, a wag in the audience arose and moved
to incorporate a resolution that the Government compel the manufac-
turers to place four legs on all pots ! The question was put and passed
unanimously !

But laying all facetiousness aside, have alcoholics a place in medical
therapeutics ? The writer has no hesitation in saying most emphatically
that they have, and believes that his position will be indorsed by most of
the conservative and thoughtful physicians.

In what I have to say, I refer to the use, and not the abuse, of alco-
holics, when prescribed by a physician for a patient.

There is no drug in the whole materia medica about which pharma-
cologists and laboratory investigators have waged a more violent war-
fare. The combat has surged back and forth Avith crimination and re-
crimination and at times acrimonious debate.

Much of the confusion has arisen from regarding alcohol as a true
heart stimulant, which it is not, yet under some conditions it may act as
such. But this we know, that in any reasonable amount it is oxidized
in the body, and to that extent it becomes a food, supplying heat and
energy and preventing nitrogenous waste. Digitalis, strychnine, atro-
pin, and adrenalin, valuable drugs as they are, cannot take the place of
alcohol. Since the laboratory experimenters do not always agree among
themselves, and clinicians do not agree with the laboratory men, where
does truth lie? I think, somcAvhere between the extremes. Such men as
Hare, Cushney, Pepper, and Tyson, than whom no men stand higher in
the medical profession, give alcoholics a place in their works on



Online LibraryMedical Society of the State of North Carolina. AnTransactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) → online text (page 13 of 58)