If there is much restlessness and the circulation is good, that is, if myocarditis is probably not present, the bromids may be of great value, especially in children. The dose should be sufficient to quiet the nervous system. The drug may be discontinued after a few days, if the conditions improve. If the bromid, except in large doses, will not cause sleep, a sufficient dose of chloral should be given. Chloral is one of the most satisfactorily acting drugs which we have to produce sleep and to cause cardiac rest. While it should not be given if there is real cardiac weakness, the good which it does is so much greater than the possible bad effect on the heart, that it should not be forgotten for some newer hypnotic. The worst part of this drug is its taste, and the best way to administer it is to have it in solution in water and the dose given on cracked ice with a little lemon juice to be followed by a good drink of water and a piece of orange pulp for the patient to chew. Ordinarily a bad-tasting drug such as chloral is well administered in effervescing water, but effeverscing waters are generally inadvisable when there is any kind of inflammation of the heart, as they are liable to cause distention of the stomach and pressure on the heart. Some physicians prefer chloralamid as a less disagreeable drug and one which acts almost as efficiently as chloral. As the close of this must be larger than the dose of chloral, it is a question of doubt as to which is the better drug to use. Of the newer hypnotics, veronal=sodium (sodium-diethyl-barbiturate) is among the best. It acts quickly, is less depressant and is a safer salt than most of the other newer hypnotics. It is the readily soluble sodium salt of veronal (diethyl-barbituric acid). When combined with any active drug, sodium seems to make it less toxic and less depressant. The dose of this drug is from 0.2 to 0.3 gm. (3 to 5 grains).
PREVENTION
If the patient is weak, the circulation depressed, the blood pressure low, and the heart rapid, the drug advisable to produce rest and sleep is almost always morphin or some other form of opium. Morphin, with few exceptions, is a cardiac tonic and a cardiac stimulant, unless the dose is much too large. As long as the bowels are daily moved and the food is not given at the time of the full action of the morphin, when digestion might be delayed or interfered with, in most patients the action of this drug during serious illness is entirely for good. The greatest mistake in using morphin for the production of sleep, or for physical and mental rest and comfort when there is not severe pain, is in giving too large a dose. If pain is not severe, or due to inflammatory distention of some undilatable part, to pressure on some nerve, to distention of some tube by a calculus or to some serious injury to the nerves, large doses of morphin are not needed. Small doses will act much more efficiently. It is excessively rare that a hypodermic of one- fourth grain of morphin sulphate is needed, except for the conditions enumerated. It is often a fact that so small a dose as one-eighth grain of morphin or even one-sixth grain will cause sufficient stimulation of a nervous patient, because its primary stimulant effect on the spinal cord is greater than its depressant effect on the brain, to require another dose (one-fourth grain altogether) to give such a patient rest. On the other hand, this patient may many times be quieted by one-tenth grain of morphin sulphate on account of the size of the dose being not sufficient to stimulate the spinal cord. Many a time clinically when one-eighth grain has failed, a dose of one-fourth grain having been apparently necessary, a change to one-tenth grain has proved entirely and perfectly satisfactory.
DIET
As intimated in the preceding paragraph, the diet during endocarditis must be carefully regulated. It must be sufficient, and appropriate for the disease in which the complication occurs, but it must be in such dosage and administered with such frequency as to cause the least possible indigestion. Large amounts of milk are rarely advisable. Too much milk is certainly given, even in rheumatism. While pretty well tolerated by children, it is often badly tolerated as far as digestive symptoms are concerned, by adults. The amount of liquid given should be governed by the amount of urine passed and by the amount of perspiration. The patient should not be overloaded with liquid if he does not need it. Enough carbohydrate must be given.
LAXATIVES
If the bowels are known to be in excellent condition and not loaded with fecal matters, brisk catharsis is not needed simply because endocarditis has developed. If the bowels have been neglected, a small dose of calomel, aided by a compound aloin tablet, is necessary and good treatment. Subsequent movements of the bowels should be daily obtained by vegetable laxatives with occasional enemas, as needed. With all inflammation of the heart and the possibility of myocarditis developing or being actually present, it is not advisable to use salines freely or often.
CARDIAC DRUGS
Whether any drug should be used which acts directly on the heart is often a question for decision. As endocarditis is generally secondary to some acute disease, the patient has become weakened already, and the circulation is not sturdy; therefore such a drug as aconite is probably never indicated. The necessary diminished diet, catharsis, hypnotic, salicylic acid and alkalies all tend to quiet the circulation and diminish any strenuosity of the heart that may be present. Unfortunately, during fever processes, digitalis in ordinary doses rarely slows the heart; and while it might slow the heart if given in large doses, it would also cause too powerful contractions of the ventricles. Digitalis is inadvisable if there is much endocardial inflammation, and especially if there is supposed or presumed to be acute myocardial inflammation. If a patient had already valvular disease from a previous endocarditis, and during this attack insufficiency of the heart was evidenced by pendent edemas, digitalis Should be administered; but it probably should not be given to other patients during the acute period of inflammation.