Disturbances of the Heart / Discussion of the Treatment of the Heart in Its Various Disorders, With a Chapter on Blood Pressure

by Oliver T. Osborne

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 cumulative action.

While many patients with ordinary dosage of digitalis may take the drug for months and years without ever showing cumulative 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 passed. 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 substitute 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.