To obtain cardiac stimulation from alcohol it must be given in strong solutions, generally in the form of whisky or brandy, for local irritation of the mouth, esophagus and stomach; reflexly the heart is stimulated and the blood pressure rises. As soon as complete absorption has taken place, the blood pressure falls. For continuous stimulation, another dose of alcohol must be given before this depression occurs. This may be in from one to three hours. To continue such stimulation, the dose of alcohol must be increased. The future of such treatment means an alcoholic sleep with depression, alcoholic excitement which is not desired, or profound nausea and vomiting, with peripheral relaxation and cold perspiration.
Obviously none of these conditions is desirable; but in arteriosclerosis, or when the blood pressure is high and the heart labors tinder the disadvantage of contracting against an abnormal circulatory resistance, alcohol may act perfectly to relieve this kind of circulatory disturbance. In this condition the alcohol should not be given concentrated, and as soon as it is thoroughly absorbed vasodilatation occurs, peripheral circulation and therefore warmth are increased, and the heart is relieved of its extra load. In such instances, in proper doses not too frequently repeated, rarely more than 1 or 2 teaspoonfuls every three hours, alcohol is a valuable drug. Such good action of alcohol is often seen when the surface of the body is cold from chilling, or the extremities are cold from vasomotor spasm. A good-sized dose of alcohol, best given hot, equalizes the circulation and acts for good. On the contrary, it is obvious that, if the patient is cold from collapse and there is cold perspiration and very low blood pressure, alcohol is not the drug indicated, although one dose may be of benefit while other more slowly acting cardiac tonics or stimulants are being administered.
During serious prolonged illness and when the patient has not had sufficient food and is not taking sufficient food, alcohol in the form of whisky or brandy, not more than a teaspoonful every three hours, acts as a necessary food, and will more or less prevent acidosis from starvation.
It will be seen that alcohol, except possibly in a single dose occasionally, or for some special reason, is rarely indicated in decompensation.
When alcohol is administered regularly, whether during a fever process or for any other reason, if it causes a dry tongue, cerebral excitement, flushed face and a bounding pulse or if there is the odor of alcohol on the breath, the dose is too large, and alcohol is contraindicated.
Ammonia: In the form of ammonium carbonate or the aromatic spirits of ammonia, this has long been used with clinical satisfaction as a cardiac stimulant. Probably, however, it is seldom wise to use ammonium carbonate. It is exceedingly irritant, and constantly causes nausea, perhaps vomiting, and often heartburn or other gastric disturbance. It has no value over the pleasanter aromatic spirits of ammonia, which is essentially a solution of ammonium carbonate. The dose of the aromatic spirits is anywhere from a few drops to half a teaspoonful, given with plenty of water. It is thought to be a quickly acting stimulant, with an effect much like alcohol, followed by very little or no depression. It is more of a cerebral irritant than alcohol, and probably has few, if any, advantages over camphor.
When but little nutriment has been taken for some days, it may be a chemical question, since ammonium compounds so readily form and become cerebral irritants, whether any more ammonium radicals should be given the patient. This is especially true with defective kidneys. In these conditions camphor is better.
3. Vasodilators.—In various conditions of high blood pressure, arteriosclerosis and even during the sthenic stage of a fever, vasodilators may be indicated. The most important are nitrites, iodids and thyroid extracts. Alcohol, as stated above, may act as a vasodilator. Aconite and veratrum viride are now rarely indicated, although possibly aconite should be used when there is high tension and the heart is acting irritably and stormily.
If the nitrites, no preparation seems to act more satisfactorily than nitroglycerin (trinitrin, glyceryl nitratis, glonoin). Its action may not be so prolonged as other forms of nitrite, such as sodium nitrite or erythrol tetranitrate, but it is not irritant, and only a little less rapid than amyl nitrite, and although the marked dilation lasts but a short time, often apparently only for minutes, still, when frequently repeated or given a few times (from four to six) in twenty-four hours, it frequently keeps the blood pressure lower than it would be without the drug. In diseases of the heart the sudden vasodilation caused by amyl nitrite inhalations is indicated only in angina pectoris. "Then the surface of the body tends to be cold, however, when the peripheral blood pressure is increased and the heart is laboring, nitroglycerin in small doses is valuable. The dose may be from 1/400 to 1/100 grain, dissolved on the tongue or given hypodermically for quick action, or given by the mouth for more prolonged action. In sudden cardiac dyspnea nitroglycerin sometimes acts specifically, especially when there is asthma. When a drop or two of the official spirits, which is a 1 percent solution, is given on the tongue, or a soluble tablet of 1/100 grain is dissolved on the tongue, the action is almost as rapid as though the dose had been administered hypodermically. Many times when such increased peripheral circulation is desired and alcohol seems indicated, nitroglycerin in small doses will act as well. It cannot be termed a cardiac stimulant, although many times a heart acts better and the pulse is fuller and stronger after nitroglycerin than before. It should not be used, except if specially indicated, in broken compensation or in other myocardial weakness.
Iodids: These have no immediate action. The vasorelaxation that often occurs from iodid is quite likely due to the stimulation of the thyroid gland by the iodin, and the thyroid gland secretes a vasodilating substance. Small doses of iodid, however, when indicated in various kinds of sclerosis, have seemed to lower blood pressure. While large doses may have more of this actioli, they are not now under consideration, and large doses are rarely indicated. Too mach iodid has been given for many conditions. If the indications for an iodid are present, such as sclerosis anywhere, or unabsorbed inflammatory products, exudation in or around the heart, or an apparent insufficiency of the thyroid, from 0.1 to 0.2 gm. (1 1/2 to 3 grains) once or twice in twenty-four hours, after meals, is all that is required to give the action desired, and the circulation is benefited. It is sometimes a question whether small doses of iodid are not actually stimulant to the heart, possibly through the action on the thyroid gland.