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RE-PRINTED FROM THE "CANADA MEDICAL k SX7R0ICAL JOT

FEBRUARY. 1888.

THE PRESENT STATE OF CARDIAC THERAFEDTICS.'

6t James Stewart, M.D.,
Professor of Pharmaoology and Tberapeuticsi MoOill Unirersity.

The subject of cardiac therapeutics is one of great im-
portance — of much more importance than is generally conceded
to it by the ordinary text-books. During the past year or two
quite a revolution has come over our ways of looking into the
future physical life of patients suffering from many of the forms
of organic heart disease. In fact, as yet, these views to which
I refer have not by any means become general. These changes
of opinion are of such paramount importance to the well-being
and happiness of those committed to our care, that it is the
bouijden duty of every practitioner to study them seriously.
The changes to which I refer consist in the much more favorable
prognosis that is admissable in the great majority of cases.

Last year, at the meeting of the British Medical Association
at Brighton, Sir Andrew Clarke created what might almost be
called a sensation by giving the life history of a very large num-
ber of cases of organic disease of the heart which he had the
opportunity of observing for very many years. The point made
by Sir Andrew was this : that patients with organic heart disease
lived much longer than they were supposed to do, and that the
great majority of them were not only able to live, but also to
work — to live with comfort and work with vigor.

No doubt a number of observers had pointed out bisfore that
cases of organic disease of the heart do frequently present them-

* The Address on Therapentics at the Twentieth Annual Meeting of the Canadian
Medical Assooiation, Hamilton, Sept. 1, 1887.

selves where the lesion had heen in existence durin>5 a lonj? liretime
without the patient's knowled<i;e that there was anythin;; seriously
wrong. There is an important therapeutic lesson to be gathered
from the history of a case of a man with one or more seriously
damaged heart valves, who has lead a long and active life,
throughout which he has been unconscious of anything wrong.
Such a case teaches us the clinical history of the course of the
disease uninfluenced by treatment and uninfluenced by the men-
tal worry necessarily present where there is a consciousness of the
presence of a grave organic lesion.

In dealing with this subject, I will first refer to the means
that should be employed when we have to do with an acute in-
flammatory process in the endocardium, and (2) the treatment
of the consequences that result from any chronic condition or
state that gives rise to secondary changes (mechanical) in the
heart ; or, in other words, the treatment of threatened or actual
loss of compensation.

Given a case of acute endocardial inflammation of, say, the
aortic valves, which leads to deformity and, consequently, to
incompetency of these valves, what are we to do to limit the
extent and, consequently, the hurtfulness of such a lesion ?
What, in other words, can be done to prevent the connective
tisssue formation assuming a great degree ?

There is one great principle in the treatment of inflammatory
affections which we must endeavor to carry out here, and that is

■ Rest. ' ■ -^ '

Rest to the inflamed valves. Complete rest is, of course, im-
possible, but relative rest is to some extent obtainable. By
giving the valves less to do we in a measure limit the extent
and degree of the inflammatory process going on in them. The
lower the blood pressure is, the less work will the valves have
to do. The treatment, then, consists, in those measures which
lower or depress the blood pressure. The first important point
to attend to is absolute rest in bed. It is not necessary to in-
sist on the importance of this — it is self-evident. We, however,
may have a high blood pressure in spite of bodily quiet. The

amount of fluid taken in should be limited, for it is a well recog-
nized physiological fact that a dry diet is the most efficient means
of lowering blood pressure. This has been conclusively proved
by Kussmaul and Tenner's experiments. Of drugs, we have a
number that markedly lower the blood-pressure, prominent
among which are chloral and the nitrites. The judicious use of
chloral in cases of endocarditis is, according to Fothergill, a
very efficient way of limiting the sclerotic process. In the
nature of things it is impossible to estimate the value of this
treatment in any individual case. It can only be expected that
at best we can limit the diseased process, und to what extent this
is accomplished in any case it is impossible to tell. No doubt
blood-letting is a powerful way of lowering the blood-pressure,
but its action is very temporary, and therefore not nearly so
efficient as a strict adherence to a dry diet. On physiological
grounds I should jud^e that the employment of frequent blister-
ing over the cardiac region is injurious. At best, the action of
blisters on the inflammatory process is very doubtful, and we
know tbat such strong irritation of the skin does, reflexly, tend
to keep up a high blood-pressure. The trifling amount of serum
drained from the tissues may be eliminated.

The Treatment op Cardiac Disease during the period of

Compensation.

When from any cause we have an obstruction to the outflow
of blood from the heart, there is a damming up of the blood in
the lesser circulation, which soon leads to changes in the vessels
and in the heart itself. The changes in the vessels are obviated
for the most part by the secondary compensatory changes in the
heart. Compensation can never be perfect, still it is so perfect
frequently that the patient is quite unconscious for many years
of any circulatory disturbance or trouble whatever. We may
say that practically we do meet with perfect compensation. As
long as the heart is able to overcome the mechanical obstructions
heaped up by disease, then so long will the patient remain well.
In other words, while compensation is good all is well.

The treatment is now directed to the maintenance of this com-

pensation. Sooner or later in many cases it shows signs of
failing, the earliest indication being usually shortness of breath.
What can we do to prevent compensation from failing, and when
it threatens or has actually set in, what measures should wo
employ ? The answers to these questions are all important.

Given a case of acute rheumatism, where there develops dur-
ing its course an acute aortic valvulitis, with subsequent sufficient
compensation to enable the patient to attend to the ordinary
duties of life, what advice are we to give ? How should the
patient live in order that he may keep up his cardiac compen-
sation ?

There are certain general therapeutic principles which it is
important to bear in mind in all cases, no matter what the cause
of the circulatory disturbance is. The first is the strengthening
of the heart-muscle. It is important to remember that the heart
is a muscle, and that its strength is increased by all those influ-
ences which increase other muscles. The usual advice given to
patients affected with heart disease is to rest as much as possible
so as to leave but as little work as possible for the heart to do.
Recentiv Oertel ot Munich has practised an entirely ditferent
method of dealing with these cases. His method of treating
these cases is just now, in Germany, attracting very marked
attention, and are very favorably received. Leyden, at the late
meeting ot the Society of Physicians, considered Oertel's treat-
ment as a distinct atlvance, and as involving a distinct thera-
peutic principle. I will endeavor, briefly, to lay before you
Oertel's method of keeping up compensation or of averting its
loss when thus threatened. He maintains that exercise is the
means we have of 8tren;ithening the heart muscle. He advises
walking — at first on the level ground and afterwards hill climb-
ing He counsels his [latients to take as much exercise as pos-
sible. The patient should walk until violent palpitation is brought
on, and then he is required to stand still till it has abated, and
until the shortness of breath is satisfied by voluntary, long, deep
inspirations. He keeps not only patients with sufficient com-
pensation, but those with insufficient compensation, at this exer-
cise, and repeats it after longer or shorter intervals of time,
according to necessity.

A second condition that he lays stress on is the keeping up of
a good state of nutrition by a diet rich in albumen, so that the
tissues during work may be replaced, and that sufficient material
may be furnished for the formation of new tissue elements, espe-
cially for the muscular hypertrophy. The food, then, should be
one especially rich in nitrogenous elements — a meat diet in the
main, the fat and carbohydrates being only allowed in limited
quantities.

Oertel further strongly insists on the regulation of the
amount of fluid. When there is excess of fluid, then we are apt
to have blood stasis with all its consequences ; the veins become
over-filled and the arteries less full. The deleterious influence
of this stasis is especially noticeable in the heart itself from over-
filling of the coronary veins, the heart-muscle in consequence
directly suffering. If there is an excess of fluid in the body
already, then it should be got rid of. The skin should be made
to act freely, and one of the best means we have for this pur-
pose is exercise. It is only when diaphoresis is not obtainable
by exercise that we should resort to other measures, as hot-air
baths, Turkish baths, and pilocarpine. The importance of regu-
lating the body fluid is at once apparent when we remember that
the venous system is always over-full ; no matter how perfect a
compensation may be, it is never su£Bcient to maintain the nor-
mal relations between the arterial and venous systems. Oertel
lays great stress on the importance of pi ■ v nting fat formation,
especially in cases after the restoration of a previous loss of com-
pensation. Owing to the incomplete filling of the arteries and
the over-fullness of the veins there is of necessity incomplete
oxidation, which leads to the deposition of fat. This is especially
marked in those who are prone to put on fat and those who par-
take freely of carbohydrates. The heart sufiiers directly as well
as indirectly. Owing to the coronary arteries being insufficiently
filled, and owing to the lack of oxygen, the heart fails to perform
its work efficiently, and in consequence we have fatty degenera-
tion of its fibres in addition to fatty deposition on its surface and
fatty intermuscular infiltration. This further enfeebles its action.

It follows, therefore, that we should constantly guard against all

those influences \?hich tend to bring about this enfeebling power.
The combustion of fat already in the body must be promoted,
and the supply of fat and carbohydrates in the food must be as
small as possible.

Now the means best adapted to promote the combustion of
fat are those which I have already alluded to for strengthening
the heart-muscles and regulating the quantity of fluid in the body.
In addition to ordinary exercise, Oertel recommends the under-
taking two or three times a year of mountain tours. This diffi-
cult exercise, with the increased sweating attending on it, the
diminution of the fluid supply and the use of a more albuminous
diet will soon reduce any fat which has accumulated. The in-
creased vigor in consequence given to the heart and the removal
of obstruction to its work will soon show itself in the restoration
of compensation, and by careful living afterwards, according to
the plan sketched, it is possible, so it is claimed, for a patient
to maintain his original state (dating from the early compensa-
tion) for very many years.

Such, in brief, is the method proposed and successfully prac-
tised by Oertel in the management of the letention of compen-
sation and its restoration when lost. I freely admit that I have
given but a very imperfect outline of it. The subject is one of
such importance that to do it full justice it would require a
treatise. Great credit is due to Oertel for the elaborate, scien-
tific, and very painstaking manner in which he has worked out
this whole subject. In his work he gives the history of a case
that he carefully treated and closely observed for nine years.

Many years ago, Stokes of Dublin recommended a somewhat
similar treatment, but in spite of his great advocacy it fell into
disuse, even if it was ever practised to any extent.

At the recent meeting of German physicians a paper was read
by Franz with the title of " Best or Work in Heart Disease."
From an extensive experience he has come to the conclusion
that in chronic cases active but careful exercise is conducive to
the strengthening and slowing of the heart's action. He pointed
how damaging it is to the circulation to have a dilated heart
beating quickly and incompletely. The stretched ventricle is

'S.Fl'>^^

never completely empty, so that finally it looses its elasticity,
and owing to its almost constant working it soon degenerates.
Now here, if we bring about a complete emptying, we give the
ventricle rest and in consequence strength. Franz claims that
this can be completely and efficiently effected by exercise —
more completely and efficiently than by any other known means.
We have, he says, in exercise a means more powerful and safer
than digitalis He further claims that the improvement is more
lasting than that effected by other means — that the work of the
heart is lessened by the disappearance of the stasis in the venous
system, and the nutrition of the heart is vastly improved through
the deeper inspirations making the blood richer in oxygen. He
advises that in cases where there is good compensation already,
that in order to maintain it ordinary gymnastics are sufficient.
He lays great stress, however, on the possibility, even probability
of this being overdone, and he insists that every exertion should
be followed by a period of rest. Where compensation is, how-
ever, lost, the greatest care must be exercised before beginning
active exercise ; the nature and the amount should be strictly
laid down. Before beginning mountain climbing, baths, with a
course of Swedish gymnastics, are advisable.

Franz believes that there is no danger whatever in patients
with heart disease exercising so long as the palpitation induced
by this work is quickly relieved by taking forced deep inspira-
tions. The deep inspirations diminishes quickly the increased
tension that is brought about in the pulmonary vessels.

Schott of Nauheim, who took part in the discussion which
followed Franz's paper, contended that mountain climbing was
only useful in a small number of cases, and that he had seen
much harm follow its practise. He, however, strongly approves
of exercise in a gentle way for the heart muscle. He therefore,
although opposed to the extreme views of Oertel, is satisBed
that much good can be effected in those cases with exercise
when practised judiciously. Both he and Franz have seen a
number of cases where mountain climbing has done irreparable
damage to the already overtaxed heart when practised by the
patients without first consulting a physician.

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•,. It will he j«voii that w** have the evidence of several competent
uuthorities that in exercise we have a rendy and all-powerful
means of effecting good when used properly, hut an agent power-
ful for evil when injudiciously employed. Time alone will enahle
us, however, to dt'termine to wljj^at extent wo can roly oi this
method ot' oKviattng the effects of a damaged coro|v6Q!«cion. Il
is a Hiihject of deep tiud far-reaching importance, and will require
time, patience, and sound physiological knowledge to determine
when it should be recommended or whether it should bo recqp* ^^
mended at all or not. * ' 'it''

It is no doubt more . ipted for cases of commencing fatty
heart and for cases of threatened heart failoro from deformity
of the chest or disease of the lungs. That it is applicable for
cases of threatened heart failure, no matter what the cause may
be, is contended for by its great promoter — Uertel. It will
make us all think a little more in the future when we are face
to face with the question. Exercise or Rest, which is it to be ?

,^ There is a time in cases of loss of compensation that exercise
is no longer possible, and where we have to resort to medicinal
agents. Of all these agents, none, on the whole, is comparable
to digitalis. The usefulness of digitalis in cases of heart failure
is great indeed. I would not occupy the time of this Associa-
tion in entering into any details as to its mode of action and em-
ployment were not I firmly convinced that there is a very im-
perfect knowledge among many practitioners of how and when
digitalis should be used. How universal is the practice to give
this agent when a cardiac lesion is diagnosed without any refer-
ence to the nature and attending consequences of such a lesion.
The great use of digitalis is in cases where there is commencing
or even very advanced loss of compensation. When compensa-
tion fails we have stasis, as evidenced by breathlessness, quick-
ened pulse, oedema of the ankles, diminished secretion of urine.
The first marked effect of heart failure is diminution in the
aortic pressure, as shown in the diminution in the amount of
urine excreted.

The essential therapeutic action of digitalis consists in its
power of raising the blood-pressure. The slowing of the pulse,

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upon which so much stress is laid, is, according to Sohmiedeberg,
a result of the high pressure. The results and symptoms of
loss of compensation in cardiac disease are mainl}', as I have
said, due to deficiency of blood in the arterial vessels and to a
too low a pressure in them. If the blood pressure be raised,
the secretion of urine increases, the effused fluids are absorbed
from the cavities and tissues of the body, and the respiratory
distress disappears. So limg as digitalis causes an increase in
the quantity of urine, so long 's it safe to proceed with its ad-
ministration. We know that d .;italis has no influence in increas-
ing the quantity of uriiiu in health or in disease where the blood
pressure ia high. Its diuretic action is entirely dependent on
its power of raising an abnormally low blood pressure. In order
to brin^i^ tbout the diuretic effect of digitalis it is necessary to
give it in full do.^es. The effect of small or even moderate doses
i^M' is to increase the general pressure, including the pressure in the
arterioles of the kidneys. While the preoaure throughout is high,
there is no diurectic action manifest. After a certain quantity
has been administered, the increased pressure in the kidneys
gives way, with the result of a rapid and often great increase in
the quantity of urine. The increased diuresis may continue
several days. If the drug is still continued, there is general
fall in the blood pressure, and in consequence the diureric action
soon ceases. Wlu-n the urine, after being increased in quantity
by digitalis, considerably diminishes, then the drug should be at
once withdrawn. This decrease is a warning which ahould never
be neglected. If it is, the ventricular contractions becomes
weaker and weaker, until finally we only hear a " toneless tic.
tac." When this stage is reached, it requires but little more
digitalis to bring about a stand-still of the heart in contraction.
Up to the production of decrease in the quantity of urine, nothing
but good is observable. ^ tv ^^ ,

Now as to the quantity of digitalis necessary to bring about
diuresis there is great variation. Different persons vary greatly
as to their susceptibility to its action. Forty minims of the tinc-
ture four times daily for three days will in the great majority of
cases bring about this diminution. Sometimes it is necessary to

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^-3

give as much as half an ounce daily in divided doses before the
result is attained. Oases of dangerous heart failure should
always be treated according to the method sketched. It is very
unscientific to expect the best results from any other way. No
doubt 10 or 15 minims of the tincture several times daily will
to some extent relieve an overtaxed ventricle ; even rest in
bed without any medication will at times prolong life ; but the
best results are only obtainable when absolute rest in bed is
combined with digitalis in full doses. "*

There is a large group of agents which belong to the digitalin
group which have lately attracted a great deal of attention.
There is Scillain, which is the active principle of squills ; Helle-
borein, which occurs in the various species of hellebore ; Olean-
drin, found in conjunction with digitalin in the common oleander ;
there is Apocynin, contained in Canadian hemp ; Adonidin, found
in the spring adonis ; Convallamarin, in the lily of the valley ;
and lastly, Strophantin. Now all these agents possess in com-
mon the property of slowing the heart and increasing the blood
pressure. Squills has been used empirically for a long time as
a diuretic and heart tonic. It enters into the composition of the
still famous Baly pill, the other ingredients being digitalis and
mercury. This is" a remarkable combination, built entirely on
empiricism long before the science of pharmacology was even
dreamt of. We have here a combination containing two heart
tonics, digitalis and squills, and a direct diuretic, mercury. It
is only a very recent discovery that mercurials, especially calo-
mel, have a direct diuretic action. It is a pmof, it one were
needed, how foolish it is to neglect the laborious acquired know-
ledge of our forefathers, call it emf)iricism if we like Of the
other agents mentioned, only 8tro|.hantin and adonidin need be
referred to ; the remainder we know little or nothing outside of
the laboratory.

Strophantin, introduced by Professor Fraser of Edinburgh,
has now been in use about two years, and although all the reports
are not confirraatoty of a very marked tonic action, still we have
sufficient evidence to enable us to say that it is a very valuable
addition to the list of cardiac tonics. It has been found well

11 '

adapted for cases of cardiac failure depending on valvular disease.
Pins of Vienna, who has given us a report of its action, claims
a hi;:h place for it, even suggesting the probability of its dis-
placing digitalis. lie found the weak, rapid and irregular pulse
of mitral disease become slow and powerful. It acted as a
prompt diuretic, being quicker in its action than digitalis. It is
worthy of a thorough test, but, as yet, we are not sufficiently
acquainted with its mode of action to determine the exact place
it will hold in cardinc therapeutics.

A few cases have been reported where adonidine has had a
very marked action m toning up a failing heart, even when digi-
talis is alleged to have failed ; but in all the reports that I have
examined, the digitalis was not administered with that freedom
that is necessary in order to obtain its full effects. Still there
is sufficient evidence to prove that in adonidine we have a very
powerful cardiac tonic and vascular diuretic.

1 will now conclude what I have to say by a few words on

' Caffeine IN Cardiac Therapeutics.

This is a most valuable agent, and deserves a much more ex-
tended use than it has up to the present time received. In
order, however, to obtain its full action, it is necessary to give
it in much larger doses than is usually prescribed, 10 to 15 gr.
in place of 2 or 3 gr. The best salt to prescribe is the natro-sali-
cylate of caffeine. The sodium salicylate dissolves it in chemi-
cally equivalent quantities, so that the natro-salicylate of caffeine
contains 50 per cent, of caffeine.

Caffeine quickly raises the blood pressure by a direct action
on the vaso-motor centre. It has also a direct diuretic action.
This, I think, has been conclusively proved by the very recent
researches of von Schroder of Strassburg. He has shown that
it has a direct stimulating influence on the epithelium of the
convoluted tubules, and probably also on the epithelium of the
glomeruli. It is on this direct diuretic action that the advan-
tages of caffeine depend. Digitalis only acts as a diuretic through
increasing the blood pressure, and on this account it takes from
three to four days before its action is manifest. Caffeine, on

the other hand, will induce a diuresis within ' hours. In cases
of paresis of the cardiac muscle, time is aii /\portant; before
the action of digitalis can be induced precious time is lost. This
is the great drawback to the use of digitalis — i.e., time consumed
before its action is manifest. Our present knowledge of caffeine
may be summed up as follows : It is of marked use in the same
class of cases as digitalis. It differs, however, from this drug
in the foUoving particulars. It is less powerful as a cardiac
tonic, but is a more powerful and prompt diuretic, and for this
reason it gives relieve quicker from all the troublesome subjec-
tive symptoms of cardiac failure. By combining the power of
digitalis with the rapidity of action of caffeine, we may obtain
the advantages of both drugs, with little of the disadvantages
of either. ,

There are many more therapeutic resources at our command
besides those mentioned. Time will prevent me from referring
to them. The wonderful powers of arsenic in painful con-
ditions of the heart, the use of opium alone or with digitalis,
the marked beneficial actions of the nitrites, etc., are all means
at our command of relieving some of the most distressing states
that afflict mankind. Much as we can do at present, there is
every reason to hope that in the near future we will be able to
do much more.