IMAGE EVALUATION TEST TARGET (MT-3) o o oo .*■> f,o?*t • . ^*v, // %.<.^ 1.0 I.I 1^128 |2.5 ;^ I4£ 12.0 2.2 1.8 ., '■^ 1 '-^ -^ ^ 6" •. VI ^;. .^% ^>> -^<^ '-'^ "*>V'^ 7 Hiotographic Sciences Corporation ^ 5 a lonj? liretime without the patient's knowled^^ .} 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. 4 V. • ?...tt . ..v» I.-*-'. :'•"•" ' V.'v"."..*.:;. 1':' .••'.>v..-;" •'.';• •;■.••,•;■" •■.."■■a" •>?.!■•.•', --^^ ■"-■"■V;.. '.^^v&'r^4y 1'°'.'. 'i.V^ !,'••,"■.:,'.•'■•■'. . •■•« »'.'' •' -„'•",'■""■,■''"'■•'''■• o' ''' ■ I •{•/■.;3i::>vr •.-■•.• ; '^^^^■ , • 'fi'.'Ch ".• Si •"'"' '', ,' ', .,=5 , ?;•.■•.•.:••. i: • o" 1°, -'o 9 f "7" •,. 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, r , . . :; c -' ._ (i1> t.rt«,i;^: >«ib, "• 'It rj^o p5**'*4t •*iL' :-■■' '^.^ '' ^_( ) i. ,' ) .!,««AV ^ » !• •• ' • -"• M»'r' i'«jA/ mm,;. Ill^#v Tvf-. >» ' d-0 ' o-o' /" 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 Xp '^^ s:-^ Gn f* "N ^-3 10 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 12 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. ^.