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Indications For Strychnin





Category: Uncategorized
Source: Disturbances Of The Heart

Strychnin is a much overused drug. It is now given for almost
everything and during almost every disease. It is true that the
administration of strychnin is largely due to the evolution of the
age in which we are now living. We have ceased to purge and bleed
and sweat, and to give large doses of aconite or veratrum viride;
have ceased to starve the patient too long; we have ceased to load
him with alcohol to the point of circulatory prostration, and we
have recognized that he must be braced from start to finish;
strychnin is the drug which has been used for this purpose, and, as
stated above, overused. Strychnin given too frequently or in too
large doses for a laboring heart can prevent its proper rest; the
diastole is shortened and the relaxation of the heart is incomplete,
its nutrition suffers, or even irregular and fibrillary contractions
of a weak heart may apparently be caused. While a large dose of
strychnin, even to one-twentieth grain hypodermically, may be used
once in serious emergency when it is deemed the drug to use, a dose
larger than one-thirtieth grain hypodermically is rarely indicated,
the frequency of such a dose should seldom be more than once in six
hours, and a smaller close of strychnin may act more satisfactorily.

Strychnin is indicated when the heart is acting sluggishly and the
contractions seem incomplete, and when digitalis either is not
indicated or is not acting perfectly. Small doses of strychnin may
aid such a heart during the administration of digitalis. In many
instances in which digitalis is contraindicated, strychnin is of
marked value. This is typically true in fatty hearts, and may be
true in arteriosclerosis, in which it often does not increase the
blood pressure at all.

2. Cardiac Stimulants.--A cardiac stimulant is a drug which makes
the heart beat more strongly and the frequence more nearly normal.
The drugs named as cardiac stimulants, however, camphor, alcohol and
ammonia, do not leave a heart better than they found it--they are
not cardiac tonics.

Camphor: This is one of the best cardiac stimulants that we possess.
It is a quickly acting nervous and circulatory stimulant, acting
principally on the cerebrum and causing a dilation of the peripheral
blood vessels. No subsequent weakness follows after a dose of
camphor. Too much will make a patient wakeful, a little often quiets
nervous irritability. It should be used as a cardiac stimulant
during serious illness more frequently than it has been; and during
the endeavor to make a noncompensating heart again compensatory
camphor will often act for good. The dose is 2 teaspoonfuls of the
camphor-water every three or four hours, as deemed advisable. Each
teaspoonful represents a little more than one-fourth grain of
camphor. The spirits of camphor, of course, may be used, if
preferred.

For cardiac emergencies, ampules of sterile saturated solutions in
oil are now obtainable and are valuable. Such hypodermic stimulation
acts quickly, and may be repeated every half hour for several times,
if the patient does not respond. The solution should be injected
slowly, and as a rule intramuscularly.

Many times while other measures are being used to repair a broken
compensation, camphor makes a splendid circulatory and nervous
bracer. Camphor has long been used as a so-called antispasmodic in
hysteric or other nervously irritable persons. It really acts as a
stimulant to the highest centers of the brain, promoting more or
less nervous control. Perhaps its ability to increase the peripheral
circulation may be one of the reasons that it seems at times to be
almost a nervous sedative by relieving internal congestion. As just
stated, after the camphor action is over there is no depression.
This is not true of alcohol.

Alcohol: It is of course now generally understood that alcohol is
not a cardiac stimulant in the sense of its being more than
momentarily helpful to a weak heart. If alcohol is pushed when a
heart is in trouble, the secondary vasodilatation and more or less
nerve prostration and muscle debility will cause greater circulatory
weakness than before it was administered.

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.

Thyroid Extract: In slow hearts and in sluggish circulation, often
in old age, quite frequently in arteriosclerosis and in every
condition of insufficient thyroid secretion (these instances are
frequent), small doses of thyroid extract will benefit the
circulation. Its satisfactory action is to increase the cardiac
activity, slightly lower the blood pressure, and increase the
peripheral circulation and the health of the skin. If it causes
tachycardia, nervous excitement, sleeplessness or loss of weight, it
is doing harm and the dose is too large, or it is not indicated. The
dose for the cardiac action desired is a tablet representing from
1/2 to 1 grain of the active substalice of the thyroid gland, given
once a day, continued for a long period.

When an improved peripheral circulation is desired, and especially
when a reduction of the pressure in the heart is desired and a
diminished amount of blood in overfilled arteries is indicated, the
value of the sitzbath, hot foot-baths, warm liquids (not hot) in the
stomach, and warm, moist applications to the abdomen should all be
remembered.

4. Cardiac Nutritives.--Iron: Nothing is of more value to a weakened
heart muscle, when the nutrition is low, the patient anemic, and the
iron of the food not properly metabolized, than tonic doses of some
iron salt. It has frequently been repeated, but should constantly be
reiterated, that there is no physiologic reason or therapeutic
excuse for the patient to pay a large amount of money for some
organic iron preparation.

Small doses of an inorganic salt act perfectly, and nothing will act
better. As previously suggested, a drop or two of the tincture of
iron, a grain or two of the reduced iron, or 2 or 3 grains of
saccharated ferric oxid, given once or twice in twenty-four hours,
is all the iron the body needs from the points of view of the blood
and the heart.

Calcium: It has lately been learned that calcium is an element which
a heart needs for perfect activity. Many patients who are ill lose
their calcium, and they may not receive a sufficient amount of it
unless milk is given them. Even if such patients are taking milk,
the heart and the whole general condition sometimes such; to improve
when calcium is added to the diet. It may be given either in the
form of lime water, calcium lactate or calcium glycerophosphate. If
a medium-sized dose is given three or four times in twenty-four
hours, it is sufficient and will often act for good.

Whether calcium can do harm in a chronic endocarditis or an
arteriosclerosis to offset the value that it seems to have in
quieting the nervous system and in being of value to a weak or
nervously irritable heart is a question which has not been decided.
Theoretically lime should not be given when there is a tendency to
calcification, or when a patient is past middle age. Lime seems to
be essential to youth, and to the welfare of nervous patients.





Next: Emergencies

Previous: Treatment Of Broken Compensation



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