Indications For Strychnin

Categories: Uncategorized
Sources: 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 f 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.