This section is from the book "Materia Medica And Therapeutics: An Introduction to the National Treatment of Disease", by John Mitchell Bruce. Also available from Amazon: The pharmacology and therapeutics of the materia medica.
Removal of the cause is rarely practicable in heart disease. The opposite is the case in cardiac disorder. Treatment here consists in relieving dyspepsia, in restoring the condition of the blood, in securing mental rest, and in removing all poisons from the system, such as alcohol, tea, and tobacco, by a reformation of diet and personal habits. Carminatives are specially valuable in dyspepsia with palpitation.
A great part of the treatment of diseases of the heart consists in counteracting the cause; that is, in the prevention and removal of dilatation. The first rational step to be taken is to lighten the load upon the heart, to lower the intraventricular pressure which it is unable to overcome. Rest, bodily and mental, is the most obvious and easy means of doing So, the patient being kept in bed, and every kind of exertion and excitement forbidden. The pressure may be further reduced by purgation, which diverts and drains the blood; or, if the condition be urgent, blood must be removed by leeching, cupping, or venesection, all of which may give great relief, or even preserve life when it is threatened. In another class of cases, the arterial tension may be lowered by means of drugs. Nitrite of Amyl acts very swiftly in this way, giving relief in that terrible form of acute distension of the heart which is called "angina pectoris," by instantly relaxing the vessels in front, as well as by accelerating the cardiac action. The same effect may be more slowly produced by the alkaline Nitrites, Potash salts, and Belladonna.
The second means of treating dilatation is by increasing the cardiac power by direct cardiac stimulants, such as Digitalis, Scilla, Alcohol, and Ammonia. Mustard or other rubefacients applied to the praecordium are indirect cardiac stimulants of great value in these cases. At the same time, the quantity and quality of the blood supplied through the coronaries to the cardiac walls must be sustained by nutritious food, and possibly by Iron: a system which demands, in turn, the strictest attention to the action of the stomach, bowels, and liver, flatulence and other digestive disturbances being highly dangerous to a weak heart.
The third means of treating dilatation is by increasing the time of cardiac rest. Three powerful direct cardiac stimulants, Digitalis, Scilla, and Convallaria, have the additional action of stimulating the inhibitory apparatus, both in the heart and medulla. They increase the force of the systole, thus thoroughly emptying the chamber, and preventing over-distension; they lengthen the time of filling the heart, that is, of emptying the veins, thus favouring the venous flow; they 'afford rest to the heart; and they also increase the arterial pressure, not only by filling the aorta better, but by stimulating the vaso-motor nerves. They are therefore indicated in that backward dilatation of chamber after chamber, ending in dropsy and visceral congestion, which we have discussed, and as a matter of fact they prove of the very greatest value in practice.
Removal of effects: Treatment of symptoms.-Cardiac pain, oppression, anxiety, and other forms of distress, can be relieved by cardiac sedatives, such as local heat or cold, Opium, Chloral and Belladonna. Of these, Opium is the most powerful, and of the greatest value. We must never forget, however, that in Opium we are administering a dangerous cardiac depressant, which paralyses in large doses every part of the circulatory apparatus; and the same remark applies to Chloral. The perfection of the therapeutic art is to use these remedies with judgment. The hypodermic injection of Morphia sometimes gives complete relief. Belladonna is a cardiac anodyne much more easily employed, because less depressant; but is much less efficacious. It is frequently applied locally to the praecordium as the Emplastrum. A rubefacient or even slight vesicant effect on the surface of the chest quickly relieves cardiac pain. Pulmonary distress from congestion of the bronchi and alveoli may be specially relieved by stimulant expectorants, such as Ammonia and Scilla, which increase and remove the bronchial flux; but here again the value of rational treatment is seen in the disappearance of dyspnoea, haemoptysis, cough, and the. physical signs of pulmonary engorgement, under the influence of purely cardiac remedies, such as Digitalis and Alcohol. Dropsy may be immediately relieved by puncture of the part, but like other symptoms disappears rapidly by the veins when the cardiac strength is restored. The same remarks apply of the visceral congestions and their temporary relief by purgatives. Diuretics are of great service in cardiac dropsy, acting partly by relieving the renal veins (salines), but chiefly by raising the arterial pressure (Digitalis and Scilla), as is fully discussed under the head of The Kidney in chapter xii (The Nervous System).
Haemorrhage - Haemostatics. - External haemorrhage is readily arrested by surgical means. If the lesion be internal, as in the stomach or lungs, we must trust chiefly to medicinal remedies which are known as haemostatics.
(a) So far the cardiac depression caused by the haemorrhage may be cautiously encouraged. In every case it is desirable to employ all available means of reducing the force, not the power of the heart, especially bodily and mental rest; and for this purpose general sedatives-Opium especially-are valuable adjuvants to the more direct measures.
(b) It is also desirable to take the pressure of the circulation off the bleeding point by dilatation of a vascular area in the neighbourhood, and in anastomotic connection; or by inducing a watery flux from it. Thus we employ purgatives in haemorrhage from the stomach, due to portal congestion, in haemoptysis or bleeding from the respiratory passages, and in cerebral haemorrhage, so as to dilate the mesenteric vessels and produce a hydragogue action on the bowels.
(c) The local measures employed for haemorrhage are variously known as local haemostatics, styptics, or local vascular astringents. They are imitations or adjuvants of the natural means just analysed, and belong to three distinct classes, according as they act upon, (1) the blood, (2) the vessel walls, or (3), the perivascular tissues.
(1) Haemostatics may act upon the blood, hastening coagulation or precipitating albumen, and thus stopping the bleeding point. Such are Tannin, and the many vegetable substances containing it - Kino, Rhatany, Catechu, Logwood, Galls, Oak-bark, etc.; Alum, Persalts of Iron, Sulphate of Copper, Sulphate of Zinc, Acetate of Lead, Nitrate of Silver, and Diluted Mineral Acids. Matico probably acts physically.
(2) The haemostatics which promote contraction of the broken vessel are Nitrate of Silver and Acetate of Lead-both very powerful; Ergot; and local cold.
(3) Substances acting upon the perivascular tissues may be made to arrest hemorrhage by combining with the connective tissues, coagulating or precipitating their albuminous substances, and rendering them more compact than normal, or constringed so that the bleeding vessels are compressed and closed. Such are-Tannin and its allies just enumerated, Lead, Silver, Persalts of Iron, and Alum.
Syncope.-Syncope demands prompt treatment. Nature suggests the first step: the patient must be laid down, with the head at least as low as the heart, so as to restore the pressure and the blood in the cardiac centre. Every possible means must then be used to restore the suspended action of the heart, including direct and indirect cardiac stimulants. The most available of these internally are Ammonia and Alcohol in the form of spirits, or wine; externally, the application of cold, fresh air, flagellation or flicking with wet towels, ammonia held to the nostrils, and the continuous current to the praecordium. Nitrite of Amyl acts quickly in some cases. If swallowing be impossible, Brandy or Ether must be injected into the rectum, or under the skin.