of advice are of moment. It not unfrequently happens that, by accident or by direct information, patients learn the fact that their pulse intermits. Then they begin to feel their own pulse, and become charged with dread of sudden death. As the disorder is of itself mental, this watchfulness and fear will increase the frequency of the intermittency. With these patients, a word from the physician timely and firmly spoken is often the best prescription. He assures them on the results of experience that their malady is not of necessity fatal; he commends them not to enquire after the symptom, and if he can succeed in persuading them to his views, which he may honestly try to do with all his influence, he will effect the most marked improvement in their condition. Again, it sometimes happens that patients conscious of the failure of the heart resort to alcoholic stimulants as a means of relief. For a moment, by its exalting the activity of the heart, alcohol affords relief, but the depression that follows calls the more rapidly for a return to the supposed remedy, and a fictitious benefit leads to a habit which excites structural changes and hastens death. (3) In cases of sudden intermittency, with symptoms of cerebral congestion, depletive measures are sound. A purgative is essential, and blistering at the back of the neck is always useful. I have seen also great advantage in these cases from abstraction of a moderate quantity of blood by the cupping glasses. (4) In chronic extreme forms of cardiac intermittency, while all the general rules laid down in Nos. 1 and 2 hold good, it becomes often imperatively necessary to subdue nervous excitement, and to induce rest. For this latter purpose, opium is the sheet anchor. It must be given freely when it is given, and not too frequently. Small and repeated doses of opium excite, depress, and give no rest. A full dose, equivalent to a grain or even two grains, produces, on the contrary, no excitement, but gives sound sleep and that quietude of circulation which is essential to secure a satisfactory relief. I have sometimes, where there was much depression, combined opium with full doses of quinine with marked benefit. (5) Concerning old people who suffer from what may be called chronic intermittency without oppressing symptoms, no special rule requires to be laid down. They are themselves usually too tired of the excitements of life to care for them, and if they are not, then the observance of the general principles applicable to children and adults extends equally to them. The above general rules of practice, written in 1868, hold good, and require no modification; but I have since learned a few details of practice which are useful, and which deserve to be added in this chapter. In the first place, whenever with intermittency of the pulse there is anæmia with atonic condition of the bowels, and distention of the stomach and intestines with gas, it is very good practice to add, to the general rules of treatment, a tonic so called, and of all tonics Easton's Syrup of the Superphosphate of Quinine, Iron, and Strychnine, is the best. This syrup, which contains the thirty-second part of a grain of strychnine in a fluid drachm, should be administered in doses of a drachm three times daily, a little time after food, and the patient should be induced to look upon the remedy in the light of a food rather than a medicine. The syrup may be continued for two and three months at a time without danger, under the careful observation of the practitioner. In some cases of intermittent pulse I find a tendency to periodical neuralgia. Sometimes the neuralgia attacks the nerves of the face, sometimes the sciatics, sometimes the pneumogastrics. When this symptom is present the intermittent action is intensified; not, I believe, from any direct connection between the neuralgic pathological state and the irregular action of the heart, but from the broken rest and anxiety which the neuralgic pain induces. In these cases, in addition to Easton's syrup, which still maintains its position, quinine in free doses-two to five grains-is required, together with morphia when it is necessary to procure sleep by artificial means. Hydrate of chloral is also useful in this class of cases, but I do not find it is better than morphia. I have, lately, sometimes combined the hydrate with morphia with advantage. There are classes of cases in which intermittent pulse is connected with great general prostration and premature breaking up of the body; cases in which there is some organic disease, such as chronic bronchitis, emphysema, senile phthisis, cirrhosis, disorganization of the kidney, or other organic change; or some general systemic disorder, such as diabetes or cancer. In any of these cases the intermittent action is a terrible addition to the distress of the sufferer, and it may require to be treated itself as the worst present evil. Under these circumstances, with an occasional alternative, I find the following compound of most service for the intermittency : Mixture of Iron, Morphia, and Ammonia. Sulphate of iron, grs. xxx. Carbonate of potash, grs. xxv. Rub together dry into a fine powder; pour on distilled Bicarbonate of ammonia, grs. xxiv. Finally add Proof alcohol, 3j. Pure glycerine to 3iij. Mix. Of this mixture the dose is from two to three fluid drachms, which dose may be taken three or four times in the twenty four hours. I know of nothing that gives such speedy relief to the intermittent action, or that more strictly acts in the sense of a "tonic," than this mixture, in the cases named. I have made many enquiries in order to ascertain if there be any one particular remedy which so influences the nervous mechanism of the heart as to exert an immediate controlling effect over intermittent action; and the result of my research is that there is only one agent which can be said positively to influence it; I mean to influence it at once in such determinate manner that an effect is seen to follow upon a cause. The agent to which I refer is alcohol, and the mention of alcohol brings up the whole question of its use in cases of intermittent action. It has been long known that the direct physiological action of alcohol is to quicken the motion of the heart, and Dr. Parkes and Count Wollowicz, in an admirable paper published in the Proceedings of the Royal Society for May 1870, have demonstrated that in a healthy man the daily increase of the beats of the heart under alcohol, as compared with the number of beats when water is the only beverage, is rather more than thirteen per cent. The results obtained by these authors are so curious and important that I subjoin them, verbatim, in a foot note.* *"The average number of beats of the heart in 24 hours (as calculated from 8 observations made in 14 hours), during the first or water period, was 106,000; in the alcoholic period it was 127,000, or about 21,000 more; and in the brandy period it was 131,000, or 25,000 more. "The highest of the daily means of the pulse observed during the first or water period was 775; but on this day two observations are deficient. The next highest daily mean was 77 beats. "If instead of the mean of the 8 days or 73.57 we compare the mean of this one day, viz., 77 beats per minute, with the alcoholic days, so as to be sure not to over-estimate the action of the alcohol, we find : On the 9th day, with 1 fluid ounce of alcohol, the heart beat 4,30 times more. On the 10th day, with 2 fluid ounces, 1,872 times more. "But as there was ephemeral fever on the 12th day, it is right to make a deduction, and to estimate the number of beats in that day as midway between the In intermittent pulse this direct action of alcohol on the heart is shown with singular effect. I have seen in an extreme case, where the fact of intermittency was recorded ten times in the minute at least, a total cessation of the phenomenon within five minutes after the administration of an ounce and a half of sound brandy, the circulation at the same time being rendered more rapid. This action of alcohol is so decisive that the patient himself soon becomes conscious of it, and perchance resorts sometimes to the remedy, as if by instinct, to his ultimate disadvantage. Here then we have an agent which for the moment gives relief to the symptom. It does not cure, but it relieves it does not now act as a narcotic, for intermittent action of the heart, a symptom not of excitement, nor of irritation, nor of over-action, but of failure of nervous power, is not directly relieved by a narcotic; but it stimulates the flag 11th and 13th days, or 18,432. Adopting this, the mean daily excess of beats during the alcoholic days was 14,492, or an increase of rather more than 13 per cent. "The first day of alcohol gave an excess of 4 per cent., and the last of 23 per cent.; and the mean of these two gives almost the same percentage of excess as the mean of the 6 days. "Admitting that each beat of the heart was as strong during the alcoholic period as in the water period (and it was really more powerful), the heart on the last two days of alcohol was doing one-fifth more work. "Adopting the lowest estimate which has been given of the daily work done by the heart, viz., as equal to 122 tons lifted one foot, the heart during the alcoholic period did daily work in excess equal to lifting 15 8 tons one foot, and in the last two days did extra work to the amount of 24 tons lifted as far. "The period of rest for the heart was shortened, though perhaps not to such an extent as would be inferred from the number of beats; for each contraction was sooner over. "The heart on the fifth and sixth days after alcohol was left off, and apparently at the time when the last traces of alcohol were eliminated, showed in the sphygmographic tracings signs of unusual feebleness; and perhaps in consequence of this, when the brandy quickened the heart again, the tracings showed a more rapid contraction of the ventricles, but less power, than in the alcoholic period. The brandy acted, in fact, on a heart whose nutrition had not been perfectly restored. "The peripheral circulation was accelerated and the vessels were enlarged; and the effect was so marked as to show that this is an important influence for good or for evil when alcohol is used. 66 Referring only to this healthy man, it is clear that the amount of alcohol the heart will bear without losing its healthy sphygmographic tracing is small, and it must be supposed that some disease of heart or vessels would eventually follow the over-action produced by large doses of alcohol." |
