The symptoms indicating arsenic are: great anxiety in the region of the heart, with fear of death; tightness in the praecordia; cannot lie down; dyspnoea and palpitation after the slightest motion; great thirst; violent, tumultuous action of the heart, alternating with feeble, irregular beating; tendency to fainting; pulse strong and jerking, or feeble, fluttering, and irregular; cold skin, hands, and feet. The pain is piercing, burning, and a sensation of soreness in the region of the heart.
The physical signs on percussion and auscultation are: dullness over a greater extent than usual in the cardiac region, especially in a vertical direction; the element of impulsion in the first sound is impaired or lost, the sounds apparently distant.
The iodide of arsenic will doubtless prove a superior remedy in such cases. Dose, the 3rd or 6th trituration.
Digitalis is one of the most useful remedies in pericarditis, but in order to use it successfully you must fully understand its sphere of action. Not only this, but you must know how to graduate the dose to suit the varying phases of the disease.
I will first give you the opinion of Baehr, and then my own. He says, “Since I have devoted, for years past, special attention to the use of this drug, I have found it much more frequently applicable in the treatment of disease than in former times; and I am now prepared to assert most positively, what I was then only able to announce in rather dubious language, that digitalis is an excellent remedy in acute diseases of the heart, more particularly in pericarditis. Digitalis is not so much adapted to inflammations setting in with very violent symptoms, but to inflammations approaching in an insidious and scarcely observable manner, more especially without any local pain, but with a rapidly increasing embarrassment of the respiration. We should take a very one-sided view of the action of this drug, if we were to regard the irregularity and slowness of the pulse as the chief criterion for its application, since a rapid and very weak pulse constitutes an equally reliable indication. Even a violent excitement of the functional activity of the heart, as generally occurs at the commencement of cardiac inflammation, is in characteristic accord with the first symptoms of poisoning by digitalis. Among all the various forms of cardiac inflammation, we consider the rheumatic form the best adapted to digitalis, and likewise if it is associated with a copious effusion of serum; less, however, in pericarditis, if the friction murmurs continue unchanged from the beginning of the disease. The sooner these murmurs disappears, the better is digitalis adapted to the case. * * Among the general symptoms, the following invite more particular attention to the use of digitalis; Rapidly increasing dyspnoea, without occasional symptoms of acute congestion of the chest; inflammation of the pleura or lungs; bronchitis; chronic catarrh of the bronchia; expectoration mixed (not streaked) with blood; spasmodic cough; livid, turgescent face, with blue lips, headache, vertigo, delirium, sopor, vomiting, at the commencement or during the course of the disease; hyperaemia of the liver; slight icterus; catarrh of the kidneys; excessive feeling of illness, not corresponding with the perceptible symptoms; great anxiety, but without any continual restlessness; aggravation by the slightest motion; a drawing, tearing pain in left shoulder.”
Dr. Baehr’s experience coincides with my own. In my several papers on the action of digitalis I have always contended for the double action of this drug, and unless such action is fully understood, you cannot prescribe it successfully. In its primary action, i.e., its pathogenetic effect in large doses, it first causes a hyper-stimulation of the cardiac tissues, manifested by increased force, and sometimes, not always, frequency of the heart’s action; and this may go on to the very verge of acute inflammation, or to a condition of the heart culminating in tetanic spasm of that organ. Digitalis is not so much indicated in acute as sub-acute pericarditis, in its first stages. It is not indicated for plastic exudation, but only for serous effusion; and not so much for the inflammation itself, as its results, and the excessive irritation of the cardiac nerves which attends it. If given in the first stages the doses must be made very small, not lower than the third decimal dilution. It is very important to understand to understand the secondary action of digitalis. After it has exhausted the nervous and vascular irritability of the heart by its primary action, a contrary condition sets in. The heart’s vitality is lowered, its pulsations decrease in force, but increase in frequency, or become very irregular and intermittent; the slightest motion or excitement increases the heart’s action in a very distressing manner, and death may occur from cardiac paralysis.
You will observe that Baehr mixes the primary and secondary symptoms and conditions in his indications. This is unfortunate, for if the practitioner does not separate the two states, he will forever be in the dark regarding the true action of the drug, and never be able to prescribe it with safety and benefit to his patient.
I have given you the symptoms and conditions indicating digitalis in the first stage of pericarditis, and the dose required. Its most useful sphere, however, is in the second and third stages, or those conditions characterized by liquid effusion, failure of the nervous and muscular power of the heart, from paresis or over-distension, and accompanied by excessive irritability. The physical signs in this condition are: absence or decrease of the friction-murmur; rapidly increasing dullness over a large area; heart-sounds weakened, especially the first, the element of impulsion in the first sound nearly or entirely lost, the sounds apparently distant. The posture is generally with the head and shoulders raised. The patient cannot lie on the left side, the slightest movement increases the distressing dyspnoea. Sometimes the urinary organs are affected, and urination becomes frequent and painful – the secretion scanty, but of nearly normal color. An excessively faint “empty” feeling at the pit of the stomach is a notable indication for digitalis. Under its use the effusion rapidly diminishes; the heart’s action soon improves in force; its irritability diminishes with the increased tonicity; the lividity of the face and lips disappears, as does the dyspnoea, vertigo, and imperfect circulation everywhere. But in order to effect this curative action, you must know the requisite dose. Any attenuation above the third decimal is useless. The tincture, or first decimal, is usually required, and must be given in doses of one to five drops every hour or two until decided improvement sets in, when the intervals between the doses may be lengthened, or the quantity decreased. I have frequently found the patient so near cardiac syncope, that I have without hesitation given ten drops of the strongest tincture, and, with my finger on the pulse, watched its effects. If the pulse did not rise, or increase in force in fifteen minutes, the dose was repeated, and this was continued until I was satisfied the dangerous exhaustion was over. In such cases of threatened or actual collapse, you may think veratrum album or arsenicum better indicated, but neither are as reliable as digitalis. After you have warded off the immediate danger, prescribe the digitalis in smaller doses, and place the patient under the influence of wine- whey, egg-nogg, beef-tea, cocoa, and other highly nutritious articles.
Spigelia is an important remedy in pericarditis, but the provings were conducted with such disregard for physical or objective symptoms, or even correct subjective symptoms, that it is difficult to define clearly its curative sphere.
Baehr says the symptoms given by him are not pathogenetic but clinical, and even these “do not contain the symptoms, of sero- plastic or serous pericarditis. On the other hand we distinctly recognize in this complex of symptoms, both the purely plastic, as well as incipient endocarditis.” He further adds that “according to practical experience, spigelia is particularly adapted to rheumatic pericarditis, likewise to sero-plastic pericarditis during its whole course, especially if the patient complains of internal local pain;” but he asks “upon what basis are we to prescribe spigelia in cases where the disease is painless and has scarcely any symptoms?”
He gives the following symptomatic indications from Hartmann; indications which are based on curative results on the sick, namely : “Undulating motion of the heart; indistinct beats of the heart running into one another; when laying the hand upon the heart, tumultuous beating of the heart, in a recumbent as well as in a sitting posture, not synchronous with the radial pulse; spasms of the chest; suffocative complaints; tremulous sensation in the chest and temples, increased by motion; tearing sensation in the chest when raising the arms over the head, and when touching the pit of the stomach; purring murmur during the beats of the heart; stitches in the region of the heart; pulsations of the carotids with a tremulous motion; great dyspnoea at every change of position; bright redness of the lips and cheeks, changing to pallor during every motion; the impulse of the heart raises the four last true ribs, the sternum and xiphoid cartilage, and displaces the dorsal vertebrae; audible beating of the heart, causing a pain that is felt through to back; cutting pains from the heart to the shoulders, as far as the head and arms; excessive dyspnoea, with a pressing, cutting pain in the abdomen, at the insertion of the ribs; arthritic pains and stiffness of the joints; dull stitches where the beats of the heart are felt, and recurring with the measured regularity of the pulse; the beats of the heart can be felt through the clothes, with anxious oppression of the chest; scraping in the throat, affection of the tracheal and bronchial mucous membranes; the beats of the heart are not synchronous with the pulse; purring murmur.” (Dose, 3rd to 12th dilutions.)
Hale wrote Lectures On Diseases Of The Heart, Materia medica and special therapeutics of the new remedies Volume 1, Materia Medica And Special Therapeutics Of The New Remedies Volume 2, Saw Palmetto: (Sabal Serrulata. Serenoa Serrulata), The Medical, Surgical, and Hygienic Treatment of Diseases of Women, New Remedies: Their Pathogenetic Effects and Therapeutic Application, Ilex Cassine : the aboriginal North American tea, Repertory to the New Remedies with Charles Porter Hart, The Characteristics of the New Remedies, Materia Medica and Special Therapeutics of the New Remedies, The Practice of Medicine, Homoeopathic Materia Medica of the New Remedies: Their Botanical Description etc.