or if these conditions are suspected. It may be used, if indicated, early in acute disease or in broken compensation in chronic heart disease. It is not indicated in acute heart failure or shock. It slows the heart, strengthens its contractions, generally raises the blood-pressure (it may lower a high pressure if there is cardiac dilatation), and increases the output of urine. If too large or too frequent doses are given, the heart may become fast, headache is present, a diminished amount of urine is passed, vomiting is frequent, and diarrhea may occur. It should not be administered too often, generally best twice in twenty-four hours. As stated, it is of no value in sudden emergencies, but in the slower emergency of auricular fibrillation it is the drug to use, and in good sized doses.

Strophanthin given intramuscularly or intravenously is of great value in heart failure in severe illness. It should be given in one sufficient dose, not ordinarily to be repeated, and should not be given after a patient is under the influence of digitalis. Ampules for intramuscular or intravenous administration may be obtained. It should be noted that the solution in these ampules should be neutral or slightly acid; if it is alkaline the drug has deteriorated.

Pituitary Extracts made from the posterior lobe of the hypophysis raise the blood-pressure and strengthen the heart; they are best given hypodermatically, and ampules may be obtained for this purpose.

Suprarenal Extracts or epinephrine preparations raise the blood-pressure both when given on the tongue for absorption in the mouth, or when given hypodermatically.

Ergot, when an assayed fluidextract is used and it is given intramuscularly, raises the blood-pressure. The dose is 1 or 2 mils, injected deeply into the deltoid muscle, and it may be repeated two or three times in twenty-four hours, if needed.

DRUGS USED TO ACCELERATE THE HEART

The drugs used for this purpose are atropine, camphor, caffeine, and strychnine. As all of these drugs act more or less on the nervous system, they are better described under that class.

DRUGS USED TO DEPRESS THE HEART

Most methods employed to depress the heart, once used so much in the first stage of acute disease, should be dropped, owing to the danger of precipitating cardiac weakness. Even the milder methods of causing slowing of the heart and lowering of the blood-pressure, in the beginning of an illness, by means of aconite or of veratrum viride are now but little used. Fortunately or unfortunately (because they are too much used) the coal-tar products, as acetanilid, phenacetin and antipyrin, and some synthetics as aspirin, not only lower the temperature and stop aches and pains, but also lower the blood-pressure and depress the heart. They are often used to accomplish all these results at once.

Aconite.-Administration.-Aconite (monkshood) is not used. as such, and is best administered in the form of the official tincture, which contains 10 per cent. of the drug. The official dose of 0.3 mils (5 minims) is too large, if it is to be repeated. The best method of giving aconite to cause slowing of the pulse and lowering of the blood-pressure is to administer a drop every half hour until the effect desired is produced, and then to stop it.

Aconitine, the alkaloid of aconite is very poisonous, and should not often be used. The dose is 0.00015 Gm. (400 of a grain).

Action. This drug acts rapidly to slow the heart and lower the blood-pressure, and it somewhat dilates the peripheral bloodvessels and lowers temperature. It is excreted in the urine.

Over-action. It may cause tingling of the tongue, tingling and numbness of the extremities, and a feeling of faintness. Toxic Action.-It causes death by depression of the respiratory center and the heart.

Treatment of Poisoning. Further absorption of the drug must be prevented by emetics; there must be absolute rest; dry heat applied; and respiratory and circulatory stimulants given.

Uses.-1. To reduce fever. For this object one drop of the tincture may be given every half hour until the pulse shows a distinct slowing and softening; it should then be stopped.

Aconite is not now much used to meet this indication, as the coal-tar drugs are more efficient in reducing temperature and promoting sweating, and at the same time they depress the heart and circulation.

2. To lower the pressure in hypertension. It is not often advisable to use aconite for this purpose, as hypertension is continuous, and the continuous use of aconite is inadvisable, on account of its weakening the heart muscle.

3. To allay peripheral pain. It is rarely advisable to use aconite for this purpose, although in full doses it will benumb the peripheral nerves, but at the same time it causes depression. Any local application of aconite is inadvisable.

Veratrum Viride.-Administration.-Veratrum viride (green hellebore, American hellebore) is not used as such, but in the form of the official fluidextract, the dose of which is o.1 mil (11⁄2 minims), or as the official tincture, which represents 10 per cent. of the drug, in the dose of 0.5 mil (71⁄2 minims). When these preparations are used to lower the blood-pressure and slow the heart, they should be used as it is advised to use aconite, namely, about 2 or 3 drops of the tincture every half hour until the results desired are obtained.

Action. This drug is more or less of a cardiac depressant (not as depressant as aconite), slows the pulse, lowers the bloodpressure, and lowers the temperature.

Over-action. It causes vomiting so soon that when administered by the mouth serious poisoning is not likely to occur. The treatment of its over-action is to wash out the stomach, administer atropine and digitalis, keep the patient quiet, and surround him with dry heat.

Uses. The only use for viratrum viride is to slow the heart and lower the blood-pressure. It is much less likely to cause cardiac depression than is aconite, but is less efficient, at least in the doses generally used. Perhaps this drug should be used more frequently and in larger doses (provided the stomach is not irritable, as it is likely to cause vomiting); however, as already stated in the case of aconite, this drug also has given place to the coal-tar drugs.

Veratrum viride has been suggested for chronic hypertension.

It is doubtful, however, if it should be used for this purpose any great length of time. It has also been highly recommended in puerperal eclampsia, administered in large doses, but profuse bleeding, from the uterus or by venesection, and the administration of thyroid extracts is better treatment.

DRUGS USED TO STRENGTHEN THE HEART

Caffeine.-Administration.—Caffeine (theine) is a basic substance obtained from the leaves of tea and from the seeds of coffee. It is also prepared synthetically. It occurs in white silky needles, has a very bitter taste, and is not very soluble in water. It is generally used in the form of the official Caffeina Citrata, which is a white powder, has a bitter, acid taste, is soluble in water, and the dose is 0.30 Gm. (5 grains). A pleasant method of administering citrated caffeine is in the official Caffeina Citrata Effervescens. This preparation contains 4 per cent. of the citrated caffeine and effervesces when placed in water. The dose is 4 Gm. (1 drachm).

Caffeine and theobromine are purins. The former is trimethylxanthin, and the latter is dimethylxanthin. Caffeine is quickly absorbed and acts quickly, and the dose may be repeated in two or three hours, if needed. It is often well to administer caffeine hypodermatically, and the official Caffeina Sodio-Benzoas, a mixture of caffeine and sodium benzoate, is the salt that is most satisfactory for this purpose. It occurs as a white powder, is very soluble in water, and the hypodermic dose is 0.20 Gm. (3 grains). It should be remembered that caffeine is often as well administered in the form of strong coffee as in any other way.

Action. While caffeine is perhaps the best cerebral and mental stimulant we possess, and inhibits mental fatigue and allows longer continued work, it, of course, cannot take the place of the cerebral rest caused by sleep. Consequently, while it stimulates, it leaves the brain more fatigued after its action is over, and when it is used repeatedly as a cerebral stimulant and to prevent sleep, when it is necessary for a person to be awake, it can do nothing but cause general nerve and brain fatigue, unless adequate sleep is obtained.

Caffeine raises the blood-pressure by stimulating the vasomotor centers, may slow and steady a weak heart by stimulation of the vagus center, and thus may strengthen the heart. However, if a heart has become irritated by nervous stimulation as by hyperthyroidism, or by cerebral irritation, or by a drug, as strychnine, caffeine will add to the irritability of the heart and will do harm. In other words, in all rapid, irritable hearts caffeine in any form, including coffee and tea, should be prohibited. A slow, weak heart may be made faster and stronger with caffeine.

It has been shown that caffeine will not protect a heart from the depressing effects of a coal-tar product, but its combination with such, as acetanilid or phenacetin, when these drugs are to be administered for headache, may make their action more effective.

While caffeine in most any form seems to prevent fatigue, and will allow a patient to go longer without food and without depression, still it has not been shown that caffeine is a valuable muscle stimulant. In muscular exertion it may increase the nervous irritability, and nervousness or increased tension or excitability is well known to interfere with the best muscular efforts. Therefore an athlete is better without coffee, tea, or caffeine stimulation before a trial of his strength is made.

With most individuals caffeine acts as a diuretic, even if the blood-pressure is not much raised. Caffeine is excreted largely by the kidneys as dimethylxanthin and uric acid.

There is no question but that a caffeine habit can be acquired, whether as such (perhaps in the form of coca cola) or as a tea or coffee habit. Coca cola, tea, and coffee "fiends" are of com

mon occurrence.

Over-action.-Over-action of caffeine is shown by great nervous irritability, rapid heart, insomnia, and, perhaps, by muscle twitchings. It may also cause both stomach and intestinal indigestion, as mostly evidenced by increased peristalsis. Perhaps some of the indigestion is caused by excessive nervous irritability, and it is well known that cerebral irritation can cause hyperacidity of the stomach.