J. M. (James Mitchell) Foster.

The Chicago medical journal and examiner online

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which we abstract the following :

One of the most important things in
connection with the administration of dig-
italis is the cumulative action of the drug ;
and the following rule should be adhered
to. Since the doses of digitalis add up, as
it were, the drug should be prescribed in
decreasing doses, and its administration
should not be continued in large doses for



more than four or five days. Beside the
cumulation of action, there is also cumu<
lation of dose, which Gubler defines as
follows : Cumulative action is the storing
of the drug in an organ (the stomach or
intestine), cumulative dosage is the storing
of the drug in the organism. From this
must be deduced the practical conclusion
that drugs that have cumulative action
should be given, in so far as possible, m
liquid form.

Huchard says that he very rarely has
any of the unpleasant effects that are so
often seen from the administration of dig-
italis, and that the reason is that he never
violates the rules that should govern the
administration of the drug. The disagree-
able effects of the drug do not appear while
oedema persists. While digitalis cures
asystolism, it may cause a kind of toxic
asystolism. Amone its disagreeable eflfects
may be mentioned a pseudo-angina, which
must be distinguished from precordial anx-
iety, and from true anginous attacks in
subjects of angina, provoked by abuse
of digitalis. The most important of these
effects, however, are those produced on the
side of the digestive tract. The preco-
cious vomiting caused by digitalis is due
to the topical action of the drug on the
gastric mucous membrane; the later vom-
iting comes on in about twenty-four or
forty-eight hours after the administration
of digitalis in large doses, and is caused by
toxic action. The numerous bad effects
ascribed to digitalis may dismay the prac-
titioner, and cause him to deprive himself
of one of the most useful of drugs. Much
can be learned, however, from a careful
reading of Huchard 's answer to the ques-
tion.

W?un should digitalis be prescribed? In
answering this question Huchard takes up
firsts cardiac affections, and discusses the
administration of digitalis according to the
period of the heart disease.
. Digitalis should not be given in the
early phases of what Huchard calls arte-
rial cardiopathies. For a long time he



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EXTRACTS AND ABSTRACTS.



26^



has insisted upon the capital distinction
between valvular and vascular or arterial
cardiopathies. The latter are nothing else
than the localization of the arterio-sclero-
sis on the heart; they are characterized,
during the greater part of their evolution,
by a more or less considerable increase of
arterial tension, which is the cause, not the
effect, of the sclerosis. Now, in the first
periods of arterio-sclerosis of the heart
may be recognized all the symptoms of
hypersystolism just described, and digitalis
should be given, if at all, only with the
greatest caution, since by increasing vascu-
lar pressure it may lead to cerebral haem-
orrhages, and by it, also, the nocturnal
palpitations are increased, dyspnoea be-
comes more intense, and anginous attacks
may be provoked.

At an advanced period of cardiopathies,
one often finds albumen in greater or less
quantity in the urine. This is not an abso-
lute contra-indication to the use of digitalis.
The dangers of the administration of active
medicines in renal affections have been
much exaggerated, though there are cer-
tainly some dangers. But they demand
prudence, not the doing away with drugs.
That digitalis can be safely used in these
cases is probably due to the fact that it is
not eliminated by the kidneys, as was
shown by Lafon some two years ago.
While albuminuria is not positive contra-
indication to the use of digitalis, therefore,
it should be used with caution in these
cases, in moderate doses for two or three
days, and its action should be carefully
watched. Used on these principles it may
diminish or cause to disappear certain
forms of albuminuria, when it is of cardiac
origin, or produced by passive congestion
of the kidneys, in the absence of any
sclerous or other lesion.

In giving digitalis in valvular lesions, the
seat of the lesion is sometimes of impor-
tance in indicating the drug. In aortic
stenosis, for example, we know that the
cardiac contractions and the pulse are
slow. Then why should we give a drug



that will slow them still more ? By doing;
this we expose the patients to the dangers
of digitalism. In aortic insufficiency the
diastolic rest of the heart is already long
enough; digitalis makes it longer, and
increases the already high arterial tension
caused by the disease. Why add to the
injurious effects of the heart disease ? In
mitral insufficiency it should be prescribed
only in cases of great cardiac irregularity,,
or of confirmed hyposystolism. In pure
mitral stenosis it often causes bad effects.
It should not be forgotten that mitral and
aortic stenosis are the two cardiopathies
that may remain latent for a long time, and
require treatment late. In aortic affec*
tions, and especially in Corrigan's disease,
digitalis is often contra-indicated for a long
time. It raises arterial tension in an affec-
tion in which this is already exaggerated ;.
by increasing the suddenness of the systole
it gives to the blood-waves violent and re-
peated oscillations, which, added to the high
tension, may cause cerebral haemorrhage ;
it prolongs the already augmented diastolic
period ; finally, it contributes, by its vaso-
constrictor action, toward increasing the
visceral and peripheric anaemia caused by
the disease. In aortic affections more than
in any other, is it wrong to localize the
lesion at the aortic valve, and then to take
no account of the localization in the treat-
ment.

But, says Huchard, the knowledge of the
orifice affected is of secondary importance
only for the indications for the drug. The
therapeutic indications must be found in the
cardiac muscle, as has been admirably^
expressed by Stokes. The situation of the
cardiac souffie, its intensity and its absence^
furnish no indications for the administra-
tion of digitalis ; it is the state of the heart
muscle and of the vessels, their feebleness
(cardio-vascular asthenia) and asystolism,
that demand digitalis. There exists in all
cardiac affections a period intermediate
between hypersystolism and asystolism,
which Huchard calls hyposystolism. Sup-
pose we have a patient in whom some months.



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^64



THE MEDICAL JOURNAL AND EXAMINER.



ago there were all the signs of normal or
«ven exaggerated compensation ; the pre-
cordial shock was strong, vibrating, and
i?ell limited, the apex beat slightly lowered,
urine normal in quantity, no trace of vis-
ceral congestion, and no oedema of the
limbs. This patient now comes with
slight perimalleolar oedema in the evening,
becomes breathless easily, and has palpita-
tions and a sensation of fullness of the
•chest. Examination shows slight conges-
tion of the liver, which is painful on
pressure, and pulmonary hypersemia and
<£dema; the cardiac contraction is soft,
unequal, and irregular, the impulse more
extended, more diffuse, less sensible, the
apex displaced, and cardiac dullness in-
creased transversely; the first sound of
the heart is more or less dulled or weak-
ened, the second a little loud in the region
•of the pulmonary orifice and to the right
^f the sternum. The pulse is feeble and
undulating, the jugulars swollen and promi-
nent, and the urine scanty. In this case
there should be no hesitation about pre-
scribing digitalis, for there are three capi-
tal indications — feebleness of cardiac
contractility, lowering of arterial and in-
crease of venous pressure, and scanty
urine, coexisting with peripheral oedema or
visceral congestion.

The urine furnishes indications for the
administration of digitalis ; if it becomes
uratic, and falls below 800, 500, or to 200
grammes a day, digitalis should be given. In
giving digitalis in heart affections we should
examine the urine as carefully as we do
the thermometer in fevers.

In either asystolism or hyposystolism
there may be three causes of error in regard
to the contra-indications of digitalis: i.
The cardiac beats may be tumultuous and
-violent, the impulse of the heart becoming
energetic for a few moments ; but examina-
tion a few moments afterward may show
that the energetic systoles are followed by
weak or aborted and precipitate ones, con-
stituting the cardiataxic asystolism of Gub-
ler. Digitalis should here be prescribed as a



tonic and a regulator. 2. We may have a
patient in whom the dilatation of the
cardiac cavities strikes against the thin
and emaciated chest walls, giving the false
sensation of energetic and violent beats.
Here the clinical error is doubled if a
therapeutic error be made by withholding
digitalis on account of supposed exagger-
ated compensation. 3. In asystolism the
dilated right heart is in immediate relation
with the thoracic wall ; if it lie close to the
diaphragm the beats may be communicated
to the whole epigastric region. The extent
of these beats is no indication of their
force ; they will be found feeble, undulat-
ing, and scarcely appreciable, and digitalis
should be prescribed.

To recapitulate with regard to valvular
lesions : Digitalis is useless in the period of
eusystolism, when the lesion is compen-
sated; it is injurious in the hypersystolic
period, when the compensation is exagger-
ated; it is efficacious in the h3rposystolic
or period of transient asystolism, when the
cardiac muscle and the vessels are suffer-
ing from asthenia, and when there are
oedemas, visceral congestions, dropsies, and
the heart beats softly and feebly; in the
period of definite asystolism, or of amyo-
cardia, when the cardiac muscle is pro-
foundly degenerated, digitalis is sometimes
useful; it may be useless, or it may be inju-
rious. It is in these cases that caffeine in
large doses sometimes gives such signally
good results.

What of the use of digitalis in palpita-
tions and tachycardia? Arterial hyper-
tension is not always a contra-indication
to the use of the drug. In a certain state
of cardiac ataxia digitalis is a true regu-
lator of the heart before being an excitor
of arterial tension and before being a
tonic to the heart. Let us take the case of
a mitral patient in the hyposystolic or asys-
tolic period. The pulse is small, miserable,
soft, depressible, and irregular ; the blood-
waves are feeble, unequal, and insufficient;
the precordial shock is scarcely apprecia-
ble, and the ventricular contractions are



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EXTRACTS AND ABSTRACTS.



365



tremulous and abortive, constituting the
flutterings of the heart that Stokes speaks
of. But in the midst of these weak and
debilitated systoles occur violent, tumultu-
ous, and precipitate beats — a veritable
state of cardiac ataxia. These palpita-
tions do not always signify increased car-
diac work. In palpitations in the hyper-
systolic period, digitalis is injurious; in the
hyposystolic period it is useful.

Tachycardia is often confounded with
palpitation of the heart. Digitalis is
inefficient in the various forms of tachy-
cardia, says Huchard

Cardiac arythmia may be classified as
valvular arythmia, myocardiac, reflex,
toxic, and nervous arythmia. Digitalis
may be used in the first, the second is re-
bellious to its action, and the other three
should have causal and hygienic treat-
ment.

Two varieties of cardiac psuedo-asthma
must be recognized — one seen in valvular
cardiopathies, the other in arterial cardi-
opathies. In the first, digitalis is useful ; in
the second, the patient must have an exclu-
sive milk diet for from two to four weeks.

In arterio-sclerosis of the heart, digitalis
alone is contra-indicated. It may be com-
bined with nitro-glycerine. Distilled water,
300 grammes; tincture of digitalis, 3 gram-
mes; alcoholic solution of nitro-glycerine
(au centi^me) gtt. xxx. Dose, two to
six tablespoonfuls a day. For angina
pectoris, digitalis is always contra-indi-
cated. It some anginous cases it may be
given, however, for the hyposystolic
symptoms. In these cases, digitalis should
be combined with nitro-glycerine or with
iodide of sodium, as, iodide of sodium, 4
grammes ; powdered digitalis, 2 grammes ;
glycerine, q. s. to make 40 pills. Take
three or four a day for from ^s^ to ten
days.

In the cardiac hypertrophy of puberty,
and the menopause, digitalis may be given
in sedative doses — small doses; in these
cases preference should be given to arterial
tension-depressors.



In nephritis and asystolism of renal ori-
gin, digitalis may be guardedly used in
chronic parenchymatous nephritis. It
should not be used in the early stages of
interstitial nephritis; in the later stages^
when the heart fails, and other symptoms^
indicate, the following may be used : Dis*
tilled water, 300 grammes; benzoate of soda
and cafl'eineafl,s grammes. Dose, four to six
spoonfuls a day.

In aneurism of the aorta Huchard used
some such formula as : Distilled water, 30a
grammes; iodide of sodium, 20 grammes;
thebaic extract, 0.05 centig. Take from
two to four or fiv^ tablespoonfuls a day^
before meals, in a little beer. Continue
during twenty or twenty-five days every
month. Or, distilled water, 300 grammes,
alcoholic solution of nitro-glycerine (au
centi^me), gtt. xxx. Dose, three to six
tablespoonfuls a day. Lessen the dose if
it causes headache.

In the first stages of exophthalmic goitre^
digitalis is often useless, sometimes injuri-
ous. Later, when the heart is temporarily
or permanently enfeebled, digitalis is indi-
cated.

In the fever of endocarditis, and the
phenomena of cardiac erethism, aconite
should be combined with digitalis. Tinct-
ure of digitalis, 6 grammes; tincture of aco-
nite root, 4 grammes. Take six drops three
or four times a day. In the paralytic form of
pericarditis (Jaccoud), tincture of digitalis
may be used in doses of twenty to forty
drops a day, or the infusion may be used.

In senile pneumonia and bronchitis, dig-
italis or caffeine must be used. Digitalis
has some disadvantages. Tanret uses the
following formula, as does Huchard :
Benzoate of soda, 3 grammes ; caffeine, 2.50
grammes; distilled water, 6 grammes. Make
the solution warm. Inject subcutaneouslj
a quantity containing 0.25 centig. of caf-
feine.

The following are some of the ways ii>
which Huchard prescribes digitalis :

Alcohol (90^)? 3 grammes, 50.
Homolle's amorphous digitaline, 0.02-



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366 THE MEDICAL JOURNAL AND EXAMINER,

centig. S.— Take ten drops— which contain EXOPHTHALMIC GOITRE CURED

one miUig. BY TREATING THE NOSE *

The following is for subcutaneous injec . ^t a meeting of the Berlin Medical So-

.• ciety, January i8, 1888 (Berliner Klitdscht

„ , , J- •. ,• X- WochenschrifL 1888, No. 6), Professor

HomoUe'samorphrousdigitalineo.iocentig. t^„,, ^' r-oj * a-

, , , Frankel reported a case of Basedow s dis-

Alcohol 25 grammes. .• u a^ a a u

ease which seemed to depend on hyper-

\yater • 25 grammes.

trophy of the nasal mucous membrane and

Ten drops contain one millig. of digitalme. ^^^ ^^^^^ y^^ cauterization.

Inject deep twice a day into the muscular r^^^ p^^j^^^ ^^^ ^ ^^^^^ ^^^^ seventeen

portion of the back. y^^^g q|^ rpj^^^.^ ^^^ ^ considerable en-

BeaujorCs oxymel diuretique-Xo give tone largement of the thyroid, and apulse of 120

to the vessels and heart, act on the kidneys, ^^^*^ ^ °^^"^^^- ^^^^^ ^^^^'^g ^^^^ ^""^.^^^.^

and calm cardiac excitability. ^^"^ ^^"^^ ^^"^^ ^^^ ^^^^^ symptoms, he mci-

. . dentally called attention to a narrowing of

^^ ^ ^^ ^ g ' " ' his nasal passages, which was so great as to

Aqueous extract of ergot aa. . . lo grammes. .^^^^^^^ ^.^^ ^.^ breathing. The galvano-

ic aci 5 g • cautery was applied to the inferior turbi-

Bromide of potassmm ^^^^^ ^^^^ ^^ ^^^^ ^^^^ ^^^^ ^^j^ ^^^ ^^j.

€herry4aurel water aa sogrammes. i^wed by a marked diminution in the fre-

Sirup of cherry. 400 grammes. ^^ ^^^ ^^^ ^ disappear-

Oxymel of squills siSgrammes. ^^^^ of the goitre on the left side. Three

Dose, two to three spoonfuls a day m weeks were allowed to elapse, during which

"^ater, no change was discovered in the patient.

^. ,. , , ,. , The pulse rate, though slower than before,

Diurectic and laxatwe powder : \,.. , „ r . j i.

"^ was still abnormally fast, and no change

Powdered sulph. of potash occurred in the goitre. The right side was

Soluble cream tartar ^j^^^ cauterized in the same way as the left

Powdered nitrate of potash aa. .6 grammes. ^^^^^ ^j^^^^ immediately, the pulse sank

Powdered digitalis leaves i gramme. ^^ ^^^^^^ ^^^ ^^^ g^jt,^ disappeared.

Make 20 powders. One, three times a Professor Frankel mentioned " one case^

•day. described by Hack in the year 1886, in

which Basedow's disease had been cured

C/iomers pills (for albuminuria with anae- ^^ treatment of the nose." This report

^^^/' has called out a paper by Dr. Hopmann,

Powdered squills {Berliner Klinische Wochenscrifi, 42), in

** digitalis aa 5 grammes, which he calls attention to a similar case

Porphyrized iron 4 grammes, reported by himself in 1885.

Make 40 pills. Take from two to six a It would seem hardly necessary to trouble

day. the reader with the theoretical points dis-
cussed in the paper, but the history of the

Diuretic and hydragogue pills : case is so interesting that we give it entire.

Digitalis ** Mrs. Hamacher, forty years old, came

Squills under my treatment on the 1 1 th of Octo-

Scammony aa 3 grammes, her, 1883, on account of a secretion of mu-

Sirup of gum q. s. cus in the throat, an inclination to hawk,

*^ , :ii rr. 1 r ^ X • together with cough and occasional dis-

Make 100 pills. Take from two to six __5 f

^ A^^ * Berliner Klinische Wochenachrif t, N08. 6-42. Abstracted

A <iay. and tnuiBUted by Dr. Lester Curtis.

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Z^l



charge of masses of firm secretion. At the
same time she complained of an uncom-
monly great prostration, and weakness in
the legs, palpitation, of the heart, and pain
in the eyes, especially the right. The
painful pressure and tension in the eyes
are accompanied by discharge of tears.
These symptoms have continued uninter-
ruptedly for two years. Drying the face
with a towel occasions an almost unendur-
able pain in the eyes, especially in the
right ; therefore, she has stopped touching
the eyes when washing the face. She has
often the appearance of motes and clouds
before the eyes. At night there appear
sparks. There is also right-sided pain in
the forehead.

**The expression is peculiarly staring.
Pressure upon the eyeballs, of which the
right is especially prominent, is extremely
painful. The pulse is 120 to 126. There
exists rhinopharyngitis sicca, with extensive
accumulation of scabs in the nose and roof
of pharynx. — on the right side much more
severe than on the left. On account of
the trouble with the eyes, I sent the pa-
tient to the Cologne eye clinic where Dr.
Samelsohn asserted the perfect soundness
of the dioptric apparatus and the retina ;
still, he showed that on both sides, and es-
pecially on the right eyeball, GrSfe's symp-
tom [want of correspondence of the mo-
tion of lid and eyeball when looking down]
could be demonstrated in a very striking
manner. The exophthalmus in connection
with this; the very marked angina; and
the general feeling of weakness, especially
in the lower extremities, as well as the ab-
sence of all other local causes for the pro-
trusion of the eyeballs, left no doubt that
we had to do with those complex symptoms
which we are accustomed to designate
Basedow's disease, although there was no
appreciable swelling of the thyroid gland.

^^ I will call attention to the fact that we
have here an incomplete form of Basedow's
disease, if we compare it with the complete
form, which presents three symptoms — ex-
ophthalmus, rapid heart, and goitre, since



in this case one of the symptoms is lacking.
However, according to Von Bamberger,
even two of them may be lacking. Von
Bamberger says in regard to this : * There
are cases which continue for years with
only the symptom of palpitation of the
heart ; others with only enlarged thyroid ;
others with only the symptoms in relation to
the eyeballs — the exophthalmus depending
upon the dilatation of the retro-bulbul
blood vessels.'

** In my case the appearance of goggle-
eyes was distinctly marked on the right
side only, while it existed on the left side
in a much less degree.

"As I have repeatedly had the experi-
ence that obstinate eye symptoms have
improved from the instant in which a nasal
affection, up to that time neglected, has
been benefited by appropriate treat-
ment, I turned my attention in the treat-
ment of my patient to the quite marked
rhinopharyngitis sicca. I have treated these
cases for many years by the insertion of
strips of cotton batting; indeed, I had al-
ready used this treatment for some time
before Gottstein (1878) published his valu-
able communication on the use of tampons
in ozcena. Since Gottstein 's publication,
I have extended this treatment to ozcena
proper, where it is of more benefit than any
other.

" In our patient there was no ozcena, only
a very considerable atrophy of the mucous
membrane, with a discharge of pus which
was not fetid. As a result of the latter and
a considerable enlargement of the nasal
passages, the secretion dried in scabs and
collected especially in the naso-pharynx
and the roof of the pharynx, and was cast
off with difficulty every few days. After
the scabs were softened and removed, by
the use of cotton for several days, there
was a certain improvement in the pain in
the forehead, the discharge of tears, and
the painful feeling upon pressure in the
right eyeball. I now found, on thorough
investigation, that in the right nasal cavity
there were small mucous polypi hanging



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368



THE MEDICAL JOURNAL AND EXAMINER.



between the atrophied middle turbinated
bone and the ethmoidal cells, passing off
probably from the latter. In the course of
the next few days I removed three of these,
of the average size of a coffee-bean.

** After this operation, a striking improve-
ment of most of the symptoms was notice-
able. The patient stated that the improve-
ment followed almost immediately upon
the conclusion of the operation. The pulse
fell from 120 to 130 beats, to from 90
to 100. Pressure upon the right eyeball
was not so painful as formerly. The gen-
eral condition improved markedly. The
patient felt herself far stronger and fresher
than before.

"In the beginning of November, GrSfe's
symptom, though still plainly evident on
the right side, had disappeared from the
left.

"On the loth of November I noted
* absence of the muscse volitantes, appear-
ance of sparks in the dark, and pain on
pressure in the right eyeball; exophthal-
mus disappearing; pulse, 92-100.'

" On the 20th of November, Dr. Samel-
sohn affirmed an equally marked improve-
ment.

" Eight days later, Grfife's symptom could
be no longer detected on the right side, and
the closure of the lids was normal ; no feel-
ing of pressure in the eyes or forehead;
pulse, 88-92.

** Patient can wash and dry the face with-
out experiencing the least unpleasant symp-
tom. The insertion of cotton was con-
tinued.

**0n the beginning of April, 1885, after
a year and a half, the patient consulted me
again, because she had been again troubled
for some months with mucous secretion in
the pharynx. She had been feeling entire-
ly well and had begun to give up the use of
the cotton; at least, she had used it quite ir-
regularly, so the drying of the nasal and
pharyngeal mucous membrane, as well as
the collection of scabs, began to appear.
Nevertheless, pain in the eyes had not ap-
peared, nor an excessive secretion of tears



or other difficulty in the eyes- Polypi had
not returned; protrusion of the eyeballs
was not present ; pulse, 92.

** While she was in this general condition,.
I showed her to the general medical society
here* on the 21st of April, 1885. After
that time the patient was for a short time, in
June, 1886, under my treatment. She com-
plained then that for about six months she
had been troubled with muscse volitantes,
clouds, and at night, the appearance of



Online LibraryJ. M. (James Mitchell) FosterThe Chicago medical journal and examiner → online text (page 59 of 63)