I
December
LECTURES ON THE VASCULO-CARDIACS.?BY A. CROMBIE.
1, 1874]
ORIGINAL COMMUNICATIONS. lectures
arteries, digitalis shuts off to some degree the supply 0f blood and oxygen to the tissues, and so lowers the body-temperature. This has been found to take place even in health
on the vasculo-cardiacs.
Professor of Materia Medica and Clinical Medicine, Medical College, Calcutta, and cx-officio Second tysicia , Medical College Hospital.
Officiating
lecture ln& ^
hi.?digitalis
digitnlis, therefore,
physiological It
?
p!obably
causes as
a
actions
we
(continued). therapeutics. drug which has the follow-
have a
:?
arteries, acting contractility of the
of the smaller
contraction
direct stimulant
to
the
The contraction is sometimes the lumen 01 these vessels. obliterate completely It raises the blood-pressure in the arterial system, and acts therefore as a mechanical augmenting the fluid
"uiscular fibres of their walls.
80
great as to
commencement of the third week, of the fever. The use of the medicine is unattended with 4.
diuretic,
Portion of the renal secretion.
In medicinal doses it slows the pulse, while it increases the energy of the ventricular contractions. 'Ilie slowing of the Pulse is due to stimulation of the vagus roots, either as the result of a direct action of the drug, or as one of the conse-
quences of the high blood-pressure. The increased energy of the heart's contractions is most Probably due to a direct action upon the muscular fibres of the
Ventricles themselves, although there is evidence that digitalis a 30 stimulates the quickening nerves. ^rith the action of digitalis in poisonous doses we have no further need to trouble ourselves in this lecture, except in so as it ig necessary to remember that it occasionally happens
toxic at, when the drug is given for some time in small doses, Oiptoms suddenly develcpe themselves, and even fatal syncope 88 Occurred as the consequence of excitement and sudden
under such circumstances. It is necessary to be prepared 0r' ari(I to warn accidents of this kind. your patients against, le that digitalis is a is theory (but it purely gratuitous one) accumulates i'1 the system till it is in sufficient quantity to give
tXeiti?n
lse to
these
I will
alarming toxic symptoms.
under the
headings
arrange the therapeutics of digitalis of the three propositions in which I have just recapitulated under those of lhe matter of the two previous lectures, and
to you. I do so which I will now point out when we shall fast coming is because I believe the day e able to predicate the uses of a huge piopoition therapeutic 01 our actions, drugs from our knowledge of their physiologicaland a few a" ^ belladonna, now can with regard to digitalis, serve as but chieflv because these propositions will convenient pegs whereon to hang the following details other^lSu difficult at the bedside. to hold together in the memory L contraction of the smaller causes then, digitalis arterie', sometimes in such a degree as to entirely prevent the Voyage of blood through certain of them. This immediately Su&ge5ts its use in internal hemorrhages, and many practitioners of haemoptysis. in favour of it in the treatment 118 is a almost always ceases symptom which, however, and if you keep your patient perfectly quiet, whic l is so a the cough control if Proper position, and you with which 8pt to shoot out the little plugs of blood-clot moreover ergot has nature occludes the and orifices ; bleeding a 111 contraction of the uch more powerful effect in causing lr
(Ackermann),
Wunderlich, Niemeyer, Thomas, and others speak enthusiastically of its power of reducing the abnormal temperature of various diseases, and notably of enteric fever, and the pyrexia that accompanies tuberculization in the lungs. We have not had the opportunity of studying the effect of digitalis in enteric fever in the wards of our hospital during the present session, but the conclusions to which Wunderlich has been led are the following :? 1. From 30 to 60 grains of digitalis, distributed over from three to five days, are required to produce a decided effect on the symptoms. The temperature of the body begins to fall before the 2. pulse rate, which may be reduced by from 30 to 60 beats. 3. These effects are most marked in the second, or at the and
By Alexander Ckomhie, M.D., Edin
.
309
corollaries,
?nrtW
Firstly,
ye?k highly
sPontaneously
danger,
suspended
you the good effect of digitalis, given along with quinia and opium after the manner of Niemeyer. In almost every case, I think, we have observed a fall of temperature after this prescription has been used. In this connection may be mentioned also the use of digitalis The sphygmograph shows that in alcoho-
in delirium tremens.
general dilatation of the blood-vessels; pulse is weak, rapid, and fluttering. Digitalis, inasmuch as it contracts the arteries, and slows and gives strength to the cardiac contractions, is to that extent antidotal to alcohol, and in this disease it may be given in lic
poisoning
there is
in asthenic cases the
doses with safety and benefit. So long ago as 1820 Drs. Pierson and Webster of America treated delirium tremens with drachm doses of tincture of digitalis, and in 1836 Clesa of Wurtetnberg published thirteen cases which he had treated successfully with a strong infusion (stille). But so universal enormous
and so strong was the belief, that digitalis was a cardiac sedative that no credence was given to these reports, till in 1860 a patient of Dr. Jones of Jersey took by mistake a draught of half
an
ounce
of the tincture.
alarmed, but the patient made
The doctor
was
greatly
rapid
recovery. Acting on the principle of profiting by our mistakes, Jones proceeded to treat his cases of delirium tremens with half ounce doses of the tincture with surprisingly excellent results. Out of 67 a
only one death, a case which was complicated previous disease of the brain. Two doses were generally sufficient, the second one being given at the end of four hours. Under the influence of the drug the pulse became firmer, fuller, and more regular, and general warmth of the skin took the place of the clammy sweats, "lhe practice has been frequently imitated with the same happy result. Sydney Ilinger states that he has seen several instances of this disease yield speedily to these huge doses of digitalis; but that on two occasions the patients suddenly fell back dead. Whether these deaths were due to the digitalis, or to the disease, which not uncases
he had
with
frequeutly
terminates in the .same manner, he could not deter-
mine; but such untoward occurrences, taken along with the dread of the sedative action of the drug on the heart, have been sufficient to stay most hands in the administration of these
use arterioles than digitalis has, and I should therefore always which energetic in large doses. Although sthenic cases appear to be equally ergot in preference to digitalis in cases featment was required. Several eminent practitioners, Dicken- amenable to the treatment, the cases in which Jones seems to with great have adopted this heroic practice were those in which Son> Barclay, we, with Trousseau, etc., have used digitalis from our advanced knowledge of the physiological action of the *Uccess in in uterine haemorrhage even and menorrhagia, drug, would now have predicated the best results, ramelv the rganic disease. In these cases I should again pre ei ergo ,
*"or the
severer asthenic forms of habitual topers in whom the cardiac ? ? of the smaller and vascular depression of this disease is most marked. Should contraction of consequence
same reason.
Corollary.?a
,
if
when the pulse rate begins to fall rapidly. The best dose is an infusion of 15 to 20 grains continued without interruption until its influence is manifested. In the fever of phthisis I have had several opportunities of showing
it is 5.
THE INDIAN MEDICAL GAZETTE.
310
yon determine to treat cases in this way, it would be well to take the precaution of enforcing the horizontal posture. 2.
Digitalis
raises the
blood-pressure
within the
arteries,
that
is to say, it increases the tension of their walls. Now, if these walls are diseased, will not digitalis increase the risk which I think it will, and I should hesitate to cases in which there was evidence of atheromatous or other changes in the walls of the larger arteries. Brunton was, I believe, the first to point out, on theoretical Btich disease
implies. prescribe digitalis in
this contraindication to its use, and there are not, so I know, any clinical observations either for or against his opinion ; but it seems to stand to reason. In eases of
grounds,
far
as
aneurism I should certainly say that it would increase the risk of rupture or of further dilatation. There is yet another
contraindication arising out of this effect of the administration of
So
1832 Sir Dominic
Corrigan,
with
great clearness of clinical observation, pointed out that
cases
digitalis.
long
ago
as
The of aortic regurgitation were aggravated by digitalis of this we can now readily understand. The drug not
season
only increases
the recoil of the arteries, and
thus will force
the blood with greater rapidity through the insufficient valve, but it at the same time lengthens the period of the diastole, or that the blood will continue to pour from the aorta back into a longer time, and will fill it fuller than if the
the ventricle for
circulatory organs were left to themselves, and thus the distress of the heart and of the patient will be increased. The diuretic action of digitalis is the rider or corollary to this It is the consequence of the high bloodsecond proposition. pressure within the arteries of the Malpighian tufts, through which the fluid portion of the renal secretion is increased. Digitalis is not diuretic in the way that potassic bitartrate, and cantharides are. It neither adds to the quantity of matter to be excreted by the kidneys, nor does it stimulate them. Its effect as a diuretic is mechanical?the result of the contraction of the arterioles and of the high blood-pressure which favours exosmosis. It is diuretic in the same way that ergot, belladonna, and a ligature placed on the aorta below the origins of the are diuretic; it increases the blood-pressure within kidneys. Now, it must be admitted that the effect of digitalis Most observers have failed as a diuretic in health is equivocal. On the contrary, Gerto notice any increase of the secretion. main Wiaogradoff, Pfaff, Stadion, and Hammond found that it lessened the amount of all the solids exoept uric acid, and lowered the specific gravity. I ask you to make a note of this statement in connection with the previous one that digitalis lowers the body-temperature. The diminution of the urinary solids, and the reduction of the temperature, both point to
renal a:teries the
lessened oxidation of the tissues as the result of contracted These observations arterioles and diminished blood-supply.
would induce us to place digitalis among the " paratriptics," drugs which lessen the waste of the tissues in the performance of their functions ; a somewhat different, and I think fallacious,
physicians from digitalis as a diuretic in Blights' disease. They eav that if digitalis lessens the amount of urinary solids excreted, including urea, it must increase the risk of uraemia poisoning. 1 think this fear is visionary, and that if digitalis diminishes the tissue-waste (which is ;he source of urea), as a more extended view of its action would seem to indicate, not only would there be less chance of waste-products accumulating in the blood to a dangerous degree, but actually less work of excretion would be thrown on the diseased kidneys. This brings us to speak of a second objection to the use of digitalis in Brights' disease, advanced by those who object to diuretics in that disease altogetber, namely, the harmful stimulation of diseased organs. But this objection to digitalis arises from an imperfect knowledge of the mode of action of diuretics. All diuretics are not stimulants to the secreting cells of the kidueys. .Cantharides and the saline diuretics are probably so, line of
making
argument has sometimes prevented
use
of
[December 1,
1874
but digitalis, and the other drugs which act similarly, cannot he said to stimulate the kidney-cells, for they simply increase the fluid portion of the urine relatively by increasing the bloodpressure within the Malpighian tufts. And here we must remark that, although the observations on the action of digitalis as a diuretic in health are not harmonious, there is a vast amount of clinical evidence showing its power
to increase the total
quantity
of the
and other diseases.
urinary
secretion in
dropsy
Nevertheless, you will frequently find, if you prescribe this drug indiscriminately in dropsical cases, and
if you endeavour to ascertain the amount of urine secreted from to day, as we always do in our wards, that in certain cases the effect looked for is by no means apparent; and I think we
day are
now
gather
in
a
some
position rules of
to
offer
some
guidance
explanation
of
this,
to
and
from it.
It has long been remarked that digitalis is much more effectual in cardiac than in renal dropsy ; and, moreover, it was the experience of Withering, to whose clear writing we are indebted to a great degree for the general adoption of digitalis as a diuretic in
dropsies, that in sthenic cases, with a warm skin, a complexion, and a tense, corded pulse, digitalis was of little, if any, service ; whereas if the pulse were feeble, the countenance pale, the lips livid, the skin cold, and the belly soft and fluctuating, the diuretic action of the medicine was generally evident. Similar observations have been made by others; florid
thus, Darwin found the medicine
most
successful when
the
patients had passed the vigour of life, and had indulged too freely in spirituous liquors. Now, it appears to me that the difference here indicated with regard -to the successful use of the drug are .referable differences in the state of the arterial system aa regards tension and blood-pressure. This is obvious in the distinctions observed by Withering and Darwin. In sthenic cases, with a florid complexion, and a tense, corded pulse, the arteries arc well filled, are contracting firmly on their contents, and the to
is already high. Such conditions nre not those indicate the successful use of digitalis regarding the action of the drug a3 a diuretic from our point of view. The
blood-pressure which
blood-pressure within the Malpighian tufts is already as high is desirable, and these are the cases which will be most benefited by free purging with hydragogue cathartics. But when thejmlse is soft and feeble, with a pale countenance, and livid lips, the condition of the arterial systeir is entirely different. The lividity shows that the blood is lying more on the venous than the arterial side, the soft feeble pulse indicate* imperfectly filled arteries and low arterial tension, and the other conditions point to general relaxation of organic fibres. Here as
there are the clearest indications for the exhibition of digitalisIt will give strength to the cardiac contractions, tone to the
walls, and firmness to the pulse; the vascula1 rise, and the proper balance of pressure in tbe be Malpighian tufts, and the function of the kidneys, will
relaxed arterial tension will restored.
It
was
under
such
circumstances that the use of tonics (iron and
older
bark) with that of digitalis, notwithstanding the apparent contradiction which their views of the action of digitalis as a cardiac physicians
learned to combine the
and vascular sedative must have made this course of actio11 but appear to be. We now know that it was no contradiction, that while iron and bark are general tonics, bracing up tbe 8 generally relaxed organic fibres, digitalis is a special tonic, fibre?) muscular vasculo-cardiac tonic, acting on the involuntary but especially those of the heart and blood-vessels. The for?1 with which we are most familiar, that wbic of
general drop3y
accom part of the malarial cachexia, and which is often an is one of this kind, nnd ascites spleen, enlarged panied by is
a
case=
generally yields readily to digitalis as a diuretic ; in these we always combine it with irou and quinia with great success. A very short consideration of the conditions of the two t of cases from one point of view will also serve to explain
December 1, 1874.]
LECTURES ON THE VASCULO-CARDIACS.?BY A. CROMBIE.
greater efficaoy of digitalis in cardiac tlian in renal dropsy. ?Iho condition of the circulation in chronic Brights disease, especially that kind characterised by the small contracted kidney, be guessed by the is one of high arterial tension. This might state of the in pale in colour, and of
quantity, urine; large specific gravity, indicating high pressure
in
the still
of But the recent researches been has disputed) George Johnson (although their accuracy in this disease, Lar evidence to continuous arteriole spasm element of the muscular the of in "-Suiting hypertrophy This spasm contractile walls of the smaller blood-vessels. of the blood from means increased in the
Permeable
Pr-
Mnlpighian
bodies.
difficulty
passage
high arterial arterial into the capillary systems, and The high arterial tension ns the inevitable consequence. tension offers a difficulty to the emptying of the left ventricle, becomes ich' accordance with the well known law, v nypertrophied to meet it; so that at last we have the passage the spasm of the the blood out of the arteries hindered by ^ Pertrophied muscles in the walls of the arterioles, while it left 13 forced into them with unusual strength by a hypertrophied yentricle. The result is a very high state of arterial tension, arteries ln consequence of which the walls of the larger .
occurring tend so frequently to degenerative changes. Dropsy, a drug Under such to be benefited by not is likely circumstances, to the hearts w ich energy and gives increases arteriole spasm disease, contractions. in the later stages of Brights' It is
only
the heart, from long continued ^hen a'i in its power of propelling the blood
mal-nutrition, begins
to
onwards, that digitalis
wil1 be found of service in the treatment of the resulting dropsy. Cardiac dropsy, on the other hand, is ever the sign of failure disease is a hindthe circulation. Every form of valvular lauce to the onwards into the arteries, easy passage of the blood to and no matter what amount of hypertrophy takes place
?veicoine it, palpitation, embarrassment, and dropsy are only so n^atiy signs that the heart is becoming inadequate to its task. of low arterial n these cases we have again the condition ension which is the indication for the successful use of digitalis
as
a
eart
_3-
t0xth
diuretic. But the consideration of the disease bring us to our third proposition.
use
of
digitalis
in
medicinal doses, the heart acts
of digitalis in The most diminished frequency, but with increased energy. be seen in enUnder the
use
marked g00d effect of the drug will therefore abled states of that organ, with a quick weak pulse. 1 had of ately under my care a thin and feeble East-Indan lady manner the a in typical Seventy-fiVe years of ag
December
LECTURES ON THE VASCULO-CARDIACS.?BY A. CROMBIE.
1, 1874]
ORIGINAL COMMUNICATIONS. lectures
arteries, digitalis shuts off to some degree the supply 0f blood and oxygen to the tissues, and so lowers the body-temperature. This has been found to take place even in health
on the vasculo-cardiacs.
Professor of Materia Medica and Clinical Medicine, Medical College, Calcutta, and cx-officio Second tysicia , Medical College Hospital.
Officiating
lecture ln& ^
hi.?digitalis
digitnlis, therefore,
physiological It
?
p!obably
causes as
a
actions
we
(continued). therapeutics. drug which has the follow-
have a
:?
arteries, acting contractility of the
of the smaller
contraction
direct stimulant
to
the
The contraction is sometimes the lumen 01 these vessels. obliterate completely It raises the blood-pressure in the arterial system, and acts therefore as a mechanical augmenting the fluid
"uiscular fibres of their walls.
80
great as to
commencement of the third week, of the fever. The use of the medicine is unattended with 4.
diuretic,
Portion of the renal secretion.
In medicinal doses it slows the pulse, while it increases the energy of the ventricular contractions. 'Ilie slowing of the Pulse is due to stimulation of the vagus roots, either as the result of a direct action of the drug, or as one of the conse-
quences of the high blood-pressure. The increased energy of the heart's contractions is most Probably due to a direct action upon the muscular fibres of the
Ventricles themselves, although there is evidence that digitalis a 30 stimulates the quickening nerves. ^rith the action of digitalis in poisonous doses we have no further need to trouble ourselves in this lecture, except in so as it ig necessary to remember that it occasionally happens
toxic at, when the drug is given for some time in small doses, Oiptoms suddenly develcpe themselves, and even fatal syncope 88 Occurred as the consequence of excitement and sudden
under such circumstances. It is necessary to be prepared 0r' ari(I to warn accidents of this kind. your patients against, le that digitalis is a is theory (but it purely gratuitous one) accumulates i'1 the system till it is in sufficient quantity to give
tXeiti?n
lse to
these
I will
alarming toxic symptoms.
under the
headings
arrange the therapeutics of digitalis of the three propositions in which I have just recapitulated under those of lhe matter of the two previous lectures, and
to you. I do so which I will now point out when we shall fast coming is because I believe the day e able to predicate the uses of a huge piopoition therapeutic 01 our actions, drugs from our knowledge of their physiologicaland a few a" ^ belladonna, now can with regard to digitalis, serve as but chieflv because these propositions will convenient pegs whereon to hang the following details other^lSu difficult at the bedside. to hold together in the memory L contraction of the smaller causes then, digitalis arterie', sometimes in such a degree as to entirely prevent the Voyage of blood through certain of them. This immediately Su&ge5ts its use in internal hemorrhages, and many practitioners of haemoptysis. in favour of it in the treatment 118 is a almost always ceases symptom which, however, and if you keep your patient perfectly quiet, whic l is so a the cough control if Proper position, and you with which 8pt to shoot out the little plugs of blood-clot moreover ergot has nature occludes the and orifices ; bleeding a 111 contraction of the uch more powerful effect in causing lr
(Ackermann),
Wunderlich, Niemeyer, Thomas, and others speak enthusiastically of its power of reducing the abnormal temperature of various diseases, and notably of enteric fever, and the pyrexia that accompanies tuberculization in the lungs. We have not had the opportunity of studying the effect of digitalis in enteric fever in the wards of our hospital during the present session, but the conclusions to which Wunderlich has been led are the following :? 1. From 30 to 60 grains of digitalis, distributed over from three to five days, are required to produce a decided effect on the symptoms. The temperature of the body begins to fall before the 2. pulse rate, which may be reduced by from 30 to 60 beats. 3. These effects are most marked in the second, or at the and
By Alexander Ckomhie, M.D., Edin
.
309
corollaries,
?nrtW
Firstly,
ye?k highly
sPontaneously
danger,
suspended
you the good effect of digitalis, given along with quinia and opium after the manner of Niemeyer. In almost every case, I think, we have observed a fall of temperature after this prescription has been used. In this connection may be mentioned also the use of digitalis The sphygmograph shows that in alcoho-
in delirium tremens.
general dilatation of the blood-vessels; pulse is weak, rapid, and fluttering. Digitalis, inasmuch as it contracts the arteries, and slows and gives strength to the cardiac contractions, is to that extent antidotal to alcohol, and in this disease it may be given in lic
poisoning
there is
in asthenic cases the
doses with safety and benefit. So long ago as 1820 Drs. Pierson and Webster of America treated delirium tremens with drachm doses of tincture of digitalis, and in 1836 Clesa of Wurtetnberg published thirteen cases which he had treated successfully with a strong infusion (stille). But so universal enormous
and so strong was the belief, that digitalis was a cardiac sedative that no credence was given to these reports, till in 1860 a patient of Dr. Jones of Jersey took by mistake a draught of half
an
ounce
of the tincture.
alarmed, but the patient made
The doctor
was
greatly
rapid
recovery. Acting on the principle of profiting by our mistakes, Jones proceeded to treat his cases of delirium tremens with half ounce doses of the tincture with surprisingly excellent results. Out of 67 a
only one death, a case which was complicated previous disease of the brain. Two doses were generally sufficient, the second one being given at the end of four hours. Under the influence of the drug the pulse became firmer, fuller, and more regular, and general warmth of the skin took the place of the clammy sweats, "lhe practice has been frequently imitated with the same happy result. Sydney Ilinger states that he has seen several instances of this disease yield speedily to these huge doses of digitalis; but that on two occasions the patients suddenly fell back dead. Whether these deaths were due to the digitalis, or to the disease, which not uncases
he had
with
frequeutly
terminates in the .same manner, he could not deter-
mine; but such untoward occurrences, taken along with the dread of the sedative action of the drug on the heart, have been sufficient to stay most hands in the administration of these
use arterioles than digitalis has, and I should therefore always which energetic in large doses. Although sthenic cases appear to be equally ergot in preference to digitalis in cases featment was required. Several eminent practitioners, Dicken- amenable to the treatment, the cases in which Jones seems to with great have adopted this heroic practice were those in which Son> Barclay, we, with Trousseau, etc., have used digitalis from our advanced knowledge of the physiological action of the *Uccess in in uterine haemorrhage even and menorrhagia, drug, would now have predicated the best results, ramelv the rganic disease. In these cases I should again pre ei ergo ,
*"or the
severer asthenic forms of habitual topers in whom the cardiac ? ? of the smaller and vascular depression of this disease is most marked. Should contraction of consequence
same reason.
Corollary.?a
,
if
when the pulse rate begins to fall rapidly. The best dose is an infusion of 15 to 20 grains continued without interruption until its influence is manifested. In the fever of phthisis I have had several opportunities of showing
it is 5.
THE INDIAN MEDICAL GAZETTE.
310
yon determine to treat cases in this way, it would be well to take the precaution of enforcing the horizontal posture. 2.
Digitalis
raises the
blood-pressure
within the
arteries,
that
is to say, it increases the tension of their walls. Now, if these walls are diseased, will not digitalis increase the risk which I think it will, and I should hesitate to cases in which there was evidence of atheromatous or other changes in the walls of the larger arteries. Brunton was, I believe, the first to point out, on theoretical Btich disease
implies. prescribe digitalis in
this contraindication to its use, and there are not, so I know, any clinical observations either for or against his opinion ; but it seems to stand to reason. In eases of
grounds,
far
as
aneurism I should certainly say that it would increase the risk of rupture or of further dilatation. There is yet another
contraindication arising out of this effect of the administration of
So
1832 Sir Dominic
Corrigan,
with
great clearness of clinical observation, pointed out that
cases
digitalis.
long
ago
as
The of aortic regurgitation were aggravated by digitalis of this we can now readily understand. The drug not
season
only increases
the recoil of the arteries, and
thus will force
the blood with greater rapidity through the insufficient valve, but it at the same time lengthens the period of the diastole, or that the blood will continue to pour from the aorta back into a longer time, and will fill it fuller than if the
the ventricle for
circulatory organs were left to themselves, and thus the distress of the heart and of the patient will be increased. The diuretic action of digitalis is the rider or corollary to this It is the consequence of the high bloodsecond proposition. pressure within the arteries of the Malpighian tufts, through which the fluid portion of the renal secretion is increased. Digitalis is not diuretic in the way that potassic bitartrate, and cantharides are. It neither adds to the quantity of matter to be excreted by the kidneys, nor does it stimulate them. Its effect as a diuretic is mechanical?the result of the contraction of the arterioles and of the high blood-pressure which favours exosmosis. It is diuretic in the same way that ergot, belladonna, and a ligature placed on the aorta below the origins of the are diuretic; it increases the blood-pressure within kidneys. Now, it must be admitted that the effect of digitalis Most observers have failed as a diuretic in health is equivocal. On the contrary, Gerto notice any increase of the secretion. main Wiaogradoff, Pfaff, Stadion, and Hammond found that it lessened the amount of all the solids exoept uric acid, and lowered the specific gravity. I ask you to make a note of this statement in connection with the previous one that digitalis lowers the body-temperature. The diminution of the urinary solids, and the reduction of the temperature, both point to
renal a:teries the
lessened oxidation of the tissues as the result of contracted These observations arterioles and diminished blood-supply.
would induce us to place digitalis among the " paratriptics," drugs which lessen the waste of the tissues in the performance of their functions ; a somewhat different, and I think fallacious,
physicians from digitalis as a diuretic in Blights' disease. They eav that if digitalis lessens the amount of urinary solids excreted, including urea, it must increase the risk of uraemia poisoning. 1 think this fear is visionary, and that if digitalis diminishes the tissue-waste (which is ;he source of urea), as a more extended view of its action would seem to indicate, not only would there be less chance of waste-products accumulating in the blood to a dangerous degree, but actually less work of excretion would be thrown on the diseased kidneys. This brings us to speak of a second objection to the use of digitalis in Brights' disease, advanced by those who object to diuretics in that disease altogetber, namely, the harmful stimulation of diseased organs. But this objection to digitalis arises from an imperfect knowledge of the mode of action of diuretics. All diuretics are not stimulants to the secreting cells of the kidueys. .Cantharides and the saline diuretics are probably so, line of
making
argument has sometimes prevented
use
of
[December 1,
1874
but digitalis, and the other drugs which act similarly, cannot he said to stimulate the kidney-cells, for they simply increase the fluid portion of the urine relatively by increasing the bloodpressure within the Malpighian tufts. And here we must remark that, although the observations on the action of digitalis as a diuretic in health are not harmonious, there is a vast amount of clinical evidence showing its power
to increase the total
quantity
of the
and other diseases.
urinary
secretion in
dropsy
Nevertheless, you will frequently find, if you prescribe this drug indiscriminately in dropsical cases, and
if you endeavour to ascertain the amount of urine secreted from to day, as we always do in our wards, that in certain cases the effect looked for is by no means apparent; and I think we
day are
now
gather
in
a
some
position rules of
to
offer
some
guidance
explanation
of
this,
to
and
from it.
It has long been remarked that digitalis is much more effectual in cardiac than in renal dropsy ; and, moreover, it was the experience of Withering, to whose clear writing we are indebted to a great degree for the general adoption of digitalis as a diuretic in
dropsies, that in sthenic cases, with a warm skin, a complexion, and a tense, corded pulse, digitalis was of little, if any, service ; whereas if the pulse were feeble, the countenance pale, the lips livid, the skin cold, and the belly soft and fluctuating, the diuretic action of the medicine was generally evident. Similar observations have been made by others; florid
thus, Darwin found the medicine
most
successful when
the
patients had passed the vigour of life, and had indulged too freely in spirituous liquors. Now, it appears to me that the difference here indicated with regard -to the successful use of the drug are .referable differences in the state of the arterial system aa regards tension and blood-pressure. This is obvious in the distinctions observed by Withering and Darwin. In sthenic cases, with a florid complexion, and a tense, corded pulse, the arteries arc well filled, are contracting firmly on their contents, and the to
is already high. Such conditions nre not those indicate the successful use of digitalis regarding the action of the drug a3 a diuretic from our point of view. The
blood-pressure which
blood-pressure within the Malpighian tufts is already as high is desirable, and these are the cases which will be most benefited by free purging with hydragogue cathartics. But when thejmlse is soft and feeble, with a pale countenance, and livid lips, the condition of the arterial systeir is entirely different. The lividity shows that the blood is lying more on the venous than the arterial side, the soft feeble pulse indicate* imperfectly filled arteries and low arterial tension, and the other conditions point to general relaxation of organic fibres. Here as
there are the clearest indications for the exhibition of digitalisIt will give strength to the cardiac contractions, tone to the
walls, and firmness to the pulse; the vascula1 rise, and the proper balance of pressure in tbe be Malpighian tufts, and the function of the kidneys, will
relaxed arterial tension will restored.
It
was
under
such
circumstances that the use of tonics (iron and
older
bark) with that of digitalis, notwithstanding the apparent contradiction which their views of the action of digitalis as a cardiac physicians
learned to combine the
and vascular sedative must have made this course of actio11 but appear to be. We now know that it was no contradiction, that while iron and bark are general tonics, bracing up tbe 8 generally relaxed organic fibres, digitalis is a special tonic, fibre?) muscular vasculo-cardiac tonic, acting on the involuntary but especially those of the heart and blood-vessels. The for?1 with which we are most familiar, that wbic of
general drop3y
accom part of the malarial cachexia, and which is often an is one of this kind, nnd ascites spleen, enlarged panied by is
a
case=
generally yields readily to digitalis as a diuretic ; in these we always combine it with irou and quinia with great success. A very short consideration of the conditions of the two t of cases from one point of view will also serve to explain
December 1, 1874.]
LECTURES ON THE VASCULO-CARDIACS.?BY A. CROMBIE.
greater efficaoy of digitalis in cardiac tlian in renal dropsy. ?Iho condition of the circulation in chronic Brights disease, especially that kind characterised by the small contracted kidney, be guessed by the is one of high arterial tension. This might state of the in pale in colour, and of
quantity, urine; large specific gravity, indicating high pressure
in
the still
of But the recent researches been has disputed) George Johnson (although their accuracy in this disease, Lar evidence to continuous arteriole spasm element of the muscular the of in "-Suiting hypertrophy This spasm contractile walls of the smaller blood-vessels. of the blood from means increased in the
Permeable
Pr-
Mnlpighian
bodies.
difficulty
passage
high arterial arterial into the capillary systems, and The high arterial tension ns the inevitable consequence. tension offers a difficulty to the emptying of the left ventricle, becomes ich' accordance with the well known law, v nypertrophied to meet it; so that at last we have the passage the spasm of the the blood out of the arteries hindered by ^ Pertrophied muscles in the walls of the arterioles, while it left 13 forced into them with unusual strength by a hypertrophied yentricle. The result is a very high state of arterial tension, arteries ln consequence of which the walls of the larger .
occurring tend so frequently to degenerative changes. Dropsy, a drug Under such to be benefited by not is likely circumstances, to the hearts w ich energy and gives increases arteriole spasm disease, contractions. in the later stages of Brights' It is
only
the heart, from long continued ^hen a'i in its power of propelling the blood
mal-nutrition, begins
to
onwards, that digitalis
wil1 be found of service in the treatment of the resulting dropsy. Cardiac dropsy, on the other hand, is ever the sign of failure disease is a hindthe circulation. Every form of valvular lauce to the onwards into the arteries, easy passage of the blood to and no matter what amount of hypertrophy takes place
?veicoine it, palpitation, embarrassment, and dropsy are only so n^atiy signs that the heart is becoming inadequate to its task. of low arterial n these cases we have again the condition ension which is the indication for the successful use of digitalis
as
a
eart
_3-
t0xth
diuretic. But the consideration of the disease bring us to our third proposition.
use
of
digitalis
in
medicinal doses, the heart acts
of digitalis in The most diminished frequency, but with increased energy. be seen in enUnder the
use
marked g00d effect of the drug will therefore abled states of that organ, with a quick weak pulse. 1 had of ately under my care a thin and feeble East-Indan lady manner the a in typical Seventy-fiVe years of ag
