He and his disciples would not have been surprised at the necessity of using material doses of this drug for the cure of dropsical conditions.
Digitalis, then, cures or relieves dropsy by its homoeopathicity to a weak heart, which it tones up, and influences in such a way as to cause it to supply the kidneys with a normal amount of blood, which blood, acting as a natural stimulus, restores their eliminating function.
Digitalis has been used in some abnormal conditions of the uterus. These conditions are characterized by inertia, or muscular debility, and are attended sometimes by haemorrhage. It is suggestive fact, also, that in almost every reported case there was some cardiac derangement present at the same time.
A medical writer, whose name has escaped me, reports a case of uterine inertia occurring during parturition. With rare intuition, he gave Digitalis, because the patient had a weak and enlarged heart. The result was that the uterus acted promptly and performed its functions. No one can doubt that the heart was first acted on, and that the uterine action was but the result of the increased cardiac tonicity. So, in cases of haemorrhage from relaxation of the uterine vessels, Digitalis has been found eminently useful; for, with the return of the normal contractility of the muscular coat of the uterine vessels.
The curative action of Digitalis in all kinds of haemorrhage can be accounted for in the same manner.
Resume. – As a brief summing up of the subject of this paper, I will offer a few remarks, which I deem of practical importance.
In the proving of medicines the prover should carefully note the primary and secondary symptoms which are evolved, and ascertain, if possible, where the first series ends, and the second begins.
In the study of a pathogenesis, when this has not been done, the physician should, by the aid of toxical observations, clinical results, etc., ascertain, if possible, and separate distinctly, the two kinds of drug effects.
In other words, he should study drug diseases, just as the pathologist studies natural diseases, in order that he may have their natural history. When this natural history of drugs and disease action is compared, a selection of the right remedy is not in the least difficult.
When the appropriate remedy has been selected, the selection of the proper dose is not any more difficult, if we bear in mind this rule, namely: For primary symptoms, the higher attenuations, or smallest dynamic doses; for secondary symptoms, the lowest attenuations, or largest dynamic quantities.
Note. Written February, 1889. – One of the most studiously prepared and thoroughly digested papers which has of late appeared upon this subject is an editorial article in the Journal of the American Medical Association, July 28th, 1888. It contains so many appropriate suggestions, and is permeated by such judicious counsel, that we cannot forbear calling attention to some of the points. Digitalis is not indicated by the presence of a cardiac lesion; there must be a cardiac malady. When the patient has entered upon the period of hypersystolism characterized by increased arterial tension, then Digitalis is injurious. Increased arterial tension Huchard regards as the cause rather than the effect of sclerosis, and in the early period of arterio-sclerosis, Digitalis should only be employed with caution.* *In large doses. (Hale.) “It should be remembered always that if we wish to strengthen the heart, we must facilitate and lighten its work.” “It is efficacious when the cardiac muscle and the vessels are suffering from asthenia, and when there are oedemas, visceral congestions, dropsies, and the heart beats softly and feebly. When the cardiac muscle is profoundly degenerated, Digitalis is sometimes useful; it may be useless, or it may be injurious. It is in these cases, sometimes, that Caffeine in large doses gives such signally good results.” The foregoing teachings, if kept in view, will be the means of saving thousands of lives annually.
ERYTHROPHLEUM.
(Casca Bark.)
The use of this bark was introduced into medicine by Dr. T. Lauder Brunton for mitral disease of the heart. It is the bark of Erythrophloeum guinense, a leguminous tree found in Central and West Africa, and used by the natives as an ordeal poison. It is met with in flat or slightly curved pieces of irregular size, and about a quarter of an inch in thickness, of a dull red brown color, smooth or nearly so on the inner surface, with a short, granular fracture, very hard externally, uneven, watery and fissured. It is inodorous and has an astringent, acrid and bitter taste. When powdered, it excites violent and persistent sneezing. Great care should be taken in powdering it to prevent the dispersal of the powder in the air, either by moistening the bark with spirits or by covering the mortar with a cloth. The active properties of Casca bark are due to the crystalline alkaloid erythrophoeline, which is soluble in water, alcohol and acetic ether, but nearly insoluble in ether, chloroform and benzol.
The most conspicuous effect of the drug is a general muscular relaxation, so that an animal poisoned with it will remain quiescent in whatever position it is placed. In a fatal dose, vomiting, contracted pupils, slow and irregular action of the heart and a quick and labored respiration are observed, followed by death, with general convulsions and sudden dilatation of the pupils, consciousness being preserved to the last. On examination the membranes of the brain are found to be highly congested. The vomiting takes place whether the drug be given internally or by hypodermic injections, but purging only takes place if given internally. The paralysis is explained by Drs. Brunton and Rye as being due not to a direct action on the muscles, motor nerves or the spinal cord itself, but to the contraction of the bloodvessels lessening the supply of blood to those parts. Dr. Brunton’s experiments have shown that it acts directly on the ends of the vagus nerve in the heart, and also on the nerve itself as much as Digitalis does. The final slowing of the heart is due to the action of the drug on the ganglionic apparatus contained in the heart itself. In the Gulstonian Lectures, published in 1877, Dr. Brunton remarks that Digitalis has hitherto been our great resort in mitral disease of the heart, but that in Casca we have probably a drug more powerful still, at least its effects upon the arterioles appear to be greater than those of Digitalis, and it is quite possible that it may succeed in those cases of mitral disease where Digitalis fails.
The action of Casca is to strengthen and slow the heart, to contract the arterioles and increase the secretion of urine. The sign of its toxic action is the reduction in the amount of urine passed, and, when this symptom appears, its use should be discontinued. It does not seem to be a cumulative poison, since, in two days after leaving it off, the urine usually becomes normal in amount.
Dr. David Drummond, who has tried it in several cases, considers it to be a very useful addition to our somewhat restricted list of therapeutic agents for the treatment of cardiac cases, serving, like Digitalis, to lower the pulse-rate, and, whilst increasing the force of the systole, to render the heart more regular, although in some cases Digitalis acts with more rapidity than certainty. The cases in which he considers Digitalis to be the more suitable drug are those in which stimulation of the cardio-inhibitory centre in the medulla is required, and Casca in those where a remedy to act upon the peripheral inhibitory apparatus in the heart is needed. It appears to act as a diuretic by contracting the arteries and increasing the blood-pressure. Casca does not seem to have been tried as a local or external application in inflammation to lessen the supply of blood by contracting the vessels.
The tincture is a preparation chiefly used, and is made of the strength of one part in ten of proof spirit. It is given in doses of 5 minims, increased to 10.
Prof. Germain See, of Paris, in his Diseases of the Heart, writes: “Erythrophloeum and Erythrophleine, discovered by Gallois and Hardy in 1876, in the active principle of the root of Erythrophleum guinense of the family of the Leguminaceae, is a glucoside which the authors proved experimentally to have a considerable toxic power and a remarkable action upon the heart. Its action upon the heart, as understood, has suggested to us the idea of introducing this substance into the therapeutics of cardiac affections; but it was necessary first to ascertain, by new physiological experiments, the toxic power of this glucoside, and especially to study its principal physiological effects, notably those which might be registered by means of the haemodynamometer, the sphygmograph and the pneumograph. It is the result of this study which we are about to communicate briefly to the Academy. The researches, begun upon frogs, were continued upon rabbits and dogs. We will only mention the experiments practiced upon these last mammals by means of hypodermic injections of a definite solution of Erythrophleine, because the limits of this article will not allow the report of experiments made upon the other animals, either by the same process or by other methods of introduction of the toxic agent into the organism. 0 gr. 01 of Erythrophleine, introduced under the skin of a dog weighing 9 kilogrammes, was without noticeable effect; 0 gr. 02 killed in two hours another of the same kind of 14 kilos. 5. In other words, in case of the dog, the hypodermic injection of one milligramme of Erythrophleine to the kilogramme of animal did not produce any evident toxic effects; 1 mgr. 5, on the contrary, to the kilogramme, was fatal at the end of a few hours. Several comparative experiments established that the toxic effects of Erythrophleine are about the same as those of Digitaline (Amorphous) of Homolle and Quevenne. The first signs of intoxication consist in a little agitation, inquietude, followed by a period of depression, which precedes the efforts at vomiting or vomiting itself. These latter phenomena are in reality the true initial symptoms of intoxication, and if the dose of poison is not too great it may cease, and the animal promptly return to its normal state. The operation of the circulatory apparatus is disturbed like that of the digestive apparatus. An increase of the intra-arterial blood-pressure is notable, the irregularity and then the relaxation of the pulse already found noted in the memoire of Gallois and Hardy. The period of relaxation is remarkable for the regularity of the heart-beats, for the energy of each pulsation and the uniformity of the intra-arterial blood-pressure. This pressure, in fact, is not modified by the respiratory movements, as it is ordinarily in the normal state, for under (or by means of) the haemodynamometric or sphygmographic tracings the undulations which result from the influence of respiration upon the blood- pressure in the animal non-intoxicated are no longer observed in the animal submitted to the action of Erythrophleine. This period is followed by another, during which the pulse is extremely weak and accelerated; the oscillations of pressure under the influence of respiration reappear; this pressure diminishes gradually; the palpitations of the heart, more and more feeble, cease now and then, then are arrested definitely, while blood-pressure becomes nil. The respiratory movements seem influenced directly by the ERythrophleine, while at the same time cardiac troubles are influenced secondarily. In a general manner, they are at the beginning slightly relaxed and fuller. When the cardiac pulsations are accelerated during the terminal period of poisoning, the respiratory movements are extremely energetic and more frequent. In almost all experiments, if not in all, the respiratory movements have ceased at the moment of the arrest of the heart. Several times, at this moment, the animal has uttered a great cry. One, two and even three minutes after the cessation of the heart’s beating, the respiratory movements have recurred, still energetic for two or three minutes, after which they were definitely arrested. The functions of diverse parts of the nervous system seem troubled by Erythrophleine. Thus, the faradic excitation of the thoracic ends of the vagus nerves in the cervical region did not determine the arrest of the heart in the intoxicated animal as it did in the healthy animal. The quick descent of blood-pressure which occurs under the influence was, on the contrary, manifested equally in the two cases. The frenative or moderative action of the pneumogastric nerve upon the heart is therefore modified by Erythrophleine, and with this substance one can dissociate, so to speak, physiologically, the two circulatory phenomena of the excitation of the cardiac branch of the vago-sympathetiques.The faradic excitation of the cephalic ends of the pneumogastrics, in an advanced period of intoxication, does not induce the acceleration of the pulse which it determined at the first in the normal conditions, but it acts upon the arterial tension as it does ordinarily, that is, by increasing it. Here is again another disjunction of physiological effects. The faradization of the cardiac ends or of the cephalic of the vago-sympathetic nerves induces them in the animal in normal condition, the same modifications of pressure as in the animal which has received the Erythrophleine. The rhythm of the heart, on the contrary, is affected by the same faradic excitations in the animal intoxicated by this alkaloid. When the animal is dying, one can see that the heart is in diastole, flabby, and yet filled with blood. Sometimes the cardiac ventricles are animated by a tremulous movement like that which succeeds the faradization of these ventricles. Generally the heart has not lost its electric contractibility. The pneumogastric nerve preserves its action on the stomach. The excito-motricity of the phrenic nerves is ordinarily diminished, or even sometimes abolished, while that of the sciatic nerve or the sympathetic cervical is not lessened.”
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.