THE USE, MISUSE, AND ABUSE OF DIGITALIS


Fortunately the homoeopathic school has other cardiac remedies that are indicated for cases to which Digitalis does not apply: Spigelia with its rapid, weak, tumultuous action: Kalmia with its slow, weak pulse; Cactus grand. with the characteristic constrictive pain; and many others play an important part in our practices. I have found Iberis very useful in cases of tachycardia.


Digitalis, properly used, is one of the most valuable remedies, unintelligently employed, it does no good, or may produce great harm. When we examine the writings of the older homoeopathic masters, the conviction is impressed upon us that they lacked the necessary knowledge of the therapeutic application of this remedy. Again, some want of enthusiasm may be attributed to inert preparations or to faulty dosage. Jahr in his Forty Years of Practice says: “Altogether the remedies that have been recommended theoretically for heart disease, more especially Iodine and Digitalis, have disappointed me.

These two remedies in my hands had to be given to large doses and then had only a palliative effect”. This note appears in Herings Guiding Symptoms; “Digitalis is not, at least in our day, and in this country, a polychrest; not a remedy applicable every day and in a majority of cases; but it is an indispensable remedy in very serious cases, in which all the polychrests we have would leave us in the lurch”. Hahnemann, with his extraordinary ability and power of medical anticipation, came near to the truth regarding the therapeutic action of Digitalis.

The following appears in Lesser Writings: “But as the direct action of foxglove persists so long (there are examples of its lasting five or six days), it may, as an antagonistically acting remedy, take the place of a permanent curative agent. The last observation is reference to the diuretic property in dropsy; it is antagonistic and palliative, but nevertheless enduring, and valuable on that account merely”.

The leading homoeopathic keynote is the extremely slow, intermittent pulse. If, however, we are to obtain the full therapeutic value of this medicinal agent, a thorough understanding of modern cardiology is absolutely necessary. Before Sir James Mackenzie revolutionized this important subject, many false ideas existed in relation to disease of the heart. Thomas Lewis says; “Recent study has thrown most of the major conception of heart disease into a melting pot, from which some have issued transformed, from which others will never issue”.

When to administer Digitalis, how to administer Digitalis, and when not to administer Digitalis, are among the most important problems of every practitioner of medicine. Fortunately, there are certain well defined conditions indicating its use. These are as follows: Auricular fibrillation, auricular flutter, and cardiac disease characterized by dropsy with dilatation of the heart. It is necessary, therefore, that we recognize these before attempting to prescribe. This is very easy in the case of auricular fibrillation. The irregular irregularity characteristic of this trouble is readily diagnosed with the stethoscope without the aid of graphic methods. It was not so simple in the case of auricular flutter until Sir James Mackenzie discovered how detect it without the aid of the electrocardiograph.

When a patient has a very a rapid pulse, it is either ordinary tachycardia or auricular flutter. In ordinary tachycardia, the impulses passing through the auriculo- ventricular bundle are normal. The auricles and ventricles are beating at the same rate. In auricular flutter the transmission is faulty and the auricles heat at twice (rarely four times) the rate of the ventricles. The beating of the auricles cannot be detected with the stethoscope. How then, can we distinguish ordinary tachycardia from auricular flutter? The patient presenting himself for examination has a regular pulse of 130 a minute. He is told to exercise.

In ordinary tachycardia the rate is increased, in auricular flutter it is usually not increased. If the pulse in auricular flutter is increased by exercise, which is extremely rare. It is exactly double. A pulse of 130 would be increased to 260. It suddenly falls to 130. The pulse is regular. If the rate falls below 130, it becomes irregular. If the ventricles respond to every third or fourth beat, it becomes regular at these paints, but irregular when it falls below. The diagnosis of cardiac drops presents no difficulty.

How and in what dose should Digitalis be administered? The beneficial results obtained in these conditions are due to the simulation of the vagus. The auriculo-ventricular transmission is retarded and the ventricle has a chance to rest. In my early years of practice I entertained the notion that Digitalis should never be prescribed excepting in the attenuations. As time passed and my clinical experience ripened, I was forced to abandon such a conception. I do not make the statement that this remedy may not be useful for certain cardiac symptoms when given in potency, but I am speaking of certain definite conditions where its beneficial action is recognized by every physician possessing an understanding of cardiac disease.

When we consider that auricular fibrillation is present in about 70 percent of the cases of heart failure with dropsy, its value cannot be over estimated. Whether we give comparatively moderate doses recommended by Mackenzie (twenty minutes three times daily), or the larger doses used by Eggleston, based on the body weight and given in single or divided doses, the objective is to stimulate the vagus and thus rest the ventricle. Digitalis sometimes changes auricular flutter into auricular fibrillation. This is followed by normal rhythm.

I know that many present will not agree with this method of administering Digitalis, but they will find that it is in harmony with such homoeopathic text books as Jossett,. Arndt, Goodno, Lawrence, Mills, Boericke, Royal, etc. Dr. Royal recommends three to five grains of the leaves (a larger dose than used by Mackenzie) every four hours. Dr. William Boericke, a high potentist, prescribed five to twenty drops of the tincture, 1 1/2 per cent infusion, or one-half to two grains of the powdered leaves.

Of course these authors make no mention of the modern terms auricular fibrillation and flutter, but they prescribed for the same conditions without knowledge of the true pathology. In other words, they found that there were certain cardiac states which would not respond to the potentized remedy. Happily both Dr. Royal and Dr. Mills are still with us and can discuss this question.

The misuse of Digitalis consists in giving doses too small to produce any effect I once travelled this road and found my tires punctured. In certain of the arrhythmiae the attenuated doses may do, but not for the failing heart of auricular fibrillation, articular flutter or cardiac dropsy.

Dr. Richard Hughes, that splendid example of a clear thinking, logical mind, claimed that Digitalis was antidoted by alcohol and that potencies above the 2x were not active. It is significant to note in this connection, that this remedy was once used as an antidote for alcoholism, but was abandoned on account of its poisonous qualities. But now, since prohibition is upon us, we do not have to worry about this-the alcohol comes already poisoned. Dr. Eugene. Nash, usually a high potentist, gave the 2nd attenuation.

THE ABUSE OF DIGITALIS.

Great care must be exercised not to push the administration too far. When the pulse rate is decreased to approximately normal, or nausea, oppression of the chest, diarrhoea of headache occur, it should be stopped and resumed only when these effects pass of and the heart action becomes rapid. The dose should be reduced to just sufficient to keep the pulse at about the normal rate.

The abuse of Digitalis is not confined to overdosing and its to continued use. It is a habit, all too prevalent, to prescribe this drug for any conceivable cardiac disorder. As a matter of fact, it is rarely beneficial, in large doses, outside of the conditions we have mentioned I have examined thousands of hearts, have watched numerous cases, showing various forms of arrhythmia, over long period of years, have treated many patients with myocarditis, senile hearts, angina pectoris, etc. My experience confirms the above statement.

Digitalis is a heart poison, exerting its action directly o the muscle. In poisonous doses it produces weakening of the myocardium with various forms of irregularity, even auricular fibrillation, Hence the homoeopathicity.

It would be impossible to report all the cases of improper use or overdosing that have come under my notice. To give Digitalis simply because the heart is weak, irregular or senile is contrary to my conception of scientific therapeutics. Such a practice may cause fatal terminations. At present I have under my care a member of one of Americas most wealthy and aristocratic families. He is a man of seventy-two years with in charming personality and great culture. A life well worth prolonging. I first saw him on May 3rd. He was suffering from acute bronchitis. His cough was most distressing. The heart action concerned me chiefly.

Pulsus alternans was present and the action was very weak. Pulsus alternans can be readily diagnosed, as you remember, when the small beat is too weak to be detected by the stethoscope or by the finger on the pulse. This can be done without the aid of the electrocardiograph. We take the blood pressure and find the systolic reading to be 200. At first we get a very slow beat, for only the larger one is detected, but as we gradually admit the air and the indicator falls twenty points or so, the alternating small beat comes through. The rate is then doubled. Extra systole is similar, but is distinguished by a pause after the small beat.

In taking the history of this patient, I learned that he had been on good size doses of Digitalis for several months. This was commenced when he was visiting Palm Beach. On his return to New York another physician was consulted. He claimed that sings of Digitalis poisoning was present and reduced the dose, giving three grains daily. I insisted that he take no Digitalis, and that he should never have taken any. That I was right, was proved by the fact that he grew worse under its use.

The bronchitis responded nicely to Phosphorus 30x. Later he received Gelsemium because of the languid, stupid, weak condition which existed. When the bronchitis was cured, I prescribed Crataegus tincture, five drops four times daily. he is now up and about his business. The condition of his heart has improved to a remarkable degree.

I have seen other cases of senile heart do very badly under Digitalis, and I think that many a life has been shortened by its routine use. Sclerosis of the coronary artery usually exists. Under Digitalis its lumen becomes more narrow and the heart receives less nourishment.

Fortunately the homoeopathic school has other cardiac remedies that are indicated for cases to which Digitalis does not apply: Spigelia with its rapid, weak, tumultuous action: Kalmia with its slow, weak pulse; Cactus grand. with the characteristic constrictive pain; and many others play an important part in our practices. I have found Iberis very useful in cases of tachycardia. Crataegus is a favorite. Aconite nap., Aconite ferox, Apocynum, Adonis, Arsenicum alb., Arsenicum iod., Aurum met., Arnica, Convallaria, Grindelia, Kali iod., Lachesis, Laurocerasus, Natrum mur., Naja, Phosphorus, Strophanthus, Squilla, Sumbul, Tabacum, Veratrum alb., Veratrum vir., etc., are among other remedies which have served me when their characteristic symptoms were present.

Before closing I would like to mention a remedy that has produced marked results in some of my cases of angina pectoris. One patient, a man weighing about 240 pounds, suffered so acutely that he could not even move his hand without great pain in the cardiac region. So rapid and marked were the results of this remedy, that he returned to his work which necessitated, long, hard auto trips. Another case was that of a butcher. His business required considerable physical labor and marked changes to extremes of temperature.

The promptness and completeness of his cure (I say cure because he has had no symptoms for over a year) was remarkable. I think that I am keeping one old gentleman about his business, who thought that he was about to take his last journey several years ago, with the aid of this medicinal substance. I refer to Latrodectus mactans. I gave the seventh centesimal potency.

One word more. Do not forget that rest is a wonderful remedy for heart failure, and that a moderate amount of alcohol (wine, a high ball on retiring, or the equivalent) often proves of great benefit to angina pectoris patients.

NEW YORK, N. Y.

DISCUSSION.

DR. W.B. GRIGGS: I dont think there is another drug that is more daily proven than digitalis. There isnt a pharmacological laboratory that manufactures digitalis preparations that isnt pharmacologically testing each batch of digitalis put out, and any man who knows anything about pharmacological work knows that it never changes. Digitalis one hundred years from today will do what it is doing today.

If you are going to use digitalis, use it where you have all of the alkaloids used. Use it in the powder, in small doses, a grain or two. In my 36 years of hospital work I have seen small doses persistently given to the patient produce better results than these tremendously big doses. That is also borne out in the experience of my co-laborers.

J.W. WAFFENSMITH: How much do you give?.

DR. GRIGGS: One ounce twice to day.

DR. A.H. GRIMMER: Digitalis is too often abused, but it undoubtedly has a specific place, a very important place, in those cases of heart disease that are on the borderline of incurability.

DR. C.B. STEARNS: I think we ought to appreciate this paper because, if you remember, it tells us what to do in the worst cases we get, the kind that we sweat blood over, the that sometimes get by us if we dont do something of this sort, and the doctor has limited its use to the very types in which it will do what you can call good. I have seen such cases, I have lost them, and I think we all have. They get water-logged, and unless you give something of that sort you lose them. But after you get them straightened out, after you have palliated until they are on earth again you can sit down and work your case out sometimes and bring them around so that you dont need to do it again. In some of these I believe you have to do it once in awhile. This is a valuable paper in showing you where and when and how.

DR. C.L. OLDS: Nash in his Leaders speaks of the use of a trituration of the leaves used in the 1x in cardiac dropsy. I think the way he uses it, he takes one grain of the 1x, places it in a teacupful of hot water and allows it to stand there an hour and repeats that about every two or three hours until he gets his effects. I have tried that with some success.

DR. J.W. WAFFENSMITH: In the typical digitalis case where the patient has been digitalized and has had the remedy over a long period of time, I want to throw out the thought that very often Digitalis in the potency will start the process that you are looking for in a favorable direction. I had a case this spring that ran very true to this and after I gave a single dose of the remedy in potency, another remedy, which was the constitutional remedy, came to the surface and the case got well.

DR. A. PULFORD: There are direct indications for digitalis. We havent heard them.

DR. D.E.S. COLEMAN: You mustnt give doses large enough to produce a heart-block.

DR. Stearns is perfectly right when he says that after we help these cases with digitalis we can often sit down and pick a remedy that will give them great relief, sometimes cure, and sometimes relief, not always a curative relief unfortunately. Dr. Nash used the second centesimal potency.

Dr. Dixon said he has an allopathic friend who claims that these cases of auricular fibrillation will die within a year. That is not so. They will live for years and years if you treat them right. You can keep them going year after year.

Dr. Pulford wanted to know the indications for digitalis. I thought he knew them so well that I didnt have to say anything about it. I just touched on it briefly. It is the slow, irregular pulse. That was the leading indication. There area lot more: The auricular fibrillation and all the irregularities. I thought Dr. Pulford know them so well he didnt want to have me mention too many of them. That wasnt the object of the paper because everybody knows the indications for digitalis.

Daniel E S Coleman