Using Digitalis to the Best Advantage



lbs. lbs. lbs. lbs. lbs. lbs. lbs.

First { Tablets 6 7 8 9 10 11 12.

{ Each 12.

{ grams.

Dose { Tincture+ 100 118 132 150 164 180 194

{ In minims.

Second { Tablets 32 4 42 5 52 6 62

Dose { Tincture 56 64 72 80 88 96 104

Third { Tablets 2 22 2 3\4 3 32 4 42

Dose { Tincture 34 40 46 52 57 63 68

Thereafter every six 12 1 3\4 2 14 22 2 3\4 3

hours until digitalization

is secured 24 28 32 36 40 43 47

TABLE II

the eighteenth century, the great Boerhaave considered foxglove to be of a “poisonous nature,” and Haller observed that England, an old woman was making a wonderful reputation with a mixture which was remarkably effective in curing dropsy

Third { Tablets 12 2 24 22 3 3/4 42 5

Dose { Tincture 26 30 35 39 43 47 51

Thereafter every six 2 1 1\3 12 2 2\3 13/4 2 24

hours until digitalization.

is secured 18 21 24 27 29 32 35

The special circumstances which call for the administration of digitalis per rectum are as follows:.

(1) In cases of unfavorable position of the cutaneous veins.

(2) In severe edema.

(3) In cases where there is danger of thrombosis and embolism.

(4) In very protracted hepatic congestion.

(5) Also for reasons to be enumerated later under conditions for intravenous administration which in addition have one or more of the above complicating factors.

Rectal administration of digitalis was introduced prior to the intravenous administration of the drug. This mode of administration was utilized when the oral method gave rise to vomiting. These first attempts were carried out with either the diluted tincture of digitalis or with the infusion. The results obtained were not very satisfactory. The reason was that these preparations irritated the mucous membrane of the rectum and cold not be retained for absorption. When the tincture was diluted to the point where its irritating properties disappeared, its was too large for the purposes in mind. The solution, because of its bulk, was often expelled.

The rectal method of administering digitalis has much in common with the intravenous mode, and results may be obtained in those cases in which the oral method is without results. This is not only so when digitalis produces nausea, but especially in those cases in which it is well borne by mouth, but in which no effect manifests itself. According to Cloetta, it is probable that the favorable results obtained from the rectal administration of digitalis are due to the fact the blood from the inferior haemorrhoidal 4eins leading from the rectum goes directly into the inferior vena thence to the heart.

Digitalis may be given per rectum in several different forms. It is always essential that before any form of digitalis is inserted into the rectum that the patient receive a preliminary cleansing enema. After evacuation, from 8 to 20 cc. of digitan is given by rectal tube and washed through with 25 cc. of tap water. A rectal tube of small calibre is inserted to a depth of about six inches from the anal orifice. The funnel into which the digitan is poured is held about fifteen inches above the level of the anus. After the tap water has been allowed to flow in, the tube is clamped, left in situ for fifteen minutes, and then slowly withdrawn. The patient is then instructed to avoid bowel movement for at least six hours.

Another method of injecting digitan rectally is to use 1 cc. of the solution in 10 cc. of water, which is injected into the rectum two or three times daily with a small glycerine syringe.

A digitalis mixture consisting of one gram of powdered leaves of digitalis, 50 cc. of simple syrup, and 150 cc. of water is preferred by some. A tablespoonful of this mixture is injected, diluted with a small quantity of warm water, preferably with a small rubber bulb so as to be retained as long as possible. This is repeated three times a day.

The most convenient and probably the most popular method of administering digitalis rectally is t he us of suppositories. It has been found that the total dosage required for digitalization per rectum is identical with the amount required when the drug is given by mouth.

Before the suppositories are inserted the patient receives the usual cleansing enema of soapsuds. The first day a rectal suppository of four cat units (six grains) is given grains. On the second day is given one suppository of four units (six grains) in the morning; this may or may not be followed at night by a suppository.

TABLE III

Body Weight of Patient.

100 115 130 145 160 175 190

lbs. lbs. lbs. lbs. lbs. lbs. lbs.

First { Tablets 3 3\4 42 5 52 62 6 2\3 7 1/3

Dose { Tincture 60 70 80 90 100 108 117

Second { Tablets 3 3\4 42 5 52 64 6 2/3 7 1/3

Dose { Tincture 60 70 80 90 100 108 117

Third { Tablets 3 3/4 42 5 52 64 6 2/3 7 1/3

Dose { Tincture 60 70 80 90 100 108 117

Thereafter every six 1 1 1\3 12 1 2\3 1 3/4 2 24

hours until digitalization

is secured- 18 21 24 27 29 32 35

of two units (three grains) or by a suppository of four units (six grains), depending upon the individual patient and upon clinical conditions, thus making a possible total dosage for the second day of four, six or eight units (six, nine or twelve grains). On the third and subsequent days are given one suppository of two unit (three grains). The Eggleston intensive of two units (three grains). The Eggleston intensive method of digitalization may be used per rectum, and the dosage is the same as when given orally.

The intravenous route, under certain conditions, becomes the only one advisable or available. Briefly, the indications may be stated as follows:.

(1) Gastric intolerance with vomiting.

(2) Failure of digitalis to act when given orally in left ventricular failure.

(3) Old standing asystole complicated by cirrhosis, ascites and enlarged, liver, constituting a double block which prevents the action of digitalis when administered by any other route.

(4) The necessity for immediate treatment as in the acute asystole of pregnancy ,of overstrain, and in the asystole of acute pericarditis or acute myocarditis.

(5) In cases of sudden collapse due to organic lesions or acute secondary weakness of the heart.

(6) In cases where operations along the gastro-intestinal tract or upper respiratory tract makes the oral or rectal administration of digitalis inadvisable.

(7) In certain cases of arteriosclerosis the stomach distends on the slightest intoxication. In such cases the intravenous route is of great value.

(8) In traumatic shock with tachycardia and low arterial pressure the intravenous route is the one of choice.

(9) It is also indicated in the beginning of the treatment of an ordinary right asystole. When the peripheral ad visceral barriers have been overcome by pleural puncture, puncture of the ascites, purgation and reduction of fluid by a restricted diet and fluid regime, digitalis treatment may be begun by one or two intravenous injections. This has the advantage of acting quickly and with smaller doses. Once the improvement has begun treatment may be continued by mouth.

The contra-indications of intravenous digitalis therapy should constantly be borne in mind. These are:.

(1) In cases where there is danger of thrombosis and embolism.

(2) In the terminal stages of asystole. No good can possibly be derived in this condition.

(3) In cases where the nitrogen products are much increased in the blood stream (azotemia).

(4) In patients with mitral disease with slowing of the pulse and signs of auricular ventricular block.

(5) In cases of extreme insufficiently powers of these organs are so impaired that the added burden of digitalis intravenously will not prove helpful.

In general, a digitalis preparation designed for intravenous injection must meet the following requirements: It must be soluble in water, or at least in a weakly alcoholic menstrum. The tincture is of course not suitable. In addition injectible digitalis must be of uniform activity. It must exhibit a minimum of undesirable side actions; it must not deteriorate rapidly, and it must, not irritate the veins into which it has been injected.

Several specialized preparations of injectible digitalis are available. Digitan solution suitable for intravenous work comes in ampules each containing 1 cc. (16 minims) of a sterilized, isotonic, aqueous solution, equivalent to 12 grains of potent digitalis leaves. Nativelles crystallized digitaline in the from of 1:1000 solution is used by French physicians in from ten to thirty-five drops, diluted with 1 or 2 cc. of distilled, isotonic water. Digitalone is a highly purified aqueous solution of digitalis. One cubic centimeter contains 15 minims. Digitos is another standardized preparation of water-soluble active principles of digitalis. Colettas soluble digitoxin, or digalen, is another preparation of injectible digitalis. Another suitable digitalis preparation for intravenous work is digifoline.

Digitalis is, without doubt, the most useful remedy in the treatment of heart failure. It is almost a specific in some forms of cardiac disease. Now, even more than ever before, digitalis is the one physiopathologic drug in all cases of cardiac derangement in which failure is the predominant note. For the greatest measures of success digitalis must be given in appropriate cases and in proper doses. Otherwise, one cannot expect the full benefit of its use.

Edward Podolski