Using Digitalis to the Best Advantage



The slow method is used in cases where the heart is decompensated, but in which no urgency exists. In these cases four doses of digitalis, every four hours during the day, are given. This is done as follows: In form of the tablets or powder one and a half grains of digitalis are administered from one to three tablets every four hours In the form of the tincture the dose is from sixteen to forty minims every four hours. By this method digitalization is obtained in from four to six days.

The rapid method is used in cases which are more urgent and in which digitalization is required in from one to three days. Here the following regime is used: First day, give four tablets (each one and a half grains) of digitalis every six hours for the first twenty-four hours. This would be equivalent to 64 minims of the tincture at each dose. On the second day the dosage is reduced as follows: Two tablets (three grains) or 32 minims of the tincture are given every four hours only during the daytime. From the third day and thereafter until complete digitalization is secured continue with the dosage of the second day schedule.

In urgent cases where intensive digitalization is required and in which the heart must be completely under the influence of the drug in from twelve to twenty-four hours, mathematical exactitude is required. The total requirements of digitalis for each patient are calculated by one of the following formulas:.

Grams of powdered digitalis leaf: C.U. X 0.15 X W.

1000.

Cc. of tincture of digitalis: C.U. X 0.15 X W.

100.

Cc. of infusion of digitalis: C.U. X W.

100

C.U. represent the milligrams of digitalis in a cat unit. Thus one and a half grains of the tablet of 16 minims of the tincture will have this equivalence. W represents the weight of the patient in pounds.

For sake of convenience three tables of the dosages in use with this method are herewith given. Table one represents the dosages for patients who have had no digitalis within ten days. Table two is for patients who have had digitalis within ten days, but in whom there is no evidence of digitalis action. Table three is for patients who have had digitalis within ten days and who at presents show evidence of digitalis action.

After the patient has been fully digitalized by any of the above methods, the equilibrium which has been thus established may be maintained by the administration of digitalis in sufficient amounts to replace that eliminated by exertion. The average rate of disappearance of the drug form the body is 12 minims of the tincture per day. There are, of course, wide variations from the normal. It is therefore suggested that in order to avoid danger of accumulation, the daily dose should not exceed 16 minims of the tincture.

Digitalis may be introduced into the body by any one of four different ways: (1) by mouth; (2) by rectum; (3) intravenously, and (4) intramuscularly. The greatest quantity of digitalis under ordinary conditions is given orally. However, special occasions may arise which demand other routes for administrated.

TABLE I

Body Weight of Patient.

100 115 130 145 160 175 190.

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.

Edward Podolski