Professor of Therapeutics, University of Pennsylvania.ÜKNTLEMEN : When asked to deliver a course on
Therapeutics at this University, in live lectures, I fellvery much like the little child who was giveii one
orange, then a second, then a third, with ever increas-ing delight ; but when a fourth was added to hispossession, dropped the whole and burst into tears. 1have hardly known what to call your attention to,but have concluded in tho first three lectures, to con-sider the cardiac remedies, and to-night shall take upthe subject of digitalis. If my lecture shall disappointsome of you in being too elementary, my defence iathat Dr. Chadwick asked me to lecture to the medicalstudents of Harvard University and not to the practi-tioners of Boston.In studying a drug it seems but natural first to con-
sider tho symptoms which it will produce in a healthyman, and then to find in experimental records tho ex-
planation of its action. Ten drops of the tincture ofdigitalis will produce in the ordinary human individualno apparent ellect ; but when the dose is repeated atshort intervals, the pulse soon becomes slower andStronger, the diastolic pauses grow very long, and theindividual heart beat sends a great rush of blood whichrises and swells with a power scarcely ever equalledunder other circumstances in the pulse. If the ad-ministration be persisted in, by and by each pulse-wavemay become forked, or, as we say, dicrotic. Thenthe waves break entirely, until at last a multitudinouspulse, irregular in its size, fragmentary and broken inits parts, with now long, now short, irregular pauses,and perverted rhythm, mark the stage of poisoning.A curious phenomena which can sometimes bo seen iaa peculiar change in the pulae when the patient's posi-tion ia altered. Thus, in tho man lying upon the bedthe pulse may be slow, full, absolutely regular ; butwhen the patient is sat up it becomes dicrotic, or
perchance goes into tho fragmentary condition justspoken of.The first point that we make out in studying these
effects is, that they are developed very slowly underthe influence of the drug, but that when once they are
developed they aro very persistent : and we learn,therefore, that digitalis is eqtiully slow of absorptionand of elimination. Sometimes digitalis seems to haveno influence even after many days of steady adminis-tration, when suddenly mostBCvere symptoms manifestthemselves. It has indeed been denied that this so-called "cumulative" action of the drug ever reallyoccurs ; but 1 have seen it repeatedly. There comesto my mind at this moment the case of a woman whohad long been using digitalis without any perceptibleelfect for the removal of a serous effusion. Sundaymorning, her pulse, which had beeu at 90, suddenlydropped to 70 ; although the digitalis was at once
stopped, Monday the pulso was GO ; Tuesday, it was50 ; Wednesday, it was 40 ; Thursday, it was close to30; and I began to wonder whether there were anybottom. Friday, however, the effect of the remedybegan to wear off, the pulse to go back up over the
1 Delivered before the Harvard Medical School Association, April27,1893.
curve, down which it had travelled. The effect of theremedy was very apparent for nine days after the with-drawal of the drug.The explanation of the cumulative action of digitalis
is probably alow absorption and still slower elimina-tion, for certainly the phenomena is especially proneto occur when the drug fails to act as a diuretic. Acurious fact which has been repeatedly noted, is thetendency to the sudden development of digitalia actionwhen patienta who have been taking the drug are
tupped for ascites. The explanation of thia phenome-non is, I believe, to be found in the fact that a drugis active only when it is within the circulation. Tapping in ascitea relievea pressure from the abdominalvessels and brings about a rapid absorption of serumto fill up the circulation. This serum has containedin it a largo percentage of digitalis, inactive becausenot in the blood ; when the serum ia taken into theblood the digitalis immediately betrays its presence.It is precisely what is sometimes Been when iodide ofpotassium is giveii after a prolonged mercurial conree.The mercury inert in the tissues, rendered soluble bythe iodide, enters the blood and suddenly shows itselfhy producing ptyalism.For the purposes of explaining the action of any
drug, wo must resort to vivisection, because by vivi-section we are enabled to vary tho terms of the experiment, and no experimental science is possible withoutsuch power. Owing to tho labors of Vulpino, Dybkow-sky, Pelikan, Meyer, Boehm, Fothergill, CJaskell andothera, we know that in the frog, digitalia producesmarked lengthening of the heart-beats, with a pro-longation of the diastole, and a marked increase in thesystolic contractions, and that this action of the drugoccurs whether the heart bo in situ or whether it be ina Williams' apparatus outside of the body. Wo furtherknow, also, that there is an absolute increase underthe influence of digitalis iu the amount of force putforth in a certain period by the heart. After a time,however, the contractions become irregular, the systolebeing broken into diastole, and the diaBtole interrupt-ing systole; then systole seems to triumph over diastole;and at last the apex of the little heart never dilutesbut remains during diastole ¡is a white contracted spot.This spot grows and grows as the contraction becomesmore and more irregular, and at last systole triumphsover diastole and the heart is arrested in spasm. Andhere 1 want to call your attention to the fact that wehave two classea of drugs which are spoken of as stim-ulants : one, liko digitalis, both in large and smalldoseB, stimulates the heart muscle to excessive con-traction so that it dies in spasm ; the other, likeammonia, lirat increasea the functional excitement ofthe heart muacle, but when in sufficient dose ends byparalyzing the.muscle so that it dies iu relaxation. Inour nomenclature both these drugs are stimulants, buttheir actions are essentially diverse, and some dayperhaps the terms " stimulants " and " depressants "will disappear from our text-books.Although usually, as already stated, the frog's heart
is arrested in systole by digitalis, sometimes in rarecases it stops in diastole, and aa it baa been found thatthis diastolic arrest never occurs when the pneumo-gastric nerves are intact and the heart in situ, it woulda priori seem certain that there must be pneumogastricexcitement under the influence of digitalis; and thatsometimes excited inhibition triumphs. This is con-firmed by the proven fact that during the action of
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digitalis there is excessive susceptibility of the parvagum ; so that even when systole is firmest and theheart almost ready to go into spasm, an irritation ofthe pneumogastric nerves, too feeble to bo iu the nor-mal animal, will cause cardiac relaxation. In the frogdigitalis stimulates the heart muscle and stimulates,also, the inhibitory apparatus. In the mammal, digi-talis when in moderato dose markedly increases theblood-pressure, producing a slow, full pulse, which byand by under the influence of sufficient doses of thedrug becomes dicrotic and then splits into parts; untilfinally we have the rapid, irregular, hobbling pulse,with low pressure.It is a law of interpretation of physiological facts, orperhaps I should say, more commonly it is a law of
physiology, which I long ago formulated, that whencorresponding anatomical systems are in the variousanimals regular in structure and in function, that drugsact upon these systema identically iu the variousspecies. The heart is similar in its structure andfunction in all mammals, indeed in all vertebratea,hence cardiac druga act alike throughout the range ofvertebrat life. The digeative organs vary in structureand in functions, hence they vary in their relations todrug forces as they do in their relations to other forces,and elaterium, which purges the man to death, willcause death in the clog by general depression withoutcausing even a watery passage. In accordance withthis law, instances of the truth of which might be multi-plied, a study of the action of digitalis upon the frog'sheart shows that the increase of the arterial pressureproduced by it in man is at least in part due to thestimulant action produced upon the heart. The rise ofpressure produced by digitalis seems, however, to be toogreat to be caused solely by an action upon the heart.What then is the condition of the vaso-motor aystem ?There haa been considerable dispute as to the effect
of the drug upon the blood-pressure in the mammalafter section of the spinal cord high up; that ia, aftercentric vaso-motor paralysis. The experiments ofGorz seem, however, to reconcile the record and toshow that after spinal section digitalis produces a risewhich is much less than that caused by the drug iu thenormal animal; and therefore stimulation of the vaso-motor centre íb in all probability a decided factor iuthe section of the drug. Further, the almost consen-taneous but independent researches of Ringer and Saios-btiry, and of Donaldson and Stevens, in the methodof Gaskell, have seemingly demonstrated that digitalisacts upon the walls of the arterioles ; especially sinceProfessor Robert hn8 confirmed them in a aeries of ex-periments made upon excised kidneys. The lirst men-tioned experimenters have found in a terrapin whoseheart has been excised and nerve centres destroyedthat when under a certain pressure liquid is made topasa through the circulation, entering by the mainartery and going out by the main vein, that the addi-tion of a little digitalis to the liquid reduces markedlythe amount of flow. The only way of explaining thisseems to bo that the digitalis contracts the fine arteriolesand therefore offers an increaeed resistance to the pus-sage of the fluid. We must therefore conclude thatdigitalis stimulates both tho pneumogastric nerve, theheart muscle, the vaso-motor centre, and also the ar-teriole walls.With this knowledge it is easy to interpret the
phenomena which digitalis produces in man. Byprolonging the diastole, bo that the ventricle becomes
over-full with blood, and energizing the systole, digitaliacaii8ea the heart to send out into the aorta an enor-mous wave of blood ; and, at the same time by contract-ing the blood-vessels, increases resistance and enor-
mously augments the general pressure. In the digitaliaheart there is a continual contest between the diastolicand tho ayatolic impulse, a contest which after a timeends in favor of systole ; and so we have interrupteddiaatoles and broken, irregular heart-contractions ; dis-agreement in the rhythm between the various parts ofthe ventricle. The dicrotic pulso marks the first stageof this change; the hobbling, broken pulse the finalcondition. The pressure in the advanced poisoning islow because the contracted left heart will not allowthe blood to paas through it.It is easy to perceive why, on raising a patient with
a very low digitalis pulse from the horizontal position,not rarely the pulse becomes dicrotic and even frag-mentary, lu such a case, whilst the patient is in thehorizontal position the balance is preserved betweensystolic and diastolic excitement ; but when the patientis sat up and impulses suddenly spring from all por-tions of the body upon the heart, demanding that itshall increase its energy, the systolic excitement risesso high that the diastole is overcome and the symp-toms of poisoning appear.It is evident that the great indication for the use of
digitalis in disease is cardiac weakness, and that theaction of the remedy should a priori bo most apparentwhen a weak, feeble pulse is dependent simply upon adilated and enfeebled heart. It is certainly proventhat the great contraindication of the use of digitalisis cardiac hypertrophy or excessive power.In the case of so-called irritable heart, seen fre-
quently in soldiers and sometimes in athletes, caaes inwhich the fundamental lesion is probably exhaustionof the pneumogastric nerves, digitalis seems to bedoubly indicated, and very frequently does great good,probably in part by strengthening the nerves of in-hibition.The application of digitalis to the relief of cardiac
valvular diaeaao ia not 80 evident. It is neither a ragthat shall slop up a leak, nor a needle which shall sewtogether the fragments of a rent valve.In some, perhaps many, cases of valvular disease,
eapecially of mitral valvular diseaae, digitalis may how-ever absolutely reduce the percentage of leak by thenotable increase of the force and rapidity with whichthe blood is driven from the heart ; the wide open,sinootli, aortic orifice offering no resistance to thepowerful stimulant; and thero ia no increase of fric-tion worthy of note; but the narrow original rent,with its perhaps projecting vegetation, offers greatresistance, and the friction rises enormously. I havesometimes compared the blood corpuscles, under thesecircumstances, to a flock of sheep driven by fright outof the corral ; butting and pushing against one another ;choking up some narrow outlet; but when the gate iswide open, rushing out in a stream that soon emptiesthe enclosure.In attempting to understand the value and use of
digitalia in valvular heart-disease, we must apply whatI believe to be the underlying principle of rationaltherapeutics, namely, to first study tho natural historyof the disease, see how nature produces relief, andthen apply our knowledge of the action of remedies bythe same principles of reason by which the worker ininorganic forces adapts his ways to his ends.
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Cardiac valvular disease is certainly in a Btrict senseof the word, incurable ; but the principle which I de-sire to impress upon the young students before me to-night, is, that though nature may be unable to repairau injured valve— even with the assistance of art,nature is often able to so atone for the valvular defi-ciency that the patient goes on living iu comfort per-haps for many decades. Those of you, who, in boy-hood have had to rise in the early frosty morning andwash from a leaky pump, know very well that thebiceps and the triceps must atone for the defectiveleather, and that if the strokes come fast enough andhard enough the icy stream soon flows freely. It isexactly in a parallel way that nature renders an imper-fect heart serviceable, and when the hypertrophy isjust sufficient to overcome the valvular defects the cir-culatory balance is restored. It is extraordinary howcomplete the combination may be, and how long sucha heart may last without causing disturbance. I re-member well an old lady who always seemed to me tohave about her person an aroma of the last century,because she had frequently sat upon the lap of GeneralWashington, and been ministered to by Rush and byPhysick; a lady who died the death of a peaceful oldage, well up towards the nineties, although for unnum-bered years she had had a loud, blowing, ayatolic mur-
mur, marking the presence of a groes lesion.For the purposes of the practitioner it is essential
to have a clear understanding of the difference betweenabsolute hypertrophy and relative hypertrophy ; theheart may be absolutely bypertrophied and yet relativelyweak or dilated (so-called). Suppose, to make thisclear, that the work required of a normal heart is x,and that the power resident in that heart is also x.Then x equals x, and the balance is complete. Now letdisease come, and the x which represents work rises,it may be, to 4 x, on account of the lack iu tho valve.The power of the heart grows greater, perchancedouble; and at last we have a heart whose work is 4a;and whose power is 2 x. Under these circumstanceswe have a heart twice as strong as normal and there-fore enormously hypertrophied ; and yet a heart inwhich increase of power ha8 not kept pace with increaseof work, and therefore is relatively weak ; x is equalto x, but 2 a; ia not equal to 4 x.In the practical problem of a heart case we have an
illustration of the difference between simple diagnosiswhich treats of the seat and nature of the lesion, andtherapeutic diagnosis which treats of the relation ofthat lesion with the needs of the system. It is possi-ble for the practitioner to be able to tell not onlywhat valve, but even what leaflet of the valve is af-fected ; to recognize in a moment organic and inor-ganio murmur to be very smooth and lluent in thecurrent speech of the heart clinic ; and yet not to beskilful iu reading the relations between work andpower.
The practical success of the doctor depends, how-ever, much more upon his aptitude for therapeuticdiagnosis than upon his skill in absolute diagnosis.In passing from this subject, I would like to point out,especially as an aid to the medical students who arebefore me, that the condition of the venous system in-dicates largely the relation between the power and thework demand in the diseased heart. When hyper-trophy is excessive, when increase of power overleapsincrease of work, we may have cardiac distress andactive congestion, but we do not get passive over-full-
liosa of the venous system and dropsical effusion.When these exist we know there is relative cardiacweakness ; and when there is relative cardiac weak-ness digitalis and its allied drugs are demanded.There has beeu a widespread belief, which has often
found utterance, that digitalis is indicated in diseaseof the mitral valve, but is contra-indicated in diseaseof tho aortic valve. This belief is unphilosophicaland in large part erroneous, although like many adelusion it enwraps a certain amount of truth. Aorticlesions are for tho most part gradually developed ;and being gradually developed they allow time for theproduction of a hypertrophy which not rarely becomesmore than compensatory. In bucIi a case digitalis in-creases the distress; but if there be relative weaknessin a heart with aortic valvular disease, digitalis is justas important as though the mitral valve wero affected.In a large proportion of cases mitral disease has beenproduced by an acute endocarditis ; and then comesthe struggle for the heart to build its structure up.Under these circumstances digitalis is a most impor-tant remedy, and its use cannot be begun too early.Just so soon or even before there is any subsidence ofthe fever and acute processes, digitalis should bo used.The importance of this early use links itself with
another clinical experience not very rare; that everynow and then a heart is found which seems weak,broken down, thoroughly incapable of its work ; butwhich under the influence of perhaps a few weeks ofdigitalis, grows into new power and becomes able tocarry its load. I have spoken of digitalis simply as astimulant to tho heart ; but digitalis is more than astimulant to the heart, it is a builder up of the heart.Worried and exhausted by continual peripheral im-pulses for more blood than it is able to supply, theweak diseased heart becomes more and more nervousand irritable, and at last goes into a perpetual seriesof rapid ineffective systoles leaves the whole arterialsystem almost bare of blood. Any one who will ex-amine the anatomical shape of the coronary arteries,will see that under these circumstances the heart itselfmust more than share in the general failure of blood-supply ; again, any one who has watched the intensewhitening of the frog's heart during systole, especiallyif the systolic impulse has been reinforced by digitalisor other drug, must be convinced, it seems to me, thatthough the coronary artery spurts during systole, dur-ing systole the blood which has become venous in theheart muscle, and the nutritive lymphatic fluids whichhave been taken into the interspaces of the heart wallare expelled, and the pathway made open and clearfor fresh blood. As this belief of mine has beensomewhat antagonistic to the general teachings ofphysiologists, I was very much pleased yesterday, invisiting Prof. Reginald Fitz's laboratory at Cam-bridge, to see his plethysmographic tracings whichshow that exactly this thing does occur during thecontraction of voluntary muscles ; and that there is a
squeezing out of blood during the contraction. Theexhausted, diseased heart is therefore underfed at atime when it is most overworked, because its blood-supply suffers, and because the congested bayous ofof its circulation are allowed to stagnate. Under theinfluence of digitalis the blood-vessels fill, the systoleenergizes, and the venous and lymph spaces are emp-tied ; and so the heart participates, more than anyportion of the body, in the increase of food.I believe, however, that digitalis affects the nutrí-
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tion of the heart for good beyond the action whichhas been spoken of. And here 1 must call your at-tention to the discoveries of Gaskell, which to mythought have opened new chapters in physiology ; andwhich 1 believe to exhibit the general basis of func-tional life. According to this discoverer there aretwo antagonistic conditions of the heart, one of func-tional activity and structural destruction, one of func-tional inactivity and structural repair ; the first thatwhich we commonly call the period of activity, thesecond that which we commonly know as tho periodof inhibition or arrested function ; systole and diastoleof the cardiac cycle. The pneumogastric ort inhibi-tory nerve is the nerve of diastole, the nerve whichovercomes functional excitement and brings about re-pair of structure. It is, in other words, a trophic nerve,and I believe digitalis improves the nutrition of theheart not simply by feeding the muscle, nor yet simplyby prolonging the period of diastole and allowing moretime for repair ; but, also, above and beyond thesethings, by stimulating the nerve which dominates andbrings about repair. I think, therefore, that digitalisis to the heart an up-builder, a tonic, a trophic stim-ulant.I have so far been speaking to you as to the use of
digitalis in the earlier stages of heart-disease; at a
time when it must be given in such moderate dosethat no danger overshadows its employment ; onlymust I insist that even in these casea that the dose benot fixed or arbitrary, but bo that which will accom-
pliah its purpose; you must also see to it that the digi-talis is of good quality, for but too often the apothecaryserves us evil. I want, in concluding this lecture, tocall 3'our attention to the use of digitalis in enormouBdoses in advanced and desperate cases of heart-disease.Perhaps I can do so better by giving a leaflet frommy own experience.
Some years since I was called by an old and out-spoken German physician of our city, to take tempo-rary charge of a lady suffering from old mitral disease,who for many weeks by day and by night had strug-gled for breath in the agony of cardiac orthopnœa.She affirmed that she never slept, but of course thiswas erroneous. 11 so chanced that the patient's win-dow overlooked a well-filled graveyard. Tho doctor,who was one of those who called a spade a spado,talked freely before his patient, and on his telling mehe had given her digitalis without avail, I asked whathad been the dose ? He said " ten drops." I said, "MayI give her forty-drop doses ? " Turning to the sufferer,he said, " Mary, won't you let the young doctor trywhat ho wants with you ? He thinks perhaps he cancure you, if you will take the risk ; and wouldn't yourather be asleep quietly under the sod yonder thanliving as you are? " The patient assented; the digi-talis was given ; and when tho doctor returned fromhis vacation, Mary answered the ring at the bell andlet him in.
About the same time I was called to see a bankerfrom Kansas City, who for some weeks had beenunder the care of a diluted dispenser of diluted noth-ings ; and who during this time had also been sufferingthe agony of orthopnœal martyrdom. I have neverseen a more marked case of Cheyne-Stokes breathing.Under the influence of enormous doses of the drug ina few weeks the banker returned to his counting-housein the far West. The triumph seemed complete, andso it was for weekB; but mark tho ultimate result.
Mary, one morning, as she trod the doorway of themarket-house, fell dead upon the threshold. Thebanker, stretching his arm across the desk that hadbeen to him the path to riches and power, fell hushedand powerless into the eternal silence. Some one
may say that under these circumstances digitaliskilled the patient, but not so, gentlemen. Digitalishad simply energized the diseased heart, quieted all itsnervous irritability, restored the balance, and enabledit to go on in comparative comfort until the last grainof power in its substance had been used up and deathcame because thero was nothing left. Even if digitaliswere the immediate cause of death, was it not betterto live a few months of comfort than to die after weeksof agony ? The digitalis certainly prolonged, notshortened the life. In such cases as these tho physi-cian is as justified in using the powerful remedy inenormous doaea aa the surgeon is justified in takingthe risk of some major operation when death ia other-wise inevitable. Be bold, therefore, in this use ofdigitalis, but temper your boldness with excesaivecaution; and remember that you judge the dose notby tho amount of the drug but by the effect, and thatthe dose is not too large until the effect is reached.Remember, also, that the effect once produced iaprobably lasting, and that, therefore, its appearanceshould be the immediate signal for the complete with-drawal of the remedy. Also, may I strongly recom-mend to you always to warn the patient or his friendsthat BO/netimes death will come as with a lightningstroke.I want first to call your attention to certain con-
traindications to the use of digitalis in chronic heart-disease.Of course, one of the greatest dilliculties that over-
shadows or encumbers our use of digitalis is itstendency to disagree with the mucous membrane ofthe gastro-intestinal tract, and of course, therefore,any irritation or irritability of that mucous membraneis a contraindication to the use of digitalis.But the special contraindications which I shall dwell
upon are much more hidden and less easily perceivedand understood. Indeed, the first contraindicationtook mo fifteen years before 1 fully comprehended theforce and power of it. 1 soon learned in my practiceof medicino that there was a set of eases of mitral in-sufficiency in which the heart-power is not equal tothe heart-work and in which, therefore, digitalis seemedto be indicated, but in which digitalis evidently addsto tho cardiac distress, and in which so far from itsdoing good it added so much of harm that 1 was ofnecessity forced soon to avoid giving it. It was longbefore I thought out the explanation of these cases,but, like Columbus's egg, when onco the problem issolved it is quite simple. In all these cases 1 noticedthat there was a very large insufficiency of the mitralvalve ; and 1 have no doubt that under these circum-stances there was also a great weakness of the leftauricle. Now, if there be an excesaive weakness ofthe auricle, and digitalis enormously strengthening thepower of the ventricular contraction drives the bloodwith great force upon the auricle, though there maybe gain so far as the ventricle is concerned, theremay be such stretching of the weakened auricle thatthe strain is too much for it. The cardiac agony whichfollows in these cases the use of digitalis is the measureor the output of a weakened auricle which cannotresist the backward pressure from the increased ven-
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tricular power. After I had worked the problem outto my owu satisfaction, my reasoning was abundantlyconfirmed by the curious experiments of Kaufmann,who found that digitalis has much more power overthe ventricle than the auricle, increasing the intra-ventricular pressure during contraction much morethan the intra-auriculnr pressure. A weakened auriclewith a widely opened mitral valve is in verity a veryimportant contraindication to the use of digitalis.The next contraindication to the uae of digitalis is
one which falls athwart the surgical use of the drug, atleast aa the surgeons have used the drug in Philadel-phia. 1 do not know whether they so employ it iuBoston. The surgical mind in its relations to medi-cal therapeutics has always struck me very like thehuman body—a thing that is wonderfully and fear-fully made; and its ways have always seemed likethe ways of Providence—past finding out. A verynotable illustration of that is found in the fact thatpareira brava has been largely used for many years bythe surgeons with the same results, but the wildIndians of South America have absolutely changedpareira brava, and the pareira brava of the markets ofto-day is no moro the pareira brava of the marketsof yesterday than an oak-tree is a potato-blossom.But the surgeons never discovered the change. Andnow I have never been able to make some of ourconservative Philadelphia surgeons understand thatthe one great contraindication above all others to theuse of digitalis is weakness of tho blood-vessels andespecially that local weakuess of the blood-vesselswhich leads to aneurismal enlargement. Any personwho understands the first principles of hydrostaticsmust know that if you increase the forward pressureof a liquid in a tube you increase also the lateralpressure. But digitalis is a far more dangerousremedy than strychnia or atropine or some other drugwhich perhaps raises the pressure even more than doesdigitalis. I have talked to you regarding the peculiarpulse-wave of digitalis. It is a mighty tide of bloodwhich rushes through the artery with great power andforce, swelling and dilating everything as it goes ; andthe great danger in the use of digitalis in aneurism isthe fact that we have not merely increased lateralpressure but an increased wave, that, rushing through,must distend, muat tear, must rend, must sweep out
edges of clots, and find its way back of the clots thatprotect the coats of an aneurism. The reason thesurgeon so rarely does harm when he gives digitalis toquiet the circulation is because, fortunately for thepatient, the surgeon usually gives the digitalis in suchdoses that it has no effect.In my hospital ward one day 1 found a man who
had just beeu brought in pulseless, cold aud in collapse.1 said: " Put this man on full doses of digitalis, hypo-dermically and by the mouth." The next day 1 camein and saw the man lying in bed quiet, composed. Iput my fingers on his pulse and felt a tremendousdigitalis throb in his artery. 1 said to the resident:" Stop the digitalis ; he does not need any more."Suddenly, with a mortal cry, the man Bprang fromthe bed. A great outburst of blood came from hismouth and nose. A shudder, a fall back, a thrillthrough the frame, death ! I said to the resident :" Do you know what has been done to that man ?I wager anything that man had an aortic aneurism,and we have ruptured it." The autopsy showed thisto bo the fact.
I want, next, very briefly to call your attention tothe employment of digitalis in acute disease. I dothis briefly, because I think I can teach you the les-oon better by contrasting in the next lecture the useof digitalis in some of the acute diseases with the useof some of its antagonists, like veratrum viride. Suf-fice it for the present to say, that in my belief when-ever you have syncope, failure of heart's action fromany cause, digitalis, though not the most rapidly act-ing ia the moat reliable of all drugs that you have;and though we employ ammonia and alcohol underthese circumstances, and employ them very properlyfor their momentary effect, digitalis should be alwaysused and used freely. You may give it under thesecircumstances hypodermically ; there is no use in giv-ing it by the mouth. You use it hypodermically, andmay use it without fear. At least, I have given it sothat the whole skin seemed full of it ; and I havenever seen any bad effects from it, except perhapssome ulcération.Digitalis is a useful drug in all cases of the heart's
failure in acute disease. Unfortunately, for reasonsthat we do not fully understand, it does not serve our
purpose in certain cases in which we most need it. Itfails us usually iu cases of fever, and that has beenshown by the researches of Lander Bruntou to bo dueto the high temperature which overcomes the actionof digitalis in some way we do not understand.It is a question of great importance in the use of
digitalis to decide as to what preparations we shalluse. There has been a widespread belief that the in-fusion of digitalis is much better than tho tincture ofdigitalis, at least large numbers of the physicianswhom I come in contact with, say : " I get effects outof the infusion I cannot get out of the tincture." Thereason is that the profession has been in the habit ofgiving the infusion in a much larger proportional dosethan it gives the tincture. The dose of the tincture isput down from five drops to ten drops, and that ofthe infusion is put down from a drachm to one-half afluid ounce. The infusion is only ten times weakerthan the tincture, and five drops of tincture of digita-lis is only equal to about thirty drops of infusion, be-cause the tincture drop ia small. And right hero letme say 1 think it is much better and safer in the caBeof this tincture always to give it by minims, especiallywhen you are giving the drug freely. If you order a
drop of digitalis, you don't know what the patientgets. If you want accuracy, you have got to dropgiving drop doses, and especially from droppers.AVith these remarks I leave the subject of digitalis,and pass on to tho consideration of drugs which wohave as adjuvants in the treatment of chronic cardiacdisease.A few words in regard to ammonia and alcohol.
They are of no service to us whatsover in the treatmentof chronic cardiac disease, save only as momentarystimulants in times of momentary or passing peril.Remember, also, that in ammonia the local action ofthe drug always overpowers tho general influence of it.The man who dies of ammoniacal poisoning dies be-cause his mucouB membranes are destroyed by theammonia. When you hold ammonia to the nostrilsof a fainting woman you rouse her, but simply by theirritation of the raucous membrane produced by thofumes of the ammonia. Ammonia is a drug of verylittle practical value. If you get it into the circula-tion its action is over in five to ten miuuteB. Iu the
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practice of medicine it is important to avoid what Icall the kangaroo system of therapeutics. You give a.man a dose of ammonia or of hydrocyanic acid; in twoor three hours, and so on, another dose ; so you gothrough the day jerking up the patient like the kan-garoo hopping across the Australasian bush. Whereyou have a drug like digitalia, that acta permanentlyand persistently, then your doses are at long intervals;where you have a fugacious remedy the doses shouldbe every few minutes.
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Original ArticlesMODERN PATHOLOGY AND THE PATHOLOGYOF NERVOUS DISEASES, WITH SOME THER-APEUTICAL DEDUCTIONS AND EXPERI-MENTS WITH ORGANIC EXTRACTS.1
BY CHARLES L. DANA, A.M., M.D.,Professor of Nervous and Mental Diseases in the New York Post\x=req-\Graduate Medical School; Visiting Physician to Bellevue Hospital.GENTLEMEN: I have some retrospections to offer
to you to-night, perhaps some homilies upon the wayour science moves ; and I have also some views or
(as I prefer to consider them) doctrines to present,upon which to solicit judgment. Whether they are
at all novel or wise or valid I cannot say. 1 hope,however, that 1 may be able to turn the attention ofneurologists for a time toward the line of thoughtand iuveBtigation which now interests me and per-suade them to a little less of the current case-re-
porting and a little less analysis of weird and rare
diseases and familiar anatomical changes. Clinicalneurology, I sometimes think, is very nearly exhaustedon present lines. You cannot deny that you are a
trillo tired of descriptions of multiple neuritis audtabes dorsalis, of the miiBcular atrophies and the richly-pictured tales of aeromegaly ; or that syringomyelianow makes you feel tho hollowness of our art, as
well as of our cords, as do the accounts of death's richharvests from cerebral surgery and the benumbingiteration of the individual standpoint as regards trau-matic neuroses. I would humbly suggest, therefore,that we give semeiology that rest and opportunity forfructification which is due to exhauated soils, or referit to the uses of the didactic teacher and the ever-gladenthusiasm of young graduates. What wo moBt neednow is to investigate more deeply into the nature ofnervous diseases, and learn, if possible, to explain theironset and to stop that reproachful funeral marchthrough the modern neurologist's consulting-rooms.
KETROS1MCCT1VE.
Iu the history of neurology there wero first onlysimples and incantations, therapeutica and theology ;next came learned theories and a pathology based on
fancy and tradition. Observant and sensible men thentook up the clinical work, and later added to it patho-logical anatomy. We are still working with this latterclass. The present is the day of the clinician and theanatomist. But their ground has become assured ;they have planted their science and we have hadenough of them for a time ; we should go back to
pathology and therapeutics, and we should try to learn,if we can, the actual and primary causes of these ner-vous diseases which so afllict mankind and harass us
1 Read at a meeting of the Boston Medico-Psychological Associa-tion, March 16, 1893.
as neurologists. It is something, perhaps, to bo ableto say to a patient : " My dear sir, you have a strip offibrous tissue in the back part of your spinal cord ; itis very small, but it will get bigger anil you will getworse. Why it comes there I do not know, why itshould get bigger I do not know, and why I cannotstop it 1 cannot understand ; but I have triangulatedyour nervous centres, located the lesion, and if ever Iget your cord I can dye the affected part a beautifulorange-yellow or a bright carmine-red." This ismodern science and modern neurological therapeusis.It is not, however, a science which opens the pórtalaof hope, but a genteelly-dressed porter that waitsalong the corridors of death announcing the moriluriin a style, I admit, of exquisite art.We have been too much in the position of the ancient
philosophers who asserted that tho world was held upon the back of a turtle; while, as for what held upthe turtle, that was not much matter. Human knowl-edge must have some limit; they drew it at the turtle;we draw it at the sclerosis. How often we say :" This is a shaking palsy, or a muscular atrophy. Ican do nothing. They all die; so must this man."But if one stops to think, he can give no reason whymuscular atrophies should be progressive, or shakingpaíses should forever shake. Perhaps they always will ;but we have no reason to suppose it, and every patientshould furnish a field of earnest effort until the mysteryof the disease is solved. I am, as you see, optimistic,hopeful of our power to unlock some day the mysteriesof life and disease and even of death, for 1 am not sosure that even senility and death are necessities. Whocan deny that the former may be but an adventitiousresultant of self-bred poisons, and the latter au un-fortunate toxiemia for which the wiser prophylaxis ofthe future will provide a remedy ? The sperm-cell isimmortal, and some day the somatic cell may bomade so.
We neurologists aro beginning already to take dif-ferent views of the nature of some nervous diseases ;but we have been slow in imbibing the doctrines oftoxines, microbes, phagocytes, ferments and defensiveproteids— things which make so large a part of gen-eral pathology. Nervous diseases .with an organicbasis, are comparatively rare and autopsies more so ;hence our pathological knowledge has accumulatedgradually and this may account somewhat for ourmisoneÍ8m.NERVOUS DISEASES IN THE EIGHTEENTH CENTURY.
Permit me to say a few words about the way ourmodern neurological nosology haB developed. It mayemphasize the position which I take to-night, that weshould be less contented than we are with our presentclinical and anatomical work. In the good old daysof Sydenham and Boerhaave there was lots of path-ology, and there was very few nervous diseases. Inthe stressful days of the present we have lots of ner-vous diseases and very little pathology. Dr. Sydenhamsaid that about two-thirds of all the diseases iu his daywere fevers, of the other third, one-half were cases ofthe " hysteric passion." Dr. George Cheyne, writing inthe early part of the last century, said that hypo-chondriasisand the "vapors" made up one-third of thedistempers of the people of condition in England.Hysteria and hypochondriasis then were about thoonly things which vexed the soul of the neurologist inthe days of good Queen Aune. Sydenham says of
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