digitalis in heart disease
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be made to restore Clause 13 to its original wording, but theChancellor of the Exchequer knows well that if this were
done he would run the risk of providing a National InsuranceBill with no medical men to carry on its insurance work.
It supports the idea that the National Insurance Bill has
been introduced to some extent at a venture to find that
while Mr. BENTHALL sees that the action of the Local Health
committees will be detrimental to the interests of medicine,which profession he feels will be improperly represented uponthem, a Friendly Society, representing over a million
persons, concludes that these committees will be largely composed of practitioners, or the creatures of practitioners.The cynical might say here that it looked rather as if
’the Local Health Committees were likely to hit off the
happy medium, and form a proper interchange of scientific- and public spirit, but men of affairs will consider that
they have been given a very strong hint to look closelyinto the constitution of the Local Health Committees.
,Similarly, the wide difference of opinion that exists as
,to how far the German model has been adequatelyfollowed leads us to suppose that the Chancellor, despite the.anxious pains that he is known to have taken, has not,been well-informed as to the position in Germany. Those
who have supported the Bill because it was understood thatsimilar legislation has worked extremely well in Germanyare beginning to falter in their support of the measure since
they have had time to compare the British scheme with
the German scheme of insurance. There can be no doubt,as Dr. ERNEST J. SCHUSTER has recently pointed out in a
pamphlet,l that, while, the German workmen’s insurance as.a whole may have worked satisfactorily, there is one
branch in the conduct of which there has been a good,deal of friction ; and that is the insurance of temporarysickness. Our readers know well that Dr. ScHUSTER’s
words are true. Dr. SCHUSTER suggests that the pro-
posed British system and its uniform rate of contribution
for benefits, not even depending upon the wages of the
insured persons, is so entirely different from the German
’system that the success or non-success of the one can hardly’be taken to furnish any guidance as to the probabilities ofthe success or non-success of the other. And now we have
before us the remarkable evidence as to the influence upon’German industries exercised by the various German insuranceschemes, which is contained in the just published report ofSir FRANCIS OPPENHEIMER upon the Trade of Germany in ’,1910. The position of our National Insurance Bill is
certainly an anxious one.
Digitalis in Heart Disease.WRITING of the use of digitalis in 1778 WITHERING
remarked: "It is much easier to write upon a disease than
upon a remedy. The former is in the hands of nature, and
a faithful observer, with an eye of tolerable judgment,cannot fail to delineate a likeness. The latter will ever be
subject to the whims, the inaccuracies, and the blunders ofmankind." Few have been better equipped by nature in
1 The Parliamentary Bill Examined and Compared with the GermanScheme (reprinted from the Journal of Comparative Legislation), byErnest J. Schuster, LL.D. London: John Murray and Co. 1911.Price 6d.
his own day or since than WILLIAM WITHERING to under-take the task, and his "rules and cautions " for the employ-ment of the drug may be perused with benefit to-day.’’ Let it be continued until it either acts on the kidneys,the stomach, the pulse, or the bowels ; let it be stoppedon the first appearance of any of these effects, and
I will maintain that the patient will not suffer
from its exhibition, nor the practitioner be disappointedin any reasonable expectation." " And his last con-
clusion, " that it has a power over the motion of the
heart to a degree yet unobserved in any other medicine,and that this power may be converted to salutary ends,"is as true now as when he wrote. He had, moreover,the acumen to add that ’’ If inadvertently the doses of
the foxglove should be presented too largely, exhibited
too rapidly, or urged to too great a length, the knowledgeof a remedy to counteract its effects would be a
desirable thing." Such a remedy, he finally remarks, mayperhaps in time be discovered, an expectation which hasnot been disappointed, for atropine largely fulfils these
conditions.
Every generation since WITHERING lived has added its
quota to our knowledge of the use of digitalis in heart
disease, "whimsical," "inaccurate," or "blundering" " attimes, to use WITHERING’S words, or nearer the truth
in other instances and expressed in terms of the current
physiology of the period. That, however, which is once
true, is always so, although interpretations of the truth,or inferences from it, may vary and be correct or
otherwise. It continues true, as WITHERING maintained,that digitalis has a power over the motion of the
heart," which the observation and skill of many have
"converted to salutary ends." Opinion has, however,
naturally varied with experience as to the circumstances
and manner in which this powerful agent has provedmost beneficial, and even after the lapse of more than
a century our ideas lack precision in the matter. In the
conclusions reached individual experience often proves to
have played too large a part and to have obscured rationalgeneralisation. It is recognised, however, that digitalis is
impotent to influence heart-rate in the presence of febrilestimulation, and we now know the importance of de-
termining the presence or absence of an infective
endocarditis in the case of old disturbed lesions, evenwhen the febrile movement is mild and intermittent.
Extrinsic conditions, such as thyroidism and pericardialtethering, we also know may render futile the potentialpower for good of the drug. Authorities, again, in all prob-ability have differed through attaching too great import-ance to personal experience, as to the value of the drug inthe case of particular lesions. Thus the agent decried byCORRIGAN in aortic cases was extolled by BALFOUR as
powerful for good when the same defect was present, whileBROADBENT split the difference and indicated its utility insuch cases when "mitral symptoms supervened. This,however, was little more than to acknowledge that an aorticcase had broken down, and the majority of observers stillattach more importance to cardiac failure in such than in
purely mitral cases, because experience has shown the
former to be more difficult of remedy. Sir WILLIAM
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BROADBENT also maintained that while mitral regurgitant Icases " almost always " benefited from the use of
cardiac tonics, this was by no means equally so in mitralstenosis.
It seems, however, to have been generally agreed in the
past that digitalis has found its most striking successes in un-
complicated mitral regurgitation associated with the generalevidence of cardiac failure, on whatever lines it has been
sought to explain this fact. In these circumstances of still
existent uncertainty on many important points, every care-
fully considered record of experience in the use of the drugis worthy of note, and such a contribution appears in the
last issue of Heart, which is wholly occupied by an articleon digitalis from the pen of Dr. JAMES MACKENZIE.
After an introductory generalisation as to the efficacy,or want of efficacy, of the drug in certain circum-
stances, he gives a detailed account of 40 cases in
which the dosage and effects of the drug were carefullynoted, and certain conclusions or impressions are finallyexpressed. Of his 40 cases no less than 20 had mitral
stenosis or were diagnosed as such, one is described as
"mitral," ten as "mitral and aortic disease," two as
"aortic," and the remaining seven constituted a miscel-
laneous group containing cases of paroxysmal tachycardia,bradycardia, and emphysema. Of the mitral stenotic cases
ten responded well to digitalis and eight apparently did
not; of the mitral and aortic, only one seems to have
answered definitely to the remedy. One of the stenotic
cases could scarcely have been expected to show definite
results, as it was evidently one of infective endocarditis,
although the fact is not mentioned in the record, and
had, of course, a fatal issue. Of the two aortic cases
neither was notably affected by the drug, while in the
miscellaneous group four improved under digitalis andthree did not. It is not the amount of material here
set forth, but the Care with which the investigation wascarried out which renders it worthy of consideration.
The language employed by Dr. MACKENZIE is largely thatof the new cardiology in which the auriculo-ventricular
bundle and the various possible starting places for cardiaccontraction and fibrillation of the auricle play a part,although he does not fail to ascribe a considerable i6le
to the action of digitalis upon the vagus in modifying theaction of the heart.
The general conclusions arrived at are, that " Cases of
auricular fibrillation are more readily and markedly affectedthan cases with the normal rhythm." In other words, thatthe irregular heart, and particularly that explosively andoften temporarily irregular heart which is usually associatedwith mitral disease, especially in younger subjects whohave suffered from rheumatic fever and in whom the
cardiac muscle is fairly sound, respond most easily to
the drug. It is admitted that in persistent irregularitiesand in older people it is less successful. Dr. MACKENZIE
suggests that the fibrillating auricle may render the
auriculo-ventricular bundle more susceptible to the actionof digitalis, which, by impeding the shower of auricular
impulses regarded as falling upon the ventricle, mayinduce calm. Digitalis, however, it is contended, at
times tends to produce auricular fibrillation. Some
evidence is adduced that the diuretic effects of digitalismay be observed without any perceptible change in the
heart, and two cases of tachycardia "arising from ars
abnormal source are mentioned in which a more normal
rate was established after the occurrence of fibrillation 06
the auricle.
The preparation of digitalis chiefly used was the tincture,.and it was given in doses of 15 or 20 minims three or fourtimes a day "until some definite reaction was obtained " ofthe kind indicated by WITHERING. The principle of push-ing the drug, as experience has taught many, is frequentlynecessary to attaining success, but, while not averse from a
guarded boldness in the use of digitalis, we own to &.
conviction that slow increase in dosage is usually quiteeffectual when remedy is possible by this means, and thatthe comparatively rapid induction of nausea or vomiting-is rarely necessary and not always safe. Incidentally.,Dr. MACKENZIE mentions some interesting observations.
on the inefficacy of some and the efficacy of other agents.which have been employed in the treatment of heart diseasesThus he found aconite, long regarded as a retardant
of cardiac action, to be quite inert in medicinal doses
Although he found strophanthus acted well in regulatingirregular hearts, he never observed it to succeed where -
digitalis had failed. Atropine, he convinced himself, was
potent in accelerating some hearts retarded by the action of
digitalis. It will thus be noted that Dr. MACKENZIE’S
experience of the use of digitalis in heart disease differs
little from that of many others who have recorded their:
observations. Yet we fully recognise his painstakingendeavour to secure trustworthy data for the formation ofmore precise and scientific opinion on the use of a drugwhich is still used by many empirically, and which, likemost agents capable of effecting good, requires to be
employed with all the circumspection possible.
Annotations." Ne quid nimis."
CERTIFICATE OF PROFICIENCY IN VACCINATION.
THE Local Government Board has issued a circular dated
Sept. 21st, 1911, with reference to the certificate of pro-ficiency in vaccination which is required to be produced’bya medical practitioner to a board of guardians before he canenter into a contract with them for public vaccination. A.
certificate of proficiency in vaccination can in general onlybe obtained from a teacher authorised by the Board afterdue instruction and examination. The Order of 1905, how-ever, permitted certificates of proficiency to be given tocertain classes of medical men after examination only andwithout a previous course of instruction. The present Orderextends the exemption from the course of instruction priorto examination to any person already holding a medicaldiploma or degree granted in a British, possession or foreign’country who is a candidate for examination by an examining-.b)dy in the United Kingdom for a diploma, licence, ordegree conferring the right of registration under the MedicalActs. The new Order supersedes the Order of 1905 and
incorporates its provisions. The following teachers and
examiners are entitled to give such certificates of proficiency