Digitalis plays an important part in the treatment of the state originally pointed out by Stokes as "weak heart," a state which is referred by German physicians to fatty and granular conditions of its muscular tissue. The above principles, though expressing much of the truth, are perhaps too absolutely laid down; for there is not so great a difference between the relations of digitalis to mitral and to aortic disease as is here indicated. Sydney Ringer2 is right in saying that it is better to consider "all the symptoms than to confine the attention simply to the nature of the valvular affection;" and in the following picture represents the class of cases in which digitalis is most strikingly useful. He says: "There is dropsy, which may be extensive. The breathing is much distressed in the earlier stages of this condition only periodically, and especially at night; but when this reaches its worst stage, the breathing is continuously bad, although it becomes paroxysmally worse. The patient cannot lie down in bed, and is perhaps obliged to sit in a chair, with the head either thrown back, or more rarely leaning forward on the bed or some other support. The jugular veins are distended, and the face is dusky and livid; the pulse is very frequent, feeble, fluttering, and irregular. The urine is very scanty, high-colored, and deposits copiously on cooling. The heart is seen and felt to beat over a too extensive area; and the chief impulse is sometimes at one spot of the chest, and sometimes at another. The impulse is undulating, and the beating very irregular and intermittent. The physical examination betrays great dilatation of the left ven-tricle, with often a not inconsiderable amount of hypertrophy. A murmur is ordinarily heard, having the characters of one produced by mitral regurgitant disease; and there may be also disease of the aortic valves."

1 Text-book of Practical Medicine, i. 357. 2 Handbook of Therapeutics, 3d ed. p. 395.

The expression above quoted, that "in disease of the aortic orifice, compensation by hypertrophy continues to take place for so long a period, that the use of digitalis may be dispensed with," is certainly not universally true. In the case of aortic insufficiency, it is, indeed, approximately correct; this affection is usually attended with great hypertrophy, and the patients, for the most part, do not well tolerate digitalis. Theoretically, also, there is the danger of exciting a tetanoid contraction, from which the heart might not recover. Even here, however, it is not always the case that hypertrophy is developed in an excessive, or even in a sufficiently compensating, degree; and in instances such as I have occasionally witnessed, in which the inadequate hypertrophy made the overburdened left ventricle liable to sudden failure, with serious or fatal results, digitalis has proved of real service; and, as for the case of aortic obstruction, any one who has given digitalis practical trial will certainly recognize it as a remedy capable of exerting most beneficial influence in suitable cases of this affection. Dr. Fothergill has pointed out that in some such patients, especially when the obstruction has suddenly arisen, it may even be right to disregard the occurrence, during the administration of the drug, of intermission of the heart's pulsations, except as a reason for increasing the dose, upon which we shall find relief given to the cardiac symptoms. Here the failure of the heart has not been really due to the drug, but to the disease, hypertrophy not having been sufficiently established to do the work of compensation without powerful artificial assistance.

It may be well to say a few words respecting the old notion of a cumulative poisonous action after repeated doses of digitalis. This notion, as every one remembers, prevailed with most physicians some twenty to thirty years ago; but the dread seems to have been quite devoid of foundation. It must be recollected that in those days the perfectly false notion prevailed that digitalis was very useful in hypertrophy, but very dangerous in dilatation and in muscular weakness of the heart.1 Recent experience has proved that the exact reverse of this is the truth; and there is much reason, therefore, to distrust the whole of the observations upon which the idea of cumulative poisoning rested; or, rather, there is good reason to think that the cases of dilated or degenerated heart, with weak and fluttering pulse, which were supposed to have ended fatally from the cumulative effects of digitalis, really sank from natural causes. And, indeed, it is certain, that were digitalis so dangerous, when continuously given in the very small doses to which it was formerly restricted, numerous persons must have fallen victims to the comparatively reckless administration of it which has distinguished many of the recent experiments, and especially to the German employment of digitalis in febrile affections.

As a general rule, it may be laid down that those cases of heart dis.

1 See, for example, Dr. Walshe (Diseases of the Heart, p. C64) for a clear enunciation of this principle.

ease will receive most benefit from digitalis in which there is weakness of heart-pulsation, irregularity (with or without dyspnoea), venous engorgement (with or without dropsy, but especially when combined with the latter), and a scanty secretion of urine. In such cases the drug induces effects as striking as are ever produced by any drug in any disease. The form which is decidedly to be preferred is the fresh infusion, made from good leaves; powdered digitalis, which was the form chiefly used by the German physicians in their researches on febrile diseases, is apt to vary greatly in strength. Of the infusion, from one to two drachms should be given every night and morning, and increased, if necessary, to a dose every three or four hours until a decided diuretic effect is produced. It is remarkable how unfailing is the occurrence of this beneficial action; for, while in health it is difficult to procure decided diuresis at all, either with small doses or large ones, in the morbid conditions described, digitalis produces a flow of urine with a certainty almost magical.