Treatment of Poisoning. - Lavage of the stomach should be immediate, emetics being too depressing if the heart is already-affected by the poison. A solution of tannic acid should be introduced into the stomach as the best chemical antidote. Diffusible stimulants may be required, the horizontal position should be maintained, and external heat applied, particularly to the abdomen. Absolute rest is imperative. The patient should not be allowed even to raise his hand or his head from the bed.

Therapeutics. - Externally and Locally. - Digitalis is of little service externally.

Internally. - Digitalis is one of the most important drugs known to medicine. The remedy is indicated in deranged conditions of the circulatory system itself, and, moreover, where, although the circulatory mechanism be normal, an abnormal state of other organs may be improved by changing the circulation in them. Digitalis is indicated in any case where there is actual failure in the dynamic power of the heart-muscle, irrespective of the nature of any primary valvular lesion inducing the hyposystolic condition.

Of course the rational use of the drug presupposes the absence of extensive fatty degeneration or interstitial myocarditis, since, should these conditions be advanced, there is danger of producing permanent asystole. It is difficult to estimate the integrity of the heart-muscle, and many cases presumably intolerant of the drug bear digitalis well.

In all conditions, therefore, in which there is insufficient driving power in the muscle with the usual accumulation of blood in the veins, digitalis is useful. As it improves the blood-supply of its own fibers it therefore aids in restoring tone to itself, and may even so increase its own power as to render the drug unnecessary.

With regard to the specific effect of the drug upon the heart-muscle this is not true, since the influence of the drug lasts but a few days, indirectly, through the additional muscle-power developed during a few weeks' administration. During or after middle life, if the vascular tension be increased, and especially if there be any sclerosis of the vessels, the administration of digitalis should be combined with that of vasodilators, to prevent contraction of the vessels and consequent increase of peripheral resistance. Of these adjuncts, opium is valuable. The nitrites are also of service.

In mitral regurgitation digitalis is an exceedingly efficient remedy. In this not infrequent lesion there is a deficiency of blood in the systemic arteries, and consequently an overaccumula-tion in the pulmonary vessels and systemic veins. Owing to this venous hyperemia, there is congestion of the lungs, stomach, liver, and the entire digestive tract, together with the attendant symptoms - dyspnea, bronchitis, deranged digestion, constipation, edema, etc.

Digitalis by improving the pumping power of the heart equalizes the circulation, fills the systemic arteries, and relieves the venous congestion with its accompanying symptoms.

Digitalis is valueless in the presence of compensatory hypertrophy, but after dilatation occurs is wonderfully effective, the size of the heart being often perceptibly diminished by a proper administration of the drug.

Digitalis may act indirectly as a tonic by improving the nutrition of the heart through the prolonged diastole and contraction of the cardiac muscle it occasions. The longer the period of diastole, the more time is allowed for the coronary arteries to fill and nourish the heart by the better blood-supply. The increased arterial tension produced by the drug causes the blood to be sent into the coronary arteries with greater force during the cardiac diastole.

The forcible contraction of the heart occasioned by this drug expels the blood from the veins of the cardiac muscle, improved nutrition of the muscle resulting from this mechanical action.

There has been some objection to the use of digitalis in cardiac ataxia resulting from aortic regurgitation, on the ground that the latter action is more forcible and extensive under its influence. The author's experience is that cases of aortic regurgitation respond to the use of this drug as promptly as any other lesion, save that it is at times necessary to give larger doses than are required in other valvular affections.

In many valvular diseases of the heart there is marked irregularity, such often being more serious than the mere leakage of blood. Digitalis by stimulating the vagus and motor ganglia causes the heart to beat more regularly. The drug is, therefore, of great service in exophthalmic goiter.

In any condition of low arterial tension, whether resulting from infection, general debility, or whatever cause, digitalis, by increasing the force of the heart and raising arterial pressure, serves a useful purpose.

In collapse from shock, poisoning, or cholera, where the great veins are dilated, it has proved an efficient agent, but it must be used in conjunction with more active and quick stimulants, such as alcohol, ether, nitrites, etc.

The functional activity of the various organs in anemia and other deranged conditions of the system may be improved by the administration of this remedy.

The circulation being improved, there is increased absorption of fluid from the tissues, as well as greater circulation of fresh intercellular fluid, favoring combustion and functional activity, while the waste products are more readily removed. This action renders digitalis valuable as a tonic.

In pneumonia, particularly if there is an irregular, fluttering heart, and evident signs of toxic action, it is of the greatest importance, being of use here to stimulate the contractile force of the cardiac muscle when the intraventricular pressure becomes stronger than the unaided muscle can resist, and dilatation is imminent, if not already begun.

In congestion of the lungs during the course of exhausting fevers, such as typhoid, and in the first stage of meningitis, bronchitis, cellulitis, etc., before transudation takes place, it is considered by many physicians to be a valuable, remedy in relieving the venous stasis. It is particularly valuable, combined with squill, in many cases of chronic bronchitis, particularly of cardiac origin.

Many observers of wide experience have recommended large doses of digitalis in delirium tremens. It is wonderfully effective in this condition, particularly where there is low arterial pressure. Small doses are more beneficial than large ones.

Digitalis has been successfully employed in acute mania and epilepsy, Gowers recommending it in the latter disease as an adjuvant to the bromides, associated with belladonna. It is fair to state that in maniacal conditions the preponderance of testimony is in favor of large doses - 1/2 to 4 fluidrams (1.8-15.0 Cc.) of the tincture.

The drug is thought to enhance the influence of ergot in postpartum hemorrhage, and when associated with iron it is of value in purpura hemorrhagica.

The drug, combined with ergot or potassium bromide according to the indications, has been successfully employed in spermatorrhea, and nocturnal emissions.

It is said that absorption of pleuritic effusion is hastened by the continued administration of digitalis.

Clifford Allbutt recommends it in sufficient doses to reduce the pulse to 45 or 50 in aneurism. This method of treatment, however, has not been widely adopted.

The remedy is invaluable as a diuretic to relieve cardiac or renal dropsy, its efficiency being more apparent in the former variety, although acute renal dropsy usually yields to its influence. Digitalis, especially combined with squills, is particularly valuable in all dropsies accompanied by lowered arterial tension. Should the renal structure be impaired, the drug is less serviceable, although, when combined with other appropriate remedies, it is decidedly beneficial in chronic Bright's disease with cardiac dilatation. In the early stages of the malady, accompanied by cardiac hypertrophy and high arterial tension, it is doubtful whether digitalis is indicated, either alone or in combination.

In conclusion, it should be stated that digitalis is recommended by all authors in every valvular disease of the heart, with the possible exception of aortic regurgitation, some writers supposing it to be harmful in this condition because of the prolonged diastole it occasions. The more recent clinical views would seem to show that even this valvular affection is not a contraindication.

Contraindications. - Digitalis should not be given when there is marked degeneration of the heart-muscle or of the arterial walls. In simple hypertrophy, apoplexy, high arterial pressure, or vascular excitement the use of the drug is inadvisable. Many physicians regard aneurism as a contraindication to the use of digitalis.

Administration. - Any of the official preparations may be given, or the powdered leaves in pills or capsules - not at too frequent intervals, however, from four to eight hours elapsing between the doses, lest the drug accumulate in the system, producing poisonous symptoms.

When digitalis has been administered for some time to a patient suffering from ascites, and the fluid is removed by paracentesis, poisoning may ensue. It is well, therefore, to discontinue the remedy for two or three days before tapping the patient.

The rapidity of the drug's action upon the heart depends upon the presence or absence of a febrile state. The stimulant action upon the heart is usually observable in from twenty-four to thirty-six hours. The effects of the drug commonly continue from three to seven days after its discontinuance.

The powdered digitalis, though the most irritant to the stomach, fully represents the drug, which is true of none of the preparations.

The infusion of digitalis, being an aqueous preparation and containing, therefore, a larger proportion of digitonin, is superior for diuretic purposes; while the alcoholic preparations, like the fluid-extract and tincture, being richer in digitalin, digitalein, and digi-toxin, are preferable when an action upon the heart is desired.

Ordinarily, therefore, digitalis should be given in solution, the tincture and infusion being the most reliable preparations; care being taken in the selection of the crude drug, upon the character of which the strength of the preparation depends.

In uncomplicated cases of cardiac failure, the result of valvular lesion, the tincture is most eligible. In cardiac failure associated with, or resulting from, kidney lesions the infusion, combined with some other diuretic, should be used.

As to the cumulative effect of digitalis, so much feared by the older writers on its action, the evil may be ascribed to improperly selected cases or faulty administration. Under proper conditions the drug may be given for months without ill effect.

Of the active constituents, digitalin is usually preferred, as it is so quickly soluble that its effects are manifested a few minutes after its administration, it possesses the full power of digitalis in its influence on the heart, with a minimum of its vasoconstrictor action.