2
976 be made to restore Clause 13 to its original wording, but the Chancellor of the Exchequer knows well that if this were done he would run the risk of providing a National Insurance Bill 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 upon them, 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 closely into the constitution of the Local Health Committees. ,Similarly, the wide difference of opinion that exists as ,to how far the German model has been adequately followed 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 that similar legislation has worked extremely well in Germany are 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 temporary sickness. 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 of the 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 insurance schemes, which is contained in the just published report of Sir 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 of mankind." Few have been better equipped by nature in 1 The Parliamentary Bill Examined and Compared with the German Scheme (reprinted from the Journal of Comparative Legislation), by Ernest 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 stopped on 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 disappointed in 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 knowledge of a remedy to counteract its effects would be a desirable thing." Such a remedy, he finally remarks, may perhaps in time be discovered, an expectation which has not 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" " at times, 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 proved most 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 rational generalisation. It is recognised, however, that digitalis is impotent to influence heart-rate in the presence of febrile stimulation, and we now know the importance of de- termining the presence or absence of an infective endocarditis in the case of old disturbed lesions, even when the febrile movement is mild and intermittent. Extrinsic conditions, such as thyroidism and pericardial tethering, we also know may render futile the potential power 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 in the case of particular lesions. Thus the agent decried by CORRIGAN in aortic cases was extolled by BALFOUR as powerful for good when the same defect was present, while BROADBENT split the difference and indicated its utility in such cases when "mitral symptoms supervened. This, however, was little more than to acknowledge that an aortic case had broken down, and the majority of observers still attach 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

Digitalis in Heart Disease

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Page 1: Digitalis in Heart Disease

976

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

Page 2: Digitalis in Heart Disease

957

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