sessed of greater medicinal activities. Professor Lloyd declares that "mature leaves of either the first or second year's growth are superior to immature or overripe leaves of any year." Little by little does scientific pharmaceutical investigation brush away the traditional cobwebs of medicine.

DESTRUCTIVE CHEMISTRY OF DIGITALIS.—While the foregoing is a matter of commercial importance, there is another side to the digitalis question that is of vital consequence to the practitioner and his patient. We refer to the destructive manipulation of the drug, both pharmacally and chemically. One hundred years ago Thompson (London Dispensatory) declared that the active principle of digitalis was unknown. Now, after a century of chemical manipulation at the hands of some of the most cultured chemists of the world, satisfactory conclusions have not been reached, and so far as the real therapeutically active constituents or constituent fragments are concerned (though many have been claimed), we are no nearer a solution than at the beginning. It might be said, with truth, that nothing of practical and safe therapeutic value has been learned in this direction since the day of Thompson, and that the therapy of digitalis rests practically to-day upon the basis laid by the father of digitalis-Witheringmore than two centuries ago.

That the chemical study of many of our drugs has not advanced their therapy, we feel certain. Indeed, it has in many instances retarded therapeutic progress. Digitalis is a notable example. Therapeutic action should be gradual, kindly, and nonshocking, like the processes of natural life itself. The ambition to find exceedingly energetic alkaloids and other fragments whose action is largely toxic, has retarded progress in diverting investigation from therapeutic channels into the stream of poisonous pollution. We do not believe it necessary to poison the body fluids and tissues in order to remedy sickness, and if as much energy had been exerted in studying the kindly and non-toxic effects of drugs, it would have been far safer to the patient and of much more credit to the profession. As a matter of scientific possibility it may be laudable for the chemist to pursue his investigations to the limit; but we do not feel that the doctor is either bound to or justified in inflicting his product upon the patient to his detri

ment. The variability of the so-called glucosids of digitalis, and the confusion that exists concerning their ultimate composition (though each manufacturer claims for his product absolute purity and the limit of chemical possibility) should make one cautious about relying upon them for therapeutic uses. In this connection witness how Schmiedebeig's brilliant analysis of digitalis, now long accepted as final, has been further split into more fragments by Kiliani, probably the greatest authority of to-day on the chemistry of digitalis. We still believe that fluid anhydrous alcoholic preparations of digitalis best represent the therapeutic possibilities of digitalis.

THE KINDLY ACTION OF MEDICINE VERSUS PHYSIOLOGIC SHOCK.-Digitalis came into use slowly and guardedly in Eclectic therapy. There was much distrust of the drug, and this was chiefly on account of its known toxic tendencies, particularly its liability to cause sudden heart-shock and its cumulative effects when given, as it was in the earlier days, in infusion and other toxic forms of administration, and as it is too frequently given to-day. Dr. Scudder was extremely cautious concerning the use of digitalis, and in his classic work "Specific Medication" advised only small doses of tincture of the dried leaves. From such doses, he declared, there were no cumulative effects. One of the cardinal principles taught by Dr. Scudder was the use of remedies for their kindly therapeutic action as opposed to what some have been pleased to term physiological action. Such action is in fact a near-toxic, and seldom, if ever, a therapeutic or remedial effect. As early as 1870 he wrote in "Specific Medication" these words: "As a rule, it is best to change the manifestations of diseased life slowly, giving sufficient time for the organism to adapt itself to the change, and gain increased strength as it returns to the condition of health. It will never do to suppress a process of disease at the risk of suppressing the organism upon which natural function depends. As a rule it is best to effect these changes insensibly, or without shock to an organ or to the entire body. In this, as in all other things, it is the slow but continued application of an opposing force that accomplishes the greatest results. Many thousands of sick have been hurried to their graves by the sudden and forcible efforts of the physician to remove disease. This is one of the most prominent errors of the old practice, and will require

considerable effort to avoid." ("Specific Medication," pp. 26-7.) That his views have had acceptance among the careful therapeutists of the regular school, as well as among the Eclectics, the following bears strong evidence: "I am firmly convinced that I have been in the habit of giving too large doses of digitalis and that the average physician gives too large doses, not only of digitalis, but of almost every other drug. There is a decided difference between the gentle, continuous, remedial action of a remedy and the sudden, repeated shocks to the system occasioned by large doses of a drug. Our methods of administration need to be restudied. The action of remedies in proper doses on sick people, instead of on healthy dogs and cats, is another thing the profession needs to know. One of the most important studies just now for the physician and pharmacist to undertake is the study of the pharmacy and remedial action of digitalis." (Dr. George F. Butler in Drug Treatise on Digitalis.)

PREPARATIONS OF DIGITALIS.-Digitalis is capable of pronounced poisonous effects or of kindly remedial action, according to the manner of its preparation and its dosage. Investigations show that water-bearing preparations of digitalis are the most toxic-acting powerfully upon the heart-and the history of cumulation and other digitalis disasters may be traced to them. The infusion, therefore, is the most dangerous of all the ordinarily employed preparations of digitalis. (We do not accept the many socalled glucosids of digitalis, of which three are heart-poisons, as normal constituents of digitalis-at least indisputably so provedbut rather as the creations of chemical manipulators or slivers of some natural structures.) Eclectic physicians largely avoid the use of the infusion, the fluid extract, and the so-called digitalins, etc., on account of the fact that they are liable to produce sudden toxic symptoms and can not be administered safely for long periods of time. There is abundant evidence to show that the least toxic of all the marketed preparations of foxglove is the specific medicine digitalis, from which is eliminated the toxic substance, and from the use of which he who expects mice-killing powers and other evidence of physiologic action will be greatly disappointed. This is the testimony of a large number of Eclectic physicians who use digitalis daily. In our own practice, with an extensive experience with digitalis, we have never witnessed poisonous results from this

preparation. In one patient, who has been kept almost constantly on small doses of specific digitalis for upwards of eight years, and is still being kept alive by it, the only adventitious occurrence was a slight chromatopsia on one occasion-a matter of small consequence, which was easily corrected by stopping the use of the drug for a few days. The therapeutic effects have in all instances been completely satisfactory. That the official preparations are often unsatisfactory and undesirable is plainly evident from the repeated efforts of pharmacists who for years have attempted to reach a more acceptable preparation of digitalis.

WITHERING'S OBSERVATIONS ON THE FOXGLOVE.-As noted in the sketch of Dr. Withering, vomiting and purging were common effects of digitalis as administered by the laity. This he at first thought also necessary to curative results, but as his studies progressed he soon learned that such effects were undesirable, and advised that the medicine "be continued until it either acts upon the kidneys, the stomach, the pulse, or the bowels; let it be stopped upon the first appearance of any one of these effects." Dr. Withering was the first to point out the diuretic powers of digitalis, and he noted that "if it purges it seldom succeeds well." He also pointed out the action of foxglove upon the pulse, showing that large doses might decrease the heart beats to 35 per minute. Thus was he the pioneer in the scientific knowledge of its effects upon the heart and kidneys, the two cardinal points of action of digitalis recognized to-day. We are fully aware that the diuretic action is denied by some to-day, but our experience is that there is increase of urine in most cases, which, of course, may be due to better heart action and increased blood pressure, rather than to any effect upon the renal glomerules. The main issue is that the renal output is increased, no matter how it is brought about, provided it is safely managed.

One can not but admire the therapeutic acumen of Dr. Withering and note in the following a foreshadowing of specific medication: "I am pretty well enabled to decide a priori upon this matter, and I wish to enable others to do the same; but I feel myself hardly equal to the undertaking. The following hints, however, aiding a degree of experience in others, may lead them to accomplish what I yet can describe but imperfectly. It seldom succeeds

in men of great natural strength, of tense fiber, of warm skin, of florid complexion, or in those with a tight and cordy pulse. If the belly in ascites be tense, hard, and circumscribed, or the limbs in anasarca solid and resisting, we have but little to hope. On the contrary, if the pulse be feeble or intermitting, the countenance pale, the lips livid, the skin cold, the swollen belly soft and fluctuating, or the anasarcous limbs readily pitting under the pressure of the finger, we may expect the diuretic effects to follow in a kindly manner."

THE USES OF DIGITALIS.-Digitalis is employed chiefly as a heart medicine and to some extent as a diuretic and antihemorrhagic agent. While possessing slight febrifuge qualities, we believe there are many better and safer remedies for the control of temperature. Too frequently physicians give digitalis without regard to conditions present, and, of course, fail to get results or possibly produce unpleasant effects that were not intended. In the investigations of Withering he clearly saw that the cases for digitalis were those marked by weakness and debility, either local or general. The work of specific medication has been along the same line, and the dose has been small. Large doses of digitalis are dangerous, but with the specific indications and small doses of a good preparation of digitalis, one need not have any fear of producing shock or of cumulation.

The true remedial power of digitalis is shown in asthenic heart diseases, organic or functional. It is one of the few agents that act upon the organic disturbances, for it will make the human pump fit its valves. Its power to cause strong and steady contraction of the heart muscles, with consequent adaptation of the rings or openings, its power to raise blood pressure, and in many instances its power to increase the renal function, make it an exceedingly useful remedy when carefully used. Locke was right when he christened digitalis "the true opium for the heart." It sedates and gives comfort, steadies the heart action, relieves dyspnoea, and in dropsical states due mostly to cardiac inefficiency assists in overcoming the edema. But, to obtain best results, the indications must be present-the weak, rapid, and irregular heart and low arterial tension. Harm always comes from its use when employed even in ordinary doses, when there is strong, vigorous heartaction, with high arterial tension-a sthenic state. A point worth