that I consider it justifies my confidence in the method. Before I proceed to give an analysis of the cases thus treated, a word as to my mode of administering the drug. I generally commence with twenty grains every fourth hour, as a dose for an adult, and then I gradually increase during the next few days to the full dose of thirty grains. Beyond this I have found that I cannot go without producing cerebral symptoms as the result, which have, however, quickly disappeared upon the diminution of the dose of the drug.

Children, I have found, require much smaller doses in proportion than adults. Where the diarrhoea has been excessive I have combined small doses of Batty's liquor opii sedativus with each dose of the remedy, until the bowels have been quieted.

With the exception of one case, which terminated fatally on the fourteenth day of fever, all the remainder progressed favourably towards recovery.

The length of time the fever lasted in each case appears to me to bear a direct ratio to the promptitude with which the drug was administered. In those cases in which I was able to exhibit the remedy during the period of incubation, the fever disappeared quicker than when it was given on the first or subsequent days of the disease. I have also administered the sulpho-carbolate of sodium to people with premonitory symptoms of typhoid, occurring in four instances in houses where I was already in attendance, and I have been glad to find that the disease has never developed itself; it has, as it were, aborted after from six to ten days of general discomfort, the bowels have assumed their natural tone and the excrement its normal appearance, the tongue has cleaned, and the patients have declared themselves to be in their usual health again. In these cases I fully believe that if the drug had not been administered, typhoid fever would have been developed.

This is, however, a matter of conjecture only, and beyond proof, and therefore I hope that everyone who has opportunities of observing the action of this remedy on the class of cases alluded to, will give the profession the benefit of their experience.

The following table gives an analysis of my cases :—

NO. LXIIL

The temperature was taken at 7 P.M.

ON DIGITALIS IN ACUTE FEBRILE DISEASES.

BY DR. ANSTIE.

IN the following short article I cannot attempt a general discussion of the supposed anti-febrile action of digitalis. The large amount of evidence on this subject which has been accumulating during the last twenty years, together with my own special experiences, would require a more elaborate analysis than could be found space for in the pages of this journal. But it may be useful to draw the attention of English observers, rather more closely than it has yet been drawn, to those objects which there is really some prospect of effecting by means of digitalis in pyrexial diseases.

The special subject which will now be discussed is suggested to us by the appearance of a pamphlet by Dr. T. W. Grimshaw1 on the action of digitalis on the weak heart of typhus; a paper which contains some remarkable facts, although I am not able to agree with all its conclusions. The question of the power of digitalis as a heart-tonic in the so-called adynamic fevers generally-not merely in typhus-is becoming very important and the following remarks will be concerned with this alone, to the exclusion of other questions, such as the power of digitalis to lower temperature in acute disease.

I can hardly preface my own observations more effectively than by bringing forward some of Dr. Grimshaw's facts. When it is remembered how strikingly the pulse of typhus fever exhibits the characters of low arterial tension and low heartforce, it must indeed be astonishing, to those who cherish any 1 Reprinted from the Dublin Quarterly Journal of Med. Science for June 1873.

remnant of the classical belief in digitalis as a heart-depressor, to find Dr. Grimshaw giving 1 ounce, and even 14 ounce of the infusion of digitalis every three hours for five or six days together, not only with impunity, but with seeming benefit. Whether the benefit was real or not, at least this is certain, that in nearly all the cases there was a total absence of those symptoms of heart-depression which used to be held up as a bugbear of digitalis treatment; indeed, on the contrary, it is asserted by Dr. Grimshaw, with apparent accuracy, that both the heart-force and the arterial tone were markedly invigorated. And in addition to this, it is to be remarked that but small amounts of alcoholic stimulants were given in any case, and in several no alcohol was administered. There were but two deaths out of twelve cases, and in the whole of the twelve recoveries the patients were adults.

I do not propose to dwell any further on the cases brought forward by Dr. Grimshaw, which have been cited simply as proof of the fact that in typhus, even of severe type, the phenomena of cardiac and vascular depression are relieved rather than aggravated by the use of digitalis in very large doses. Observe, that these cases, in which the infusion of digitalis was employed, stand on a very different footing from experiments in which large doses of the tincture had been employed so long as the evidence consisted only of instances in which the latter preparation had been used it was impossible say how far the result had been influenced by the large quantities of alcohol necessarily given. In Dr. Grimshaw's cases, on the contrary, we have to deal with an uncomplicated digitalis

to

action.

It would be a mistake, however, to limit our consideration of digitalis as a heart-tonic in febrile diseases to the case of typhus It must not be forgotten that the latter is an affection that runs a brief course, and in which asthenia is not the mode in which death usually occurs. Some of the best authorities on fevers have remarked that the issue in uncomplicated typhus depends upon the intensity with which the nervous system is affected, far more than on cardiac asthenia of local origin; and certainly the characteristic aspect of such cases is pre-eminently that of overwhelming nervous poisoning. No doubt the muscular tissue of

the heart is frequently, if not always, considerably changed, and both Murchison1 and Buchanan2 state, from personal observation, that in fatal cases this affection is not a mere fatty softening, but sometimes, at least, involves more or less elaborate changes of the same kind as those which have been so carefully described by Zenker as occurring in the heart and voluntary muscles of typhoid patients. But on the whole it seems evident that local cardiac changes count for much less in a brief disease like typhus than in a prolonged affection like that form of typhoid in which death occurs from simple heart-failure at an advanced period, and in which "Zenkerism" of the cardiac muscular substance is especially pronounced. It is in connection with this latter form of fever that I have more especially studied the question of weak heart in febrile disease; and before speaking of digitalis as a remedy, I wish to make some remarks upon the clinical facts of the case.

I doubt whether any published account of typhoid fever gives a just idea of the frequency with which sudden failure of the heart-and this alone-is the cause of death in cases of typhoid which run a longer course than four weeks. I do not mean that all these deaths are instantaneous; but the following is a fair average description of what happens :-Either from the original intensity of the febrile attack, or from the existence of severe complications, the heart has been kept pulsating at a rate varying from 120 to 150 or more, under an internal temperature which was always very high, even at the daily minimum, for some four or five weeks. The inflammatory complications, or the intestinal ulceration, however, have fairly subsided, and the pulse now begins to change. But instead of the simultaneous diminution of frequency and increase of arterial tone which would show the passage to convalescence, we remark (if we observe with attention) a very different kind of pulse-change. Careless feeling of the radial pulse might lead one to believe that the pulse, though somewhat irregular, had diminished very greatly in frequency; but a thoroughly skilled finger, or still more surely a sphygmograph, would immediately bring out the fact that many small intermediate pulsations had been over1 On "Continued Fevers of Great Britain," second edition. Article, "Typhus Fever," in Reynolds' Syst Med. vol. i.