Alia5r,Pi9i8?-  )  Digitalis  Therapy.  2$ 
forms  of  chronic  cardiac  disease  which  require  more  or  less  continu- 
ous digitalis  medication,  the  duration  of  effect  and  the  duration  of 
action  are  nearly  the  same.  In  such  cases  the  duration  of  action  and 
effect  of  digitalis  and  digitoxin  are  far  greater  than  those  of  the 
other  members  of  the  group,  in  which  case  the  difference  is  over- 
come by  increased  frequency' of  dosage,  or,  what  amounts  to  the 
same  thing,  a  relatively — not  actually — larger  dose  of  equal  fre- 
quency. 
Digipuratum  is  one  of  those  specialties  that  have  come  into  wide 
use  partly  through  their  intrinsic  value,  but  mainly  because  of  a 
most  persistent  and  effective  campaign  of  adroit  advertising,  and  it 
may  be  taken  as  an  example  of  the  specialties  on  which  all  too  many 
clinicians  have  come  to  fix  their  sole  reliance  in  digitalis  therapy.  It 
is  certainly  true,  however,  that  while  digipuratum,  like  many  other 
specialties,  exerts  a  satisfactory  cardiac  action,  it  is  in  no  way-  es- 
sential, since  exactly  the  same  actions  can  be  induced  by  official  mem- 
bers of  the  group  in  the  hands  of  any  one  who  masters  the  really 
simple  technic  of  administration. 
In  all  cases  requiring  digitalis  therapy,  digitalis  itself  in  the 
form  of  the  powder,  the  tincture,  fluidextract,  extract  or  infusion 
may  be  used  orally  with  the  sole  exception  of  those  relatively  rare 
cases  in  which  immediate  relief  is  imperative,  and  which  require  in- 
travenous or  intramuscular  administration.  In  such  cases  the 
typical  digitalis  action  can  be  induced  immediately  by  the  intramus- 
cular or  intravenous  injection  of  strophanthin  or  crystalline  ouabain 
(so-called  crystalline  strophanthin,  not  true  crystalline  Kombe 
strophanthin,  which  is  not  commercially  available). 
It  is  necessary  to  call  attention  again  to  the  difference  between 
an  immediate  action  and  immediate  effect,  because  it  has  long  been 
taught,  without  a  particle  of  real  evidence,  that  the  action  of  digitalis 
cannot  be  induced  promptly.  The  whole  range  of  digitalis  action  up 
to  the  maximum,  that  is,  cardiac  stoppage,  can  be  induced  within 
from  five  to  fifteen  seconds  by  the  intravenous  injection  of  digitalis 
tincture,  deprived  of  its  alcohol,  or  digitoxin.  This  simple  experi- 
ment disposes  forever  of  the  mischievous  claim  that  digitalis  action 
is  slow.  The  effect  of  therapeutic  doses  is  gradually  induced;  the 
action  is  immediate.  A  bullet  fired  through  the  heart  acts  instanta- 
neously ;  the  effect  is  a  fatal  hemorrhage,  the  rapidity  of  which  de- 
pends largely  on  the  size  of  the  wound.   With  suitable  dosage,  digi- 
