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Societa' Italiana di Biochimica e Biologia Molecolare
In collaborazione con:
Dipartimento di Scienze Biochimiche "A. Rossi Fanelli"
Istituto Pasteur - Fondazione Cenci Bolognetti
Sapienza Universita' di Roma
ACCOUNT OF THE FOXGLOVE,
Some of its Medical Uses:
PRACTICAL REMARKS ON DROPSY,
AND OTHER DISEASES.
WILLIAM WITHERING, M. D.
Physician to the General Hospital at Birmingham.
nonumque prematur in annum.
BIRMINGHAM: PRINTED BY M. SWINNEY;
FOR C.G.J. AND J. ROBINSON, PATERNOSTER ROW, LONDON. MDCCLXXXV
After being frequently urged to write upon this subject and as often declining to do it, from apprehension of my own inability, I am at length compelled to take up the pen, however unqualified I may still feel myself for the task.
The use of the Foxglove is getting abroad, and it is better the world should derive some instruction, however imperfect, from my experience, than that the lives of men should be hazarded by its unguarded exhibition, or that a medicine of so much efficacy should be condemned and rejected as dangerous and unmanageable.
It is now about ten years since I first began to use this medicine. Experience and cautious attention gradually taught me how to use it. For the last two years I have not had occasion to alter the modes of management; but I am still far from thinking them perfect.
It would have been an easy task to have given select cases, whose successful treatment would have spoken strongly in favour of the medicine, and perhaps been flattering to my own reputation. But Truth and Science would condemn the procedure. I have therefore mentioned every case in which I have prescribed the Foxglove, proper or improper, successful or otherwise. Such a conduct will lay me open to the censure of those who are disposed to censure, but it will meet the approbation of others, who are the best qualified to be judges.
To the Surgeons and Apothecaries, with whom I am connected in practice, both in this town and at a distance, I beg leave to make this public acknowledgement, for the assistance they so readily afforded me, in perfecting some of the cases, and in communicating the events of others.
The ages of the patients are not always exact, nor would the labour of making them so have been repaid by any useful consequences. In a few instances accuracy in that respect was necessary, and there it has been attempted; but in general, an approximation towards the truth, was supposed to be sufficient.
The cases related from my own experience, are generally written in the shortest form I could contrive, in order to save time and labour. Some of them are given more in detail, when particular circumstances made such detail necessary; but the cases communicated by other practitioners, are given in their own words.
I must caution the reader, who is not a practitioner in physic, that no general deductions, decisive upon the failure or success of the medicine, can be drawn from the cases I now present to him. These cases must be considered as the most hopeless and deplorable that exist; for physicians are seldom consulted in chronic diseases, till the usual remedies have failed: and, indeed, for some years, whilst I was less expert in the management of the Digitalis, I seldom prescribed it, but when the failure of every other method compelled me to do it; so that upon the whole, the instances I am going to adduce, may truly be confidered as cases lost to the common run of practice, and only snatched from destruction, by the efficacy of the Digitalis; and this in so remarkable a manner, that, if the properties of that plant had not heen discovered, by far the greatest part of these patients must have died.
There are men who will hardly admit of any thing which an author advances in support of a favorite medicine, and I allow they may have some cause for their hesitation; nor do I expect they will wave their usual modes of judging upon the present occasion. I could wish therefore that such readers would pass over what I have said, and attend only to the communications from correspondents, because they cannot be supposed to possess any unjust predilection in favour of the medicine: but I cannot advise them to this step, for I am certain they would then close the book, with much higher notions of the efficacy of the plant than what they would have learnt from me. Not that I want faith in the discernment or in the veracity of my correspondents, for they are men of established reputation; but the cases they have sent me are, with some exceptions, too much selected. They are not upon this account less valuable in themselves, but they are not the proper premises from which to draw permanent conclusions.
I wish the reader to keep in view, that it is not my intention merely to introduce a new diuretic to his acquaintance, but one which, though not infallible, I believe to be much more certain than any other in present use.
After all, in spite of opinion, prejudice and error, TIME will fix the real value upon this discovery, and determine whether I have imposed upon myself and others, or contributed to the benefit of science and mankind.
Birmingham, 1st July, 1785.
The Foxglove is a plant sufficiently common in this island, and as we have but one species, and that so generally known, I should have thought it superfluous either to figure or describe it; had I not more than once seen the leaves of Mullein (notes: a) gathered for those of Foxglove. On the continent of Europe too, other species are found, and I have been informed that our species is very rare in some parts of Germany, existing only by means of cultivation, in gardens.
Our plant is the Digitatis purpurea (notes: b) of Linnaeus. It belongs to the 2nd order of the 14th class, or the DIDYNAMIA ANGIOSPERMIA. The essential characters of the genus are, Cup with 5 divisions. Blossom bell shaped, bulging. Capsule egg-shaped, 2-celled. (Linn.)
DIGITALIS purpurea. Little leaves of the empalement eggshaped, sharp. Blossoms blunt; the upper lip entire. (Linn.)
STEM. About 4 feet high; obscurely angular; leafy.
LEAVES. Slightly but irreguarly serrated, wrinkled; dark green above, paler underneath. Lower leaves egg-shaped; upper leaves spear-shaped. Leaf-stalks fleshy; bordered.
FLOWERS. Numerous, mostly growing from one side of the stem and hanging down one over another. Floral-leaves fitting, taper-pointed. The numerous purple blossoms hanging down, mottled within; as wide and nearly half as long as the finger of a common-sized glove, are sufficient marks whereby the most ignorant may distinguish this from every other British plant; and the leaves ought not to be gathered for use but when the plant is in blossom.
PLACE. Dry, gravelly or sandy soils; particularly on sloping ground. It is a biennial, and flowers from the middle of June to the end of July.
I have not observed that any of our cattle eat it. The root, the stem the leaves, and the flowers have a bitter herbaceous taste, but I don't perceive that nauseous bitter which has been attributed to it.
This plant ranks amongss the LURIDAE, one of the Linnaean orders in a natural system. It has for congenera, NICOTIANA, ATROPA, HY0SCYAMUS, DATURA, SOLANUM, &c. so that from the knowledge we possess of the virtues of those plants, and reafoning from botanical analogy, we might be led to guess at something of its properties.
I intended in this place to have traced the history of its effects in diseases from the time of Fuchsius, who first describes it, but I have been anticipated in this intention by my very valuable friend, Dr. Stokes of Stourbridge, who has lately sent me the following
FUCHSIUS in his hist. stirp. 1542, is the first author who notices it. From him it receives its name of Digitalis, in allusion to the German name of Fingerhut, which signifies a finger-stall, from the blossoms resembling the finger of a glove.
SENSIBLE QUALITIES. Leaves bitterish, very nauseous. LEWIS Mat. med. i. 342.
SENSIBLE EFFECTS. Some persons, soon after eating of a kind of omalade, into which the leaves of this, with those of several other plants, had entered as an ingredient, found themselves much indisposed, and were presently after attacked with vomitings. DODONAEUS pempt. 170.
It is a medicine which is proper only for strong constitutions, as it purges very violently, and excites excessive vomitings. RAY. hist. 767.
BOERHAAVE judges it to be of a poisonous nature, hist. plant., but Dr. ALSTON ranks it among those indigenous vegetables, "which, though now disregarded are medicines of great virtue, and scarcely inferior to any that the Indies afford." LEWIS Mat. med. i. p.343.
Six or seven spoonfuls of the decoction produce nausea and vomiting, and purge; not without some marks of a deleterious quality. HALLER hist. n. 330 from Aerial Infl. p. 49, 50.
M. SALERNE, a physician at Orleans, having heard that several turkey pouuts had been killed by being fed with Foxglove leaves, instead of mullein, he gave some of the same leaves to a large vigorous turkey. The bird was so much affected that he could not stand upon his legs, he appeared drunk, and his excrement became reddish. Good nourishmnent restored him to health in eight days.
Being then determined to push the experiment further, he chopped some more leaves, mixed them with bran, and gave them to a vigorous turkey cock wigh weighed seven pounds. This bird soon appeared drooping and melancholy; his feathers stared, his neck became pale and retracted. The leaves were given him for four days, during which time he took about a handful. These leaves had been gathered about eight days and the winter was far adanced. The excrements, which are naturally green and well formed, became, from the first, liquid and reddish like those of a dysenteric patient.
The animal refusing to eat any more of this mixture which had done him so much mischief, I was obliged to feed him with bran and water only; but notwithstanding this, he continued drooping, and without appetite. At times he was seized with convulsions, so strong as to throw him down; in the intervals he walked as if drunk; he did not attempt to perch, he uttered plaintive cries. At length he refused all nourishment. On the fifth or sixth day the excrements became as white as chalk; afterwards yellow, greenish, and black. On the eighteenth day he died, greatly reduced in flesh, for he now weighed only three pounds.
On opening him we found the heart, the lungs, the liver, and gall-bladder shrunk and dried up; the stomach was quite empty, but not deprived of its villous coat. Hist. de l'Academ. 1748. p. 84.
EPILEPSY. "It hath beene of later experience found also to be effectual against the falling sicknesse, that divers have been cured thereby; for after the taking of the Decot. manipulor. ii. c. polypod. quercin. contus. iv ounces in cerevsia, they that have been troubled with it twenty-six years, and have fallen once in a weeke, or two or three times in a moneth, have not fallen once in fourteen or fifteen moneths, that is until the writing hereof." Parkinson, p. 654.
SCROPHULA. "The herb bruised, or the juice made up into an ointment, and applied to the place, hath been found by late experience to be availeable for the King's Evill." Park. p. 654.
Several hereditary instances of this disease said to have been cured by it. AEREAL INFLUENCES, p. 49, 50. quoted by HALLER hist. n. 330.
A man with scrophulous ulcers in various parts of the body, and which in the right leg were so virulent that its amputation was proposed, cured by succ. express. cochl. i. bis bara xiv. dies, in 1/2 pinta cerevisiae calidae.
The leaves remaining after the pressing out of the juice, were applied every day to the ulcers. Pract. ess. p. 40 quoted by MURRAY apparat. nzedicam. i. p. 491.
A young woman with a scrophulous tumour of the eye, a remarkable swelling of the upper lip, and painful tumours of the joints of the fingers, much relieved; but the medicine was left off, on account of its violent effets on the constitution. Ib. p. 42 quoted as above.
A man with a scrophulous tumour of the right elbow, attended for three years with excruciating pains, was nearly cured by four doses of the juice taken once a month. Ib. p. 43. as above.
The physicians and surgeons of the Worcester Infirmary have employed it in ointments and poultices with remarkable efficacy. Ib. p. 44. It was recommended to them by Dr. Baylies of Evesham, now of Berlin, as a remedy for this disease. Dr. Wall gave it a tryal, as well externally as internally, but their experiments did not lead them to observe any other properties in it, than those of a highy nauseating medicine and drastic purgative.
WOUNDS In confiderable estimation for the healing all kinds of wounds, Lobel. adv. 245.
Principally of use in ulcers, which discharge considerably, being of little advantage in such as are dry. HULSE, in R. hist. 768.
Doctor BAYLIES, phyfician to his Prussian Majesty informed me, when at Berlin, that he employed it with great fuccess in caries, and obstinate sore legs.
DYSPNOEA Pituitosa Sauvages i. 657. "Boiled in water, or wine, and drunken, doth cut and consume the thicke toughnesse of grosse, and slimie flegme, and naughtie humours. The same, or boiled with honied water or sugar, doth scoure and clense the brest, ripeneth and bringeth foorth tough and clammie flegme. It openeth also the stoppage of the liver spleene and milt, and of the inwarde parts." GERARDE hist. ed. I. p. 647.
"Whensoever there is need of a rarefying or extenuating of tough flegme or viscous humours troubling the chest, the decoction or juice hereof made up with sugar or honey is availeable, as also to clense and purge the body both upwards and downwards sometimes, of tough flegme, and clammy humours, notwithstanding that these qualities are found to bee in it, there are but few physitions in our times that put it to thefe ues, but it is in a manner wholly negleted." PARKINSON, p. 654.
Previous to the year 1777, you informed me of the great success you had met with in curing dropsies by means of the sol. Digitalis, which you then considered as a more certain diuretic than any you had ever tried. Some time afterwards, Mr. Russel, surgeon, of Worcester, having heard of the success which had attended some cases in which you had given it, requested me to obtain for him any information you might be inclined to communicate respecting its use. In confequence of this applica tion, you wrote to me in the following terms. (notes: c)
In a letter which I received from you in London, dated September 29, 1778, you write as foliows: "I wish it was as easy to write upon the Digitalis I despair of pleasing myself or instructing others, in a subject so difficult. 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."
The figure of the Foxglove, facing the Title Page, is copied by the permission and under the inspection of Mr. Curtis, from bis admirable work, entitled FLORA LONDINENSIS. The accuracy of the drawings, the beauty of the colouring, the full descriptions, the accurate specific distinctions, and the uses of the different plants, cannot fail to recommend that work to the patronage of all who are interested in the encouragement of genius, or the promotion of useful knowledge.
Fig. 1. The Empalement.
Fig. 2, 3, 4. Four CHIVES two long and two short. TIPS at first large, turgid, oval, touching at bottom, of a yellowish colour, and often spotted; lastly changing both their form and situation in a singular manner.
Fig. 5, 6, 7. SEED-BUD rather conical, of a yellow green colour. Shaft simple. Summit cloven.
Fig. 8. Honeycup a gland, surrounding the bottom of the Seed-bud.
Fig. 9. SEED-VESSEL, a pointeci oval capsule, of two cells and two valves, the lowermost valve splitting in two.
Fig. 10. SEEDS numerous, blackish, small, lopped at each end.
As the more obvious and sensible properties of plants such as colour taste, and smell, have but little connexion with the diseases they are adapted to cure; so their peculiar qualities have no certain dependence upon their external configuration. Their chemical examination by fire, after an immense waste of time and labour, having been found useless, is now abandoned by generai consent. Possibly other modes of analysis will be found out, which may turn to better account; but we have hitherto made only a very small progress in the chemistry of animal and vegetable substances. Their virtues must therefore be learnt, either from obferving their effects upon insects and quadrupeds; from analogy, deduced from the already known powers of some of their congenera, or from the empirical usages and experience of the populace.
The first method has not yet been much attended to; and the second can only be perfected in proportion as we approach towards the discovery of a truly natural system; but the last, as far as it extends, lies within the reach of every one who is open to information, regard of the source from whence it springs.
It was a circumstance of this kind which first fixed my attention on the Foxglove.
In the year 1775, my opinion was asked concerning a family receipt for the cure of the dropsy. I was told that it had long been kept a secret by an old woman in Shropshire, who had sometimes made cures after the more regular practitioners had failed. I was informed also, that the effects produced were violent vomiting and purging; for the diuretic effects seemed to have been overlooked. This medicine was composed of twenty or more different herbs; but it was not very difficult for one conversant in these subjects, to perceive, that the acive herb could be no other than the Foxglove.
My worthy predecessor in this place, the very humane and ingenious Dr. Small, had made it a practice to give his advice to the poor during one hour in a day. This practice, which I continued until we had an Hospital opened for the reception of the sick poor, gave me an opportunity of putting my ideas into execution in a variety of cases; for the number of poor who thus applied for advice, amounted to between two and three thousand annually. I soon found the Foxglove to be a very powerful diuretic; but then, and for a considerable time afterwards, I gave it in doses very much too large, and urged its continuance too long; for misled by reasoning from the effects of the squill, which generally acts best upon the kidneys when it excites nausea, I wished to produce the fame effect by the Foxglove. In this mode of prescribing, when I had so many patients to attend to in the space of one, or at most of two hours, it will not be expected that I could be very particular, much less could I take notes of all the cases which occurred. Two or three of them only, in which the medicine succeeded, I find mentioned amongst my papers. It was from this kind of experience that I ventured to assert, in the Botanical Arrangement published in the course of the following spring, that the Digitalis purpurea "merited more attention than modem practice bestowed upon it."
I had not, however, yet introduced it into the more regular mode of prescription; but a circumstance happened which accelerated that event. My truly valuable and respectable friend, Dr. Ash, informed me that Dr. Cawley, then principal of Brazen Nose College, Oxford, had been cured of a Hydrops Pectoris, by an empirical exhibition of the root of the Foxglove, after some of the first physicians of the age had declared they could do no more for him. I was now determined to pursue my former ideas more vigorously than before, but was too well aware of the uncertainty which must attend on the exhibition of the root of a biennial plant, and therefore continued to use the leaves. These I had found to vary much as to dose at different seasons of the year; but I expected, if gathered always in one condition of the plant, viz. when it was in its flowering state, and carefully dried, that the dose might be ascertained as exacttly as that of any other medicine; nor have I been disappointed in this expectation. The more I saw of the great powers of this plant, the more it seemed necessary to bring the doses of it to the greatest possible accuracy. I suspected that this degree of accuracy was not reconcileable with the use of a decoction, as it depended not only upon the care of those who had the preparation of it, but it was easy to conceive from the analogy of another plant of the fame natural order, the tobacco, that its actiive properties might be impaired by long boiling. The decoction was therefore discarded, and the infusion substituted in its place. After this I began to use the leaves in powder, but I stilil very often prescribe the infusion.
Further experience convinced me, that the diuretic effects of this medicine do not at all depend upon its exciting a nausea or vomiting; but, on the contrary, that though the increased secretion of urine will frequently succeed to, or exist along with these circumstances, yet they are so far from being friendly or necessary, that I have often known the discharge of urine checked, when the doses have been imprudently urged so as to occasion sickness.
If the medicine purges, it is almost certain to fail in its desired effect; but this having been the case, I have seen it afterwards succeed when joined with small doses of opium, so as to restrain its action un the bowels.
In the summer of the year i776, I ordered a quantity of the leaves to be dried, and as it then became possible to ascertain its doses, it was gradually adopted by the medical practitioners in the circle of my acquaintance.
In the month of November 1777, in consequence of an application from that very celebrated surgeon, Mr. Russel, of Worcester, I sent him the following account, which I choose to introduce here, as shewing the ideas I then entertained of the medicine, and how much I was mistaken as to its real dose. "I generaily order it in decoction. Three drams of the dried leaves, collected at the time of the blossoms expanding, boiled in twelve to eight ounces of water. Two spoonfuls of this medicine, given every two hours, will sooner or later excite a nausea. I have sometimes used the green leaves gathered in winter, but then I order three times the weight; and in one instance I used three ounces to a pint decoction, before the desired effect took place. I confider the Foxglove thus given, as the most certain diuretic I know, nor do its diuretic effects depend merely upon the nausea it produces, for in cases where squil and ipecac. have been so given as to keep up a nausea several days together, and the flow of urine not taken place, I have found the Foxglove to succeed; and I have, in more than one instance, given the Foxglove in smaller and more distant doses, so that the flow of urine has taken piace without any sensible affection of the stomach; but in general I give it in the manner first mentioned, and order one dose to be taken after the sickness commences. I then omit all medicines, except those of the cordial kind are wanted, during the space of three, four, or five days. By this time the naufea abates, and the appetite becomes better than it was before. Sometimes the brain is confiderably affected by the medicine, and indistinct vision ensues; but I have never yet found any permanent bad effects from it."
"I use it in the Ascites, Anasarca, and Hydrops Pectoris; and so far as the removal of the water will contribute to cure the patient, so far may be expected from this medicine: but I wish it not to be tried in ascites of female patients, believing that many of these cases are dropsies of the ovaria; and no sensible man will ever expect to see these encysted fluids removed by any medicine."
"I have often been obliged to evacuate the water repeatedly in the same patient, by repeating the decoction; but then this has been at such distances of time as to allow of the interference of other medicines and a proper regimen, so that the patient obtains in the end a perfect cure. In these cases the decoction becomes at length so very disagreeable, that a much smaller quantity will produce the essect, and I often find it necessary to alter its taste by the addition of Aq. Cinnam. sp. or Aq. Juniper. composita."
"I allow, and indeed enjoin my patients to drink very plentifully of small liquors through the whole course of the cure; and sometimes, where the evacuations have been very sudden, I have found a bandage as necessary as in the use of the trochar."
Early in the year 1779, a number of dropsical cases offered themselves to my attention, the consequences of the scarlet fever and sore throat which had raged so very generally amongst us in the preceding year. Some of these had been cured by squills or other diuretics, and relapsed; in others, the dropsy did not appear for several weeks after the original disease had ceased: but I am not able to mention many particulars having omitted to make notes. This, however, is the less to be regretted, as the symptoms in all were very much alike, and they vere all without an exception cured by the Foxglove.
This last circumstance encouraged me to use the medicine more frequently than I had done heretofore, and the increase of practice had taught me to improve the management of it.
In February 1779, my friend, Dr. Stokes, communicated to the Medical Society at Edinburgh the result of my experience of the Foxglove; and, in a letter addressed to me in November following, he fays, "Dr. Hope, in consequence of my mentioning its use to my friend, Dr. Broughton, has tried the Foxglove in the Infirmary with success. Dr. Stokes also tells me that Dr. Hamilton cured Dropsies with it in the year 1781.
I am informed by my very worthy friend Dr. Duncan, that Dr. Hamilton, who learnt its use from Dr. Hope, has employed it very frequently in the Hospital at Edinburgh. Dr. Duncan also tells me, that the late very ingenious and accomplished Mr. Charles Darwin, informed him of its being used by his father and myself, in cases of Hydrothorax, and that he has ever since mentioned it in his lectures, and sometimes employed it in his practice.
At length, in the year 1783, it appeared in the new edition of the Edinburgh Pharmacopoeia into which, I am told, it was received in consequence of the recommendation of Dr. Hope. But from which, I am satisfied, it will be again very soon rejected, if it should continue to be exhibited in the unrestrained manner in which it has heretofore been used at Edinburgh, and in the enormous doses in which it is now directed in London.
In the foliowing cases the reader will find other diseases besides dropsies; particularly several cases of consumption. I was induced to try it in these, from being told, that it was much used in the West of England, in the Phthisis Pulmonalis, by the common people. In this disease, however, in my hands, it has done but little service, and yet I am disposed to wish it a further trial, for in a copy of Parkinson's Herbal, which I saw about two years ago, I found the following manuscript note at the article Digitalis, written, I believe, by a Mr. Saunders, who practised for many years with great reputation as a surgeon and apothecary at Stourbridge, in Worcestershire.
"Consumptions are cured infallibly by weak decoction of Foxglove leaves in water, or wine and water, and drank for constant drink. Or take of the juice of the herb and flowers, clarify it, and make a fine syrup with honey, of which take three spoonfuls thrice in a day, at physical hours. The use of these two things of late has done, in consumptive cases, great wonders. But be cautious of its use, for it is of a vomiting nature. In these things begin sparingly, and increase the dose as the patients strength will bear, least, instead of a sovereign medicine, you do real damage by this infusion or syrup."
The precautions annexed to his encorniums of this medicine, lead one to think that he has spoken from his own proper experience.
I have lately been told that a person in the neighbourhood of Warwick, possesses a famous family receipt for the dropsy, in which the Foxglove is the active medicine; and a lady from the western part of Yorkshire assures me, that the people in her country often cure themselves of dropsical complaints by drinking Foxglove tea. In confirmation of this, I recollect about two years ago being desired to visit a travelling Yorkshire tradesman. I found him incessantly vomiting, his vision indistinct, his pulse forty in a minute. Upon enquiry it came out, that his wife had stewed a large handful of green Foxglove leaves in half a pint of water, and given him the liquor, which he drank at one draught, in order to cure him of an asthmatic affection. This good woman knew the medicine of her country, but not the dose of it, for her husband narrowly escaped with his life.
It is probable that this rude mode of exhibiting the Foxglove has been more general than I am at present aware of; but it is wonderful that no author seems to have been acquainted with its effects as a diuretic.
In which the Digitalis was given by the Direction of the Author.
It was in the course of this year that I began to use the Digitalis in dropsical cases. The patients were such as applied at my house for advice gratis. I cannot pretend to charge my memory with particular cases, or particular effects and I had not leisure to make notes. Upon the whole, however, it may be concluded, that the medicine was found useful, or I should not have continued to employ it.
December 8th. A man about fifty years of age, who had formerly been a builder, but was now much reduced in his circumstances, complaind to me of an asthma which first attacked him about the latter end of autumn. His breath was very short, his countenance was sunken, his belly large; and, upon examination, a fluctuation in it was very perceptibie. His urine for some time past had been small in quantity. I directed a decoction of Fol. Digital. recent. which made him very sick, the sickness recurring at intervals for several days, during which time he made a large quantity of water. His breath gradually drew easier, his belly subsided, and in about ten days he began to eat with a keen appetite. He afterwards took steel and bitters.
January 14th. A poor man labouring under an ascites and anasarca, was directed to take a decoction of Digitalis every four hours. It purged him smartly, but did not relieve him. An opiate was now ordered with each dose of the medicine, which then aaed upon the kidneys very freely, and he foon lost all his complaints.
March 15th. A poor boy, about nine years of age, was brought for my advice. His countenance was pale, his pulse quick and feeble, his body greatly emaciated, except his belly, which was very large, and, upon examination, contained a fluid. The case had been considered as arising from worms. He was directed to take the decoction of Digitalis night and morning. It operated as a diuretic, never made him sick, and he got well without any other medicine.
Withering reports here 70 more cases of outpatients an inpatients, whose therapy he directly supervised, plus over 50 more from his colleagues and correspondents. These were fundamental for the evaluation of his work in the XVIII century, but nowadays make quite a monotonous reading and have been omitted from the present transcription. Withering's conclusions from such a large collection of successes and failures of Digitalis, are reported below.
OF THE FOXGLOVE.
Every part of the plant has more or less of the fame bitter taste, varying, however, as to strength, and changing with the age of the plant and the seafon of the year.
ROOT. - This varies greatly with the age of the plant. When the stem has shot up for flowering, which it does the second year of its growth, the root becomes dry, nearly tasteless, and inert.
Some practitioners, who have used the root, and been so happy as to cure their patients without exciting sickness, have been pleased to communicate the circumstance to me as an improvement in the use of the plant. I have no doubt of the truth of their remarks, and I thank them. But the case of Dr. Cawley puts this matter beyond dispute. The fact is, they have fortunately happened to use the root in its approach to its inert state, and consequently have not overdosed their patients. I couuld if necessary, bring other proof to shew that the root is just as capable as the leaves, of exciting nausea.
STEM. - The stem has more taste than the root has, in the season the stem shoots out, and less taste than the leaves. I do not know that it has been particularly selected for use.
LEAVES. - These vary greatly in their efficacy at different seasons of the year, and, perhaps, at different stages of their growth; but I am not certain that this variation keeps pace with the greater or lesser intensity of their bitter taste.
Some who have been habituated to the use of the recent leaves, tell me, that they answer their purpose at every season of the year; and I believe them, notwithstanding I myself have found very great variations in this respect. The solution of this difficulty is obvious. They have used the leaves in such large proportion, that the doses have been sufficient, or more than sufficient, even in their most inefficacious state. The Leaf-stalks seem, in their sensible properties, to partake of an intermediate state between the leaves and the stem.
FLOWERS. - The petals, the chives, and the pointal have nearly the taste of the leaves, and it has been suggested to me, by a very sensible and judicious friend, that it might be well to fix on the flower lor internal use. I see no objection to the proposition; but I have not tried it.
SEEDS. - These I believe are equaliy untried.
From this view of the different parts of the plant, it is sufficiently obvious why I still continue to prefer the leaves.
These should be gathered after the flowering stem has shot up, and about the time that the blossoms are coming forth.
The leaf-stalk and mid-rib of the leaves should be rejected, and the remaining part should be dried, either in the sun-shine, or on a tin pan or pewter dish before a fire.
If well dried, they readily rub down to a beautiful green powder, which weighs something less than one-fifth of the original weight of the leaves. Care must be taken that the leaves be not scorched in drying, and they should not be dried more than what is requisite to allow of their being readily reduced to powder.
I give to adults, from one to three grains of this powder twice a day. In the reduced state in which physicians generally find dropsical patients, four grains a day are sufficient. I sometimes give the powder alone; sometimes unite it with aromatics, and sometimes form it into pilis with a sufficient quantity of soap or gum ammoniac.
If a liquid medicine be preferred, I order a dram of these dried leaves to be infused for four hours in half a pint of boiling water, adding to the strained liquor an ounce of any spirituous water. One ounce of this infusion given twice a day, is a medium dose far an adult patient. If the patient be stronger than usual, or the symptoms very urgent, this dofse may be given once in eight hours; and on the contrary in many instances half an ounce at a time will be quite sufficient. About thirty grains of the powder or eight ounces of the infusion, may generally be taken before the nausea commences.
The ingenuity of man has ever been fond of exerting itfelf to vary the forms and combinations of medicines. Hence we have spirituous, vinous, and acetous tinctures; extracts hard and soft, syrups with sugar or honey, &c. but the more we multiply the forms of any medicine, the longer we shall be in ascertaining its real dose. I have no lasting objection however to any of these formulae except the extract, which, from the nature of its preparation must ever be uncertain in its effects; and a medicine whose fullest dose in substance does not exceed three grains, cannot be suppofed to stand in need of condensation.
It appears from several of the cases, that when the Digitalis is disposed to purge, opium may be joined with it advantageously; and when the bowels are too tardy, jalap may be given at the same time, without interfering with its diuretic effets; but I have not found benefit from any other adjunct.
From this view of the doses in which the Digitalis really ought to be exhibited, and from the evidence of many of the cases, in which it appears to have been given in quantities six, eight, ten or even twelve times more than necessary, we must admit as an inference either that this medicine is perfectly safe when given as I advise, or that the medicines in daily use are highly dangerous.
The Foxglove when given in very large and quickly-repeated doses, occasions sickness, vomiting, purging, giddiness, confused vision, objects appearing green or yellow; increased secretion of urine, with frequent motions to part with it, and sometimes inability to retain it; slow pulse, even as slow as 35 in a minute, cold sweats, convulsions, syncope, death.(notes: d)
When given in a less violent manner, it produces most of these effects in a lower degree; and it is curious to observe, that the sickness, with a certain dose of the medicine, does not take place for many hours after its exhibition has been discontinued; that the flow of urine will often precede, sometimes accompany, frequently follow the sickness at the distance of some days, and not unfrequently be checked by it. The sickness thus excited, is extremely different from that occasioned by any other medicine; it is peculiarly distressing to the patient; it ceases, it recurs again as violent as before; and thus it will continue to recur for three or four days, at distant and more distant intervals.
These sufferings of the patient are generally rewarded by a return of appetite, much greater than what existed before the taking of the medicine.
But these sufferings are not at all necessary; they are the effects of our inexperience, and would in similar circumstances more or less attend the exhibition of almost every active and powerful medicine we use.
Perhaps the reader will better understand how it ought to be given, from the following detail of my own improvement, than from precepts peremptorily delivered, and their source veiled in obscurity.
At first I thought it necessary to bring on and continue the sickness, in order to ensure the diuretic effects.
I soon learnt that the nausea being once excited, it was unnecessary to repeat the medicine, as it was certain to recur frequently, at intervals more or less distant.
Therefore my patients were ordered to persist until the nausea came on, and then to stop. But it soon appeared that the diuretic effects would often take place first, and sometimes be checked when the sickness or a purging supervened.
The direction was therefore enlarged thus - Continue the medicine until the urine flows, or sickness or purging take place.
I found myself safe under this regulation for two or three years; but at length cases occurred in which the pulse would be retarded to an alarming degree, without any other preceding effect.
The directions therefore required an additional attention to the state of the pulse, and it was moreover of consequence not to repeat the doses too quickly, but to allow sufficient time for the effects of each to take place, as it was found very possible to pour in an injurious quantity of the medicine, before any of the signals for forbearance appeared.
Let the medicine therefore be given in the doses, and at thee intervals mentioned above: - let it be continued until it either acts on the kidneys, the stomach, the pulse or the bowels; let il be stopped upon the first appearance of any one 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.
If it purges, it seldom succeeds well.
The patients should be enjoined to drink very freely during its operation. I mean, they should drink whatever they prefer, and in as great quantity as their appetite for drink demands. This direction is the more necessary, as they are very generally prepossessed with an idea of drying up a dropsy, by abstinence from liquids, and fear to add to the disease, by indulging their inclination to drink.
In cases of ascites and anasarca; when the patients are weak, and the evacuation of the water rapid; the use of proper bandage is indispensably necessary to their safety.
If the water should not be wholly evacuated, it is best to allow an interval of several days before the medicine be repeated, that food and tonics may be administered; but truth compels me to say, that the usual tonic medicines have in these cases very often deceived my expectations.
From some cases which have occurred in the course of the present year, I am disposed to believe that the Digitalis may be given in small doses, viz. two ar three grains a day, so as gradually to remove a dropsy, without any other than mild diuretic effects, and without any interruption to its use until the cure be compleated.
If inadvertently the doses of the Foxglove should be prescribed 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 may perhaps in time be discovered. The usual cordials and volatiles are generally rejected from the stomach; aromatics and strong bitters are longer retained; brandy will sometimes remove the sickness when only slight; I have sometimes thought small doses of opium useful, but I am more confident of the advantage from blisters. Mr. Jones (Page 135) in one case, found mint tea to be retained longer than other things.
Independent of the degree of disease, or of the strength or age of the patient, I have had occasion to remark, that there are certain constitutions favourable, and others unfavourabie to the success of the Digitalis.
From large experience, and attentive observation, I am pretty well enable 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 fibre, of warm skin, of florid complexion, or in those with a tight and cordy pulfe.
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.
In cases which foil every attempt at relief, I have been aiming, for some time past, to make such a change in the constitution of the patient, as might give a chance of success to the Digitalis.
By blood-letting, by neutral salts, by chrystals of tartar, squills, and occasional purging, I have succeeded, though imperfectly. Next to the use of the lancet, I think nothing lowers the tone of the system more effectually than the squill, and consequently it will always be proper, in such cases, to use the squill; for if that fail in its defired effect,it is one of the best preparatives to the adoption of the Digitalis.
A tendency to paralytic affections, or a stroke of the palsy having actually taken piace, is no objection to the use of the Digitalis; neither does a stone existing in the bladder forbid its use. Theoretical ideas of sedative effects in the former, and apprehensions of its excitement of the urinary organs in the latter case, might operate so as to make us with-hold relief from the patient; but experience tells me, that such apprehensions are groundless.
To prevent any improper influence, which the above recitals of the efficacy of the medicine, aided by the novelty of the subject, may have upon the minds of the younger part of my readers, in raising their expectations to too high a pitch, I beg leave to deduce a few inferences, which I apprehend the facts will fairly fupport.
I. That the Digitalis will not universally act as a diuretic.
II. That it does do so more generally than any ather medicine.
III. That it will often produce this effect after every other probable method has been fruitlessly tried.
IV. That if this fails, there is but little chance of any other medicine succeeding.
V. That in proper doses, and under the management now pointed out, it is mild in its operation, and gives less disturbance to the system, than squill or almost any other active medicine.
VI. That when dropsy is attended by palsy unsound viscera, great debility, or other complication of disease, neither the Digitalis, nor any other diuretic can do more than obtain a truce to the urgency of the symptoms; unless by gaining time, it may afford opportunity for other medicines to combat and subdue the original disease.
VII. That the Digitalis may be used with advantage in every species of dropsy, except the encysted.
VIII. That it may be made subservient to the cure of diseases, unconnected with dropsy.
IX. 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.
The following remarks consist partly of matter of fact, and partly of opinion. The former will be permanent; the latter must vary with the detetion of error, or the improvement of knowledge. I hazard them with diffidence, and hope they will be examined with candour; not by a contrast with other opinions, but by an attentive comparison with the phoenomena of disease.
2. When the abdominal viscera in general are greatly enlarged, which they sometimes are, without effused fluid in the cavity of the abdomen; the disease is incurable. After death, the more solid viscera are found very large and pale. If the cavity contains water, that water may be removed by diuretics.
3. In swollen legs and thighs, where the resistance to pressure is considerable, the tendency to transparency in the skin is not obvious, and where the alteration of posture occasions but little alteration in the state of distension, the cure cannot be effected by diuretics.
Is this difficulty of cure occasioned by spissitude in the effused fluids, by want of proper communication from cell to cell, or is the disease rather caused by a morbid growth of the solids, than by an accumulation of fluid?
Is not this disease in the limbs similar to that of the viscera (2)?
4. Anasarcous swellings often take place in palsied limbs, in arms as well as legs; so that the swelling does not depend merely upon position.
5. Is there not cause to suspect that many dropsies originate from paralytic affections of the lymphatic absorbents? And if so, is it not probable that the Digitalis, which is so effectual in removing dropsy, may also be used advantageously in some kinds of palsy?
In every other situation the disease yields to diuretics and tonics.
10. In the greater part of what are called asthmatical cases, the real disease is anasarca af the lungs, and is generally to be cured by diuretics. (See 1) This is almost always combined with some swelling of the legs.
11. There is another kind of asthma, in which change of posture does not much affect the patient. I believe it to be caused by an infarction of the lungs. It is incurabile by diuretics; but it is often accompanied with a degree of anasarca, and so far it admits of relief.
Is not this disease fimilar to that in the limbs at (3) and also to that of the abdominal viscera at (2)?
It has seldom happened to me to be called upon in the earlier stages of this complaint, and the symptoms are first so similar to those usually attendant upon dentition and worms, that it is very difficult to pronounce decidedly upon the real nature of the disease; and it is rather from the failure of the usual modes of relief, than from any other more decided observation that we at length dare to give it a name.
At first the febrile symptoms are sometimes so unsteady, that I have known them mistaken for the symptoms of an intermittent, and the cure attempted by bark.
In the more advanced stages, the diagnostics obtrude themselves upon our notice, and put the situation of the patient beyond a doubt. But this does not always happen. The variations of the pulse, so accurately described by the late Dr. Whytt, do not always ensue. The dilatation of the pupils, the squinting, and the aversion to light, do not universally exist.The screaming upon raising the head from the pillow or the lap, and the flushing of the cheeks, I once considered as affording indubitable marks of the disease; but a child which I sometime since attended with Dr. Ash, the pulse was uniformly about 85 (except during the first week, before we had the care of the patient). The child never shewed any aversion to the light; never had dilated pupils, never squinted, never screamed when raised from the lap or taken out of the bed, nor did we observe any remarkable flushing of the cheeks; and the sleep was quiet, but sometimes moaning.
Frequent vomiting existed from the first, but ceased for several days towards the conclusion. One or two worms came away during the illness and it was all along difficult to purge the child. Trhree days before death, the right side became lightly paralytic, and the pupil of that eye somewhat dilated.
After death, about two ounces and a half of water were found in the ventricles of the brain, and the vessels of the dura mater were turgid with blood.
If I am right as to the nature of hydrocephalus, that it is at first dependant upon inflammation, or congestion; and that the water in the ventricles is a confequence, and not a cause of the disease; the curative intentions ought to be extremely different in the first and the last stages.
It happens very rarely that I am called to patients at the beginning, but in two instances wherein I was called at first the patients were cured by repeated topical bleedings, vomits, and purges.
Some years ago I mentioned these opinions, and the success of the pratice resulting from them, to Dr. Quin, now physician at Dublin. That gentle man had lately taken his degree, and had chosen hydrocephalus for the subject of his thesis in the year 1779. In this very ingenious essay, which he gave me the same morning, I was much pleased to find that the author had not only held the same ideas relative to the nature of the disease, but had also confirmed them by dissections.
In the year 1781, another case in the first stage demanded my attention. The reader is referred back to case LXIX for the particulars.
I have not yet been able to determine whether the Digitalis can or cannot be used with advantage in the second stage of the hydrocephalus. In case XXXIII the symptoms of death were at hand; in case LXIX the practice, though successful was too complicated, and in case CLI the medicine was certainly stopped too soon.
When we consider what enormous quantities of mercury may be used in this complaint, without affecting the salivary glands it seems probable that other parts may be equally insensible to the action of their peculiar stimuli, and therefore that the Digitalis ought to be given in much larger doses in this, than in other diseases.
The intermitting pulse, and pain in the arms, sufficiently distinguish this disease from asthma, and from anasarcous lungs.
It is very universally cured by the Digitalis.
19. I lately met with two cases which had been considered and treated as angina pectoris. They both appeared to me to be cases of hydrothorax. One subject was a clergyman, whose strength had been so compleatly exhausted by the continuance of the disease, and the attempts to relieve it, that he did not survive many days. The other was a lady, whose time of life made me suspect effusion. I directed her to take small doses of the pulv. Digitalis, which in eight days removed all her complaints. This happened six months ago, and she remains perfectly well.
21. Dropsies in the chest either with or without anasarcous limbs, are much more curable than those of the belly. Probably because the abdominal viscera are more frequently diseased in the latter than in the former cases.
23. Where appearances of anasarca point out the true cause of the complaint, as in cases XXIV, and XXXIV the happiest effects may be expected from the Digitalis; and men of more experience than myself in cases of insanity, will probably employ it successfully in other less obvious circumstances.
26. The ovarium dropsy is generally slow in its progress; for a considerable time the patient though somewhat emaciated, does not lose the appearance of health and the urine flows in the usual quantity. It is seldom that the practitioner is called in early enough to distnguish by the feel on which side the cyst originated, and the patients do not attend to that circumstance themfelves. They generally menstruate regularly in the incipient state of the disease, and it is not until the pressure from the sac becomes very great, that the urinary fecretion diminishes. In this species of dropsy, the patients, upon being questioned, acknowledge even from a pretty early date, pains in the upper and inner parts of the thighs, similar to those which women experience in a state of pregnancy. These pains are for a length of time greater in one thigh than in the other, and I believe it will be found that the disease originated on that side.
27. The ovarium dropsy defies the power of medicine. It admits of relief, and sometimes of a cure, by tapping. I submit to the confideration of pratitioners, how far we may hope to cure this disease by a seton or a caustic. In the LXIst case the patient was too much reduced, and the disease too far advanced to allow of a cure by any method; but it teaches us that a caustic may be used with safety.
28. When tapping becomes necessary, I always advise the adoption of the waistcoat bandage or belt, invented by the late very justly celebrated Dr. Monro, and described in the first volume of the Medical Essays. I also enjoin my patients to wear this bandage afterwards, from a persuasion that it retards the return of the disease. The proper use of bandage, when the disorder first discovers itfelf, certainly contributes much to prevent its increase.
31. The younger part of the female sex are liable to a disease very much resembling a true consumption, and from which it is difficult to distinguish it; but this disease is curable by steel and bitters. A criterion of true phthisis has been sought for in the state of the teeth; but the exceptions to that rule are numerous. An unusual dilatation of the pupil of the eye, is the most certain characteristic. (notes: f)
32. Sydenham asserts, that the bark did not more certainy cure an intermittent, than riding did a confumption. We must not deny the truth of an assertion, from such authority, but we must conclude that the disease was more easily curable a century ago than it is at present.
33. If the Digitalis is no longer useful in consumptive cases, it must be that I know not how to manage it, or that the disease is more fatal than formerly; for it would be hard to deny the testimony cited at page 9. I wish others would undertake the enquiry.
34. When phthisis is accompanied with anasarca, or when there is reason to suspect hydrothorax, the Digitalis will often relieve the sufferings, and prolong the life of the patient.
35. Many years ago, during an attendance upon Mr. B., of a consumptive family, and himself in the last stage of a phthisis; after he was so ill as to be confined to his chamber, his breathing became so extremely difficult and distressing, that he wished rather to die than to live, and urged me warmly to devise some mode to relieve him. Suspecting serous effusion to be the cause of this symptom, and he being a man of sense and resolution, I fully explained my ideas to him, and told him what kind of operation might afford him a chance of relief; for I was then but little acquainted with the Digitalis. He was earnest for the operation to be tried, and with the assistance of Mr. Parrott, a very respectable surgeon of this place, I got an opening made between the ribs upon the lower and hinder part of the thorax. About a pint of fluid was immediately discharged, and bis breath became easy. This fluid coagulated by heat.
After some days a copious purulent discharge issued from the opening, his cough became less troublefome, his expectoration less copious, his appetite and strength returned, he got abroad, and the wound, which became very troublesome, was allowed to heal
He then undertook a journey to London; whilst there he became worse: returned home, and died consumptive some weeks afterwards.
37. This species of dropsy may originate from other causes than child birth. In the beginning of last March, a gentleman at Wolverhampton desired my advice for very large and painful swelled legs and thighs. He was a temperate man not of a dropsical habit, had great pain in his groins, and attributed his complaints to a fall from his horse. He had taken diuretics, and the strongest drastic purgatives with very little benefit. Considering the anasarca as caused by the diseased inguinal glands, I ordered common poultice and mercurial ointment to the groins, three grains of pulv. fol. Digitalis night and morning, and a cooling diuretic decoction in the day-time. He soon lost his pain, and the swellings gradually subsided.
(a) Verbascum of Linnaeus
(b) The trivial name purpurea is not a very happy one, for the blossoms, though generally purple, are someimes of a pure white.
(c) See the extract from this letter a page 5.
(d) I am doubtful whether it does not sometimes excite a copious flow of saliva. See cases at pages 115 154, and 155.
(e) See an original and valuable treatise by Dr. Fowler, entitled Medical Reports of the Effects of Tobacco.
(f) Many years ago I communicated to my friend, Dr. Percival, an account of some trials of breathing fixed air in consumptive cases. The results were published by him in the second Vol. of his very useful Essays Medical and Experimental, and have since been copied into other publications. I take this opportunity of acknowledging that I fuspect myself to have been mistaken in the nature of the disease there mentioned to have been cured. I believe it was a case of Vomica, and not a true Phthisis that was cured. The Vomica is almost always curable. The fixed air corrects the smell of the matter, and very shortly removes the hectic fever. My patients not only inspire it, but I keep large jars of the effervescing mixture constantly at work in their chambers.