Part 9

This is the second time that I have relieved this patient by the infusion of Foxglove. I used the same proportion of the fresh leaves the first time as I did of the dried ones the last. The violent vomiting which followed the use of the infusion made with the dried leaves, did not take place with the fresh though she took near a pint made with the same proportion of the herb fresh gathered.

REMARKS.

The above is a very instructive case, as it teaches us how small a quantity of the infusion was necessary to effect every desirable purpose. At first sight it may appear from the concluding paragraph, that the green leaves ought to be preferred to the dried ones, as being so much milder in their operation; but let it be noticed, that the same quantity of infusion was prepared from the same weight of the green as of the dried leaves, and consequently, as will appear hereafter, the infusion with the dried leaves was five times the strength of that before prepared from the green ones. We need not wonder, therefore, that the effects of the former were so disagreeable, when the dose was five times greater than it ought to have been. But what makes this matter still more obvious, is the mistake mentioned at first, of two tea spoonfuls only being given for a dose. Now a tea spoonful, containing about a fourth or a fifth part of the contents of a table spoon, the dose then given, was very nearly the same as that which had before been taken of the infusion of the green leaves, and it produced precisely the same effects for it increased the urinary discharge, without exciting the violent vomiting.

Letter from Doctor JOHNSTONE, Physician, in Birmingham.

Dear SIR,

The following cases are selected from many others in which I have given the Digitalis purpurea; and from repeated experience of its efficacy after other diuretics have failed. I can recommend it as an effectual, and when properly managed, a safe medicine.

I am, &c. E. JOHNSTONE.

Birmingham, May 26, 1785.

_March_ 8th, 1783, I was called to attend Mr. G----, a gentleman of a robust habit, who had led a regular and temperate life, Æt. 68. He was affected with great difficulty of respiration, and cough particularly troublesome on attempting to lie down, oedematous swellings of the legs and thighs, abdomen tense and sore on being pressed, pain striking from the pit of the stomach to the back and shoulders; almost constant nausea, especially after taking food, which he frequently threw up; water thick and high-coloured, passed with difficulty and in small quantity; body costive; pulse natural; face much emaciated, eyes yellow and depressed. He had been subject to cough and difficulty of breathing in the winter for several years; and about four years before this time, after being exposed to cold, was suddenly deprived of his speech and the use of the right side, which he recovered as the warm weather came on; but since that time had been remarkably costive, and was in every respect much debilitated. He first perceived his legs swell about a year ago; by the use of medicines and exercise, the swellings subsided during the summer, but returned on the approach of winter, and gradually increased to the state in which I found them, notwithstanding he had used different preparations of squills and a great variety of other diuretic medicines. I ordered the following mixture.

R. Foliorum Digitalis purpur. recent. [Symbol: dram]iii. decoque ex aq. fontan. [Symbol: ounce]xii ad [Symbol: ounce]vi colaturæ adde Tinctur. aromatic.

Syr. zinzib. aa [Symbol: ounce]i. m. capt. cochl. duo larga secunda quaque hora ad quartam vicem nisi prius nausea supervenerit.

_March_ 9th. He took four doses of the mixture without being in the least sick, and made, during the night upwards of two quarts of natural coloured water.

10th. Took the remainder of the mixture yesterday afternoon and evening, and was sick for a short time, but made nearly the same quantity of water as before, the swellings are considerably diminished, his appetite increased, but he is still costive.

R. Argent, viv. balsam peruv. aa [Symbol: dram]ss tere ad extinctionem merc. et adde gum. ammon. [Symbol: scruple]iii aloes socotorin. [Symbol: dram]ss rad. scil. recent. [Symbol: scruple]ss syr. simpl. q. s. f. mass. in pil. xxxii divid. cap. iii. bis in die.

14th. Continues to make water freely. The swellings of his legs have gradually decreased; soreness and tension of the abdomen considerably less.

Omittant. pil. cap. mistur. c. decoct. Digitalis. &c. 3tia quaque hora ad 3tiam vicem.

15th. Made a pint and a half of water last night, without being in the least sick, and is in every respect considerably better. Repet. Pillul. ut antea.

21st. Makes water as usual when in health, and the swellings are entirely gone.

R. Infus. amar. [Symbol: ounce]v. tinctur. Rhei spirit. [Symbol: ounce]ii. spirit vitriol. dulc. [Symbol: dram]ii. syr. zinzib. [Symbol: dram]vi. m. cap. cochl. iii. larg. ter in die.

He soon gained sufficient strength to enable him to go a journey, and returned home in much better health than he had been from the time he was affected with the paralytic stroke, and excepting some return of his asthmatic complaint in the winter, hath continued so ever since.

CASE II.

R---- Howgate, a man much addicted to intemperance, particularly in the use of spirituous liquors, Æt. 60, was admitted into the Hospital near Birmingham, _May_ 17, 1783. He complained of difficulty of breathing, attended with cough, particularly troublesome on lying down; drowsiness and frequent dozing, from which he was roused by startings, accompanied with great anxiety and oppression about the breast; oedematous swellings of the legs; constant desire to make water, which he passed with difficulty, and only by drops; pulse weak and irregular; body rather costive; face much emaciated; no appetite for food.--Cap. pil. scil. iii. ter in die.[6]

[Footnote 6: R. Rad. scil. recent. sapon. castiliens. pulv. Rhei opt. aa. [Symbol: scruple]i. ol. junip. gutt. xvi. syr. bals. q. s. f. mass. in pil. xxiv. divid.]

_May_ 20th. The pills have had no effect.--Cap. mistur. c.[7] Decoct. Digital. &c. cochl. ii. larg. 3tia quaque hora, ad 3tiam vicem.

[Footnote 7: Prepared in the same manner as in the former case.]

_May_ 21st. Made near two quarts of water in the night, without being in the least sick. He continued the use of the mixture three times in the day till the 30th, and made about three pints of water daily, by which means the swellings were entirely taken away; and his other complaints so much relieved, that on the 6th of June he was dismissed free from complaint, except a slight cough. But returning to his old course of life, he hath had frequent attacks of his disorder, which have been always removed by using the Digitalis.

Extract of a letter from Mr. LYON, Surgeon, at Tamworth.

--Mr. Moggs was about 54 years of age, his disease a dropsy of the abdomen, attended with anasarcous swellings of the limbs, &c. brought on by excessive drinking. I believe the first symptoms of the disease appeared the beginning of November, 1776; the medicines he took before you saw him, were squills in different forms, sal diureticus and calomel, but without any good effect; he begun the Digitalis on the 10th of July 1777; a few doses of it caused a giddiness in the head, and almost deprived him of sight, with very great nausea, but very little vomiting, after which a considerable flow of urine ensued, and in a very short time, a very little water remained either in the cavity of the abdomen, or the membrana adiposa, but he remained excessive weak, with a fluttering pulse at the rate of 150 or frequently 160 in a minute; he kept pretty free from water for upwards of twelve months; it then collected, and neither the Digitalis nor any other medicine would carry it off. I tapped him the 2d of August 1779 in the usual place, and took some gallons of water from him, but he very soon filled again, and as he had a very large rupture, a considerable quantity of the water lodged in the scrotum, and could not be got away by tapping in the usual place. I therefore (on the 28th of the same month) made an incision into the lower part of the scrotum, and drained off all the water that way, but he was so very much reduced, that he died the 8th or 9th of _September_ following, which was about two years and two months after he first begun the Digitalis.

I have had several dropsical patients relieved, and some perfectly recovered by the Digitalis, since you attended Mr. Moggs, but as I did not take any notes or make any memorandums of them, cannot give you any of them.

Communications from Dr. STOKES, Physician, in Stourbridge.

Dear SIR,

I accept with pleasure your invitation to communicate what I know respecting the properties of _Digitalis_; and if an account of what others had discovered before you,[8] with a detail of my own experience, shall be allowed the merit of at least a well meant acknowledgment, for the early communication you were so kind to make me, of the valuable properties you had found in it; I shall consider my time as well employed. A knowledge of what has been already done is the best ground work of future experiment; on which account I have been the more full on this subject, in hopes that given with the cautions which you mean to lay down in the cure of dropsies, it may prove alike useful in that of other diseases, one of which stands foremost among the _opprobria_ of medicine.

[Footnote 8: See this account in the Introduction.]

CASE I.

Mrs. M----. Orthopnea, pain, and excessive oppression at the bottom of the sternum. Pulse irregular, with frequent intermissions. Appetite very much impaired. Legs anasarcous.

_Empl. vesicator. pectori dolent._ _Infus. Digital. e [Symbol: dram]iii. ad. aq. &c. [Symbol: ounce]viii. cochl. j. o. h. donec nausea excitetur vel diuresis satis copiosa proveniat._

I ordered it of the above strength, and to be repeated often, on account of the great emergency of the case, but the nausea excited by the first dose prevented its being given at such short intervals. A 3d dose I found had been given, which was followed by vomitings. All her complaints gradually abated, but in about a fortnight recurred, notwithstanding the use of infus. amar. &c.

_Dec. 2. Infus. Digit. e. [Symbol: dram]iss ad aq. &c. [Symbol: ounce]viii. cochl. ii. horis &c. u. a._

Complaints gradually abated, swellings of the legs nearly gone down.

About a month afterwards you was desired to visit this patient.[9]

[Footnote 9: For reasons assigned at p. 100, I did not intend to introduce any case, occurring under my own inspection, in the course of the present year; but it may be satisfactory to continue the history of this disease, as Dr. Stokes's narrative would otherwise be incomplete.

1785.

CASE.

_Jan._ 5th. Mrs. M----, Æt. 48. Hydrothorax and anasarcous legs, of eight months duration. She had taken jallap, squill, salt of tartar, and various other medicines. I found her in a very reduced state, and therefore directed only a grain and half of the Pulv. Digital. to be given night and morning. This in a few days encreased the secretion of urine, removed her difficulty of breathing, and reduced the swelling of her legs, without any disturbance to her system.

Three months afterwards, a severe attack of gout in her legs and arms, removing to her head, she died.

Dr. Stokes had an opportunity of examining the dead body, and I had the satisfaction to learn from him, that there did not appear to have been any return of the dropsy.]

On the examination of the body I noticed, among others, the following appearances.

About ¾ oz. of bloody water flowed out, on elevating the upper half of the scull, and a small quantity also was found at the base.

BRAIN. Blood-vessels turgid with blood, and many of those of considerable size distended with air.

A very slight watery effusion between the _Pia Mater_ and _Tunica arachnoidea_. About ¾ oz. of watery fluid in the _lateral ventricles_.

THORAX. In the left cavity about 4 oz. of bloody serum; in the right but little. Lungs, the hinder parts loaded with blood. Adhesions of each lobe to the pleura. _Pericardium_ containing but a very small quantity of fluid. _Heart_ containing no coagula of blood. _Valves of the Aorta_ of a cartilaginous texture, as if beginning to ossify.

_Abdominal Viscera_ natural, and a profusion of _Fat_ under the integuments of the abdomen and thorax, in the former to the thickness of an inch and upwards, and in very considerable quantity on the mesentery, omentum, kidneys, &c.

OBS. The intermitting pulse should seem to have been owing to effusions of water in some of the cavities of the breast, as it disappeared on the removal of the waters.

CASE II.

Mrs. C---- of K----, Æt. 80. Orthopnoea, with sense of oppression about the proecordia. Unable to lie down in bed for some nights past. Anasarca of the lower extremities. Urine very scanty. Complaints of six weeks standing. Had taken _sal. diuret. c. ol. junip.--Calom. c. jalap, et gambog.--Et ol. junip. c. ol. Terebinth._ without effect.

_Feb._ 7. _Infus. Digital. e. [Symbol: dram]iii. ad aq. &c. [Symbol: ounce]viii. cochl. ii. 4tis horis._ Ordered to drink largely of _infus. baccar. junip._ The third dose produced great nausea which continued ten hours, during which time the urine made was about a quart. The next day her apothecary directed her to begin again with it. The second dose produced vomiting. During the next twenty hours she made two quarts of water, about four times as much as she drank.

From this time she took no more of the _infus. Digital._ but continued the _inf. bacc. junip._ until about _March_ 2d, when all the swellings were gone down, her respiration perfectly free, and she herself quite restored to her former state of health. On the 29th she had an attack of jaundice which was some time after removed; since which she has enjoyed a good state of health, excepting that for some little time past her ancles have been slightly oedematous, which will I trust soon yield to strengthening medicines.

CASE III.

Mrs. M---- G----, Æt. 64. Has had sore legs for these thirty-four years past. Orthopnoea. Sense of oppression at the proecordia. Pulse intermitting. Legs anasarcous. Urine scanty, high-coloured.

_Infus. Digital. c. [Symbol: dram]iss ad aq. bull. [Symbol: ounce]viii. cochl. ii. 4tis horis._

Took six doses, when nausea was excited. Urine a quart during the course of the night. The flow of urine continued, and complaints relieved. Sal. Mart. c. extr. gent. and afterwards with the addition of extr. cort. for which last ingredient she had a predilection, confirmed the cure.

On the same day the next year I was called in to her for a similar train of symptoms, excepting that the pulse was but just perceptibly irregular.

_Infus. Digital. u. a. præscript._

The directions on the phial not being attended to, _two doses of it were given after a nausea had been excited_, which, with occasional vomitings, became exceedingly oppressive. A saline draught, given in Dr. Hulme's method, a draught _sal. c. c. gr. xii. c. conf. card. gr. x._ produced no immediate effect, but the nausea gradually abating, inf. bacc. junip. was ordered; but this appeared to augment it, and a great propensity to sleep coming on, I directed _sal. c. c. conf. card, aa gr. viii. 4tis horis_, which removed the unpleasant symptoms and _myrrh. c. sal. mart._ completed the cure. During the use of the above medicines, the urine was augmented, and the pulmonary complaints removed, even before the nausea left her; and the sores of her legs which were much inflamed before she began with the infus. Digital. in a day's time assumed a much healthier appearance, and on her other complaints going off, they shewed a greater tendency to heal than she had ever observed in them for twenty years before. This instance is a very pleasing confirmation of the experience of Hulse and Dr. Baylies, and of the advantage to be derived from a medicine, which, while it helps to heal the ulcers, removes that from the constitution which often renders the healing of them improper.

In one case in which I ordered it, the infusion, instead of digesting three hours as I had directed, was suffered to stand upon the leaves all night. The consequence was that the first dose produced considerable nausea.

The two following cases, with which I have been favoured by a physician very justly eminent, convince me of the necessity there is that every one who discovers a new medicine, or new virtues in an old one, should, in announcing such discoveries, publish to the world the exact manner in which he exhibits such medicines, with all the precautions necessary to obtain the promised success.

In these (says my correspondent) "the infusion was given in small doses, repeated every hour or two, till a nausea was raised, when it was omitted for a day or perhaps two, and then repeated in the same manner.

"An ASCITES emptied by it, but filled again very speedily, though _its use was never discontinued_, and who afterwards found no salutary effects from it. Ended fatally.

"In an ANASARCA it sometimes increased the quantity of urine, and abated the swelling, but which as often returned in as great a degree as before, though _the medicine was still given_, and always increased in quantity so as to excite nausea. Ended fatally.

"I have tried it in many other cases, but found very little difference in the success attending it."

May we not be allowed to conjecture that the inefficacy of _its continued use_ is owing to its narcotic property gradually diminishing the irritability of the muscular fibres of the absorbents, or possibly of the whole vascular system, and thus adding to that weakened action which seems to be the cause of the generality of dropsies, which leads us to caution the medical experimenter against trying it, at least _against its continued use, even in small doses_, in other diseases of diminished energy, as continued fever, palsy, &c.

I remain with the greatest truth,

Your obliged and affectionate friend,

JONATHAN STOKES.

Stourbridge, May 17, 1785.

The three following Hospital Cases, which Dr. STOKES had an opportunity of observing, are related as instances of bad practice, and tend to demonstrate how necessary it is when one physician adopts the medicine of another, that he should also at first rigidly adopt his method.

CASE I.

Esther K----, Æt. 33. General anasarca, ascites, and dyspnoea, of seven months duration.

_Decoct. c Digit. [Symbol: dram]iv. c. aq. [Symbol: pound]i. coquend. ad [Symbol: pound]ss. cap. [Symbol: ounce]i. 2dis. horis._ 1st DAY. 4th dose made her sick. 2d DAY. The first dose she took to-day produced vomiting.

3d DAY. _Minuatur dosis ad [Symbol: ounce]ss._ This stayed upon her stomach, but produced an almost constant sickness. Stools more frequent, water scarce sensibly increased; and her swellings not at all reduced.

4th DAY. _Cap. Calomel. gambog. scill. &c._

OBS. Sufficient time was not allowed to observe its effects, neither was the patient enjoined the free use of diluents. The disease terminated fatally.

CASE II.

William T----, Æt. 42. Ascites, with cough and dyspnoea. Abdomen very much distended. The rest of his body highly emaciated. Urine thick, high coloured, and in very small quantity.

_Decoct. Digit. (u. in Esther K----,) 4tis horis._

1st DAY of taking it. The 4th dose produced sickness.

2d. Vomiting after the second dose.

10th. Urine increased to [Symbol: pound]vi.

11th. Flow of urine continues. Abdomen quite flaccid.

12th. Abdomen not diminished.

15th: A smart purging came on, and the flow of urine diminished.

23d. Belly much bound. Took a cathart. powder, which was followed by a diminution of the abdomen.

29th. To take a cathart. powder every 4th morning, continuing the decoct. Digit.

32d. Urine exceedingly scanty.

35th. _Vin. scill. [Symbol: ounce]ss. o. m. &c._ This produced diuretic effects.

44th. Tapped. Terminated fatally.

OBS. Here the medicine was _continued till it ceased to produce diuretic effects_; and these effects were not aided by any strengthening remedies.

CASE III.

George R----, Æt. 52. Ascites, general anasarca, and dyspnoea. His legs so greatly distended that it was with great difficulty he could draw the one after the other.

_Infus. Digital. [Symbol: dram]iiiss. ad. aq. [Symbol: pound]ss. cap. [Symbol: ounce]i. altern. horis donec nauseam excitaverit._ _Rep. 3tiis diebus. tempore intermedio cap. sol. guaic. [Symbol: ounce]i. ter in die ex inf. sinap._

1st DAY of taking it. Became sickish towards night.

2d DAY. Made a great quantity of water during the night, and spat up a great deal of watery phlegm. The first dose he took in the morning has produced a sickness which has continued all day, but he has never vomited.

3d. DAY. The change in his appearance so great as to make it difficult to conceive him to be the same person. Instead of a large corpulent man, he appeared tall, thin, and rather aged. Breathes freely, and can walk up and down stairs without inconvenience.

4th DAY. _Decoct. bacc. junip. and cyder for common drink._

6th DAY. A second course of his medicine produced a flow of urine almost as plentiful as the former, though he drank little or nothing at the time. In a day or two after he walked to some distance.

12th DAY. _Pot. purgans illico._

14th DAY. _Pot. purg. c. jalap. [Symbol: dram]ss. 4tis diebus._ _Infus. Dig. 3tiis diebus._

17th DAY. _R. Gamb. gr. iii. calom. gr. ii. camph. gr. i. syr. simpl. fiat pil. o. n. sum._ _Infus. Digit. 3tiis diebus._

21st DAY. Made an out-patient. The super-abundant flow of urine continued for the first three days after his last course; but since, the flow of saliva has been nearly equal to that of urine.

The smalls of his legs not quite reduced, and are fuller at night. He has shrunk round the middle from four feet two inches to three feet six inches; and in the calves of his legs, from seventeen inches to thirteen and a half.[10]

[Footnote 10: In the three last recited cases, the medicine was directed in doses quite too strong, and repeated too frequently. If Esther K---- could have survived the extreme sickness, the diuretic effects would probably have taken place, and, from her time of life, I should have expected a recovery. Wm. T---- seems to have been a bad case, and I think would not have been cured under any management. G. R---- certainly possessed a good constitution, or he must have shared the fate of the other two.]

OBS. The waters were here very successfully evacuated, but as you remarked to me, on communicating the case to you at the time, tonic medicines should have been given, to second the ground that had been gained, instead of weakening the patient by drastic purgatives.

A CASE from Mr. SHAW, Surgeon, at Stourbridge.--Communicated by Doctor STOKES.