Chapter 11

G---- A----, a husbandman, aged 57. Was in the year 1782 affected with a slight, but constant pain in his breast, with difficult respiration. His countenance was yellow; the abdomen swelled, and hard; his urine high coloured, and in small quantity; appetite and sleep little. Complained of frequent nausea, and of sudden profuse sweatings, which seemed for a short time to relieve the dyspnoea.

After the exhibition of an emetic, six grains of calomel were given, with a purge of jalap in the morning, and repeated in a few days, with some appearance of advantage. He was then directed to take some pills of squill, soap, and rhubarb, with a draught twice a day, consisting of infus. amar. simp. and sal tartari. The skin soon became clearer and the pain in his breast considerably diminished. But every other circumstance remaining the same, and a fluctuation in the belly being now more evident, the infusion of Digitalis as prescribed in case third, was given in the dose of one ounce twice a day.

On the 5th day the effects were apparent, and he continued his medicine for a fortnight without nausea, making four or five pints of water every night, but little in the day, and gradually losing the symptoms of his disease.

In 1784, this person had a relapse, and was again cured by similar treatment.

CASE V.

R---- H----, Aged 43. Towards the end of the year 1783, became affected with slight cough and expectoration of purulent matter. In December his skin became universally of a pale yellow colour. The abdomen was swelled and hard; his appetite little, and he complained of a violent and constant palpitation of the heart, which prevented him from sleeping. The urine pale, and in small quantity. The pulse exceedingly strong, and rebounding; beating 114 to 120 strokes every minute. He suffered violent pain of his head, and was very feeble and emaciated. After bleeding, and the use of gentle aperient medicines, he continued to take the infusion of Digitalis for some days, without any sensible effect. Other diuretics were tried to as little purpose. Repeated bleeding had no effect in diminishing the violent action of the heart. He died in January following, under complicated symptoms of phthisis and ascites.

CASE VI.

A man aged 57, who had lived freely in the summer of 1784, became affected with oedematous swelling of his legs, for which he was advised to drink Fox Glove Tea. He took a four ounce bason of the infusion made strong with the green leaves, every morning for four successive days.

On the 5th he was suddenly seized with faintness and cold sweatings. I found him with a pale countenance, complaining of weakness, and of pain, with a sense of great heat in his stomach and bowels. The swelling of the legs was entirely gone, he having evacuated urine in very large quantities for the two preceding days. He was affected with frequent diarrhoea. The pulse was very quick and small, and his extremities cold.

A small quantity of broth was directed to be given him every half hour, and blisters were applied to the ancles, by which his symptoms became gradually alleviated, and he recovered perfectly in the space of three weeks; except a relapse of the anasarca, for which the Digitalis was afterwards successfully employed, in small doses, without any disagreeable consequence.

CASE VII.

S---- D----, a middle aged single woman, was affected in the year eighty-one, with a painful rigidity and slight inflammation of the integuments on the left side, extending from the ear to the shoulder. In every other particular she was healthy. The use of warm fomentations, and opium, with two or three doses of mercurial physic, afforded her ease and the inflammation disappeared, but was succeeded by an oedematous swelling of the part, which very gradually extended along the arm, and downward to the breast, back, and belly. Friction, electricity and mercurial ointment were amongst the number of applications unsuccessfully employed to relieve her for the space of three months, during which time she continued in good general health.

In _November_ she became ascitic, passing small quantities of urine, and soon afterwards a sudden dyspnoea gave occasion to suppose an effusion of water in the thorax. The Digitalis, squills, and cantharides were given in very considerable doses without effect. She died the latter end of December following.

CASE VIII.

W---- C----, a collier aged 58, was attacked in the spring of 1783 with a tertian ague, which he attributed to cold, by sleeping in a coal pit, and from which he recovered in a few days, except a swelling of the lower extremities, which had appeared about that time, and gradually increased for two or three months. The legs and thighs were greatly enlarged and oedematous. His belly was swelled, but no fluctuation perceptible. He made small quantities of high coloured water. The appetite bad, and pulse feeble. He had taken many medicines without relief, and was now so reduced in strength, as to sit up with difficulty. An infusion of the Digitalis was directed for him, in the proportion of one ounce of the fresh leaves to a pint of water, two ounces to be taken three times a day, until the stomach or bowels became affected. Upon the exhibition of the sixth dose, nausea supervened, and continued to oppress him at intervals for two or three days, during which he passed large quantities of pale urine. The swelling, assisted by moderate bandage rapidly diminished, and without any repetition of his medicine, at the expiration of sixteen days, he returned to his labour perfectly recovered.

OF THE PREPARATIONS and DOSES, OF THE FOXGLOVE.

Every part of the plant has more or less of the same bitter taste, varying, however, as to strength, and changing with the age of the plant and the season 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 over dosed their patients. I could, 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 for internal use. I see no objection to the proposition; but I have not tried it.

SEEDS.--These I believe are equally 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 pills 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 for an adult patient. If the patient be stronger than usual, or the symptoms very urgent, this dose 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 itself 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 formulæ 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 supposed 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 effects; 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.

EFFECTS, RULES, and CAUTIONS.

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.[11]

[Footnote 11: I am doubtful whether it does not sometimes excite a copious flow of saliva.--See cases at pages 115, 154, and 155.]

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 the intervals mentioned above:--let it be continued until it either acts on the kidneys, the stomach, the pulse, or the bowels; let it 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 maybe 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 or 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.

CONSTITUTION of PATIENTS.

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 unfavourable to the success of the Digitalis.

From large experience, and attentive observation, I am pretty well enabled to decide _a priori_ upon this matter, and I wish to enable others to do the same: but I feel myself hardly equal to the undertaking. The following hints, however, aiding a degree of experience in others, may lead them to accomplish what I yet can describe but imperfectly.

It seldom succeeds in men of great natural strength, of tense fibre, of warm skin, of florid complexion, or in those with a tight and cordy pulse.

If the belly in ascites be tense, hard, and circumscribed, or the limbs in anasarca solid and resisting, we have but little to hope.

On the contrary, if the pulse be feeble or intermitting, the countenance pale, the lips livid, the skin cold, the swollen belly soft and fluctuating, or the anasarcous limbs readily pitting under the pressure of the finger, we may expect the diuretic effects to follow in a kindly manner.

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 desired 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 place, 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.

INFERENCES.

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 support.

I. That the Digitalis will not universally act as a diuretic.

II. That it does do so more generally than any other 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.

PRACTICAL REMARKS ON DROPSY, AND SOME OTHER DISEASES.

The following remarks consist partly of matter of fact, and partly of opinion. The former will be permanent; the latter must vary with the detection 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.

ANASARCA.

§ 1. The anasarca is generally curable when seated in the sub-cutaneous cellular membrane, or in the substance of the lungs.

§ 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 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?

ASCITES.

§ 6. If existing alone, (_i. e._) without accompanying anasarca, is in children curable; in adults generally incurable by medicines. Tapping may be used here with better chance for success than in more complicated dropsies. Sometimes cured by vomiting.

ASCITES and ANASARCA.

§ 7. Incurable if dependant upon irremediably diseased viscera, or on a gouty constitution, so debilitated, that the gouty paroxysms no longer continue to be formed.

In every other situation the disease yields to diuretics and tonics.

ASCITES, ANASARCA, and HYDROTHORAX.

§ 8. Under this complication, though the symptoms admit of relief, the restoration of the constitution can hardly be hoped for.

ASTHMA.

§ 9. The true spasmodic asthma, a rare disease--is not relieved by Digitalis.

§ 10. In the greater part of what are called asthmatical cases, the real disease is anasarca of 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 incurable by diuretics; but it is often accompanied with a degree of anasarca, and so far it admits of relief.

Is not this disease similar to that in the limbs at (§3,) and also to that of the abdominal viscera at (§2.)?

ASTHMA and ANASARCA.

§ 12. If the asthma be of the kind mentioned at (§§ 9 and 11,) diuretics can only remove the accompanying anasarca. But if the affection of the breath depends also upon cellular effusion, as it mostly does, the patient may be taught to expect a recovery.

ASTHMA and ASCITES.

§ 13. A rare combination, but not incurable if the abdominal viscera are sound. The asthma is here most probably of the anasarcous kind (§ 10;) and this being seldom confined to the lungs only, the disease generally appears in the following form.

ASTHMA, ASCITES, and ANASARCA.

§ 14. The curability of this combination will depend upon the circumstances mentioned in the preceding section, taking also into the account the strength or weakness of the patient.

EPILEPSY.