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 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 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.