CASE XI.

Mrs. Smith, about 50 years of age, after a tedious illness of many weeks, had a jaundice, and became dropsical in the legs. Two spoonfuls of the decoction, with three drams twice a day, increased her urine, and abated the swelling.

CASE XII.

Widow Chatterton, about 60 years of age. Took the decoction in the same way for dropsy of the legs, with little effect.

CASE XIII.

—— Genders, about thirty-four years of age, was delivered of three children, and became dropsical of the abdomen. She passed little or no urine, had constant thirst, and no appetite. She took two spoonfuls of an eight ounce decoction, with three drams twice a day. By the time she had finished the bottle, (which must have been on the fourth day,) she had evacuated all her water, and could go about. Her appetite increased with every dose, and she recovered without farther help.

CASE XIV.

Miss M—— M——, in her 20th year. Had been infirm from her cradle, and, after various sufferings, had an astonishing oedematous swelling of one leg and thigh, of many weeks standing. She passed little or no urine, and had all her other complaints. She took 2 spoonfuls of an eight oz. decoction of two drams, twice a day. Her urine immediately increased; and, on the third day, the swelling had entirely subsided.

CASE XV.

Mr. P——, 65 years of age, and of a full habit of body. Had lived freely in his youth, and for many years led rather an inactive life. His health was much impaired several months, and he had a considerable distention, and evident fluctuation in the abdomen, and a very great oedema of the legs and thighs. His breathing was very short, and rather laborious, appetite bad, and thirst considerable. His belly was bound, and he passed very small quantities of high-coloured urine, that deposited a reddish matter. He had taken medicines some time, and, I believe, the Digitalis; and had been better.

A blister was applied to the upper and inside of each thigh; he took two spoonfuls of the decoction, with three drams of the dry leaves, two or three times a day; and some opening physic occasionally.

He lived at a considerable distance, and I did not visit him a second time; but I was well informed, about ten days or a fortnight afterwards, that his urine increased amazingly upon taking the decoction, and that the water was entirely evacuated.

CASE XVI.

Mrs. G——, aged 50 years. After being long ailing, had a large collection of water in the abdomen and lower extremities. Her urine was high-coloured, in small quantities, and had a reddish sediment. She took the decoction of Digitalis, squills, &c. without any effect. The chrystals of tartar, however, cured her speedily.

CASE XVII.

Mr. ——, about 50 years of age, complained of great tension and pain across the abdomen, and of loss of appetite; his urine, he thought, was less than usual, but the difference was so trifling he could speak with no certainty: his belly seemed to fluctuate. Among other things he tried the Foxglove leaves dried, twice a day; and, although it appeared to afford him relief, yet the effect was not permanent.

CASE XVIII.

Mr. W——, aged between 60 and 70 years; and rather corpulent: was considerably dropsical, both of the belly and legs, and his urine in small quantities. Three grains of the dry leaves, twice a day, evacuated the water in less than a fortnight.

CASE XIX.

Sarah Taylor, 40 years of age, was admitted into the Dispensary for dropsy of the abdomen and legs; and was relieved by the Decoctum digitalianum.

CASE XX.

Lydia Smith, aged 60. Dispensary. Laboured many years under an asthma, and became dropsical. She took the decoction without effect.

CASE XXI.

John Leadbeater, aged 15 years. Had a quotidian intermittent, which was removed by the humane assistance of an amiable young lady. His intermittent was soon attended by a very considerable ascites; for which he became a patient of the Dispensary. He took a decoction of Foxglove night and morning. His urine increased immediately, and he lost all his complaints in four days.

CASE XXII.

William Millar, aged 50 years. Admitted into the Dispensary for a tertian ague, and general dropsy. The dropsy continuing after the ague was removed, and his urine being still passed in small quantities; he took the powdered leaves, and recovered his health in five days.

CASE XXIII.

Ann Wakelin, 10 years of age. Had for several weeks a dropsy of the belly after an ague. She took a decoction of Foxglove, which removed all complaint by the fourth day.

CASE XXIV.

Ann Meachime; a Dispensary patient. Had an ascites and scantiness of urine. She took the powder of Foxglove, and evacuated all her water in three days.

It may not be improper to observe, 1st. That various diuretics had long been given in many of these cases before I was consulted. And, 2dly. That the exhibition of the Foxglove was but seldom attended with sickness.

REMARKS.

These Cases, thus liberally communicated by my friend, Dr. Jones, are more acceptable, as they seem to contain a faithful abstract from his notes, both of the unsuccessful as well as the successful Cases.

The following Tabular View of them will give us some Idea of the efficacy of the Medicine.

Anasarca 7 Cases Cured 3 Relieved 1 Failed 3 Ascites 5 Cases Cured 4 Relieved 1 OEdematous leg 1 Case Cured 1 Ascites and anasarca 7 Cases Cured 4 Relieved 2 Failed 1 Asthma and dropsy 1 Case Failed 1 Hydrothorax and gout 1 Case Cured 1 ——, ascites and anasarca— 2 Cases Cured 2

A CASE of Anasarca communicated by Mr. JONES, Surgeon, in Birmingham.

Dear SIR,

Having lately experienced the diuretic powers of the Foxglove, in a case of anasarca; I do myself the pleasure of communicating a short history of the treatment to you.

I am, &c. W. JONES.

Birmingham, May 17th, 1785.

My patient, Mrs. C——, who is in her 51st year, had the following symptoms, viz. alternate swelling of the legs and abdomen, a little cough, shortness of breath in a morning, thirst, weak pulse, and her urine, which was so small in quantity as seldom to amount to half a pint in twenty-four hours, deposited a clay-coloured sediment.

April 16th, 1785, I directed the following form:

R. Fol. Digitalis siccat. [Symbol: dram]ii. Aq. fontanae bullient. [Symbol: ounce]viii. f. infus. et cola. Sumat cochl. larga iii. o. n. et mane.

On the 17th she had taken twice of the infusion, and though by mistake only two tea spoonfuls for a dose, yet the quantity of urine was increased to about a pint in the twenty-four hours. She was then directed to take two table spoonfuls night and morning. And.

On the 18th, a degree of nausea was produced. A pint and half of urine was made in the last twenty-four hours. During the time above specified she had two or three stools every day. The infusion was now omitted.

On the 19th the swelling of the legs was removed. A degree of nausea took place in the morning, and increased so much during the day, that she vomited up all her food and medicine. As she was very low, and complained of want of appetite, a cordial julep was directed to be taken occasionally, as well as red port and water, mint tea, &c. She informed me that whatever she took generally staid about an hour before it came up again, and that the mint tea staid longest on the stomach. The vomiting decreased gradually, and ceased on the 22d. The discharge of urine remained considerable during the three following days, but its quantity was not measured.

22d. A dose of neutral saline julep was directed to be taken every fourth hour.

On the 23d she complained of thirst, and thought the discharge of urine not so copious as on the preceding days, therefore the saline julep was continued every fourth hour, with the addition of thirty drops of the following medicine:

R. Aceti scillitic. [Symbol: dram]vi. Tinct. aromat. [Symbol: dram]ii. Tinct. thebaic. gutt. xx. m.

The bowels have been kept open from the 19th, by the occasional use of emollient injections.

On the 24th the legs were much swelled again; she complained of languor and a degree of nausea. The discharge of urine increased a little since the 23d. Her pulse was low and her tongue white. The urine, which had been rendered clear by the infusion of Foxglove, now deposited a whitish sediment.

On the 25th her appetite began to return, the swelling of the legs diminished, and she thought herself much relieved. The urine was considerable in quantity, and clear.

On the 26th she was thirsty and languid. The swelling was removed; the quantity of urine discharged in the last twenty-four hours was about a pint. She continued to mend from this time, and is now in good health.

A giddiness of the head, more or less remarkable at times, was observed to follow the use of the Foxglove, and it lasted nine or ten days.

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, AEt. 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 colaturae 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, AEt. 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——, AEt. 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 3/4 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 3/4 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——, AEt. 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——, AEt. 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. praescript.

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——, AEt. 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——, AEt. 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——, AEt. 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.

Matth. D——, AEt. 71. Tall and thin. Disease a general anasarca, with great difficulty of breathing. The lac ammoniac. somewhat relieved his breath; but the swellings increased, and his urine was not augmented. I considered it as a lost case, but having seen the good effects of the Digitalis, as ordered by Dr. Stokes in the case of Mrs. G——, I gave him one spoonful of an infusion of [Symbol: dram]ii to half a pint, twice a day. His breath became much easier, his urine increased considerably, and the swellings gradually disappeared; since which his health has been pretty good, except that about three weeks ago, he had a slight dyspnoea, with pain in his stomach, which were soon removed by a repetition of the same medicine.

Mr. Shaw likewise informs me, that he has removed pains in the stomach and bowels, by giving a spoonful of the infusion, [Symbol: dram]iss. to [Symbol: ounce]viii. morning and night.

A Letter from Mr. VAUX, Surgeon, in Birmingham.

Dear SIR,

I send you the two following cases, wherein the Digitalis had very powerful and sensible effects, in the cure of the different patients.

CASE I.

Mrs. O—— of L—— street, in this town, aged 28, naturally of a thin, spare habit, and her family inclinable to phthisis, sent for me on the 11th of June, 1779, at which time she complained of great pain in her side, a constant cough, expectorated much, which sunk in water; had colliquative sweats and frequent purging stools; the lower extremities and belly full of water, and from the great difficulty she had in breathing, I concluded there was water in the chest also. The quantity of water made at a time for three weeks before I saw her, never amounted to more than a tea-cup full, frequently not so much. Finding her in so alarming a situation, I gave it as my opinion she could receive no benefit from medicine, and requested her not to take any; but she being very desirous of my ordering her something, I complied, and sent her a box of gum pills with squills, and a mixture with salt of tartar: these medicines she took until the sixteenth, without any good effects: the water in her legs now began to exsude through the skin, and a small blister on one of her legs broke. Believing she could not exist much longer, unless an evacuation of the water could be procured; after fully informing her of her situation, and the uncertainty of her surviving the use of the medicine, I ventured to propose her taking the Digitalis, which she chearfully agreed to. I accordingly sent her a pint mixture, made as under, of the fresh leaves of the Digitalis. Three drams infused in one pint of boiling water, when cold strained off, without pressing the leaves, and two ounces of the strong juniper water added to it: of this mixture she was ordered four table spoonfuls every third hour, till it either made her sick, purged her, or had a sensible effect on the kidneys. This mixture was sent on the seventeenth, and she began taking it at noon on the eighteenth. At one o'clock the following morning I was called up, and informed she was dying. I immediately attended her, and was agreeably surprised to find their fright arose from her having fainted, in consequence of the sudden loss of twelve quarts of water she had made in about two hours. I immediately applied a roller round her belly, and, as soon as they could be made, 2 others, which were carried from the toes quite up the thighs. The relief afforded by these was immediate; but the medicine now began to affect her stomach so much, that she kept nothing on it many minutes together. I ordered her to drink freely of beef tea, which she did, but kept it on her stomach but a very short time. A neutral draught in a state of effervescence was taken to no good purpose: She therefore continued the beef tea, and took no other medicine for five days, when her sickness went off: her cough abated, but the pain in her side still continuing, I applied a blister which had the desired effect: her urine after the first day flowed naturally. Her cure was compleated by the gum pills with steel and the bitter infusion. It must be observed she never had any collection of water afterwards.

It affords me great pleasure to inform you that she is now living, and has since had four children; all of whom, I think I may justly say, are indebted to the Digitalis for their existence.

There appears in this case a striking proof of the utility of emetics in some kinds of consumptions, as it appears to me the dropsy was brought on by the cough, &c. and I believe these were cured by the continual vomitings, occasioned by the medicine.

CASE II.

Mr. H——, a publican, aged about 48 years, sent for me in March, 1778. He complained of a cough, shortness of breathing, which prevented him from laying down in bed; his belly, thighs and legs very much distended with water; the quantity of urine made at a time seldom exceeded a spoonful. I requested him to get some of the Digitalis, and as they had no proper weights in the house, I told them to put as much of the fresh leaves as would weigh down a guinea, into half a pint of boiling water; to let it stand till cold, then to pour off the clear liquor, and add a glass of gin to it, and to take three table spoonfuls every third hour, until it had some sensible effect upon him.

Before he had taken all the infusion, the quantity of urine made increased, (he therefore left off taking it), and it continued to do so until all the water was evacuated. His breathing became much better, his cough abated, though it never quite left him; he being for some time before asthmatic. By taking some tonic pills he continued quite well until the next spring, when he had a return of his complaint, which was carried off by the same means. Two years after, he had a third attack, and this also gave way to the medicine. Last year he died of a pleurisy.

I am, &c. JER. VAUX

Moor-Street, 8th May, 1785.

P. S. You must well recollect the case of Mrs. F——.—It was "a general dropsy—every time she took the medicine its effects were similar, viz. The discharge of urine came on gradually at first, increased afterwards, and the whole of the water both in the belly, legs, &c. was perfectly evacuated. Although the effects were only temporary, they were exceedingly agreeable to the patient, making her time much more comfortable."—(See Case XLIII.)

A Letter from Mr. WAINWRIGHT, Surgeon, in Dudley.

Dear SIR,

It gives me great pleasure to find you intend to publish your observations on the Digitalis purpurea.

Several years are now elapsed since you communicated to me the high opinion you entertained of the diuretic qualities of this noble plant. To ensure success, due attention was recommended to its preparation, its dose, and its effects upon the system.

I always gave the infusion of the dried leaves; the dose the same as in the prescriptions returned. If the medicine operated on the stomach or bowels, it was thought prudent to forbear. When the kidneys began to perform their proper functions, and the urine to be discharged, a continuance of its farther use was unnecessary.

These remarks you made in the case of the first patient for whom you prescribed the Digitalis in our neighbourhood, and I have found them all necessary at this present period. From the decided good effects that followed from its use, in those cases where the most powerful remedies had failed, I was soon convinced it was a most valuable addition to the materia medica.

The want of a certain diuretic, has long been one of the desiderata of medicine. The Digitalis is undoubtedly at the head of that class, and will seldom, if properly administered, disappoint the expectation. I can speak with the more confidence, having, in an extensive practice, been a happy witness to its good qualities.

For several years, I have given the infusion in a variety of cases, where there was a deficiency in the secretion of the urine, with the greatest success. In recent obstructions, I do not recollect many failures. In anasarcous diseases, and in the anasarca, when combined with the ascites; in swellings of the limbs, and in diseases of the chest, when there was the greatest reason to believe an accumulation of serum, the most beneficial consequences have followed from its use.

Had I been earlier acquainted with your intention to publish an account of the Digitalis, I could have transmitted some cases, which might have served to corroborate these assertions: but I am convinced the Digitalis needs not my assistance to procure a favorable reception. Its own merit will ensure success, more than a hundred recited cases.

I could wish those gentlemen who intend to make use of this plant, to collect it in a hot dry day, when the petals fall, and the seed-vessels begin to swell.

The leaves kept to the second year are weaker, and their diuretic qualities much diminished. It will therefore be necessary to gather the plant fresh every season.

These cautions are unnecessary to the accurate botanist, who well knows, that a plant in the spring, though more succulent and full of juices, is destitute of those qualities which may be expected when that plant has attained its full vigour, and the seed-vessels begin to be manifest. But for want of attention to these particulars, its virtues may be thought exaggerated, or doubtful, if beneficial consequences do not always flow from its use. There are diseases it cannot cure; and in several of those patients in this town, who first took the Digitalis by your orders, there was the most positive proof of the viscera being unsound. In these desperate cases it often procured a plentiful flow of urine, and palliated a disease which medicine could not remove.

At a remote distance, physicians are seldom applied to for advice in trifling disorders. Many remedies have been tried without relief, and the disease is generally obstinate or confirmed.—It would not be fair to try the merits of the Digitalis in this scale. It might often fail of promoting the end desired. I flatter myself the reputation of this plant will be equal to its merit, and that it will meet with a candid reception.

As there is no pleasure equal to relieving the miseries and distresses of our fellow-creatures, I hope you will long enjoy that peculiar felicity.

Permit me to return my thankful acknowledgments, for your free communication of a medicine, by which means, through the blessing of providence, I have been enabled to restore health and happiness to many miserable objects.

I am, &c. Yours, J. WAINWRIGHT.

Dudley, April 26th, 1785.

CASE of Mr. WARD, Surgeon, in Birmingham.—Related by himself.

In September, 1782, I was seized with a difficulty of breathing, and oppression in my chest, in consequence of taking cold from being called out in the night. My tongue was foul; my urine small in quantity; my breath laborious and distressing on the slightest exercise. I tried the medicines most generally recommended, such as emetics, blisters, lac ammoniacum, oxymel of squills, &c. but finding little or no relief, I consulted Dr. Withering, who advised me to try the following prescription.

R. Fol. Digital. purp. siccat. [Symbol: dram]iss. Aq. bullientis [Symbol: ounce]iv. Aq. cinn. sp. [Symbol: ounce]ss. digere per horas quatuor, et colaturae capiat cochlear. i. nocte maneque.

He also desired me to take fifty drops of tincture of cantharides three or four times a day.

After taking eight ounces of the infusion, and about twelve drams of the drops, I was perfectly cured, and have had no return since. The medicine did not occasion sickness or vertigo, nor had they any other sensible effect than in changing the appearance, and increasing the quantity of the urine, and rendering the tongue clean. After the last dose or two indeed, I had a little nausea, which was immediately removed by a small glass of brandy.

Birmingham, 1st July, 1785.

Communications from Mr. YONGE, Surgeon, in Shiffnall, Shropshire.

Dear SIR,

I have great satisfaction in complying with your just claim, by transcribing outlines of the subsequent cases, for insertion in your long requested tract on the Digitalis purpurea. The two first of these you will easily recollect, the cures having been conducted immediately under your own management, and the whole may add to that weight of evidence which long experience enables you to adduce of the efficacy of that valuable medicine. I have recited the only instances of its failure which occur to me, but many other, though successful cases, wherein its utility might seem dubious, and also the accounts received from people whose accuracy might be suspected, I shall not for obvious reasons trouble you with.

I am, dear Sir, Your obliged friend, WILLIAM YONGE.

Shiffnall, May 1, 1785.

CASE I.

A Gentleman aged 49, on the night of the 21st of August, 1784, awaked with a sense of suffocation, which obliged him to rise up suddenly in bed. I found him complaining of difficult respiration, particularly on lying down; the countenance pale, and the pulse smaller and quicker than usual. Some brandy and water having been given, the symptoms gradually abated, so that he slept in a half recumbent posture. The following day he expressed a sense of anxiety and weight in the chest, attended by quicker breathing upon motion of the body. That evening an emetic of ipecacoanha was given, and afterwards a draught, with vitriolic aether and confect. card. aa [Symbol: dram]i to be repeated as the symptoms should require it. He continued to be affected with slighter returns of the dyspnoea at irregular intervals, until September 15th, when upon a more severe attack, the emetic was repeated. He now recollected some slight pain in his arms which had affected him previous to this last seizure, and was disposed to consider his complaint as rheumatic. Pills with gum ammoniac. gum guaiac. and antimonial powder were directed, with infus. amar. simpl. twice a day. The bowels were regulated by aperient pills of pulv. jalap. aloes and sal. tartar. and [Symbol: dram]iss balsam peruv. was given occasionally to alleviate the paroxysms of dyspnoea.

From this period until the beginning of November, little amendment or variation happened, except that respiration became more permanently difficult, and particularly oppressed upon motion, nor was it relieved by the expectoration of a mucous discharge, which now increased considerably. Squills, musk, ol. succini, aether, with other medicines of the same kind, were now used, but without success. The effects of opium and venaefection were tried. The appetite diminished, and his sleep became short and disturbed. He sometimes slept lying upon his back, but generally upon his left side. The urine which had hitherto been of good colour, and sufficient quantity, now became diminished, and lateritious; and the ancles oedematous.

On the 15th of November a blister was laid over the sternum, and [Symbol: dram]iss of oxymel scillitic. was given every eight hours.

On the 18th, a more copious discharge of urine took place; the swelling of the feet soon disappeared, and the respiration became gradually relieved.

On the 30th [Symbol: dram]i tinct. cantharidum twice a day in pyrmont water, with pills of ammoniac, sal tartar. et extract. gentian. were substituted, but

On the 7th of December, from some symptoms of relapse, the oxymel was used as before, and continued to be taken until the 27th, in doses as large as could be dispensed with on account of the great nausea which attended its exhibition: The urine was made in the quantity of four or five pints each day, during the whole time; the quantity then drank being seldom more than three pints. But now the sickness being exceedingly depressing, the strength failing, and the diuretic effects beginning to cease, the following prescription was directed.

R. Fol. Digitalis purpur. pulv. [Symbol: scruple]ss. Spec. Aromatic. [Symbol: scruple]i. sp. lav. c. f. pilul. no. x. capiat i. nocte maneque, et alternis diebus sensim augeatur dosin.

In three days the effect of this medicine became visible, and when the dose of the Digitalis had been increased to six grains per day, the flow of urine generally amounted to seven pints every twenty-four hours. Not the least sickness, nor any other disagreeable symptom supervened, though he persevered in this plan until the end of January at which time the dyspnoea was removed, and he has continued gradually to regain his flesh, strength, and appetite, without any relapse.

CASE II.

About the middle of the year 1784 a lady aged 48, returned from London, to her native air in Shropshire, under symptoms of complicated disease. It was your opinion that the plethoric state, consequent to that period, when menstruation first begins to cease, had under various appearances, laid the foundation of that deplorable state which now presented itself. The skin was universally of a pale, leaden colour; her person much emaciated, and her strength so reduced, as to disable her from walking without support. The appetite fluctuating, the digestion impaired so much, that solids passed the intestines with little appearance of solution: She had generally eight or ten alvine evacuations every day, and without this number, febrile symptoms, attended with severe vertiginous affection, and vomiting regularly ensued. The stools were of a pale ash colour. The urine generally pale, and at first in due quantity. The region of the stomach had a tense feel, without soreness: the feet and ancles oedematous, her sleep was uncertain: the pulse varying between 94 and 100, and feeble, except upon the approach of the menstrual periods, which were now only marked by its increased strength, and exacerbation of other febrile symptoms. Emetics, saline medicines, and gentle aperients were necessary to alleviate these. Six grains of ipecac, operated with sufficient power, and half a grain of calomel would have purged with great violence.

From the time of her arrival till the middle of August, mercury had been continued in various forms, and in doses such as the irritable state of her stomach and bowels would admit of. Spirit. nitri dulc.; sal. tartar, squill, and cantharides were alternately employed as diuretics, but without success, to retard the progress of an universal anasarca which was then advanced to such degree and accompanied by so great debility, and other dreadful concomitants, as to threaten a speedy and fatal catastrophe.

On the 16th of August you first saw her, and directed thus.

R. Mercur. cinerei gr. ii. Fol. Digital, purpur. pulv. [Symbol: scruple]i. f. mass. in pill. no. xvi. dividend.—sumat unam hora meridiana, iterumque hora quinta pomeridiana quotidie. Capiat lixivii saponac. gutt. L. in haust. juscul. sine sale parati omni nocte.

On the 20th the flow of urine began to increase, and she continued the medicine in the same dose until the 20th of September, discharging from six to eight pints of water each day for the first week, and which quantity gradually diminished as she became empty. During this period she complained not of any sickness, except from the lixivium, which was after the first dose reduced to 20 drops; and her appetite and strength increased daily, though it was evident that no bile had yet flowed into the bowels, nor was the digestion at all improved. The anasarcous appearances being then removed, the Digitalis was omitted, and pills, composed of mercur. cinereus, aloes, and sal tartari directed twice a day, with [Symbol: dram]i. of vin. chalybeat. in infus. amar. simpl.

Her amendment in other respects proceeded slowly, but regularly, from that time until the 9th of October; when the state of plethora again recurring, with its usual attendant symptoms, [Symbol: ounce]iv. of blood were taken from the arm; and this was upon the same occasion, repeated in the following month, with manifest good consequences; though in both instances the colour of the blood, as flowing from the vein could hardly be called red, and the coagulum was as weak in its cohesion as possible. The state of the stomach and bowels was by this time greatly improved, in common with other parts of the system; but no intromission of bile had yet happened: the hardness about the hypogastric region, though less, continued in a considerable degree, and you ordered pills of mercury rubbed down, and rust of iron, to be taken twice a day, with a decoction of dandelion and sal sodae.

A cataplasm of linseed was applied every night over the stomach and right side; and, with little deviation from this plan, she continued to the end of the year, improving in her general health, but the hepatic affection yet remaining. It was then determined to try the effects of electricity, and gentle shocks were passed through the body daily, and as nearly as could be through the liver, in various directions.

On the fifth day there was reason to think that some gall had been secreted and poured out, and this became every day more evident; but it flowed only in small quantity, and irregularly into the bowels, as appeared from the faeces being partially tinged by it.

In February the lady left this neighbourhood, and though convalescent, yet so nearly well as to promise us the satisfaction of seeing her perfectly restored.

June 29. The bile is now secreted in pretty good quantity, her appetite is perfectly good, her strength equal to almost any degree of exercise, and her health in general better than it has been for some years.

CASE III.

Mr. W——, aged—. In June, 1782, was affected with slight difficulty in respiration, upon taking exercise or lying down in bed. These symptoms increased gradually until the end of July, when he complained of sense of weight and uneasiness about the proecordia; loss of appetite; and costiveness. The urine was small in quantity, and high coloured; his pulse feeble, and intermitting; he breathed with difficulty when in bed, and slept little. After the exhibition of an emetic, and an opening medicine of rhubarb, sena, and sal tartari, he was directed to take half a dram of squill pill, pharm. Edinburg. night and morning, with [Symbol: dram]ss sal. sodae in [Symbol: ounce]iss. infus. amar. simpl. twice a day; and these medicines were continued during ten days, without any sensible effect. A blister was then applied to the sternum, and six grains of calomel given in the evening. The symptoms were now increased very considerably, in every particular; and the following infusion was substituted for the former medicines.

R. Fol. Digital. purpur. [Symbol: dram]iii. Cort. limon. [Symbol: dram]ii. infund. Aq. bullient. [Symbol: pound]i. per hor. 2 et cola. sumat cochl. i. primo mane et repet. omni hora.

Sometime in the night considerable nausea occurred, and the following day he began to make water in great quantity, which he continued to do for three or four days. The pulse in a few hours became regular, slower, and stronger, and, in the course of a week, all the symptoms entirely vanished, and an electuary of cort. peruvian, sal martis, and spec. aromatic. confirmed his cure.

In February, 1784, this gentleman had a relapse of his disease, from which he again soon recovered by the same means, and is now perfectly well.

CASE IV.

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 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.



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.

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

Sec. 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.

Sec. 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 (Sec. 2)?

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

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

ASTHMA.

Sec. 9. The true spasmodic asthma, a rare disease—is not relieved by Digitalis.

Sec. 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 Sec. 1.) This is almost always combined with some swelling of the legs.

Sec. 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 (Sec.3,) and also to that of the abdominal viscera at (Sec.2.)?

ASTHMA and ANASARCA.

Sec. 12. If the asthma be of the kind mentioned at (Sec.Sec. 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.

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

ASTHMA, ASCITES, and ANASARCA.

Sec. 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.

Sec. 15. In epilepsy dependant upon effusion, the Digitalis will effect a cure; and in the cases alluded to, the dropsical symptoms were unequivocal. It has not had a sufficient trial in my hands, to determine what it can do in other kinds of epilepsy.

HYDATID DROPSY.

Sec. 16. This may be distinguished from common ascites, by the want of evident fluctuation. It is common to both sexes. It does not admit of a cure either by tapping or by medicine.

HYDROCEPHALUS.

Sec. 17. This disease, which has of late so much attracted the attention of the medical world, I believe, originates in inflammation; and that the water found in the ventricles of the brain after death, is the consequence, and not the cause of the illness.

It has seldom happened to me to be called upon in the earlier stages of this complaint, and the symptoms are at 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 the 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 in 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. Three days before death, the right side became slightly 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 consequence, 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 practice resulting from them, to Dr. Quin, now physician at Dublin. That gentleman 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.

HYDROTHORAX.

Sec. 18. Under this name I also include the dropsy of the pericardium.

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.

Sec. 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.

HYDROTHORAX and ANASARCA.

Sec. 20. This combination is very frequent, and, I believe, may always be cured by the Digitalis.

Sec. 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.

INSANITY.

Sec. 22. I apprehend this disease to be more frequently connected with serous effusion than has been commonly imagined.

Sec. 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.

NEPHRITIS CALCULOSA.

Sec. 24. We have had sufficient evidence of the efficacy of the Foxglove in removing the Dysuria and other symptoms of this disease; but probably it is not in these cases preferable to the tobacco.[12]

[Footnote 12: See an original and valuable treatise by Dr. Fowler, entitled, Medical Reports of the Effects of Tobacco.]

OVARIUM DROPSY.

Sec. 25. This species of encysted dropsy is not without difficulty distinguishable from an ascites; and yet it is necessary to distinguish them, because the two diseases require different treatment and because the probality of a cure is much greater in one than in the other.

Sec. 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 distinguish by the feel on which side the cyst originated, and the patients do not attend to that circumstance themselves. 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 secretion 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.

Sec. 27. The ovarium dropsy defies the power of medicine. It admits of relief, and sometimes of a cure, by tapping. I submit to the consideration of practitioners, 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.

Sec. 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 itself, certainly contributes much to prevent its increase.

OVARIUM DROPSY with ANASARCA.

Sec. 29. The anasarca does not appear until the encysted dropsy is very far advanced. It is then probably caused by weakness and pressure. The Digitalis removes it for a time.

PHTHISIS PULMONALIS.

Sec. 30. This is a very increasing malady in the present day. It is no longer limited to the middle part of life: children at five years of age die of it, and old people at sixty or seventy. It is not confined to the flat-chested, the fair-skinned, the blue eyed, the light-haired, or the scrophulous: it often attacks people with full chests, brown skins, dark hair and eyes, and those in whose family no scrophulous taint can be traced. It is certainly infectious. The very strict laws still existing in Italy to prevent the infection from consumptive patients, were probably not enacted originally without a sufficient cause. We seem to be approaching to that state which first made such restrictions necessary, and in the further course of time, the disease will probably fall off again, both in virulency and frequency.

Sec. 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.[13]

[Footnote 13: 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 suspect 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.]