FOOTNOTES:
[6] R. Rad. scil. recent. sapon. castiliens. pulv. Rhei opt. aa. ℈i. ol. junip. gutt. xvi. syr. bals. q. s. f. mass. in pil. xxiv. divid.
[7] Prepared in the same manner as in the former case.
[8] See this account in the [Introduction].
[9] For reasons assigned at [p. 100], I did not intend to introduce any case, occurring under my own inspection, in the course of the present year; but it may be satisfactory to continue the history of this disease, as Dr. Stokes's narrative would otherwise be incomplete.
1785.
CASE.
Jan. 5th. Mrs. M——, Æt. 48. Hydrothorax and anasarcous legs, of eight months duration. She had taken jallap, squill, salt of tartar, and various other medicines. I found her in a very reduced state, and therefore directed only a grain and half of the Pulv. Digital. to be given night and morning. This in a few days encreased the secretion of urine, removed her difficulty of breathing, and reduced the swelling of her legs, without any disturbance to her system.
Three months afterwards, a severe attack of gout in her legs and arms, removing to her head, she died.
Dr. Stokes had an opportunity of examining the dead body, and I had the satisfaction to learn from him, that there did not appear to have been any return of the dropsy.
[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.
OF THE
PREPARATIONS and DOSES,
OF THE
FOXGLOVE.
Every part of the plant has more or less of the same bitter taste, varying, however, as to strength, and changing with the age of the plant and the season of the year.
ROOT.—This varies greatly with the age of the plant. When the stem has shot up for flowering, which it does the second year of its growth, the root becomes dry, nearly tasteless, and inert.
Some practitioners, who have used the root, and been so happy as to cure their patients without exciting sickness, have been pleased to communicate the circumstance to me as an improvement in the use of the plant. I have no doubt of the truth of their remarks, and I thank them. But the case of Dr. Cawley puts this matter beyond dispute. The fact is, they have fortunately happened to use the root in its approach to its inert state, and consequently have not over dosed their patients. I could, if necessary, bring other proof to shew that the root is just as capable as the leaves, of exciting nausea.
STEM.—The stem has more taste than the root has, in the season the stem shoots out, and less taste than the leaves. I do not know that it has been particularly selected for use.
LEAVES.—These vary greatly in their efficacy at different seasons of the year, and, perhaps, at different stages of their growth; but I am not certain that this variation keeps pace with the greater or lesser intensity of their bitter taste.
Some who have been habituated to the use of the recent leaves, tell me, that they answer their purpose at every season of the year; and I believe them, notwithstanding I myself have found very great variations in this respect. The solution of this difficulty is obvious. They have used the leaves in such large proportion, that the doses have been sufficient, or more than sufficient, even in their most inefficacious state. The Leaf-stalks seem, in their sensible properties, to partake of an intermediate state between the leaves and the stem.
FLOWERS.—The petals, the chives, and the pointal have nearly the taste of the leaves, and it has been suggested to me, by a very sensible and judicious friend, that it might be well to fix on the flower for internal use. I see no objection to the proposition; but I have not tried it.
SEEDS.—These I believe are equally untried.
From this view of the different parts of the plant, it is sufficiently obvious why I still continue to prefer the leaves.
These should be gathered after the flowering stem has shot up, and about the time that the blossoms are coming forth.
The leaf-stalk and mid-rib of the leaves should be rejected, and the remaining part should be dried, either in the sun-shine, or on a tin pan or pewter dish before a fire.
If well dried, they readily rub down to a beautiful green powder, which weighs something less than one-fifth of the original weight of the leaves. Care must be taken that the leaves be not scorched in drying, and they should not be dried more than what is requisite to allow of their being readily reduced to powder.
I give to adults, from one to three grains of this powder twice a day. In the reduced state in which physicians generally find dropsical patients, four grains a day are sufficient. I sometimes give the powder alone; sometimes unite it with aromatics, and sometimes form it into pills with a sufficient quantity of soap or gum ammoniac.
If a liquid medicine be preferred, I order a dram of these dried leaves to be infused for four hours in half a pint of boiling water, adding to the strained liquor an ounce of any spirituous water. One ounce of this infusion given twice a day, is a medium dose for an adult patient. If the patient be stronger than usual, or the symptoms very urgent, this dose may be given once in eight hours; and on the contrary in many instances half an ounce at a time will be quite sufficient. About thirty grains of the powder or eight ounces of the infusion, may generally be taken before the nausea commences.
The ingenuity of man has ever been fond of exerting itself to vary the forms and combinations of medicines. Hence we have spirituous, vinous, and acetous tinctures; extracts hard and soft, syrups with sugar or honey, &c. but the more we multiply the forms of any medicine, the longer we shall be in ascertaining its real dose. I have no lasting objection however to any of these formulæ except the extract, which, from the nature of its preparation must ever be uncertain in its effects; and a medicine whose fullest dose in substance does not exceed three grains, cannot be supposed to stand in need of condensation.
It appears from several of the cases, that when the Digitalis is disposed to purge, opium may be joined with it advantageously; and when the bowels are too tardy, jalap may be given at the same time, without interfering with its diuretic effects; but I have not found benefit from any other adjunct.
From this view of the doses in which the Digitalis really ought to be exhibited, and from the evidence of many of the cases, in which it appears to have been given in quantities six, eight, ten or even twelve times more than necessary, we must admit as an inference either that this medicine is perfectly safe when given as I advise, or that the medicines in daily use are highly dangerous.
EFFECTS, RULES, and CAUTIONS.
The Foxglove when given in very large and quickly-repeated doses, occasions sickness, vomiting, purging, giddiness, confused vision, objects appearing green or yellow; increased secretion of urine, with frequent motions to part with it, and sometimes inability to retain it; slow pulse, even as slow as 35 in a minute, cold sweats, convulsions, syncope, death.[11]
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.