An Account of the Foxglove and some of its Medical Uses, William Withering [reading eggs books txt] 📗
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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.
[11] I am doubtful whether it does not sometimes excite a copious flow of saliva.—See cases at pages 115, 154, and 155.
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.
PRACTICALREMARKS 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 phœnomena of disease.
ANASARCA.§ 1. The anasarca is generally curable when seated in the sub-cutaneous cellular membrane, or in the substance of the lungs.
§ 2. When the abdominal viscera in general are greatly enlarged, which they sometimes are, without effused fluid in the cavity of the abdomen; the disease is incurable. After death, the more solid viscera are found very large and pale. If the cavity contains water, that water may be removed by diuretics.
§ 3. In swollen legs and thighs, where the resistance to pressure is considerable, the tendency to transparency in the skin not obvious, and where the alteration of posture occasions but little alteration in the state of distension, the cure cannot be effected by diuretics.
Is this difficulty of cure occasioned by spissitude in the effused fluids, by want of proper communication from cell to cell, or is the disease rather caused by a morbid growth of the solids, than by an accumulation of fluid?
Is not this disease in the limbs similar to that of the viscera (§ 2)?
§ 4. Anasarcous swellings often take place in palsied limbs, in arms as well as legs; so that the swelling does not depend merely upon position.
§ 5. Is there not cause to suspect that many dropsies originate from paralytic affections of the lymphatic absorbents? And if so, is it not probable that the Digitalis, which is so effectual in removing dropsy, may also be used advantageously in some kinds of palsy?
ASCITES.§ 6. If existing alone, (i. e.) without accompanying anasarca, is in children curable; in adults generally incurable by medicines. Tapping may be used here with better chance for success than in more complicated dropsies. Sometimes cured by vomiting.
ASCITES and ANASARCA.§ 7. Incurable if dependant upon irremediably diseased viscera, or on a gouty constitution, so debilitated, that the gouty paroxysms no longer continue to be formed.
In every other situation the disease yields to diuretics and tonics.
ASCITES, ANASARCA, and HYDROTHORAX.§ 8. Under this complication, though the symptoms admit of relief, the restoration of the constitution can hardly be hoped for.
ASTHMA.§ 9. The true spasmodic asthma, a rare disease—is not relieved by Digitalis.
§ 10. In the greater part of
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