CASEII.

R. Fol. Digitalis purpur. pulv. ℈ss.Spec. Aromatic. ℈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 beenincreased 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 ofJanuaryat which time the dyspnœa was removed, and he has continued gradually to regain his flesh, strength, and appetite, without any relapse.

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 stomachhad a tense feel, without soreness: the feet and ancles œdematous, 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 ofAugust, 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 ofAugustyou first saw her, and directed thus.

R. Mercur. cinerei gr. ii.Fol. Digital, purpur. pulv. ℈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 ofSeptember, 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 ʒi. 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, ℥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 ofthe 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 sodæ.

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 fæces being partially tinged by it.

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

June29. The bile is now secreted in pretty good quantity, her appetite is perfectly good, her strength equal to almost any degree of exercise, and herhealth in general better than it has been for some years.

Mr. W——, aged—. InJune, 1782, was affected with slight difficulty in respiration, upon taking exercise or lying down in bed. These symptoms increased gradually until the end ofJuly, when he complained of sense of weight and uneasiness about the prœcordia; 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 ʒss sal. sodæ in ℥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. ʒiii.Cort. limon. ʒii. infund.Aq. bullient. ℔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.

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

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 dyspnœa.

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 andthe 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.

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.

A man aged 57, who had lived freely in the summer of 1784, became affected with œdematous 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 diarrhœa. 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.

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 œdematous 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.

InNovembershe became ascitic, passing small quantities of urine, and soon afterwards a sudden dyspnœa 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.

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 coalpit, 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 œdematous. 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.

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 theIntroduction.[9]For reasons assigned atp. 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.

[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 theIntroduction.

[9]For reasons assigned atp. 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.

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.

Everypart 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-stalksseem, 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.

TheFoxglove 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 necessaryto 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 orderedto 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 quantityas 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 desirablething. 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 (Page135) in one case, found mint tea to be retained longer than other things.

FOOTNOTES:[11]I am doubtful whether it does not sometimes excite a copious flow of saliva.—See cases at pages115,154, and155.

[11]I am doubtful whether it does not sometimes excite a copious flow of saliva.—See cases at pages115,154, and155.

Independentof 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 decidea prioriupon 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, orthe 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.

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 diureticcan 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.

Thefollowing 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.

§ 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?

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

§ 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.

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

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

§ 10. In the greater part of what are called asthmatical cases, the real disease is anasarca of the lungs, and is generally to be cured by diuretics. (See§ 1.) This is almost always combined with some swelling of the legs.

§ 11. There is another kind of asthma, in which change of posture does not much affect the patient. I believe it to be caused by an infarction of the lungs. It is incurable by diuretics; but it is often accompanied with a degree of anasarca, and so far it admits of relief.

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

§ 12. If the asthma be of the kind mentioned at (§§ 9and11,) 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.

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

§ 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.

§ 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.

§ 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.

§ 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 symptomsare 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 sameideas 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 toCase LXIXfor 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. InCase XXXIII. the symptoms of death were at hand; inCase LXIX. the practice, though successful, was too complicated, and inCase 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.

§ 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.

§ 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.

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

§ 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.

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

§ 23. Where appearances of anasarca point out the true cause of the complaint, as in casesXXIV. andXXXIV. 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.

§ 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]

§ 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.

§ 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 menstruateregularly 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.

§ 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 theLXIst casethe 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.

§ 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.

§ 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.

§ 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.

§ 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 thestate 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]

§ 32. Sydenham asserts, that the bark did not more certainly cure an intermittent, than riding did a consumption. We must not deny the truth of an assertion, from such authority, but we must conclude that the disease was more easily curable a century ago than it is at present.

§ 33. If the Digitalis is no longer useful in consumptive cases, it must be that I know not how to manage it, or that the disease is more fatal than formerly; for it would be hard to deny the testimony cited at page 9. I wish others would undertake the enquiry.

§ 34. When phthisis is accompanied with anasarca, or when there is reason to suspect hydrothorax, the Digitalis will often relieve the sufferings, and prolong the life of the patient.

§ 35. Many years ago, during an attendance upon Mr. B——, of a consumptive family, and himself in the last stage of a phthisis; after he was so ill as to be confined to his chamber, his breathing became so extremely difficult and distressing, that he wished rather to die than to live, and urged me warmly to devise some mode to relieve him. Suspecting serous effusion to be the cause of this symptom, and he being a man of sense and resolution, I fully explained my ideas to him, and told him what kind of operation might afford him a chance of relief; for I was then but little acquainted with the Digitalis. He was earnest for the operation to be tried, and with the assistance of Mr. Parrott, a very respectable surgeon of this place, I got an opening made between the ribs upon the lower and hinder part of the thorax. About a pint of fluid was immediately discharged, and his breath became easy. This fluid coagulated by heat.

After some days a copious purulent discharge issued from the opening, his cough became less troublesome, his expectoration less copious, his appetite and strength returned, he got abroad, and the wound, which became very troublesome, was allowed to heal.

He then undertook a journey to London; whilst there he became worse: returned home, and died consumptive some weeks afterwards.

§ 36. This disease admits of an easy and certain cure by the Digitalis.

§ 37. This species of dropsy may originate from other causes than child birth. In the beginning of lastMarch, a gentleman at Wolverhampton desired my advice for very large and painful swelled legs and thighs. He was a temperate man, not of a dropsical habit, had great pain in his groins, and attributed his complaints to a fall from his horse. He had taken diuretics, and the strongest drastic purgatives with very little benefit. Considering the anasarca as caused by the diseased inguinal glands, I ordered common poultice and mercurial ointment to the groins, three grains of pulv. fol. Digitalis night and morning, and a cooling diuretic decoction in the day-time. He soon lost his pain, and the swellings gradually subsided.

THE END.

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