Case II
R—— Howgate, a man much addicted to intemperance, particularly in the use of spirituous liquors, Æt. 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; œdematous 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
May 20th. The pills have had no effect.—Cap. mistur. c.7 Decoct. Digital. &c. cochl. ii. larg. 3tia quaque hora, ad 3tiam vicem.
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.
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 ʒiii. ad. aq. &c. ℥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. ʒiss ad aq. &c. ℥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
On the examination of the body I noticed, among others, the following appearances.
About ¾ 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 ¾ 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——, Æt. 80. Orthopnœa, with sense of oppression about the prœcordia. 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. ʒiii. ad aq. &c. ℥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 œdematous, which will I trust soon yield to strengthening medicines.
CASE III.
Mrs. M—— G——, Æt. 64. Has had sore legs for these thirty-four years past. Orthopnœa. Sense of oppression at the prœcordia. Pulse intermitting. Legs anasarcous. Urine scanty, high-coloured.
Infus. Digital. c. ʒiss ad aq. bull. ℥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. præscript.
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.