It’s very easy to wish yourself back to a particular historical period or event: I do it the whole time. But every so often you come across an important corrective to the idyll. One such is William Withering’s An Account of the Foxglove, and Some of its Medical Uses (1785). He published the work with some misgivings, because ‘it is better the world should derive some instruction, however imperfect, from my experience, than that the lives of men should be hazarded by its unguarded exhibition, or that a medicine of so much efficacy should be condemned and rejected as dangerous and unmanageable’.
In late eighteenth-century Britain, life expectancy was (very broadly speaking) in the high forties. It was dragged down of course by huge numbers of infant deaths: if you lived to 21, you might expect another 40 years if you were a man, though childbirth dramatically reduced the prospects for many women.
Withering (1741–99) was a Shropshire man from a medical family (his grandfather apparently delivered the infant Samuel Johnson). Like so many other physicians (or intended physicians like Charles Darwin), he was apprenticed to an apothecary and then studied medicine at Edinburgh, graduating in 1766. A friend of the Darwin family (he was one of the Lunar Men) and of the botanist Richard Pulteney, he settled in Birmingham (eventually at Edgbaston Hall), and became the most prosperous practitioner outside London: he also treated as many as 3,000 poor patients a year for free.
It may have been his friendship with Pulteney that increased his interest in botany beyond the physician’s usual material medica. He was certainly influenced by Helena Cookes, a young patient who he encouraged in her botanical drawings, and married on 12 September 1772. In 1776 he published his two-volume Botanical Arrangement of All the Vegetables Naturally Growing in Great Britain (coming soon!), in which (according to the ODNB), he was the ‘first to delineate systematically in English the flora of Great Britain, using and extending the Linnaean system of classification’.
But his work on the foxglove made him famous, and pioneered the use of the drug digitalin, still used today in cases of congestive heart failure. The book cites cases from his own experience and those of fellow physicians in the West Midlands, and most make fairly revolting reading. The key terms are:
- Ascites: the medical name for a build up of fluid in the abdomen
- Anasarca: characterised by widespread swelling of the skin, due to effusion of fluid into the extracellular space
- Hydrothorax: a type of pleural effusion in which serous fluid accumulates in the pleural cavity
- Dropsy: now called oedema, observable swelling from fluid accumulation in body tissues
Withering had heard of a Shropshire folk remedy for dropsy containing a great number of herbs, but in which he realized that the significant active diuretic ingredient must be foxglove. He was also aware that the leaves and root of the plant were extremely toxic and caused both severe vomiting and diarrhoea, if not death.
He therefore began systematically to experiment with doses, deciding that young spring leaves, subsequently dried, produced the most controllable drug. He used it only when all other remedies had failed: in one case, after ‘calomel, saline, draughts, jalap purges, chrystals of tartar, pills of gum ammoniac, squills, and soap, sal succini, eleterium, &c. … infusion of Digitalis was directed … and he recovered a pretty good state of health’.
Here are six other cases where the outcome wasn’t so cheery:
- Mr L, aged 35. Ascites and anasarca, the consequence of very intemperate living. After several weeks of treatment, with good diuretic effect, the patient returned to his intemperate ways, and ‘did not survive many weeks’.
- Mr E, aged 61. ‘Hydrothorax, ascites and anasarca, consequences of hard drinking.’ Foxglove leaves being not available, Withering made a version using the roots: the purging and vomiting side-effects were so great that the doses could not be continued, and the patient died.
- B, aged 12. ‘Scrufulous, consumptive, and at length anasarcous. Took infus. Digital. without advantage.’ Died two months later.
- Mr S, aged 45. The foxglove and many other remedies failed and he died. Withering suspected lead poisoning, but was baffled, as the family pump was wooden. However, a casual conversation with a pump-maker revealed that the had removed the heavily corroded lead pump at Mr S’s house only three years before.
- Mrs G, aged 62. ‘Ascites and very hard legs … she died a few weeks afterwards.’
- Mrs D, aged 72. ‘A thin woman, with very large anasarcous legs and thighs … she had very great pain in them, and they were red and black in places (possibly because an earlier physician had ‘scarified’ them). She was too feeble to be given foxglove, and died.
But of the 180-odd cases described, most end happily: ‘he soon lost all his complaints; he got on well without any other medicine; he has since remained in good health; he has had no relapse; the symptoms of dropsy disappeared; the patient soon recovered; I saw him two years later in perfect health; the Digitalis infusion entirely cured her’.
This is obviously good news: but think of the poor patients, many of whom did not see Withering, the acknowledged go-to man for foxglove, until their own physician had tried all sorts of unpleasant remedies. Squills, for example, turn up frequently: scilla maritima was used by the ancient Greeks as a diuretic, but its active agents are still not fully understood, and it is sufficiently toxic to be used in rat poison. A mercury ointment was often employed externally on the swollen limbs, and like the dreaded calomel, it wouldn’t have helped.
The underlying problem is that dropsical swellings are symptoms, not causes. They could indicate kidney failure, cirrhosis of the liver (all those hard-drinking men…), post-childbirth infection, the last stages of tuberculosis, asthma, lead poisoning, tertian ague and other fevers, and almost anything encompassed by ‘diseases of the viscera’. All extremely nasty, painful and, at that time, mostly incurable: and Dr Darwin, with the best of intentions, would be giving you ‘blue vitriol, elaterium, and calomel; decoction of pareira brava [the root of a South American vine], and guiacum wood [the resin thereof was used for varnishes], with tincture of cantharides(!); oxymel of squills, decoction of parsley roots, etc.’, before he summoned the foxglove man.