In 1785 William Withering, physician and botanist in Birmingham, England, wrote a book describing how for ten years he had used an extract of foxglove to treat patients afflicted with swollen legs and abdomen. He said he had often been urged to write on this subject and had been rather diffident about it, feeling unqualified for the task; but as the use of the foxglove was spreading, in England and abroad, he thought it better to share his experience, “however imperfect,” rather than have the “lives of men hazarded by its unguarded exhibition, or that a medicine of so much efficacy should be condemned and rejected as dangerous and unmanageable.”

In his book he relates how in 1775 he was asked to give his opinion about a remedy for dropsy that had “long been kept a secret by an old woman in Shropshire, who had sometimes made cures after the more regular practitioners had failed.” He was told that the remedy often caused violent vomiting and purging, and found that its diuretic action seemed to have been overlooked. Although the medicine was made up of twenty or more different herbs, “it was not very difficult for one conversant in these subjects to perceive that the active herb could be no other than the foxglove.” So having made it a practice to “give advice to the poor during an hour in a day” he used the opportunity to try the drug on these patients, found that it was a powerful diuretic, but that initially he had given it too long and in too large doses. He also noted that the diuretic effect “did not at all depend upon its exciting a nausea or vomiting,” so he refined the way he prescribed it, using either the dry powder or boiling the dried leaves in water and preparing a “decoction,” reducing the dose, sometimes giving opium concomitantly to “refrain its action on the bowels.”

In the introduction to his book Withering described the variety of foxglove he used as digitalis purpurea, a flower commonly found and named digitalis in 1542 because its petals resemble the finger of a glove. It had been used occasionally as a medicine but was generally considered poisonous and fit only for strong constitutions because of its violent purging and vomiting effects. At one time it had been tried experimentally on turkeys, which became very weak, appeared drunk and unable to stand on their legs, and their “excrements became reddish.” Over the years physicians had prescribed foxglove in differing doses for different conditions, sometimes as an ointment, poultice, or boiled in water or wine, with varying effects. But Withering used it for its diuretic effects, carefully describing his patients who evidently suffered from a variety of diseases of the heart, kidneys, or liver, all troubled by severe swelling of the abdomen and legs, and often by difficulty in breathing. In his book he presented the detailed history of 163 cases treated between 1775 and 1785, several letters and communications from other physicians who had used the drug, a set of concluding instructions on how to prepare the medicine, “effects, rules, and cautions” on how to prescribe the drug, and some concluding “practical remarks on dropsy and other diseases.”

Born in 1741 in Shropshire in the west of England, William Withering was the only son of a prosperous apothecary. In 1762 he enrolled in the medical faculty of the University of Edinburgh, then one of the leading schools in Britain, famous for distinguished teachers such as Alexander Monro and William Cullen. He wrote his MD dissertation on “malignant putrid sore throat,” later elaborated to the “sore throat of scarlet fever.” After graduating in 1766 he established himself as a consultant physician in the small town of Stafford and was appointed to the local infirmary. There he had enough leisure to study botany and become expert at it. He collected many varieties of plants and published in 1776 a complete classification of all plants growing in Great Britain, using the Linnean nomenclature and describing their appearance, natural history, uses, and poisonous properties.

At Stafford Withering had a wide circle of friends and was happy, but his earnings of less than 100 pounds a year hardly sufficed to support a family. In 1775 he was informed by Dr. Erasmus Darwin, a prominent physician in the area, of a vacancy arising in a thriving medical practice, and accordingly moved and established himself in Birmingham. There in 1765 a meeting of “the Nobility and Gentry of the Neighbouring Country and of the Principal Inhabitants of the Town” had been held to consider building a “General Hospital for the Relief of the Sick and Lame . . . presumed to be greatly beneficial to the populous country about it, as well as that place.” A subscription had been undertaken and at a cost of 3,000 pounds the Birmingham General Hospital was built and opened its doors in 1779. It had 116 beds, and Withering with three other physicians, as well as several surgeons, were appointed to its staff.

By 1780 Withering had developed a large consulting practice, earning 2,000 pounds a year, a very large amount in those days, especially as there was no income tax. The work was demanding, however, requiring him to have covered in one year an estimated 6,000 miles by carriage. In addition, he held a daily clinic for the poor at the Birmingham General Hospital, seeing about ten patients a day (2,000 to 3,000 annually) without charge. It was there that Withering that first studied the effects of the foxglove.

Yet then as now, a consulting practice, however successful, was not all sunshine. Patients could be difficult, competing physicians jealous and malicious. In 1781 Withering was slandered and unjustly blamed for the sudden death of a young woman with puerperal fever whom he had visited several times despite fracturing his clavicle in a carriage accident and requiring an assistant to accompany him and help him dress and undress. Some years later Dr. Charles Darwin unfairly accused him of “ungenteel medical behavior” because he had questioned his diagnosis and altered the regimen of a jaundiced woman whom he had initially treated but then to all appearances had signed off.

This episode may have been the result of a longstanding enmity between Withering and Charles’ highly influential father Erasmus Darwin, an irascible and imperious physician who did not welcome rivals in medicine or science and was prone to take credit for their innovations. After the publication of Withering’s book, he claimed priority for using the foxglove and published a paper in which he did not even mention Withering’s name. It is indeed possible that both physicians had learned about the use of foxglove at the same time when jointly seeing a patient in consultation. But Withering’s approach was more detailed and systematic, and he clearly deserves the credit for studying, developing, and popularizing this form of therapy.

Despite his heavy medical commitments in Birmingham, Withering remained active in studying botany, mineralogy and chemistry, also politics, economics, and even meteorology. He had several papers published in the prestigious transactions of the Royal Society, and was elected to the membership of that Society in 1785, the year he published his account of the foxglove. He was also a member of the Lunar Society, which had been founded in Birmingham in 1765 to have its members meet every month at full moon to exchange views on literature, art, and science. The Lunar Society had many distinguished members, including Josiah Wedgewood, James Watt, Joseph Banks, Samuel Galton, Benjamin Franklin, as well as Dr. Erasmus Darwin.

By 1791 Withering’s health had begun to deteriorate; he had several attacks of pleurisy or hemoptysis, and resigned from the hospital as it became obvious that he was suffering from consumption, i.e. tuberculosis. Hoping the better winter climate would improve his health and unable to go to the South of France because of the French Revolution, he travelled twice to Portugal, in 1792 and again in 1793. He did not improve and found the weather too hot; and on his second trip his ship was pursued by pirates. By 1797 he was even too ill to write. In July 1799 he had an attack of pleurisy and felt so ill that he took a lancet and bled himself—“with great composure and dexterity.” The end came in October of that year.

The introduction of digitalis into medical practice represents a milestone in the therapy of heart disease and especially congestive failure, and its impact continued to be felt until relatively recent times. Cardiologists who in their youth treated their patients with large doses of digitalis are likely to hold William Withering in greater esteem and reverence than those of more recent training who now hardly ever prescribe the drug. With the discovery of potent diuretic drugs and cardiac agents, digitalis has almost descended into oblivion, but the story of its discovery and its evaluation by careful observation and meticulous recording of patients’ illnesses remains an important chapter in the history of medicine.

References

1. Withering, William. An account of the foxglove and some of its medical uses: with practical remarks on dropsy, and other diseases. Birmingham, 1785.
2. Peck TW, Wilkinson KG. William Withering of Birmingham. Baltimore.The Williams and Wilkins C, 1950.
3. GC Cook. Erasmus Darwin FRS (1731-1802) and the foxglove controversy. Journal of Medical Biography 1999;7:86.