An Account of the Foxglove (1785)

Table of Contents

1. 1. Dropsy in the Eighteenth Century
2. 2. The Old Woman’s Receipt (1775)
3. 3. The Mother Hutton Legend
4. 4. Too Much, Too Long: Early Lessons
5. 5. Leaf, Infusion and Powder
6. 6. From Birmingham to the Edinburgh Pharmacopoeia
7. 7. One Hundred and Sixty-Three Cases
8. 8. Effects, Rules and Cautions
9. 9. The Nine Inferences
10. 10. An Early Model of Honest Reporting
11. Key Research Papers
12. Connections
13. Featured Videos

1. Dropsy in the Eighteenth Century

“Dropsy” was not one disease but a description: the body slowly filling with watery fluid. Eighteenth-century physicians sorted it by where the water gathered. Anasarca was swelling of the skin and limbs, the puffy legs and thighs that pit when pressed. Ascites was fluid in the belly. Hydrops pectoris or hydrothorax was water in the chest, which left the patient breathless, often unable to lie flat. Withering uses all three terms throughout his book, and many of his patients are described as having several at once.

Today we know that this kind of swelling has several causes — kidney disease, liver disease, malnutrition — but that a large share of it comes from the heart. When the heart pumps weakly, blood backs up in the veins, pressure rises in the small vessels, and fluid seeps out into the tissues and the lungs. The modern name for that condition is congestive heart failure. Withering did not know this. He thought of dropsy as a problem of retained water, and of a good dropsy medicine as one that made the patient pass that water as urine.

The treatments available to him were harsh. Historians of the period describe bleeding as a common dropsy treatment of the time (Buchtel and Ventura, 2006). Purging medicines emptied the bowels; squill, the bulb of the sea onion, was the standard diuretic and was thought to work best when it made the patient sick; and when the swelling became unbearable a surgeon could drain the fluid through a hollow instrument called a trochar, which Withering mentions in passing. None of these reliably changed the course of the illness, and a patient with severe dropsy could expect to die of it.

That background matters for reading the book. When Withering describes a patient who “made a large quantity of water” and whose swelling went down, he is describing what looked, to him and to the patient, like a near-miracle — and what we can now recognise as the effect of a drug that helps a failing heart pump more strongly and more slowly.

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2. The Old Woman’s Receipt (1775)

The book opens its historical section with a short essay on how the healing properties of plants could be learned. Chemistry, Withering wrote, had so far told physicians very little. A plant’s virtues had to be learnt from observing its effects on animals, from its likeness to related plants, or “from the empirical usages and experience of the populace” — the folk knowledge of ordinary people, which, he added, “lies within the reach of every one who is open to information, regardless of the source from whence it springs.”

Then he tells his own story:

“In the year 1775, my opinion was asked concerning a family receipt for the cure of the dropsy. I was told that it had long been kept a secret by an old woman in Shropshire, who had sometimes made cures after the more regular practitioners had failed. I was informed also, that the effects produced were violent vomiting and purging; for the diuretic effects seemed to have been overlooked.”

A “receipt” is the old word for a recipe. Withering continues that the medicine “was composed of twenty or more different herbs; but it was not very difficult for one conversant in these subjects, to perceive, that the active herb could be no other than the Foxglove.” He was already a serious botanist — his Botanical Arrangement of British plants appeared the following year — and the herbal tradition he was drawing on was an old one. Historians of herbal diuretics trace a line from the “wise women” of folk medicine to Withering (Kinne-Saffran and Kinne, 2002), and foxglove itself had long been used in European folk medicine, including rubbed into the skin, before he took it up (Groves and Bisset, 1991).

Two details in that short passage deserve attention. First, Withering says only that his opinion was asked about the recipe and that he was told its origin; he does not say he met the woman, and he never names her. Second, the people who used the recipe had noticed its violent effects on the stomach and bowels but had missed the effect that interested him — the flow of urine. That observation, more than the identification of the herb, is what turned a folk remedy into a subject of study.

He was in a good position to test it. His predecessor in Birmingham, Dr William Small, had given free advice to the poor for one hour a day, and Withering continued the practice “until we had an Hospital opened for the reception of the sick poor.” The poor who came for advice, he wrote, “amounted to between two and three thousand annually.” The first numbered case in the book, dated 8 December 1775, is a former builder “much reduced in his circumstances” with a swollen belly and short breath, who was given a decoction of fresh foxglove leaves, became very sick for several days, passed “a large quantity of water”, and recovered his breath and appetite.

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3. The Mother Hutton Legend

Many popular histories of medicine give the old woman a name — “Mother Hutton” — and tell how Withering visited her, bought her secret, and built his discovery on it. Some add a picture of a kindly Shropshire herb-woman handing over her plants. The story is a legend.

None of it appears in Withering’s writings. As the passage quoted above shows, he wrote only of “a family receipt” kept secret by “an old woman in Shropshire”, gave her no name, and described himself as being consulted about the recipe rather than meeting its owner. The name “Mother Hutton” and the familiar image come from a 1928 drug-company advertising illustration by the artist William Meade Prince. The picture was widely reproduced, and the story attached to it came to be repeated as if it were history.

The historian D. M. Krikler traced how the legend grew in a short paper titled “Withering and the foxglove: the making of a myth” (Krikler, 1985), published in the bicentenary year of the Account, alongside a longer paper on the foxglove, “the old woman from Shropshire” and Withering. The old woman herself was real, on Withering’s word; the name, the meeting and the portrait were added a century and a half later.

The legend has a certain appeal, because it makes a neat story about folk wisdom being recognised by science. The real story is in some ways more interesting: an anonymous recipe, passed on second-hand, a physician who recognised one plant among twenty, and a decade of careful — and at first mistaken — trial and error before the book appeared.

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4. Too Much, Too Long: Early Lessons

One of the most striking things about the Account is how openly Withering describes his own mistakes. Of his first years with the plant he wrote:

“I soon found the Foxglove to be a very powerful diuretic; but then, and for a considerable time afterwards, I gave it in doses very much too large, and urged its continuance too long; for misled by reasoning from the effects of the squill, which generally acts best upon the kidneys when it excites nausea, I wished to produce the same effect by the Foxglove.”

In other words, he copied the habits of the drug he already knew. Squill was believed to work best when it made the patient queasy, so he pushed foxglove until it did the same. He admits too that with so many poor patients to see in an hour or two he could not take notes; “two or three of them only, in which the medicine succeeded, I find mentioned amongst my papers.” Even so, that early experience was enough for him to write, in the Botanical Arrangement published the following spring, that Digitalis purpurea “merited more attention than modern practice bestowed upon it.”

He reprints a letter he sent in November 1777 to a Worcester surgeon, Mr Russel, introducing it, in his own words, “as shewing the ideas I then entertained of the medicine, and how much I was mistaken as to its real dose.” In that letter he described a decoction of three drams of dried leaves boiled in water, given every two hours until it caused nausea. By 1785 he regarded that method as far too strong. He also reported that some patients’ vision was affected — “indistinct vision ensues” — though at that stage he had “never yet found any permanent bad effects from it.”

The most important lesson came later. With experience he became convinced that “the diuretic effects of this medicine do not at all depend upon its exciting a nausea or vomiting”. Sickness, he found, was not merely unnecessary but could work against the treatment: “I have often known the discharge of urine checked, when the doses have been imprudently urged so as to occasion sickness.” Here, two centuries before anyone could measure a drug level in the blood, is a clear clinical description of the difference between an effective dose and a toxic one.

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5. Leaf, Infusion and Powder

What moved foxglove from an occasional experiment into Withering’s regular practice was a report about an Oxford academic. His friend Dr Ash told him that Dr Cawley, “then principal of Brazen Nose College, Oxford, had been cured of a Hydrops Pectoris, by an empirical exhibition of the root of the Foxglove, after some of the first physicians of the age had declared they could do no more for him.”

Withering decided to pursue the plant “more vigorously than before”, but not with the root. He was, he wrote, “too well aware of the uncertainty which must attend on the exhibition of the root of a biennial plant, and therefore continued to use the leaves.” Foxglove lives for two years, building a rosette of leaves in the first and flowering in the second, and its chemistry changes as it grows. He had found that the leaves too “vary much as to dose, at different seasons of the year”, and his solution was standardisation: leaves gathered “always in one condition of the plant, viz. when it was in its flowering state, and carefully dried”, so that “the dose might be ascertained as exactly as that of any other medicine.” In the summer of 1776 he had a quantity of leaves dried for this purpose, and the medicine “was gradually adopted by the medical practitioners in the circle of my acquaintance.”

He then changed the way it was prepared. A decoction — a long boiling — depended on the care of whoever made it, and, reasoning by analogy from tobacco, “another plant of the same natural order”, he suspected that “its active properties might be impaired by long boiling.” So “the decoction was therefore discarded, and the infusion substituted in its place” — leaves steeped rather than boiled. After that he began to use the leaves dried and ground to a powder, “but I still very often prescribe the infusion.”

The Cawley story itself turns up again at the end of the book. Dr Cawley’s brother, Robert Cawley, wrote to Withering in May 1785 that the late Dr Cawley “was greatly relieved, and his life, perhaps, prolonged for a year, by a decoction of the Foxglove root”, but that he had been “dreadfully sick and ill for several days before the secretion of urine came on.” Withering added a note: if the root had been gathered in its active state, Dr Cawley “did not take at each dose less than twelve times the quantity a strong man ought to have taken.” The case that first encouraged him, in other words, was also an example of exactly the overdosing he spent the book warning about.

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6. From Birmingham to the Edinburgh Pharmacopoeia

News of the medicine travelled through letters and medical societies. Early in 1779, Withering recalled, a number of dropsy cases appeared in Birmingham following an epidemic of scarlet fever and sore throat the year before, and “they were all without an exception cured by the Foxglove” — though he admits he had again omitted to make notes. That experience encouraged him to use the medicine more often.

In February 1779 his friend Dr Jonathan Stokes “communicated to the Medical Society at Edinburgh the result of my experience of the Foxglove.” Later that year Stokes wrote to say that Dr Hope had “tried the Foxglove in the Infirmary with success”, and that Dr Hamilton, who learnt its use from Hope, went on to employ it frequently in the hospital at Edinburgh. Withering also records that Charles Darwin — the young medical student son of Erasmus Darwin, who died in 1778 — had told Dr Duncan of Edinburgh about its use “by his father and myself, in cases of Hydrothorax”. The early history of who used foxglove first in this circle later became a matter of dispute, discussed by historians on the Life and Career page of this wing (Fulton, 1934).

Then came official recognition: “At length, in the year 1783, it appeared in the new edition of the Edinburgh Pharmacopœia, into which, I am told, it was received in consequence of the recommendation of Dr. Hope.” A pharmacopoeia is the official list of approved medicines and how to prepare them, and entry into the Edinburgh one meant that foxglove was now a recognised medicine across much of Britain.

Withering did not greet this as a triumph. In the same paragraph he predicted that the plant would “be again very soon rejected” if it continued to be given “in the unrestrained manner in which it has heretofore been used at Edinburgh, and in the enormous doses in which it is now directed in London.” Part of his purpose in writing the book, he makes clear, was to stop a useful medicine being discredited by careless prescribing.

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7. One Hundred and Sixty-Three Cases

The heart of the book is a long run of case reports, arranged year by year from 1775 to 1785 and numbered in Roman numerals from Case I to Case CLXIII — 163 of Withering’s own patients. (Some modern summaries give a slightly lower figure; the count here is taken from the numbering in the 1785 text.) After them come letters and case reports sent by other practitioners, among them surgeons and physicians who had used the medicine under his direction or on their own.

The cases are short, practical notes. A typical entry gives the date, the patient’s sex and approximate age (he admits in the preface that “the ages of the patients are not always exact”), the kind of dropsy, what had been tried before, how the foxglove was given, and what happened. The patients range from the poor who came to him for free advice to tradesmen, gentlemen and their families, and from children to the elderly. The last numbered case, Case CLXIII, is Sarah Ford, aged 42, admitted as an out-patient of the Birmingham General Hospital on 26 February 1785 with chest pain, breathlessness and swollen legs after squills and other remedies had failed; she was discharged on 20 March with no symptom remaining.

What makes the series unusual is that it is not a collection of successes. Patients who were not helped, patients who were too ill to benefit, patients who died, and patients in whom Withering judged the medicine to have been given wrongly are all included. Many entries end with a short comment on why the treatment did or did not work. Some describe the drug failing because the dropsy was caused by something it could not touch, such as a fluid-filled cyst or advanced disease of an organ; others describe sickness, purging or a slowed pulse when the doses were pushed. The historian of medicine Ulrich Tröhler, writing on the book’s preface, describes it as an appeal for caution when reporting on a new medicine (Tröhler, 2007).

The cases also show Withering’s own practice changing over the decade — the early decoctions of fresh leaves, the move to dried leaves, and then infusions and pills of powdered leaf, sometimes combined with other medicines. Readers today can follow, case by case, a physician learning how to use a powerful drug.

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8. Effects, Rules and Cautions

After the cases, Withering gathered what he had learned into a section headed “Effects, Rules, and Cautions”. It opens with one of the earliest clear descriptions of digitalis poisoning:

“The Foxglove 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.”

Almost every item on that list is still recognised as a sign of cardiac glycoside toxicity. The yellow-green tinge to vision is a classic, well-known feature; the slow pulse reflects the drug’s effect on the heart’s electrical conduction; nausea and vomiting are the commonest early warning signs. An emergency-medicine review of the book notes that Withering was largely unaware of the drug’s effects on the heart, yet treated many patients who would now be diagnosed with congestive heart failure, and recorded striking examples of its toxicity (Bessen, 1986).

He also noticed features of the drug’s timing that later pharmacology would explain: the sickness “does not take place for many hours after its exhibition has been discontinued”, and it recurs “for three or four days, at distant and more distant intervals” — a description that fits a drug which builds up in the body and leaves it slowly. “These sufferings are not at all necessary,” he concluded; “they are the effects of our inexperience.”

Rather than lay down rules without explanation, he chose to show how his rules had developed, explaining that a reader would understand them better “from the following detail of my own improvement, than from precepts peremptorily delivered, and their source veiled in obscurity.” At first he thought it necessary to bring on the sickness; then he stopped the medicine once nausea came; then he stopped it as soon as the urine flowed or sickness or purging appeared. That served him for two or three years, until “cases occurred in which the pulse would be retarded to an alarming degree, without any other preceding effect.” His final rule, as he recorded it, was that the medicine be continued only “until it either acts on the kidneys, the stomach, the pulse, or the bowels” and stopped at the first appearance of any one of those effects, with doses spaced far enough apart for each to take effect — because, he wrote, “it was found very possible to pour in an injurious quantity of the medicine, before any of the signals for forbearance appeared.”

Modern readers will recognise in this the idea of titrating a drug to its effect, and the idea that the pulse is a window on its action. These are reported here as part of the history of the book; how digoxin is used today is a question for clinicians and is covered, as research findings, on the legacy page of this wing.

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9. The Nine Inferences

The case reports end with a short list that has been quoted ever since. Withering introduces it with an explicit warning to his younger readers: he wanted “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.” He would deduce only “a few inferences, which I apprehend the facts will fairly support.” In his own words:

1. “That the Digitalis will not universally act as a diuretic.”
2. “That it does do so more generally than any other medicine.”
3. “That it will often produce this effect after every other probable method has been fruitlessly tried.”
4. “That if this fails, there is but little chance of any other medicine succeeding.”
5. “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.”
6. That when dropsy comes with “palsy, unsound viscera, great debility, or other complication of disease”, no diuretic “can do more than obtain a truce to the urgency of the symptoms”, unless by gaining time it lets other medicines treat the original disease.
7. “That the Digitalis may be used with advantage in every species of dropsy, except the encysted.”
8. “That it may be made subservient to the cure of diseases, unconnected with dropsy.”
9. “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.”

The list is notable for what it leads with. The very first inference is a limitation — the drug does not always work — and the sixth is a frank statement that in patients with serious underlying disease it can only buy time. The “encysted” dropsies excluded in the seventh were fluid-filled cysts, such as ovarian cysts, which he had already noted in 1777 no medicine could be expected to remove.

The ninth inference is the one most often quoted today. Withering had noticed that foxglove slowed and changed the pulse in a way no other medicine did. But he still believed that its main work was on the kidneys; the understanding that the heart was the drug’s primary site of action, and that the flow of urine followed from better heart function, came later (Bessen, 1986; Wray, Eisner and Allen, 1985). Inference IX is best read as an observation and a prediction rather than a discovery that foxglove was a heart drug — a prediction that later research went on to confirm.

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10. An Early Model of Honest Reporting

The passage of the Account most admired by modern writers is not about foxglove at all. It is in the preface, where Withering explains why he included every case:

“It would have been an easy task to have given select cases, whose successful treatment would have spoken strongly in favour of the medicine, and perhaps been flattering to my own reputation. But Truth and Science would condemn the procedure. I have therefore mentioned every case in which I have prescribed the Foxglove, proper or improper, successful or otherwise.”

He knew this would expose him to criticism — “Such a conduct will lay me open to the censure of those who are disposed to censure” — but trusted it would “meet the approbation of others, who are the best qualified to be judges.” Tröhler’s 2007 essay on this preface in the Journal of the Royal Society of Medicine is titled “Withering’s 1785 appeal for caution when reporting on a new medicine” (Tröhler, 2007). The problem Withering named — selective reporting of only the successes — is still recognised as a major source of bias in medical research, and modern rules on registering trials and publishing all results are aimed at it.

Later writers have drawn other lessons from the book as well. Withering’s insistence on leaves gathered at one stage of growth and carefully dried was an attempt to standardise a variable natural product; his patient adjustment of doses described a narrow gap between a helpful and a harmful amount; and his descriptions of patients who responded very differently to the same preparation anticipated the study of individual variation in drug response. A clinical pharmacologist writing on his legacy groups these as lessons about non-standard preparations, individual differences in response, dose–response and adverse effects (Breckenridge, 2006). Earlier assessments of Withering and his book make similar points about his care as a clinical observer (Silverman, 1989; Krikler, 1985).

He was modest about what he had achieved. “Experience and cautious attention gradually taught me how to use it,” he wrote of the ten years since he first used the plant, and of his methods, “I am still far from thinking them perfect.” The book does not claim to have found a cure for dropsy; it claims to have learned, slowly and with mistakes, how to use one powerful plant more safely — and it shows its working. The later story of that plant, from the isolation of digoxin to modern trials, is told on the other pages of this wing.

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Key Research Papers

1. Silverman ME. William Withering and An Account of the Foxglove. Clin Cardiol. 1989;12(7):415-8. PubMed PMID: 2663265
2. Krikler DM. The foxglove, "The old woman from Shropshire" and William Withering. J Am Coll Cardiol. 1985;5(5 Suppl A):3A-9A. PubMed PMID: 3886750
3. Krikler DM. Withering and the foxglove: the making of a myth. Br Heart J. 1985;54(3):256-7. PubMed PMID: 3899150
4. Tröhler U. Withering's 1785 appeal for caution when reporting on a new medicine. J R Soc Med. 2007;100(3):155-6. PubMed PMID: 17339312
5. Bessen HA. Therapeutic and toxic effects of digitalis: William Withering, 1785. J Emerg Med. 1986;4(3):243-8. PubMed PMID: 3543113
6. Buchtel L, Ventura HO. Lunar Society and the discovery of digitalis. J La State Med Soc. 2006;158(1):26-30. PubMed PMID: 16602482
7. Fulton JF. Charles Darwin and the history of the early use of digitalis. Bull N Y Acad Med. 1934;10(8):496-506. PubMed PMID: 19311925
8. Kinne-Saffran E, Kinne RK. Herbal diuretics revisited: from "wise women" to William Withering. Am J Nephrol. 2002;22(2-3):112-8. PubMed PMID: 12097727
9. Groves MJ, Bisset NG. A note on the use of topical digitalis prior to William Withering. J Ethnopharmacol. 1991;35(2):99-103. PubMed PMID: 1809828
10. Wray S, Eisner DA, Allen DG. Two hundred years of the foxglove. Med Hist Suppl. 1985;(5):132-50. PubMed PMID: 3915521
11. Breckenridge A. William Withering's legacy--for the good of the patient. Clin Med (Lond). 2006;6(4):393-7. PubMed PMID: 16956147

PubMed Topic Searches

1. PubMed: Withering, foxglove, 1785
2. PubMed: History of digitalis and dropsy
3. PubMed: Digitalis toxicity and yellow vision (xanthopsia)
4. PubMed: History of selective reporting in clinical research

Further Reading

• Withering W. An Account of the Foxglove, and some of its Medical Uses: with Practical Remarks on Dropsy, and Other Diseases. Birmingham; 1785. Full text: Project Gutenberg eBook #24886
• Lee MR. William Withering (1741–1799): a biographical sketch of a Birmingham Lunatic. James Lind Library Bulletin; 2005. James Lind Library

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Connections

• William Withering: Foxglove and the Birth of Digitalis
• William Withering: Life and Career
• Foxglove: The Plant and the Science of Digitalis
• From Foxglove to Digoxin: Legacy and Later Research
• Pharmacology
• Heart Failure
• Heart Failure: History and Discovery
• Edema and Swelling
• Atrial Fibrillation
• Arrhythmia
• Hawthorn
• Otto Loewi and Henry Dale

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