Part 4
M. Laennec considers that the tartar emetic, when administered with the freedom which I have described, exerts a highly useful power in diminishing inflammatory action in continued fever, and in the phlegmasiæ; and he is most satisfied with its action, when, after the first day or two, it ceases to produce any sensible effect on the stomach.
Reflecting on the extraordinary circumstance of the exhibition of this active medicine in such immense quantity with seeming impunity, I thought it probable that the French preparation might be weaker than our own; but on comparing the crystals which I procured at Paris, with those prepared according to the London Pharmacopœia, I could not discover any difference; nor is there the least essential distinction in the mode of preparation, as directed by the London Pharmacopœia and the French codex. I have lately had many opportunities of prescribing tartar emetic on the principle of treatment which I have described; and I have been perfectly satisfied with its useful agency; but I have usually commenced with one grain, and never exceeded two grains, for the first twenty-four hours; nor found it necessary to go beyond eight in the progressive quantity; except in one case of insanity, in which sixteen grains were given daily for a short time, with the greatest advantage. In the quantity of two grains, it has usually produced considerable sickness for the first day or two; but afterwards, even the increased doses have seldom caused any nausea.
With some persons, however, the first dose of a quarter of a grain produces active sickness. It appears to me probable that the maximum of usefulness[7] is to be found in a moderate range of doses; and that it is desirable to avoid trying how much the stomach and the constitution will possibly bear. Have we a security that the accumulation of a very large quantity might not produce violent effects? Indeed, I am informed of an instance in which the amount of sixty grains was taken in divided doses in a short time; the direction being given that the medicine should be repeated till vomiting was produced. At length, such severe sickness did take place, as could not be restrained for many weeks.
In the treatment of active inflammation, I have usually joined nitre in moderate doses, with tartarized antimony, in a saline draught; and when the inflammatory action has so far yielded, that I have had confidence in not requiring the further use of the lancet, and therefore not apprehended the inconvenience to which I have adverted at page 27, of disguising the disease, I have added digitalis to the draught occasionally; thus obtaining a combination of sedative medicines of great efficacy; and, according to my experience, not disagreeing with the stomach during the active state of the disease.
We must always keep in mind that the effect of medicine is in the greatest degree relative to the particular disease for which it is administered, and to the force of such disease. The doses of active medicines are to be diminished as symptoms abate.
In the case of a gentleman suffering from enlargement of the liver, and with whom mercury in any form acted very unfavourably, I obtained the most satisfactory results from the use of tartar emetic as an alterative; this medicine never occasioning that nervous irritation which invariably attended the use either of calomel or the pilula hydrargyri.
The practice which I have here related, of administering large doses of tartar emetic, and that recommended by Dr. Hamilton, of the free use of purgatives, appear very opposite to the doctrines of Broussais, which inculcate such a tender regard to the susceptibility of the stomach and intestinal canal, as almost to discountenance the use of emetics and purgatives, from the apprehension of producing _gastrite_, or _gastro-enterite_.
We are greatly indebted to the ingenuity and industry of the French chemists for many important results in vegetable chemistry; and as the most valuable of all the discoveries made, I may mention the separation of the essential principle of the yellow bark (cinchona cordifolia) called _quinine_; which, for medical use, is afterwards combined with sulphuric acid, forming the now well-known medicine, sulphate of quinine[8].
I do not consider it to be proved, that the sulphate of quinine embraces all the useful qualities of the entire bark; although, from its power in curing intermittent fever, we may conclude that it possesses the most important. Two of the principles which are removed by the process for obtaining the sulphate, namely, the quinic acid, and resin, must not be disregarded.
I have sometimes found the decoction of bark more acceptable to the stomach, and more useful, than the sulphate of quinine, and particularly grateful when given with the carbonate of potash and lemon juice in effervescence, adding also some tincture and syrup of orange peel.
Bark in substance very often oppresses the stomach, and seems to impair both the appetite and digestion, which in general become improved by the influence of the sulphate of quinine. Indeed, formerly, when in the habit of directing large and frequent doses of the powder of bark for the cure of ague, I found it expedient almost to forbid food, seeing that the stomach was sufficiently occupied with the presence of the bark. It is scarcely necessary to observe, that, in some cases of ague, where the digestive organs, and the liver especially, are in fault, bark, in any form, is not the appropriate medicine for the cure.
The sulphate of quinine is unquestionably a powerful and excellent tonic, and at the same time does not stimulate unfavourably. I am accustomed to prescribe it with great success to patients convalescent from gout; to whom on all former occasions, bark in its other forms had proved unsuitable, tending to re-excite the gouty action.
The acetate of morphine is another of the new medicines derived from the French chemists, which we can administer advantageously to those individuals who are too much stimulated by the ordinary preparations of opium. The process[9] employed for the separation of morphine from opium, removes the resin, the narcotine, and meconic acid.
The black or Lancastrian drop owes its useful quality to the circumstance of its containing a larger proportion of acetate of morphine than the other principles of opium; but it is not so pure a preparation as the acetate of morphine, prepared as I have described.
It appears to me that half a grain of the acetate of morphine is about equal to a grain of the extract of opium.
When immediate relief from severe pain is sought to be obtained, and that opium does not materially disagree with the patient, a preference is due to the tincture of opium, as being a more powerful anodyne than any of the other preparations which I have mentioned. I have found, by experiment, that the resin, separated from the other parts of opium, has an anodyne power, not inconsiderable.
The hydrocyanic (prussic) acid is a valuable medicine, but requires, according to my observation, more care in the administration of full doses, than any other medicine. It may be given in small doses, usually, without any inconvenience. When its qualities were first proclaimed, it was too highly extolled as a remedy in phthisis pulmonalis; and, from consequent disappointment, I conceive that its just merits are not sufficiently appreciated. In some cases of hectic fever, attended with urgent cough, I have procured the happiest effects from the use of this medicine. I have not, with the adult patient, in any instance, prescribed more than twenty-four minims as the total quantity, in twenty-four hours; and usually have confined myself to the extent of fifteen, always commencing with small doses.
In order that this medicine may be given with reliance on its properties, it is necessary that it should be kept in the dark, in a cool situation, and that the vial should be accurately stopped. I proceed to offer a cursory account of several of the other new medicines.
The alcoholic extract of nux vomica exerts a special and powerful influence on the spinal marrow, and has produced very beneficial effects in some urgent cases of paralysis. It may be given either in general or local palsy, provided that inflammatory action be not present; that there be no indications threatening apoplexy; and that due care be taken in its administration.
In order to obtain the beneficial effects of the medicine in very confirmed cases of paralysis, we are informed by M. Magendie, that the paralytic limbs should experience some convulsive action; and this, he says, usually takes place in the course of a few days. Then the dose of the medicine is to be lessened. It is administered with most advantage in the form of a pill. A quarter of a grain is the least dose which need be used in the beginning for an adult; and it may be given twice or thrice in the day. The dose is to be increased according to its effects: and it is stated by M. Magendie, that some persons have borne the augmented quantity of thirty grains in the day: but from four to six grains per diem, is the maximum amount usually required. This distinguished physiologist mentions that, in Italy, the following tincture is very much employed for the treatment of paralytic limbs, by means of friction:
Alcohol, one ounce, Dry extract of nux vomica, three grains.
Dr. Edwards, at Paris, was successful with nux vomica in a case of amaurosis, or gutta serena, accompanied with a paralysis of the upper eye-lid. It has afforded great benefit in many cases of local paralysis, affecting different parts of the body in different examples.
A medical friend informs me, that he obtained very great advantage from this medicine in the treatment of a severe case of tic douloureux, after various other medicines had failed to give relief.
In a case of long standing paralysis of one of the lower extremities, I have had great cause to be gratified with the useful agency of the alcoholic extract, in relieving the symptoms of neuralgia. The patient, a gentleman between thirty and forty years of age, had been afflicted with occasional pains of great severity coming on suddenly, causing complete disability, lasting about twelve hours, and during such period, producing exquisite tenderness of the limb. With the abatement of pain, sleep followed; and, on awaking, this tenderness had so completely passed away, that he could bear a free handling of the parts; but the muscular power of the limb was weakened during the day, it was frequently affected with convulsive action, and its usual debility became much increased.
The case is in progress; but up to the present time the medicine has evidently produced good effects, and without causing any tetanic action of the muscles, which I have mentioned as being considered desirable in some cases; although an unusual sense of tightness was produced. Not the least pain has returned, and the limb is stronger. When I had increased the dose to a grain and a quarter during two days, the sense of tightness, joined with much feeling of weight, became troublesome, and I suspended the use of the extract. In forty-eight hours these symptoms disappeared, and the medicine has been resumed without any kind of disagreement. I may add, with satisfaction, that the retentive power of the bladder, which had been for a long time affected, became materially improved.
It has been discovered by M. M. Pelletier and Caventou, that the nux vomica, the bean of St. Ignatius, and the upas poison, owe their active power over man and animals, to two particular vegetable alkalies, the strychnine and brucine.
_Strychnine_ is procured in the state of crystals, by a complicated chemical process, from the nux vomica. Its action on the animal economy, as proved by experiments on dogs, is so extremely powerful, that one would conceive it to be inadmissible as a medicine; but M. Magendie relates that he has administered it in paralytic cases with good effects. From an eighth to a quarter of a grain is the usual dose. Brucine has been found combined with strychnine in the nux vomica. In St. Ignatius’s bean, and in the upas, brucine bears a similar relation to that which cinchonine has to quinine in the cinchona barks, the strongest of which (cinchona cordifolia) contains the largest relative proportion of quinine. In the same manner the bean and upas, which are much more active substances than the nux vomica, contain little of the brucine, and much of strychnine. In the upas, strychnine is almost pure[10].
For medicinal purpose, brucine is procured from “la fausse angusture” (angustura ferruginea). The process is in most respects similar to that employed for strychnine. It is administered in pills, and has been employed in paralytic cases with reported success by M. Magendie, and by M. Andrals fils, in doses from half a grain to five grains; and it is assuredly a much safer preparation than strychnine.
The active properties of ipecacuanha have been found by M. M. Magendie and Pelletier, to reside in an immediate principle which they have called _emetine_. They consider that it may be advantageously substituted for ipecacuanha, as an emetic, it being divested of the offensive odour and taste of that substance, and which M. Caventou found by experiment to be foreign to the emetic qualities of the medicine. As an emetic, from a quarter to a whole grain in solution may be first given, and a quarter or half a grain repeated every twenty minutes till the due effect be produced.
_Veratrine_ is an alkali procured by a long chemical process from the plants of the family of veratrum. It appears to be the chief active principle residing in the colchicum autumnale, and in white hellebore. M. Magendie states that the dose of a quarter of a grain usually affects the intestinal canal rather powerfully. In a case of apoplexy, he prescribed two grains in the twenty-four hours without producing much effect on the bowels. He comments on this result, as proving how much the state of the nervous system influences the action of medicines.
M. Magendie suggests that the use of veratrine might be preferable to the tincture of colchicum and the eau médicinale (which latter medicine he considers to be substantially veratrine), on account of the greater uniformity of the preparation.
In the treatment of gout, I am induced to avoid the active preparations of colchicum entirely; and in employing the acetum colchici, which is very mild, I use it only in combination with other medicines, and desire to procure from its agency rather an auxiliary operation, than that of colchicum distinctly. I have endeavoured to explain my sentiments fully on the subject in my Treatise on Gout and the disordered State of the Digestive Organs.
With these observations, I shall now conclude my summary view of the nature of the principal new medicines, which have been added to our list of remedies by the science and industry of our continental neighbours[11].
It would lead to an interesting field of inquiry, were we to examine the general customs and the habits of living in different countries, in relation to health; and to trace the influence of climate, soil, political and civil institutions, laws, religion, &c. But the subject would demand a volume, rather than a few pages, and be foreign to my present limited purpose.
According to what I have learned from others, and from my own personal observation, I should state that the diseases which arise from repletion, as apoplexy and gout, occur more frequently in this country than in France. I am persuaded also, that the latter disease has increased amongst the middle classes of society in this country, with the progress of luxury and refinement.
The quantity of solid meat consumed at the English table, and the use of heavy malt liquors, together with strong wines not sparingly taken, may be contrasted with the extenuated dishes of the French, and their beverage of lemonade, vin ordinaire, and weak though grateful wines.
I am aware that the French generally eat a greater variety, and take a larger quantity of food than the English; but their meats are stewed, their soups are not heavy, and their vegetables are well dressed. Oil is a plentiful ingredient in many of their dishes, and they scarcely use spices. Altogether their food appears calculated to pass the digestive organs readily; and when the nature of the liquors and some other circumstances are considered, the total regimen is not, I apprehend, so much suited to produce repletion and its evils, as that commonly pursued in this country.
In London, the extreme lateness of the hours both for dining and evening amusement is obviously unfavourable to the constitution. In Paris, fashion in this respect is more rational; and the custom of remaining a short time at the dinner table, after the repast, and the period of conviviality consequently being abridged, much difference of result must follow in regard to the health of the inhabitants of these great cities. The French people are far less inclined to be sedentary than the English, and appear to be active and cheerful both by nature and habit. I conclude, therefore, from these and other causes which might be mentioned, that the medical system of practice must, of necessity, vary considerably in the two countries.
Paris is altogether less humid than London; and the superior clearness of its atmosphere is in great measure to be attributed to the use of wood fires.
A general notion is entertained that the water of Paris is deleterious to strangers, as producing disorder of the stomach and bowels. Not denying the fact of such indisposition occurring to those who visit Paris for a short time, I may still question the nature of the cause.
I have examined the filtered[12] water of the Seine, and obtained the following results:
Its specific gravity is 1.0002.
Solution of muriate of barytes added to the water produces an immediate but slight milkiness.
Oxalate of ammonia causes, in a few seconds, a considerable milkiness.
Nitrate of silver does not occasion any immediate change; but, after standing several minutes, an effect is just perceptible.
Lime water does not disturb the transparency of the water.
From this examination the conclusion follows, that it is a water containing a very minute quantity of solid ingredient. In one thousand parts the specific gravity is only 2/10 higher than that of distilled water. From the nitrate of silver causing so slight a change, we see that the water is almost free from the muriates. It is evident that the chief solid ingredients are the sulphate and the carbonate of lime. Although I should certainly consider that a water still less impregnated with these salts, and especially the sulphate of lime, would be more wholesome, yet, when the small proportion existing in this water is estimated, I am led to the conclusion, that the disorder of the digestive organs, which commonly happens to the visitors of Paris, is not attributable to the water of the Seine, but to the new mode of living, and above all to the free, and sometimes intemperate, use of the light acid or acescent wines. In such cases, weak brandy and water should be substituted, and if wine be taken, care should always be observed to procure such as is of the best quality, and the most free from acid.
Since the printing of the sheets on the subject of the stethoscope, I have met with many interesting and important cases, proving to my further and complete satisfaction the value of the indications afforded by the instrument.
In reverting to the subject, I shall offer a concise account of two instances in which I derived an accuracy of instruction for my treatment, which I could not otherwise have obtained.
A lady fifty years of age, who enjoyed good health generally, and was not subject to cough, had been ill with symptoms of pneumonia and bronchitis, a week before I was consulted. I found the following symptoms: the pulse frequent, hard, and rather full; the skin hot; cheeks flushed; the tongue much furred; the urine high-coloured, not depositing sediment; the bowels torpid; cough rather occasional than constant, but for the most part violent; the expectoration copious and muco-puriform. In the upper parts of the right and left sides of the chest, the indications afforded by the stethoscope were, very sharp and strong sounds, both in inspiration and expiration, conjoined with the mucous rattle. She did not experience any pain, nor any sensible difficulty of respiration, although it was evident that she did not breathe naturally; and fits of coughing were easily excited. Her countenance had a very feverish and anxious look. Previously to my visit she had been bled only once.
I directed a free bleeding from the arm in the morning, and the application of twenty leeches over the chest in the evening. I prescribed small doses of tartar emetic, in a saline draught, every four hours; some calomel, James’s powder, colocynth, and extract of poppy at bed time, with a saline aperient in the morning, and other general means. The blood was extremely cupped, with a dense buffy coat. The bleeding from the arm was twice repeated in the course of the three following days; and as the sounds were still indicated by the stethoscope, although in a less degree, the leeches were again applied twice in the course of the week; the medicines being regularly administered. By these means the pulse became reduced from one hundred and twenty to ninety, and acquired a degree of softness. When the heat of skin abated, a blister was applied on the chest; but it appeared to have the effect of creating more febrile irritation; and without affording relief to the cough. I have observed this disadvantage to follow from blistering in other cases of an inflamed and irritable state of the lungs; and I apprehend that we should, under such circumstances, take into consideration whether or not this peculiar stimulus may produce more injury than benefit, from the irritation which it creates in the chest being more influential than the counter-action produced on the surface.
The tartar emetic proved very decidedly useful in its effects. I did not increase the dose beyond three grains in the twenty-four hours, and in the commencement of its use, the smaller doses occasioned much sickness; but with the advantage of removing morbid secretions. The cough becoming very irritable, syrup of poppy was added to the saline antimonial draught; and, when all necessity for bleeding was removed, the infusion of digitalis, in small doses, was also employed; for, in this case, inflammatory action prevailed to a most troublesome degree. Indeed, the complaint became chronic, the fever decidedly hectic, and the situation of the patient appeared to be precarious. The expectoration had strongly a puriform appearance, was streaked with blood, and was very copious: its odour was faint, but not particularly offensive. The sounds which I have mentioned became less acute, and the rattle was more mucous. At this period I directed the use of tartar emetic ointment over the chest, which produced an extensive pustular eruption; and the advantage of this counterirritation was very marked. I have the pleasure of adding that this patient is now most favourably convalescent. She is taking with advantage, as a mild restorative medicine, an infusion of the cortical part of sarsaparilla in lime water, mixed with an equal portion of milk made hot.