It is a truth universally admitted, that the arm of physic has derived
much additional power and increased energy, from the resources which are
furnished by the mixture and combination of medicinal bodies. I by no
means intend to insinuate that the physician cannot frequently fulfil
his most important indications by the administration of one simple
remedy; I only contend that, in many cases, by its scientific
combination with other medicines, it will not only act with greater
certainty and less inconvenience, but that its sphere of influence may
be thus more widely extended, and its powers so modified or changed, as
to give rise to a remedy of new powers. Such a theory is amply justified
by the state of combination in which certain medicinal principles are
found in our more efficient vegetable remedies, while the medicinal
practice founded upon it is thus, as it were, sanctioned by Nature’s own
prescriptions; enter but her laboratory, and you will soon be satisfied,
that many of her potent remedies do not owe their valuable powers to any
one specific ingredient, but to the combined or modified energies of
various, and sometimes opposite principles. This view of the subject
opens an interesting and unexplored field[239] of medical and chemical
research, and I shall endeavour to avail myself of the novelties its
investigation may present, and of the hints it may suggest for the
improvement of _extemporaneous combination_. By contemplating the laws
by which Nature effects her wise purposes, we may learn to emulate her
processes, and even in some cases to correct and assist her
operations:[240] such at least has been the happy result of our labours
in the other departments of natural knowledge. It is said for instance
that by observing the means used by nature for preventing the diffusion
of light in the eye-ball, Euler derived an important hint for the
improvement of his telescope; and more lately, the structure of the
crystalline humour of the eye has been successfully imitated in the
invention of achromatic lenses. On the other hand, it is hardly
necessary to observe to what extent these instruments of art are capable
of improving and multiplying the powers of that natural organ, to the
contemplation of whose structure and functions, we are, as I have just
stated, so greatly indebted for their origin and perfection. So shall I
endeavour to shew, in the progress of this work, that the combinations
of nature, as exemplified in her more valuable remedies, are capable, if
properly studied, of suggesting many important hints for improving the
arrangements of art; while art in return may frequently supply the
defects, or extend the advantages of natural compounds.
AN ANALYSIS
OF
THE OBJECTS TO BE OBTAINED BY MIXING AND COMBINING MEDICINAL SUBSTANCES.
The objects to be attained, and the resources which are furnished, by
MEDICINAL COMBINATION, together with the different modes of its
operation, and the laws by which it is governed, may with much practical
advantage be arranged in the following order.
I.
TO PROMOTE THE ACTION OF THE BASIS, OR PRINCIPAL MEDICINE.
A.—_By combining together several different Forms, or Preparations, of
the same substance_.
The utility of such a combination is obvious, whenever we desire the
full and general effects of _all_ the principles of a medicinal body in
solution; thus, where the _Bark_ is required in the cure of an
intermittent fever, and the stomach will not allow the exhibition of the
powder, it will be eligible to conjoin in one formula, the tincture,
decoction, and extract, as exemplified by _Formulæ 42, 126, 127_. The
necessity of such a combination may be expressed by the following canon.
_Whenever the chemical nature of the medicinal substance will not admit
of the full solution of all its active principles in any_ ONE _Solvent_,
_and its exhibition in substance is at the same time impracticable_. For
farther illustrations see _Form. 2, 25, 33, 38, 70, 109_.
Practitoners, probably without having reasoned upon the theory, have
very generally adopted the practice, of combining the different
solutions of the same substance; for in the prescriptions of practical
physicians we commonly find, that the decoction or infusion of a
vegetable remedy is quickened by a certain portion of a corresponding
tincture.
B.—_By combining the Basis with Substances which are of the_ SAME
NATURE, _that is, which are_ INDIVIDUALLY _capable of producing the same
effect, but with less energy than when in combination with each other._
Dr. FORDYCE first established the existence of the singular and
important law, that _a combination of similar[241] remedies will produce
a more certain, speedy, and considerable effect than an equivalent dose
of any single one_; a fact which does not appear to have been known to
any ancient physician. The earliest mention of it that I can find is by
VALISNIERI, the favourite pupil of Malpighi, who filled the medical
chair at Padua in 1711, nearly ninety years before Fordyce published his
valuable memoir on the combination of medicines, but he does not attempt
any generalization[242] of the subject; he merely states, as the result
of careful experiments, that twelve drachms of _Cassia Pulp_ are about
equivalent in purgative strength to four ounces of _Manna_; and yet,
says he, if we give eight drachms of _Cassia Pulp_, in combination with
four drachms of _Manna_, we obtain double the effect! How, adds the
professor, can this possibly happen? Surely the very contrary _ought_ to
obtain, since four drachms of _Cassia_ are much more than equivalent to
an equal weight of _Manna_; the strength of the former being to that of
the latter as 8 to 3.
The truth of this law of medicinal combination must be continually felt
by the practitioner in the ordinary routine of his practice, viz.
NARCOTICS will better fulfil the intention of allaying irritation and
pain, when composed of several of such medicines in combination, than
when they consist of any single one, even should the dose, in this
latter case, be increased. See _Formulæ 3, 4, 5_.
ANTISPASMODICS acquire increased efficacy by the application of the same
principle. _Form. 20, 21, 22, 23, 24, 25_.
BITTER TONICS are also thus exalted, see _Form. 39, 40, 41_. The
beneficial effects, however, which arise from combinations of this kind
will admit of a satisfactory explanation upon another principle; we may,
for instance, consider them as medicines, differing from each other in
their composition, and producing by their union an assemblage of bitter,
astringent, and aromatic principles.
AROMATIC and DIFFUSIBLE STIMULANTS. There are perhaps no remedies which
receive greater mutual benefit be intermixture with each other, than the
individuals which compose this class; for they not only thus acquire
increased force and efficacy, but at the same time they lose much of
their acrimony; if, for instance, any one spice, as the dried capsule of
the _Capsicum_, be taken into the stomach, it will excite a sense of
heat and pain; in like manner will a quantity of _Black Pepper_; but if
an equivalent quantity of these two stimulants be given in combination
with each other, no such sense of pain is produced, but, on the
contrary, a pleasant warmth is experienced, and a genial glow felt over
the whole body; and if a greater number of spices be joined together,
the chance of pain and inflammation being produced is still farther
diminished. The truth of this law is also strikingly illustrated, as Dr.
Fordyce has observed, by that universal maxim in cookery, _never to
employ one spice, if more can be procured_; the object, in this case,
being to make the stomach bear a large quantity of food without
nausea.[243] This same principle also finds an illustration of its
importance, as it regards the class of stimulants, in the following
preparations of our Pharmacopœia, viz. “_Pulvis Cinnamomi Compositus_;
_Infusum Armoraciæ compositum_; _Infusum Aurantii Compositum_; _Spiritus
Lavendulæ compositus_; _Tinctura Cinchonæ composita_; _Tinctura
Valeriana Ammoniata_; and the _Confectio Opii_, the elegant and
scientific substitute for the celebrated _Mithridate_ or _Theriaca_. The
practitioner is also referred to _Form. 45, 47_, and to _Allii Radix_.”
The local action of these stimulants would appear to be placed under the
dominion of the same law, and perhaps the origin of the custom, so long
observed, of mixing together the varieties of snuff, may thus receive a
plausible and philosophical explanation; certain it is that by such
combination the harsh pungency of each ingredient will be diminished,
whilst the general potency of the application, in exciting the nerves,
will be increased, and rendered more grateful; the same principle will
direct the formation of safe and efficient plaisters and lotions; the
_Emplastrum Cumini_ of the London, and the _Emplastrum Aromaticum_ of
the Dublin Pharmacopœia, offer examples of its judicious application.
ASTRINGENTS. For illustrations see _Form. 51, 58_.
EMETICS are certainly more efficient when composed of _Ipecacuan_ united
with _Tartarized Antimony_, or _Sulphate of Zinc_, than when they simply
consist of any one of such substances in an equivalent dose. See _Form.
63, 65_.
CATHARTICS not only acquire a very great increase of power by
combination with each other, but they are at the same time rendered less
irritating in their operation; the _Extractum Colocynthidis compositum_
affords an excellent example of a compound purgative mass being much
more active and manageable, and less liable to irritate, than any one of
its components separately taken. Additional examples of this fact are
furnished by _Formulæ 70, 76, 78, 79, 81, 88_. In many cases, however,
the fact of purgatives thus accelerating and correcting each other’s
operation may be explained by considering them as substances endowed
with different powers, as already demonstrated, (p. 88), and which will
be more fully considered in the third division of this Essay.
DIURETICS. Under this class of medicinal agents it may be observed that,
_whenever a medicine is liable to produce effects different from those
we desire, its combination with similar remedies is particularly
eligible_, by which the action of the basis may be directed and fixed;
thus the individuals which compose the class of Diuretics are uncertain
in their operation, and disposed when exhibited singly to produce
diaphoretic, and other contrary effects; it is, therefore, in such
cases, highly judicious to unite several of them in one Formula, by
which we increase their powers, and are more likely to ensure their
operation. _Formulæ 101, 103, 108, 109, 110, 111, 115_, are constructed
upon this principle.
DIAPHORETICS. Our maxim, “VIS UNITA FORTIOR,” certainly applies with
equal truth to this class of medicinal agents. _Form. 122, 124_.
EXPECTORANTS. More is frequently to be gained by the co-operation of
these remedies than can be obtained by the exhibition of them
separately, as in _Form. 134, 135_.
DEMULCENTS do not appear to obtain any other benefit from combination
than, occasionally, a convenience and efficacy of application arising
from a suitable degree of consistence and solubility. See article
“_Trochisci_.”
The operation of the law which has thus formed the first object of this
inquiry, will be found, like every other, to have a natural and well
defined limit; it is easy to perceive that by multiplying the number of
ingredients too far, we shall either so increase the quantity and bulk
of the medicine as to render it nauseous and cumbersome, or so reduce
the dose of each constituent as to fritter away the force and energy of
the combination.
The propriety of combining _several_ stimulants, of the diffusible
class, in _one_ formula, has been questioned on different grounds. Dr.
Chapman, in his work on Therapeutics, adduces some arguments on this
point, which, although they fail in establishing his general position,
certainly suggest an important exception to the practice in question;
“by directing,” says he, “stimulating remedies, _separately_, we shall
economise our resources in many lingering diseases.” The justness of
this statement must be admitted to its fullest extent, and practitioners
will, on certain occasions, do well to act in conformity with the views
that suggested it; for instance, in the feeble forms of protracted
fevers, where the indications are to be met with the continued action of
stimulants, it will certainly be salutary to alternate the use of
_camphor_, _ammonia_, and other remedies of a similar nature, in
preference to presenting them all at once in combination, so that the
system may not lose its susceptibility by the continued impression of
the same stimulant; the same motive should induce us, on particular
occasions, to employ in succession different narcotics, for each of them
affects sensibility in its own peculiar manner.[244] The nervous system,
as _Richerand_ has very justly observed, may be compared to a soil, rich
in different juices, and which requires the cultivator to plant the
germs of a diversified vegetation to develope the whole of its
fecundity; to insure a perpetual return, therefore, it will be right to
sow a succession of different seeds. Hoffman also has offered us some
advice upon this subject; he directs us in the treatment of chronic
diseases to suspend the administration of remedies, at intervals, and
afterwards to resume them, lest the system should become _habituated_,
and ultimately _insensible_ to their influence.
But there remains for our investigation a still more important
precaution respecting this law of medicinal combination;—that, in
combining substances in the manner, and for the object just related, the
practitioner should be well satisfied that their medicinal virtues are
in reality _practically_ SIMILAR, or he will fall into an error of the
most fatal tendency; it has been already shewn, and I hope I shall not
be considered tedious by again directing the reader’s attention to the
fact, that medicines are not necessarily similar because they have been
arranged in the same artificial division of remedies; in order to
establish a perfect similarity _their operations must be found by
experience to continue similar under every condition of the human body;
and that, moreover, they must owe such similarity to modes of operation
which are compatible with each other, and consonant with the general
mode of cure_; we have only to refer to the history of Diuretics (_page
92_) for a full illustration of this important truth; thus _Squill_,
_Calomel_, and _Digitalis_, are each powerful Diuretics, but
nevertheless they cannot be considered _similar_ remedies, since
_Digitalis_ will entirely fail in its effects in the very cases that
_Calomel and Squill_ succeed; and _Squill_ will prove inert when
_Digitalis_ is capable of producing the most powerful influence; this
arises from their modes of operation being dissimilar, and consequently
requiring for their success such different states of the living system.
_Squill_, it will be seen, acts _primarily_ on the urinary organs, by
stimulating the secreting vessels of the kidneys; _Mercury_, on the
contrary, acts primarily on the absorbents, and _secondarily_ on the
kidneys; whereas _Digitalis_ produces its effects by diminishing
arterial action, and increasing that of absorption.
Dr. Blackall, in his “Observations upon the Cure of Dropsies,” has
offered some remarks so valuable in themselves, and so illustrative of
this important subject, that I shall take leave to quote the passage.
“Many physicians,” he observes, “are fond of combining _Squill_,
_Calomel_, and _Digitalis_, as a diuretic in dropsy; a practice unsafe,
and not very decidedly possessing the merit even of being consistent.
_Digitalis_ greatly depresses the action of the heart and arteries, and
controls the circulation, and it seems most unreasonable to believe that
its curative powers can be independent of such an effect; on the other
hand, _Mercury_, if it does not pass off quickly, is always exciting
fever, and raising and hardening the pulse; speaking from experience,
where the urine is coaguable, and _Digitalis_ agrees, both the others
are, often at least, positively injurious. On the contrary, where the
urine is foul, and not coaguable, and _Squills_ with _Calomel_ render
service, I have on that very account, made less trial of Digitalis, and
cannot therefore speak of it from much experience.” See _Form. 103_, and
the _note_ thereon.
The individual medicines which compose the class of DIAPHORETICS vary no
less in their primary operations, as the synoptical arrangement at _page
99_ very fully exemplifies; thus, in the cure of intermittent fevers,
diaphoretics are useful both in the paroxysm, and during the
intermission; in the first case they shorten its duration; in the second
they support the tone of the extreme vessels, and prevent its
recurrence; but in these opposite states of disease a very different
kind of diaphoretic is required—to fulfil the first indication, a
cooling and relaxing one is necessary; to answer the second, the
stimulating diaphoretic is exacted; the one may be said to _solicit_,
the other to _extort_, perspiration. So again EMMENAGOGUES can only be
considered relative agents, since the suppression of the catamenia may
depend upon, or be connected with, very different states of the system;
in some cases with a diminished, and in others with an increased state
of excitement; for on many occasions the suppression of the menses is
the effect, and not the cause of disease; _Boerhaave_ has very justly
observed, that it is a most dangerous error to ascribe all the diseases
of young females to a retention of the catamenia, which often do not
appear because the patients are disordered from other causes. If,
therefore, we were to attempt a combination of the several medicines
which have gained reputation as _Emmenagogues_, it is very obvious, that
we should bring together an assemblage of adverse and incompatible
remedies; nor would the physician be less inconsistent were he to
combine EXPECTORANTS, without a due regard to their modes of operation;
it is only necessary to observe their classification, as presented at
page 102, to become satisfied how greatly the success of such remedies
must depend upon their scientific adaptation to each particular case.
The class of ANTISPASMODICS may likewise embrace remedies of the most
opposite tendency, for spasm may occur under the most opposite
circumstances—in an extreme condition of weakness, as in nervous
affections, and in an highly excited state, as in cholic, &c.; it is
hardly necessary, therefore, to point out the mischief that must arise
from the fortuitous and indiscriminate admixture of the individual
substances which are thus unavoidably arranged in the same artificial
classification. _Bark_ and _Steel_ are also too often considered as
equivalent _Tonics_; in Dropsy, says Dr. Blackall, it is far otherwise,
the former being infinitely to be preferred after the dropsy of young
persons, of acute disease, and of sound stamina; the latter being suited
to a vitiated rather than to a feeble habit, and indicated more by a
pale sallow complexion, and a want of red colour in the blood, as shewn
by the paleness of the lips, than by any other signs. Need we then
adduce farther illustrations of the obvious but important fact, that the
terms employed to denote the different classes of remedies are
frequently but relative ones, expressive of effects which are produced
only in reference to a particular state of the living body? and as this
necessarily varies in different states of health and disease, it follows
that medicines are convertible agents, and that when we attempt to
institute general rules respecting their administration, without taking
into consideration the constitution and circumstances of the patient
upon whom they are to operate, we shall generally be disappointed in the
result. We may say of medicines what Van Swieten said of diet, “to
assert that such, or such a thing be wholesome, without a knowledge of
the condition of the person for whom it is intended, is like a sailor
pronouncing the wind to be fair without knowing to what port the vessel
is bound.” Boerhaave was so fully impressed with this truth that he
exclaimed, “_nullum ego cognosco remedium, nisi quod tempestivo usu fiat
tale_.”
Although medicines which produce the same ultimate effects by modes of
operation obviously different, cannot be considered SIMILAR, in the
sense affixed to the term in the present section, yet if these different
modes of operation be not physiologically incompatible with each other,
the union of such remedies may not only be admissible, but even useful;
and it will, accordingly, constitute an object of inquiry in a
succeeding section. (III. A.)
C.—_By combining the Basis with Substances of a_ DIFFERENT NATURE, _and
which do not exert any Chemical influence upon it, but are found, by
experience, to be capable of rendering the Stomach, or System, or any
particular organ, more susceptible of its action_.
Thus it is that the system is rendered more susceptible of the influence
of Mercury, by combining it with Antimony and Opium.[245] Where the
stomach is insensible to impressions, the exhibition of Opium previous
to, or in combination with, any active medicine, often assists its
operation; this is remarkably striking in some states of mania, when
emetics will fail, unless the stomach be previously influenced and
prepared by a narcotic; indeed, in ordinary cases of inirritability of
stomach, the addition of a small quantity of opium will often render an
emetic active.[246]
So again the system, when it is in that particular condition which is
indicated by a hot and dry skin, is unsusceptible of the expectorant
powers of Squill, unless it be in union with antimony or some powerful
diaphoretic, (_Form. 134_.) Squill is by no means disposed to act upon
the urinary organs, when exhibited singly; but calomel, and some other
mercurial preparations,[247] when in conjunction with it, appear to
direct its influence to the kidneys, and to render these organs more
susceptible of its operation; (103, 106.) Upon the same principle,
_Antimonial Wine_ quickens the operation of saline cathartics (69);
_Opium_ increases the sudorific powers of _Antimony_ (124); and the
purgative operation of _Jalap_ is promoted by _Ipecacuan_ (84). Dr.
Aikin asserts that fifteen grains of the former purgative when combined
with two or three grains of the latter root, will purge more than double
that quantity of Jalap when administered without such an adjunct.
Sir John Pringle speaks of the advantages which may be obtained by
combining an alkali with a bitter infusion, by which the diuretic
effects of the former will be increased, while the latter is calculated
to remove any gastric debility, and to impart a general tone to the
body: there is no doubt but that _Bitters_, from their invigorating
influence upon the _primæ viæ_, (_see page 78_) increase the effects of
remedies whose operation is connected with changes _in transitu_, or
with absorption, as in the exhibition of certain diuretics;[248] they
also frequently render the stomach and bowels more susceptible of bodies
that act by impression, as purgatives, emetics, &c.
We may discover the operation of such a principle in some of the more
active compounds presented to us by nature: many herbs owe their
efficacy to a cause of this kind. _Elaterium_, as I have ascertained by
experiment, contains a purgative element, _sui generis_, (_Elatin_) and
a bitter principle, which in itself is quite inert, and yet its presence
in the compound renders the alimentary canal more susceptible of the
impression of the active ingredient, and therefore increases its force.
See _Extract_. _Elaterii._ The history of _Senna_ will afford some
interesting facts in farther elucidation of this subject; the leaves of
this plant, like _Elaterium_, appear to contain an active principle, in
combination with a bitter, which latter ingredient, although destitute
of purgative properties, considerably increases those of the former; for
if this be removed, as happens when Senna is transplanted into the south
of France, the purgative principle is weakened, but may be again
restored by the artificial addition of some bitter extractive. The fruit
or pods of Senna[249] contain only the purgative principle, and are
therefore comparatively feeble, unless the defect be compensated by art.
Dr. Cullen has observed that a much smaller quantity of the leaves is
required for a dose if they be infused in company with some bitter
plant; and it has been found that the watery infusion of _Rhubarb_ is
rendered more purgative by the addition of _Calumba_.
The experiments of Seguin have established beyond all doubt that the
active principle of vegetable astringents is a peculiar element, to
which the name of _Tannin_ has been given; but the efficacy of this
ingredient is undoubtedly enhanced by the presence of the gallic acid
with which it is usually associated, although this acid, when separated
from the native combination, is incapable of producing the least
astringent effect; that peculiar flavour which we so commonly experience
in unripe fruits, and which we designate by the term _acerbness_, is the
result of a combination of the astringent principle with some vegetable
acid. The relative sweetness of sugar, when in different degrees of
purity, depends upon the operation of the same law of combination; _pure
sugar_, as Dr. Mac Culloch has very justly observed, however paradoxical
it may appear, _is not so sweet as that which is impure_; the sweetness
of _melasses_, compared with that of refined sugar, is too well known to
require more than a bare mention; the vegetable extractive matter in
this case, increases the effect of the saccharine principle with which
it is combined; for the same reason grapes, differing very materially in
their proportion of saccharine matter, may seem _to the taste_ equally
sweet, and such in fact is the case on comparing the luscious grapes of
Spain, with the _Chasselas_ of Paris; and yet the vinous produce is
entirely different, the result of the one being a sweet and luscious
wine, while that of the other is hard and dry, because, in truth, these
grapes contain very different proportions of sugar; and however
powerfully the extractive matter may modify the effects of this
principle upon the palate and organs of taste, it cannot alter the
quantity of alcohol resulting from its fermentation.[250] Crystallized
sugar also appears less sweet to the taste than loaf sugar, but this may
depend upon the different state of aggregation, and, consequently, the
different degrees of solubility possessed by the sugar in these two
forms.
In some cases, the addition of certain bodies will induce the absorbents
to admit and carry into the circulation remedies which, in a more simple
state, they would reject as injurious; this position is supported by the
fact of mercury being more readily absorbed when in combination with
animal matter, see _Ung: Hydrarg:_ and it is probable that iron, in the
form of a _tanno-gallate_, will be more acceptable than when presented
in a more purely mineral state: see _Ferri Sulphas_.
Does it not therefore appear from the preceding remarks, that _certain
elements exist in the composition of vegetable remedies, as furnished by
nature, which, although individually inert, confer additional strength
and impulse upon the principle of activity with which they are
associated_.[251]
The solutions of saline cathartics appear likewise to gain an accession
of power and celerity of operation by impregnation with _Carbonic acid
gas_, depending probably upon the intestines thus receiving a degree of
distention favourable to the action of the salt, (19, 23.) Certain it is
that the operation of emetics, as well as that of glysters, is
materially increased by the stimulus of distention.
In enumerating the methods to be adopted for increasing the energies of
a remedy, by rendering the system more susceptible of its action, it is
right to know that, under certain circumstances, Venesection deserves a
distinguished rank amongst the ADJUVANTIA. The fact is strikingly
discovered in the exhibition of _Mercurial[252] Preparations_, and some
other alterative medicines. Whether the “_Vis Conservatrix_,” which
Nature, when in a state of health and vigour, opposes to the admission
of poisonous substances into the circulation, be overcome by
blood-letting, is a question which I shall leave others to decide; but
thus much reiterated practice has taught me, that the system in a strong
and healthy condition frequently is overcome the moment the stomach
becomes deranged, the circulation languid, or the general tone of the
system impaired. I have frequently seen this during my Hospital
practice: if a patient who has been using mercurial friction, or taking
the preparations of that metal without effect, be transferred into a
close and unhealthy ward, his appetite soon fails, the tongue becomes
furred, and the system instantly yields to the influence of the remedy.
Nauseating doses of _antimony_[253] frequently repeated, or the
accidental supervention of any disease of debility, will be attended
with the same phenomena. My practice has also afforded me an opportunity
of appreciating the debilitating effects of despondency in a case of
this description; a patient had been taking mercurial medicines, and
using frictions for a considerable period, without any apparent effect:
under these circumstances he was abruptly told that he would fall a
victim to his disease; the unhappy man experienced an unusual shock at
this opinion, and in a few hours became violently salivated.[254]
VENESECTION, moreover, increases the effects of cathartic medicines. I
have often noticed this fact in contending with a plethoric diathesis;
whenever the bleeding preceded the purgative, the effects of the latter
have been uniformly more speedy and considerable; in obstinate
constipation the same fact has been observed, and mild remedies have
been known to act more powerfully, when preceded by blood-letting, than
potent ones have when exhibited antecedent to it. Venesection has
certainly an extraordinary power in awakening the susceptibility of the
_primæ viæ_ to remedial impressions; in some diseases, as in the
_Cynanche Trachealis_, or Croup, so great is the insensibility of the
stomach, that Emetics frequently fail in their effects; and Dr. Hamilton
has given as much as a hundred grains of _Calomel_ in the twenty-four
hours: in such cases previous venesection affords most extraordinary
assistance. Dr. Fothergill also remarks that emetics are more beneficial
after bleeding, (_Dissert. Med. Inaug. de Emet. usu._) The effects of
_Bark_, _Steel_, and other tonics, are certainly influenced in the same
manner; whether in any case it may be prudent or judicious to have
recourse to such a practice, is a question not immediately connected
with the present inquiry.
Limited must have been the experience of that practitioner who has not
frequently witnessed the utility of Venesection in producing a state of
system favourable to the operation of various remedies. In acute
diseases, how frequently does an opiate succeed in allaying irritation
after copious bleeding, which could not be made to occasion any
beneficial influence previous to that operation? In Pneumonia I have
repeatedly seen such a plan of treatment act like a charm upon the
patient.
PURGATIVES also awaken the susceptibility of the body to mercurial
impressions, and it is remarked by Dr. Chapman that this practice
affords a resource which rarely disappoints the practitioner. This class
of remedies moreover seems capable of exalting the efficacy, and indeed
of accelerating the benefit to be derived from many alteratives, when
administered _previous_ to the exhibition of these latter substances;
the advantages of a course of Steel medicines are undoubtedly increased
by such means. The febrifugous and antiseptic properties of diluted
muriatic acid (see _Form. 145_.) are inconsiderable, unless its
exhibition be accompanied with cathartics. I beg to refer the
practitioner to some cases published by me in the _Medical and Physical
Journal for December_, 1809, in further illustration of these views.
Experience enables me also to state that _Diuretics_ are considerably
assisted by similar means, having many instances in my case book of the
failure of these agents before, and their successful operation after,
the exhibition of a cathartic. Dr. Darwin observes that “_Absorptions
are always increased by Inanition_,” and in support of this position
refers to the frequent advantage derived from evacuations in the cure of
ulcers. I have certainly seen obstinate sores in the leg cured by small
and repeated bleedings. Dr. Chapman arrives at the same conclusion,
although by a different train of reasoning; he states that the
blood-vessels and absorbents[255] are to a certain extent “antagonising
powers:” instructed by this obvious fact, we ought, says he, in the
exhibition of diuretics to regulate the state of the system by
interposing purgatives, or even venesection, as the state of the
circulation may indicate.
EMETICS also, in certain conditions of the system, would appear to
render the stomach more sensible to the impression of other remedies;
Dr. Eberle, of Philadelphia,[256] has remarked such an effect with
respect to the administration of the Peruvian Bark.
CHANGE OF DIET AND OF HABITS may be also classed amongst the
_Ajuvantia_, but the young practitioner must be warned that he is not to
exercise his _Caduceus_ as Sancho’s Doctor did his wand. I have seen a
young disciple of Esculapius so vex his patient, that his food became
more nauseous to him than his medicine, and I verily believe his
Physician was more irksome than his disease. It was well observed by Dr.
Percival that the prejudices of the sick should never be contemned with
wantonness, or opposed with harshness; for, silenced by authority, they
will operate secretly and forcibly on the mind, creating fear, anxiety,
and watchfulness. And with regard to diet it may be here stated, that no
function of the body is so materially influenced by mental impressions
as that series of actions constituting what is termed _Digestion_—the
unexpected communication of any distressing event destroys the keenest
appetite,[257] and converts the sensation of hunger into one of disgust
at the bare idea of food: a fact which did not escape the penetrating
eye of our immortal Shakespeare, for he represents Henry dismissing
Wolsey from his government with these words—
—— Read o’er this;
And after, this: and then to breakfast
_with what appetite_ you have.
If feelings of disgust are excited by the repast, the stomach will never
act with healthy energy on the ingesta; and in cases of extreme
aversion, they are either returned, or they pass through the alimentary
canal almost unchanged: on the other hand, the gratification which
attends a favourite meal is in itself a specific stimulus to the organs
of digestion, especially in weak and debilitated habits. Dr. Merriman
has lately communicated to me a case which affords a striking
illustration of the powerful influence of the mind upon these organs: a
lady of rank labouring under menorrhagia, suffered with that irritable
and unrelenting state of stomach which so commonly attends that disease,
and to such a degree that every kind of aliment and medicine was alike
rejected: after the total failure of the usual expedients to appease the
stomach and procure relief, she applied to Miss Prescott, and was
_magnetised_, when she immediately, to the astonishment of all her
friends, ate a beef steak, and continued to repeat the meal every day
for six weeks, without the least inconvenience! but the disease itself,
notwithstanding this treacherous amnesty of the stomach, continued with
unabated violence, and shortly afterwards terminated her life.
The diet of a sick person ought never to _combine too much nutriment in
too small a space_;[258] when so given it will even in health be
followed by _fermentation_ instead of _digestion_; and although we may
admit the expediency of that domestic maxim, “_a little and often_,” yet
this is to be received with limitation; no one, for instance, who
possesses any philosophical knowledge, will adapt his practice to the
notions of Sir William Temple, who asserted that “the stomach of a
valetudinarian was like a school-boy, always doing mischief when
unemployed,” and that we should therefore not allow it any interval of
repose: to this I answer, that the conversion of aliment into blood is
effected by a series of elaborate processes, several of which are only
perfectly performed during the quiescence of the rest: it would seem,
for instance, that the process of _chylification_ is incompatible with
that by which the first changes are produced in the stomach; this is
evident from the well-known fact, that our appetite for food ceases when
the former process commences, although the repast should, at the time,
have been insufficient to satisfy the craving of nature; whereas, in
diseases of imperfect, or depraved digestion, as in _Diabetes_, _Tabes
Mesenterica_, &c. we find that the appetite for food is never satisfied
by the most nutritive meals. It merits notice also, that whenever the
stomach be called into action during the assimilating stages of
digestion, the process will, in weak persons, be much disturbed, if not
entirely suspended. These views have long since confirmed me in the
propriety of treating mesenteric affections in a manner very different
from that which is generally pursued; and I may add that the result has
been very satisfactory. The plan to which I allude, consists in
enforcing longer intervals between each meal, which should be scanty,
and in quantity short of what the appetite may require; in this way are
the unwilling absorbents induced to perform their duties with greater
promptitude and activity; but it is a practice which, from the extreme
anxiety of friends and relatives, the feelings of craving and hunger
expressed by the patient, and the mistaken but universal prejudice
respecting diet, it is always painful to propose, and generally
impossible to enforce; where, however, circumstances have given a full
and unreserved controul, the advantage of the plan has been most
decisive.
There is still another remark which I am desirous of offering, in this
place, on the subject of Diet; _viz._—that in all cases of feeble or
imperfect digestion, _the Valetudinarian ought never to take his
principal meal in a state of fatigue_—and yet let me ask, whether there
is a habit more generally pursued, or more tenaciously defended? Aye,
and defended too upon _principle_—the invalid merchant, the banker, the
attorney, the government clerk, are all impressed with the same belief,
that after the sedentary occupations of the day, to walk several miles
to their villas, or to fatigue themselves with exercise before their
dinner, or rather early supper, will sharpen their tardy stomachs, and
invigorate their feeble organs of digestion. The consequence is
obvious,—instead of curing, such a practice is calculated to perpetuate,
and even to aggravate the malady under which they suffer; by calling
upon the powers of digestion at a period, when the body is in a state of
exhaustion from fatigue. Often have I, in the course of my practice in
this town, cured the Dyspeptic invalid, by merely inducing him to
abandon so mischievous a habit.
II.
TO CORRECT THE OPERATION OF THE BASIS, BY OBVIATING ANY UNPLEASANT
EFFECTS IT MIGHT BE LIKELY TO OCCASION, AND WHICH WOULD PERVERT ITS
INTENDED ACTION, AND DEFEAT THE OBJECTS OF ITS EXHIBITION.
A. _By_ MECHANICALLY _separating, or_ CHEMICALLY _neutralizing, the
offending Ingredient_.
The scientific physician, from his knowledge of the chemical composition
of a medicine, and of the principles upon which its different qualities
depend, is enabled to remove or render inert the element which imparts
to it a deleterious operation; thus it has been found that the peculiar
principle in the _Spanish Fly_, which so frequently irritates the
urinary organs, is soluble in boiling water; ebullition in water
therefore offers the means of depriving it of the power of thus acting
upon the kidneys, while it does not effect any alteration in its
vesicatory properties. It is upon the same principle that many vegetable
substances of a very acrid nature, become harmless by boiling, or by
chemical manipulation, and some of them might even in times of scarcity
and want, be introduced as wholesome and nutritious articles of diet.
The experiments of _Westring_ shew that the bitterness of the _Lichen
Islandicus_ may be entirely removed by maceration in an alkaline ley,
and a tasteless, but highly nutritious fecula be thus obtained; in the
same manner the _Æsculus Hippocastanum_ (Horse Chesnut) may be deprived
of its bitterness, leaving a residuum which will afford a kind of bread;
and according to _Parmentier_ (_Recherches sur les vegetaux
nourissans_,) excellent starch may be also made from it. _Dr. Darwin_
observes, that if the roots of _White Bryony_ be rasped into cold water,
and agitated with it, the acrid juice of the root along with the
mucilage will be dissolved, or swim in the water; while a starch
perfectly wholesome and nutritious will subside, and may be
advantageously used as food; by a similar species of address the French
prepare from the acrid _Arum_ the harmless, but highly prized cosmetic,
called _Cyprus powder_.
There are many substances which receive a much pleasanter mode of
operation by having their solubilities increased or diminished; thus the
griping occasioned by several drastic purgatives is obviated by the
addition of some alkali: and the nauseating tendency of _Camboge_, which
arises from its too easy solubility, is prevented by incorporating it
with some insoluble body; as in the _Pilulæ Cambogiæ Comp:_ but the
farther consideration of this question will be resumed in the fourth
section of the Analysis. (iv. c.)
Numerous attempts have been made to correct the inconvenient effects of
_Opium_, such as nausea, head-ache, and costiveness, by removing the
resinous element, upon which such evils have been supposed to depend,
and we have accordingly been at different times presented with a variety
of _Formulæ_ for the accomplishment of so desirable an object; (_see
Opium_). More recently, opium has been discovered to possess _two_
active principles, viz. _Morphia_ and _Narcotine_, which would appear
from the researches of M. Majendie to exert very different powers upon
the animal system; the former imparting to opium its _soporific_, the
latter, its _exciting_ property; whence it is proposed to remove this
latter principle in order to render the operation of opium milder, and
at the same time to divest it of those objectionable properties which so
greatly limit its medicinal utility. _See Opium._
B. _By adding some substance capable of guarding the stomach, or system,
against its deleterious effects._
The virtues of our most important remedies are frequently lost, or much
invalidated, for want of proper attention to the circumstances
comprehended in this section. It may be almost admitted as an axiom that
_whenever an_ ALTERATIVE _medicine acts with violence upon the primæ
viæ, its energies are uselessly expended, and the object of its
exhibition defeated_. So again, _Diaphoretics_, _Diuretics_, and many
other remedies, suffer a diminution in their effects, whenever they
stimulate the stomach or bowels to excess. _Guaiacum_ thus loses its
anti-arthritic, _Squill_ its diuretic, and _Antimony_ and _Ipecacuan_
their diaphoretic, virtues; the action of these substances may therefore
require correction, and a medicine must be selected capable of
fulfilling that intention. _Opium_ has very extensive powers as a
corrigent. _See Form. 57, 100, 106, 110_. Dr. Mead combined alkaline
salts, when intended to act as diuretics, with opium, in order to
prevent their action upon the bowels. _Acetate of Lead_, when
administered in cases of hæmopthysis, or uterine hemorrhage, should also
be guarded by the addition of a small portion of the same narcotic. Dr.
Sutton, of Greenwich, has lately written a paper to shew, that where we
wish to limit the operation of an emetic to the stomach, and to prevent
its action on the bowels, we should add five or six drops of laudanum to
the emetic draught, which in his experience has answered the purpose in
question.[259] The griping and nauseating tendency of some remedies
receives correction by the addition of _Aromatic stimulants_, or
_Essential oils_, (69, 71, 78, 84, 85, 92,) or by small portions of a
corresponding tincture, (70, 76.) It has been already stated, that the
griping from _Senna_ and _resinous_ purgatives may be, in a great
degree, obviated by the addition of alkalies; it remains to be observed,
that the same remedies are also mitigated in severity, by _saline_
purgatives, (77.) I learn from Sir Henry Halford, that in his practice
he has found the addition of _Extract of Hyoscyamus_ render the
operation of the _compound extract of Colocynth_ much more mild, and no
less efficacious. Of the value of such a combination, I am myself able
to bear ample testimony. _Alum_ is corrected in its tendency to disturb
the bowels by the addition of _Nutmeg_, (_Form. 53_,) or some aromatic;
and the drastic operation of _Colocynth_ may be mitigated by trituration
with _Camphor_. There are several substances which are deprived of their
acrimonious qualities by trituration with mucilage, milk, barley-water,
&c. The tendency which mercurial preparations possess of affecting the
bowels, is, with the exception of _Corrosive Sublimate_, corrected by
_Opium_, but the acrid operation of this latter salt is more securely
guarded against by the decoction of _Guaiacum_ or _Mezereon_, or by the
plentiful exhibition of mucilaginous drinks and broths. In certain
diseases of the uterus and vagina, astringent lotions are indicated, but
it may happen, as in the cauliflower excrescence, or in the oozing
tumour of the labium, that such applications are too irritating; in such
cases the effect of the lotion is _corrected_ by the addition of
mucilage. The enfeebling influence of _Digitalis_, _Tobacco_, and some
other narcotics, is successfully opposed by aromatics and stimulants. It
has already been stated that several attempts have been made to correct
the operation of _Opium_ by the application of mechanical and chemical
resources; it would, however, appear that, for obviating its effects
upon the intestinal excretions, the judicious addition of some purgative
will offer the most effectual corrigent; and, according to my own
experience, the _Aloetic_ preparations are to be preferred upon such an
occasion, as in _Form. 11, 12, 13_. In some cases, I have found that a
combination of the watery infusion of _Opium_ with some bitter, will
secure the narcotic virtues without those consecutive effects upon the
alimentary canal, which we are always so desirous to obviate; the
_Decoctum Aloes compositum_ also furnishes upon such an occasion a very
appropriate adjunct. Let us remember that one of the effects of opium is
to paralyse, for a time, the muscular fibres of the intestines: now
experience has taught us that the remedies above directed have a
peculiar tendency to augment the peristaltic motions of the _primæ viæ_.
Upon the same principle the addition of calomel will prevent the
paralysing influence of this narcotic upon the biliary functions. I have
known several patients who could never take opium unless in such a form
of combination.
In general, a formula contains but one _corrigent_; but circumstances
may occur, where two different ingredients are required to obviate two
very different effects, as in _Form. 16_, in which the _Nitric acid_ is
introduced for the purpose of counteracting the deleterious effects of
the opium upon the nervous system, while the _Aloetic_ preparation is
calculated to obviate its particular tendency upon the alimentary canal.
Sometimes the unpleasant or perverse operation of a medicine may be
obviated by changing the form of its exhibition, the period at which it
is taken, or the extent of its dose; Dr. Cullen, for instance, found
that the nauseating operation of _Camboge_ might be obviated, by
repeating small doses at short intervals. (89.)
Before quitting the present subject, it deserves notice, that there is
frequently a _chemical_ condition of the stomach that may interfere with
the mild operation of a medicine, and may therefore require
consideration: this is particularly exemplified in the action of those
antimonial preparations which are liable to become emetic and drastic by
the presence of an acid; it is, for this reason, very eligible to guard
such substances with antacid adjuncts. See _Antimonii Sulphuretum_, and
_Form. 125, 128_. There is also, upon some occasions, an irritable state
of the _primæ viæ_ depending upon a deficient secretion of mucus, which
renders even small doses of any active medicine mischievous;
mucilaginous decoctions in such a case will offer the readiest
_corrigent_; see _Scammonia_.
The vinous infusion of _Colchicum_ appears to act more violently when
acid is present in the stomach; small doses of _Magnesia_ may therefore
precede, and accompany its exhibition, with advantage.
III.
TO OBTAIN THE JOINT OPERATION OF TWO OR MORE MEDICINES.
A. _By uniting those substances which are calculated to produce the_
SAME ULTIMATE RESULTS, _although by totally different modes of
operation_.
It has been already stated, (_page 152_), that we may frequently combine
substances together whose modes of operation are dissimilar, with
considerable advantage, provided they be not physiologically
incompatible with each other. We may illustrate this subject by a
reference to the operation of purgatives; a series of medicinal
substances may be produced, each of which has the property of exciting
catharsis, but by a very different mode of action; one for instance
stimulates the muscular fibres of the intestines; a second acts upon the
exhalant vessels, and mucous glands; and a third exerts its influence
upon the neighbouring organs, so as to produce an increased flow of
their secretions into the bowels; but since such modes of action are
quite compatible with each other, they may be simultaneously
established, not only without any loss of efficacy, but with the most
decided advantage; suppose, for instance, we administer a substance
which, either from its insolubility or peculiar nature, acts exclusively
upon the muscular fibres of the alimentary canal, its peristaltic
motions will be undoubtedly thus increased, and the contents of the
bowels evacuated, but the operation will be slow, and probably
accompanied with considerable _tormina_; now it is evident that if to
such a remedy we add those which can produce an increased flow of serous
fluids, the effect will be both quicker and easier. _The infusion of
Senna_ is thus quickened and corrected by _Soluble Tartar_. In the same
manner various substances included in the class of diuretics, which,
although different, still if they be not adverse in their operation, may
be conjoined; _Digitalis_ and _Potass_ are not similar, nor are they
incompatible, for while the alkali, through the medium of the
circulation, stimulates the secreting organs of the kidneys, the
foxglove may, by its sympathetic action, rouse the energy of the
absorbents. In the administration of diaphoretics we shall frequently
derive additional force, as well as certainty, by combining those which
act by relaxing the cutaneous emunctories, with those which prove
diaphoretic by imparting a general increase of momentum to the blood.
B. _By combining Medicines which have entirely different powers, and
which are required to obviate different symptoms, or to answer different
indications._
Arrangements constructed upon this principle constitute some of the most
valuable remedies with which we are acquainted; they are in general
_extemporaneous_, because their value depends upon their being varied
and modified according to the symptoms and circumstances of each
particular case. The following general elucidation of the subject may
serve to demonstrate the nature and importance of such combinations.
PURGATIVES _with_ ANTISPASMODICS. The practice suggested by Drs. Stoll
and Warren, in the treatment of _Cholica Pictonum_, affords a striking
example of the expediency of combinations of this nature. It is found in
that disease, as well as in others attended with spasmodic constriction
of the intestinal canal, that purgatives produce no effects unless the
spasm be allayed by combining them with _Opium_, (_see Form. 71, 75,
76_,) it is from such a cause that the purgative so popular with tailors
and shoemakers, and which consists of _Aloes_ with _Sagapenum_ or
_Galbanum_, affords such prompt relief in the spasmodic cholic to which
they are subject.
PURGATIVES _with_ TONICS. In the exhibition of cathartics how frequently
it occurs in practice that the patient’s strength will hardly allow the
evacuation; in such a case the addition of _steel_ as a roborant (_Form.
72, 92, 93_,) or even of _æther_, or _ammonia_, as a diffusible
stimulant, is strongly indicated: the Cheltenham waters offer a natural
combination of this character. So again in the cure of dropsy we have
often two indications to fulfil—to evacuate the water, and to support
the strength of the patient; hence the necessity of combining brisk and
stimulating purges, such as _Scammony_, _Jalap_, &c. with active tonics,
(83.) In the treatment of amenorrhæa the same medicinal arrangement is
not unfrequently indicated.
PURGATIVES _with_ MERCURIAL ALTERATIVES. In habitual costiveness, where
there appears to be a deficiency of bile, a combination of _Pilula
Hydrargyri_, with certain _Aloetic_ compounds, may prove serviceable;
for while the latter remedy will, in the absence of bile, supply to the
intestines a congenial stimulus, the former will tend to restore the
bilious secretion by its influence upon the hepatic system. _See Form.
79, 81_.
PURGATIVES _with_ DIAPHORETICS. This combination of effects is often
useful in practice, but it is desirable that the latter should not be
established until the operation of the purgative upon the bowels has
subsided. This is accomplished by certain doses of _Tartarized Antimony_
in conjunction with some purgative. The _Pulvis Aloes Compositus_ of our
Pharmacopœia produces a somewhat similar effect.
DIAPHORETICS _with_ TONICS. How frequently is the practitioner desirous
of determining to the skin, and at the same time of supporting the
strength of the general system? in the progress of a continued fever we
are repeatedly called upon to fulfil such indications. Dr. Bree[260]
also observes that “in the exhibition of _Diaphoretics_ the addition of
a bitter infusion, or tincture, is frequently proper; for the stomach
should be gently excited and strengthened during the use of a
diaphoretic draught.” On the other hand, _Tonics_ not unfrequently
require the aid of a diaphoretic; for instance, in the cure of _Cynanche
maligna_, the use of bark is indicated; but if the skin be hot and dry,
it should be accompanied with a diaphoretic. _See Form. 126_.
ANTISPASMODICS _with_ TONICS, _or_ NARCOTICS. Under the history of
Antispasmodics, (_page 78_) it is stated that there are certain bodies
which seem to exert an absolute control over inordinate muscular action,
from whatever general cause it may have arisen; in administering such
remedies, however, the intelligent practitioner will not overlook the
peculiar condition of the system in its relations to the disease; where
debility is present, the _Antispasmodic_ will be usefully combined with
a _Tonic_; and, in certain morbid states of the nervous system, with a
_Narcotic_.
ASTRINGENTS _with_ DIAPHORETICS. Dr. Fordyce has observed, that
combinations of this kind are often indicated in cases of Diarrhœa,
where it is necessary to astringe the vessels of the intestines, and at
the same time to relax those of the skin; such an indication, he says,
may be fulfilled by exhibiting _Tormentil root_, or any other vegetable
astringent, with _Ipecacuan_.
ASTRINGENTS _with_ NARCOTICS, and ABSORBENTS. It has been already
observed, that in a Diarrhœa, depending upon the influx of acrid fluids
into the intestines, there are three modes of treatment by which the
malady may be obviated, viz. by a narcotic, _diminishing the
irritability of the intestines_; by an astringent, _restraining the
serous excretion_; and by an absorbent, _neutralizing the acrid matter_.
As the modes of action are not incompatible with each other, they maybe
simultaneously established with the greatest advantage. _See Form. 52_.
ASTRINGENTS _with_ TONICS. A combination of certain medicines belonging
to these two classes is frequently indicated; in the treatment of
passive hemorrhage, we have to astringe the bleeding vessels, and, at
the same time, to cure the hemorrhagic diathesis by remedies which are
capable of restoring the general tone of the system. In the treatment of
the chronic and humid coughs of old persons, I have very frequently
witnessed the beneficial union of the warm and stimulating influence of
_Myrrh_ with the astringent effects of _Sulphate of Zinc_. _Form. 69_
presents the combination which I have usually adopted with success on
such occasions.
DIURETICS _with_ TONICS. As Dropsy is frequently associated with great
debility, the practitioner should combine his diuretics with some tonic
medicine; but in forming a judgment upon the case he must be guided by
those precepts which have been laid down under the consideration of
Diuretics at page 97. See _Form. 114_.
DIURETICS _with_ AROMATIC STIMULANTS. Such a combination will be found
advantageous in those cases where the powers of the system require to be
excited by more prompt measures than those afforded by the agency of
tonics. _Ethereal_ preparations, with Squill and other stimulating
diuretics, are well calculated upon such occasions to afford valuable
assistance. _Form. 101–116._
TONICS _with_ DIFFUSIBLE STIMULANTS. In the cure of dyspepsia, we
frequently require a remedy, for the purpose of obviating debility, that
is more sudden in its action, and prompt in its effects, than that of a
bitter _tonic_, whose operation is almost imperceptible; while the case
may at the same time stand in need of that permanent increase of tone,
which the latter remedy can alone supply; such an indication therefore
must be fulfilled by combination. _Form. 40, 42._
TONICS _with_ PURGATIVES. In the exhibition of tonic medicines it is
frequently essential to accompany their operation with purgation; in
intermittent fevers, for instance, when attended with a redundant
secretion of bile, or any obstruction of the viscera, the _bark_ must be
given in combination with some laxative, for which purpose Boerhaave has
recommended _Muriate of Ammonia_; _Mead_, _Rhubarb_; whilst in many
cases, experience suggests the propriety of selecting some of the warmer
cathartics, especially the Alöetic: and I shall take this opportunity to
observe, that notwithstanding the opinion so strongly expressed by
Sydenham, that “_to add any thing to the bark argues either ignorance or
craft_,” the most respectable testimony may be adduced to demonstrate
the great advantages which have arisen from the various combinations of
this heroic remedy. Sir George Baker has said that “_there is less of
reason than of severity_,” in the above remark of Sydenham; for that it
was found in the cure of the intermittent fever, which he describes,
that, according to circumstances, sometimes the _Virginian snake root_,
and in other cases _Myrrh_, were added with propriety and advantage;
and, according to the experience of several practitioners, a drachm of
the _rust of iron_, and the same quantity of the powder of _black
pepper_, added to each ounce of _bark_, were the means of subduing the
most inveterate agues. _Formula 44_ presents a combination, which we
learn from Dr. Petrie’s letter to Sir George Baker, constitutes a
celebrated Dutch remedy for an ague, and which was tried with success in
the hospital at Lincoln, in those obstinate intermittents which
prevailed in the year 1781. Hillary speaks of an epidemic intermittent
at Barbadoes, in which the bark was of no avail, unless combined with
saline remedies, or some of the tonic bitters. Dr. Barton has stated
that Bark combined with Mercury in a small proportion, is one of the
best remedies for removing the swelling of the spleen after an
intermittent.
EXPECTORANTS _with_ DIFFUSIBLE STIMULANTS. We have seen that
expectorants may be usefully associated with tonics; it sometimes occurs
that these remedies require the addition of some diffusible stimulant.
In certain states of _Peripneumonia notha_, where the powers of life are
ebbing, and the lungs become inundated with viscid mucus, I have
experienced the value of a combination of some stimulating expectorant
and _ammonia_.
ANTACIDS _with_ TONICS. In the cure of cardialgia we have obviously two
indications; to neutralize the offending acid by some chemical agent,
and to correct the morbid state of the digestive functions by some
appropriate remedy. _See Form. 152_. The same observation will apply in
the treatment of certain cases of chlorosis, where cardialgia is not
unfrequently a very vexatious attendant, and solicits the union of
emmenagogues with antacids, or absorbents, as in _Form. 99_.
LITHONTHRYPTICS _with_ NARCOTICS. As a palliative in calculous
irritation, the union of alkalies and opium proves a valuable resource.
Henbane may likewise be advantageously combined with a Lithonthryptic;
for, be it remembered, that few narcotics are more efficacious in
allaying nephritic irritation. (_Form. 156._) We have also frequently
two important indications to fulfil in the treatment of urinary
concretions; where the lithic acid diathesis prevails, it will be
necessary to neutralize any acidity in the first passages, and at the
same time to regulate the functions of the skin; we have moreover to
give tone to the digestive organs; so that, in such cases, the art of
medicinal combination is well calculated to extend our resources.
In the formation of these compounds we should rarely attempt to fulfil
more than two indications, although cases may occur in which it will be
eligible to assail the disease with an engine of _triple_ powers, as
exemplified by _Form. 52_ .
In constructing, however, such complex arrangements the practitioner
must of course take care that he does not fall into the error of
CONTRAINDICATION, and combine substances which possess properties
essentially different, and which are at variance with, or directly
opposed to each other; it is an error of the most serious description,
and unfortunately is one of too common occurrence in the lower walks of
medical practice; “_crimine ab uno disce omnes_.” I lately met with a
country practitioner who, upon being asked by a lady whom he attended,
the intention of three different draughts which he had sent her,
replied, that one would warm, the second cool her, and that the third
was calculated to moderate the too violent effects of either; thus it is
that discredit and contempt fall upon the use of medicines, which ought
only to attach to the ignorant pretenders, or designing knaves who
administer them.
Having, in the commencement of this inquiry, stated that all the
principles of combination, capable of practical application in the
construction of extemporaneous formulæ, are exemplified in the
composition of the various productions of Nature, I shall conclude the
present section by shewing, that _many of our most valuable vegetables
owe their useful properties to the joint operation of the several
distinct and different ingredients which enter into their composition_.
How many substances does Nature produce in the vegetable kingdom, in
which the permanent tonic quality of bitterness exerts its influence in
union with the transient stimulating powers of an aromatic principle?
indeed there is a series of vegetable remedies of this kind: commencing
with those that are simply bitter, we gradually proceed through the
different species, each blending as we advance an increasing proportion
of aroma, until we arrive at those in which the aromatic quality greatly
preponderates. _Peruvian Bark_ may be said to combine within itself the
properties of _bitterness_, _astringency_, and _aroma_; a fact which
suggested the probability of our being able to produce an artificial
compound that might emulate the effects of Cinchona, and to a certain
extent the idea appears to have been realised; for we are told by Dr.
Cullen, that he frequently succeeded in the cure of an intermittent by a
combination of _Oak Bark_ and _Gentian_, when neither bitters nor
astringents, separately, produced the least impression; and I am
informed by Dr. Harrison, that in the Horncastle Dispensary, of which he
was for many years physician, he never employed any other remedy for
curing the ague of Lincolnshire than equal parts of _Bistorta_
(astringent) and _Calamus Aromaticus_ (bitter and aromatic), neither of
which plants, _individually_, ever produced the least benefit in such
diseases. Berzelius attempted to produce a compound of this description
by adding to the bark of the _Ash_ some _Tormentil root_ and _Ginger_;
and he observes that it acted as an excellent tonic, and that according
to the experiments of his friends it seemed to cure quartan agues.[261]
In the aromatic barks and woods, such as those of the _Canella_,
_Orange-peel_, _Sassafras_, &c. the aromatic principle[262] is combined
with a bitter ingredient; a union which proves of singular service in
the formidable bowel complaints so common in tropical climates.
The great superiority of the hop, as an ingredient in our malt liquors,
depends upon the fact of its containing within itself several distinct
and independent elements of activity, which the other bitter herbs that
have at different times been employed as its substitute, do not possess.
The philosophy of its operation may be adduced as a striking
illustration of the present subject; first, then, it contains a _bitter_
principle, which imparts to the beverage a tonic quality and an
agreeable flavour; while at the same time an _aromatic_ ingredient adds
a warm and stimulant property and modifies the bitterness; the hop,
moreover, contains an _astringent_ ingredient (_Tannin_ and _Gallic
Acid_), the effects of which are to precipitate the vegetable mucilage,
and thus to remove from the beer the active principle of its
fermentation; every attempt therefore to substitute an ordinary bitter
for that of the hop must necessarily fail, unless a compound can be so
artfully constructed as to contain in due proportions, the principles of
bitterness, astringency, and aroma. _Quassia_ must therefore necessarily
prove but a sorry substitute; it will impart bitterness enough, but it
will not be modified by agreeable aroma; and as it contains no
astringent principle, it will fail in precipitating the vegetable
mucilage, or gluten; in consequence of which the beer so manufactured
will be in a perpetual state of fermentation until it is entirely
spoilt.[263] _Rhubarb_ is another medical plant which may be brought
forward in elucidation of the analogies subsisting between natural and
artificial combinations; in this case Nature has presented us with a
singular and most important union of medicinal powers,—that of an
astringent, with a cathartic property! virtues, which we might, without
the light of experience, have pronounced to be incompatible with each
other; and yet we find that in this instance the property of astringency
never interferes with, or opposes the purgative force, since the former
does not display itself unless the substance be administered in small
doses; or, when given in larger ones, not until it has ceased to operate
as a cathartic.
IV.
TO OBTAIN A NEW AND ACTIVE REMEDY NOT AFFORDED BY ANY SINGLE SUBSTANCE.
A. _By combining medicines which excite different actions in the Stomach
and System, in consequence of which_ NEW, _or modified results, are
produced._
This constitutes by far the most obscure part of the subject of
medicinal combination, and must ever continue so until we become better
acquainted with the laws which govern the action of medicinal substances
upon the living system. That the most valuable effects, however, are
really produced by such arrangements, we have the testimony of long
experience, and examples are furnished in the valuable and well-known
operation of many officinal preparations; thus the “_Pulvis Ipecacuanhæ
compositus_” contains as its active elements, _Opium_ and _Ipecacuanha_;
and yet, in well regulated doses, it neither possesses the narcotic
operation of the former, nor the nauseating effects of the latter; they
appear to be mutually lost, and converted into a powerful diaphoretic:
so again, the emetic operation of _Sulphuret of Antimony_, and the
specific influence of _Calomel_, are changed by combination with each
other, giving rise to a remedy eminently distinguished for its powers as
an alterative. Dr. Bree observes that _Tincture of Squills_ combined
with _Extract of Henbane_, and the _Nitric Acid_, have been proved by
much experience to be expectorant and sedative in a paroxysm of asthma,
although each article, uncombined, had been given without success. See
_Form. 139_. The efficacy of _Hemlock_, in quieting Pulmonary
irritation, has been frequently adverted to in the course of this work;
I have to state, in this place, that its value, on such occasions, is
generally enhanced by combination with _Ipecacuanha_.
It is probable that many of our natural remedies owe their efficacy to
the results of a similar species of combination. In the fourth edition
of this work it was stated that, according to the assertion of Dr.
Chapman, “_Kino_, when administered in union with _Calumba_, constituted
a pretty certain, and powerful purgative;” since the publication of this
fact, I have investigated what, if true, would appear to be a most
extraordinary anomaly in the philosophy of medicinal combination, and I
find that the statement of Dr. Chapman[264] is not borne out by
experiment. That we might arrive at a just conclusion upon this subject,
I requested the assistance of my friend Dr. John Davy, whose character
for experimental accuracy, and whose situation as Superintendant of the
Medical Division of the General Military Hospital at Chatham, seemed to
point him out as a person peculiarly adapted for such an inquiry; the
result of his trials does not establish that of the experiments of Dr.
Chapman, but on the contrary it seems to prove, that neither _Kino_ nor
_Calumba_, when taken separately, has a constipating effect, and that in
the form of powder (especially the _Calumba_) each has an aperient
quality, which is not increased by exhibiting the two medicines together
in a state of mixture. The trials from which these inferences are drawn
were made on different individuals in tolerable health, and they were
repeated more than once; in some cases they were given separately, and
in others, mixed together, in doses varying from a scruple to a drachm
of each.
B. _By combining Substances which have the property of acting chemically
upon each other; the result of which is the formation of_ NEW COMPOUNDS,
_or the decomposition of the original Ingredients, and the developement
of their more_ ACTIVE ELEMENTS.