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.
The other case was that of a young woman, affected with many of the
same symptoms which I have related in the foregoing case, but in a
more acute degree. From accidental circumstances timely treatment had
been omitted; and I found the highest degree of general fever, with
a pulse frequent, hard, and obstructed. The breathing was laborious,
but not attended with any fixed pain in the chest. Her voice was
rather hoarse, and had lost its natural tones. The cough was urgent,
and the expectoration took place with difficulty. The expectorated
matter was, for the most part, frothy, and had a remarkably acid
odour. The cheeks were flushed with a deep hue of purplish red, and
the lips assumed a very dark appearance. Such was the laboured state
of the circulation, that the patient was affected with an almost
constant disposition to faint. She complained of a sense of extreme
burning, and also of soreness, over the whole of the chest. She had
not enjoyed any sleep for three nights, nor any in the day; her mind
was occasionally delirious; and her countenance wore the greatest
anxiety.