ly speaking, we hardly can assign a triple character to nauseants when we join the physiological operation of diaphoresis and expectoration, and make it one general process of exosmosis. It appears what is a diaphoretic is more or less an expectorant, and vice versa, that is, if the excretory flow is turned off from the kidneys by confining the body in a warm place. The question is one of great diagnostic importance, in particular in the initiatory stage of a pulmonary disease. To lay your hand on the skin, and by the degree of its temperature and moisture diagnose a pulmonary hyperæmia, is by no means an impossibility. But to practice such artistic skill in diagnosis, we must mark the difference between a physiological and pathological perspiration. The asthenic perspiration of a chronic disease would hold no exact relation to the organic trouble that may exist. There is, evidently, a law that governs the operations of the lungs and skin, not as organs of aeration alone, but as performing their functions under the influence of atmospheric air.* Nux vomica has two very distinctive properties; constitutionally, as a powerful excitant of tne cerebro-spinal system; locally, somewhat like cocaine, as a local anesthesia-a dual action, but of a decided antagonistic character. This antagonistic dual action we find in opium as a stimulant narcotic-its effects on the iris alone betray the powerful internal tension it produces, which at the same time may be masked by a state of insensibility. In the case of tartar emetic given internally, vomiting occurs in consequence of the irritation of the mucous lining of the stomach, but the drug through its direct effect on the cardiac tissue, causes at the same time reduction in the force of the heart's action. When chloroform is given by inhalation we have a direct action on the cerebro-spinal nerve centres, particularly on the cerebrum, at the same time we have a checking of the heart's action through reflex action aroused by local contact of the drug with the mucous lining of the air passages.t It is sometimes necessary in practice to annul the dual action of a remedy by synergistic means, where it is desirable to have but one organ acted upon. Thus, bicarbonate of soda joined with calomel, results in nothing more than an alterative cathartic. Digitalis, as already stated, will affect either the heart or the kidneys, according to the nature of the solvent. Turpentine affects both the intestines and kidneys, but an adjuvant of castor oil will confine its action to the bowels, with little or no communication with the kidneys. A reverse action could be effected by suspending the peristaltic intestinal canal. This may sometimes be resorted to with advantage in puerpural paralysis of the sphincter vesicæ,‡ nevertheless, running the imminent risk of inflicting a serious damage upon the urinary or the force to split up a drug in two, assigning each part to two different organs, in which each performs a function of its own? To solve the question, we have first to learn what class of remedies possess these characteristics. These are nearly all medicines of a high power, and without this physiological division many of them would become toxic in the extreme. Therefore, it is a protective measure on the part of the economy when receiving drugs of this class. Arsenic is strictly a dual drug, at least up to its point of cumulative action. Medicines Tolerated by Force of Habit. It is a noted fact that several of the most powerful substances are habitually received into the economy, even in formidable doses, apparently with no bad effect, at least with no immediate danger to life. The articles thus abused, for it is nothing else, are alcoholic drinks, tobacco, opium and other narcotics, and even arsenic and others. It may be unnecessary to state that a person having the pernicious habit of taking any drug to a high tolerance, is always a precarious subject for medication in any serious disease. The main reason is that any therapeutic habit will inflict an irreparable damage on the powers of absorption. When we take into consideration the exceedingly delicate processes some remedies undergo in their transition through the system before the absorbents receive them, and on their route to the different organs of election, their operative effects, and then their mysterious elimination, we know well, why longevity is denied to such, and why the blessings of medicine when sick does not rest on them! What is the pathology of resisting an enormous dose of a dangerous substance by force of habit? The learned Gubler supposes that "it is an equilibrium established between the intensity of the action of a medicament, and the reaction of the system." This would make it a normal physiological operation, which surely is not the case. If the reaction of the system is equal to the intensity of the drug thus abused, how would we account for the progressive asthenic condition of the drunkard, and the opium eater, the longer they indulge in their habits? It is a well-established fact that any medicinal substance of any power introduced into the system, not indicated as an absolute necessity does harm, and when such is persistently used, it will develop a cachexia eventually ending in an incurable organic disease. The drunkard may die from cirrhosis of the liver or granular degeneration of the kidneys, the opium eater from general denutrition, the arsenic-eater from fatty degeneration, and the slave to tobacco from an early arrival of his disease of predisposition. But all hold alike a common functional malady in the first course of their habit. This being a blunted condition of the absorbents, which is soon transmitted to the nervous system, and finally establishes a functional cerebral lesion, known by the term PRELIMINARY OBSERVATIONS. 'craving." The degree of this brain trouble varies-in some cases it is curable, though usually not so. Hardly ever will a confirmed drunkard become radically reformed. It is not owing to any extraordinary resistance of the system that gives tolerance of these noxious substances--but they have so worn out the powers of absorption for that particular kind of a substance, that its admission into the system is so slow and gradual, that no immediate serious consequence can follow, and when the substance finally finds its way into the circulation, further protection is rendered by the albuminoids as it is hurriedly carried to its assigned emunctories. The very weakness of the living tissues through which the substance passes facilitates its excretion exosmotically, on the principle that an indigestible ingesta may induce a diarrhoea. Sometimes, changes in the system will take place where the absorbents have been aroused by some means, and should the victim at the time take the usual enormous dose of one of these substances he has been in the habit of takIt is not infreing, it may be with fatal results. quently the case that the drunkard, and the opium, and the arsenic eater, are unexpectedly destroyed in this way. A tolerance of medicine is not to be confounded with a tolerance brought about by a force of habit. Tetanus will bear an extraordinary tolerance of medicine, but the cause of this lies in the nature of the disease and the state collapse, of the absorbents, and not by any force of habit. All diseases bordering on bear the same tolerance and all from the same pathological cause. It is well to keep in mind that a tolerance of are many remedies, where On Craving. The sense of craving, psychologically, is a de- and likewise among soldiers that have been for But there may be a therapeutic craving con- Where it is strongly manifested as in chlorosis, and in gestation, as is usually the case, although if of a morbid and ridiculous aspect in itself, it is well to give it attention, and determine what nature demands. What was the matter with the pregnant woman that craved a bite from her butcher's shoulder, a story once told in one of our medical lecture rooms? Should such a case actually occur, what would be the diagnosis? In all probability a deficiency of the phosphates in the woman's system. She selected the butcher intuitively through some association with the very material she needed. Why the craving was not meat itself, may have been owing to a hysterical fancy, or as but a a partial part in the meat was required. Crav· ing is never over-wise in asking what is really needed, except sometimes in diet, where all animal life through instinct are governed by the same laws. Now and then we learn of a case where by gratifying the craving of a certain kind of a diet, a cure of the disease is made, which before Dr. T. K. Griffith reresisted all medication. ported a case of this kind-an obstinate nurse's sore mouth which had resisted the usual local At the time and constitutional treatment. ripe tomatoes made their appearance she eagerly craved them as food, and she was allowed to eat them. An immediate improvement followed, the mouth healed, the appetite returned, and the patient gained strength and got well. To show that we cannot always accept craving as a guide, in the treatment of diseases, I will cite a case I once had in my military experience. An officer of high rank was under my treatment for dysentery, which finally terAs his appetite reminated in convalescence. I a turned, he strongly craved hard-boiled eggs. positively forbade him to eat them; but nevertheless he ate them, and with a keen relish. But the eggs refused digestion, he was thrown at once into a relapse of the disease, closely associated with a collapse in which he died. Accumulation of Action. One of the accidents of medicine is the accumulation of action of several of our most potent remedies, such as strychnine, quinine, mercury, digitalis, arsenic, iodine, phosphorus, lead, etc. In prescribing any remedies of this class for any length of time it is well to bear in mind their These cumulative tendencies, for should their explosion take place, it may be with dire results. substances are apt to be stored away in their respective places of selection, and it is their reabsorption, either spontaneously or through medicinal influences that causes their reappearance into the circulation, and again brings into exhi There is one bition their characteristic effects. feature to be noted in the treatment of a disease with some of these remedies, that is, the *Prof. J. J. Mulheron. use of the medicine can be advantageously suspended as its power will continue to manifest itself for some time afterwards, although the patient may have ceased to take the medicine. If the substance is a metal and has accumulated with bad effects it may be necessary to hasten its re-absorption, which is readily effected by the use of iodide of potassium. With both lead and mercury it forms double salts, which are soluble, and there is very good reason for believing that the formation of these salts takes place in the economy, and that the metal which has been lying in an insoluble condition in the various tissues is taken up and excreted.* Severe salivation and ulcerative stomatitis have sometimes resulted from the use of the potassium salt in those who had previously taken large quantities of mercury.† It is well known that iodide of potassium is indicated as a curative agent in what we might call the accumulated stage of syphilitic poisoning, and where the tissues are infiltrated with gout poison, then the addition of the iodide to the bicarbonate of potash is eminently useful. A distinction has been made between the accumulation of action, and the accumulation of doses. Accumulation of doses signifies that there is accumulation of the substance in the digestive organs, as happens with strychnine pills which do not dissolve altogether, producing symptoms of more or less gravity. Accumulation of action, which signifies that the medicament passes into the parenchyma of the different organs, and accumulates there-and the quantity taken up by the work of absorption and eliminated, not approaching sufficiently the quantity of the substance injected, there ensues accumulation in the histological elements of the tissue. How can this phenomenon be explained? It would seem that the process is, as if the intervals between the successive doses administered of the active substance were sufficiently short, so that there is a portion of the action of the first dose in the system at the time the following dose is administered, and so on, for the following doses. To avoid accumulation of doses, the best means is not to employ medicines in a solid state; and it can be readily understood that there will be no accumulation with feeble doses, for they are destroyed and eliminated with facility, nor with substances which pass easily through the economy, and which act, for instance, solely on the globules. These substances are generally eliminated with great rapidity, as are the gases themselves; ether, chloroform, ammonia, in fine all the substances which act principally on the blood are eliminated with celerity, and accumulation is difficult. On the contrary, the substances which sojourn more or less in the system penetrate into the parenchyma, and at last are incorporated with the immediate principles, or with cellular parietas, or take part in tissue formation; such substances are the ones which show themselves particularly favorable for the production of what is called accumulation of action.* Medical Diseases. If a medicine of any power is given in large doses, frequently repeated for a long time, there is a decided risk of causing disease of the organ on which it specially acts.* We speak here not of poisons, nor of the untoward effects of drugs, nor of idiosyncracies, but of a few remedies in general use. COLCHICUM is a drastic cathartic; but it tends also to render the bowels inactive, to diminish the alimentary secretions, and materially to weaken the functions of the liver. In the general character of the medicine, it may with truth be stated that sooner or later, in proportion as it is freely employed, it will lead to a broken state of health.† NITRATE OF SILVER, in medicinal doses, is for some time at least attended by no observable effects. After a time a staining of the skin of a sort of bluish gray color takes place. This is permanent, and after death a similar staining of many internal organs has been seen. In a few favorable cases, the skin staining is said to have disappeared after the use of iodide of potassium and hyposulphite of soda. The silver is deposited in the tissues in the form either of oxide or of solid silver. In animals, symptoms indicating a paralyzing action on the cerebro-spinal centers have been observed, as well as a disorganizing effect on the blood.‡ IODINE. There are few remedies that have as wide a range of therapeutic application as iodine. In large doses it causes an elevation of the bodily temperature, emaciation, and an increased waste of the nitrogenous tissues of the body. It exerts its greatest influence on the albuminous compounds of the body. The tendency of the compounds of iodine is to produce catarrhal effects on the mucous membrane, and an eruption of the skin; and it develops a train of symptoms known as iodism. The common experience that iodine effects a reduction of hyperplastic glandular tissue, finds a physiolog ical counterpart in the effect of the prolonged employment of medicinal doses of iodide of potassium on the testicles, ovaries and mammæ.¶ IRON. When this remedy is administered in severe anæmia or chlorosis, the first doses should be very minute-smaller than those which cause the constitutional symptoms of iron intoxication-such as a stricture in the temples or chest, flushings of the face, or fullness of the head. In somewhat increased and prolonged doses, iron and even the ferruginous waters are followed by disturbance of digestion, diminution of appetite, gastric oppression and vomiting; and these results are particularly liable to follow when the drug is taken on an empty stomach. Defecation is retarded and the stools are blackened by a sulphuret of iron. More recent observations have demonstrated the ferrous salts to be better tolerated than the ferric. Ferrum redactum, the phosphate, and the pyrophosphate of iron are said to disturb digestion but slightly. On the other hand, the PRELIMINARY OBSERVATIONS. salts with organic acids (lactate, citrate, and acetate of iron) interfere very much with pep tonization.* QUININE. Organs differing most widely in their nature are influenced by quinine and manifest pathological changes. The following symptoms are observed as indicating disturbances which it causes of the central nervous system: headache, deafness, general muscular irritability with chilliness and a feeling of dizziness, which disappear on the person assuming the horizontal position. The skin of many persons is affected in a peculiar manner by the internal exhibition of even small doses of quinine. For the purpose of preventing the head symptoms which so frequently attend the employment of quinine, Wade recommends bromhydric acid. Rivet has recommended the subcutaneous ad ministration of morphine as a remedy against the accidents following the use of quinine. Lightfoot observed a rapid disappearance of the quinine eruption after the taking of 25 drops of tincture of hyoscyamus and alkaline baths. Heusinger powdered the affected portions of the skin with wheat flour.* SALICYLIC ACID. The internal exhibition of this acid causes a repulsive taste, and a burning and grating sensation in the mouth and throat. After its absorption we may have buzzing in the ears, difficulty of hearing, and profuse perspiration; these symptoms do not however contra-indicate the further employment of the drug.* Perspiration supervenes in about two-thirds of the cases, and is sometimes as profuse as that following jaborandi. BALSAM OF COPAIBA, when employed for a long time, and not necessarily in large doses, affects the various mucous membranes injuriously. It not infrequently causes loss of appetite, gastric oppression, nausea and vomiting, and sometimes congestion of the conjunctiva and pharynx, and irritation of the kidneys and bladder to the extent of even causing nephritis and cystitis. The manner in which these effects are produced is clear. Balsam of copaiba, like other resinous substances, causes irritation of various degrees of severity of the mucous membranes, perhaps through the oil of copaiba, or copaibic acid which it contains. Its elimination is effected through the lungs and kidneys, and ALUM. The continued use of small doses of *Dr. L. Lewin. †Bertagnini. alum is prone to induce a cough in persons with administered to children, nervous an eruption, with or without itching, has been DIGITALIS shares with only a few other drugs CHLOROFORM. fatal cases of chloroform narcosis, death occurs ceases, either simultaneously with or before the *Dr. L. Lewin. †Beginaud. To impose an additional physiological tax, by medicine, on any of the emunctories that are already in an abnormal erethistic condition, is apt to induce irreparable mischief. We find this forcibly exemplified where tartar emetic is given in diarrhoea; pilocarpine (under an excessive general exosmosis already referred to in certain lesions of the lungs, with a defect in the power of expectoration. The kidneys are very liable to be injured by some substance that has its outlet through them. Thus, with arsenic certain cases of albuminuria have been considered due to the passage of the poison through the kidneys. Anything beyond a single cathartic of calomel, is especially to be avoided in this disease.‡ Chlorate of potassium, in large doses, gives rise to gastro-intestinal irritation, and a peculiar nephritis, with scanty and dark urine. It has recently been shown that the dark urine is due to decomposed blood, which blocks up the renal tubes or is discharged in the form of peculiar blood casts.‡ It may After a course of a mercurial treatment, iodine should be given with great caution. cause salivation, but of a much milder character than that from mercury, except in cases where mercury has been previously used, when it is really mercurial salivation renewed by the increased solubility of the metal in an iodic solution. Digitalis, as a cardiac remedy, is useless in the period of eusystolism, when the lesion is compensated; it is injurious in the hypersystolic period, when the compensation is exaggerated; it is efficacious in the hyposystolic or period of transient asystolism, when the cardiac muscles and the vessels are suffering from asthenia, and when there are cedemas, visceral congestion, dropsies, and the heart beats softly and feebly; in the period of definite asystolism, or of amy ocardia when the cardiac muscle is profoundly degenerated, digitalis is sometimes useful, it may be useless, or it may be injurious. It is in these cases sometimes that caffeine in large doses gives signally good results.† When the blood or the nervous system is much impaired, the initiatory treatment should not be of a heroic character. Thus in nervous patients, nervines should be given with precaution. In pernicious and extreme anæmia, when iron is administered, the smaller should be the dose, and the less stimulating the preparations used in the commencing treatment, and as improvement continues the size of the dose or the form of combination may be changed.* Many of the untoward effects of medicine may be attributed to not adapting the first dose to the nature of the case. Even under the best of circumstances, the remedy used, to make it acceptable, must be joined with a corrective, as the use of bromo hydric acid with quinine or any of the alkaloids of cinchona. Untoward Effects of Medicines There are several conditions in which a drug in medicinal doses may bring about deleterious effects. The drug itself may not be of a standard purity, it may not be properly administered, or it may be acted upon under pathological changes. All active drugs taken into the body, cæteris paribus, respectively have their established effect and their route through the system. It is strictly a physiological process; but when from some cause, a medicine is changed into an injurious compound, through vitiated secretions, or diverted from its natural course in its transition through the economy, we have to contend with injurious results. It is a known fact that the secretions are not always the same, therefore medicines brought under their influence may fail to have their legitimate action. Yet if injurious compounds are thus formed, it would be but the natural result of a chemical reaction and under similar circumstances would have the same effect in all cases. It is not in this light we consider the subject; but simply as a disease of the inhibitory apparatus of the system. This disease appears to be an orgasm of those parts that are concerned in the election of the remedies, or their elimination. It must not be confounded with idiosyncrasy as is often done by writers on the subject. It may be at times difficult to draw a line between the two; but by a close examination we will find one a disease and the other not. When we speak of an idyosincrasy of a person that faints at the sight of blood; will vomit at the sight of sputa, or at the smell of carrion, etc., how can we associate these mental phenomena with the subject under consideration? There are four ways by which medicines affect the human system: 1. Physiologically, comparatively with uniform results. 2. Pathologically, with untoward effects. 3. Toleration by habituation. 4. Toxic. The system has the power to *Prof. R. T. Edes. +Journal Am. Med. Association. Prof. Adolph Gubler. |