MEDICAL INTELLIGENCE. 559 Medical Entelligence. times, viz., eighty times from the foot, and 940 from the arm. All this she survived, but was cured by having to take a journey ia a rough vehicle, which THE LONDON AND PROVINCIAL MEDICAL brought on the regular menstrual discharge, and she DIRECTORY. We trust that the announcement respecting the issuing of the circular, by the editor of this work, in a recent number of this Journal, has not escaped the notice of our readers. To assist in rendering such a work correct is for the advantage of every genuine member of the profession, and we would urge upon the members of the Provincial Association not to be behind others of their medical brethren in returning answers to the circulars, containing all such particulars as it is desirable should be known. No care nor attention on the part of the editor can avail in rendering the work what it might be, a faithful and correct index to the profession, unless the members will themselves give the information which is required to mark them distinctly, as legitimately belonging to it. SANITARY COMMISSION. Lord Robert Grosvenor, Dr. Southwood Smith, Professor Owen, Mr. Chadwick, and Mr. L. Jones, have been appointed Commissioners to inquire into the means necessary to be adopted for the improvement of the sanitary condition of London. afterwards married and lived healthily for many years. Recueil de Médecine, 1757. PROGRESS OF THE CHOLERA. It is with regret that we have to announce the almost simultaneous appearance of the cholera in several provinces of Russia. Moscow, Smolensko, Plescow, Riga, and Odessa, are all suffering under the disease, and there is but too much reason to apprehend its spread throughout Europe. SOCIETY OF APOTHECARIES. Gentlemen admitted Licentiates, Thursday, September 16, 1847:-George Moseley, Hampstead; Samuel Burgess, Frodsham, Cheshire; Thomas Parker Rust, Wells, Norfolk. Thursday, September 25:-Henry Lambden, Burgh, Lincolnshire; John T. Campion, Exeter; John Coghlan Haverty, Liverpool. TESTIMONIAL TO JAMES MASH, ESQ. On Friday, (Sept. 10th,) a very handsome silver inkstand value forty guineas, was presented to Mr. James Mash, of Northampton, bearing the following inscription:-"This testimonial was presented to James Mash, Esq., House Surgeon to the Northampton General Infirmary, by the late pupils of that Institution, and some of the General Practitioners of the town and neighbourhood, as a mark of respect and esteem for his professional attainments and private virtues. Sept. 10, 1847.” OBITUARY. Died, Aug. 21st, aged 36, of fever, Richard Mackenzie Hiddleston, Esq., Resident Medical Officer at the House of Recovery, Leeds. Sept. 2nd, at Trafalgar Cottage, Manor-Hamilton, aged 62, James Dundas, Esq., R.N., F.R.C.S.I., Surgeon to the Dispensary, and Medical Attendant of the Workhouse. Mr. Dundas contracted malignant typhus fever during his attendance in the temporary fever hospital. He was Assistant Surgeon of H.M.S. Cyclops, at the battle of Trafalgar, and on leaving the service he devoted a long and useful life to the cause of humanity and science; his loss will be long felt by the community and members of his own profession. Sept. 5th, at Granard, aged 72, Dr. M'Cormick, A PATIENT BLED ONE THOUSAND AND Medical Attendant of the Union Workhouse. TWENTY TIMES. A young woman, in whom the menses became sup. pressed, suffered from severe hysterical symptoms, vomitings, and epileptic attacks, which nothing was found to soothe and relieve but a small venesection; and in the course of three years, from the age of sixteen to nineteen, she was bled no less than ona thousand and twenty Sept. 8th, at Carraroe, of fever, John B. M'Donough, Esq., Surgeon, employed under the Central Board of Health as Medical Officer for the seaside portion of the Outerard Relief District. Sept. 9th, aged 49, Thomas Weatherill, Esq., M.D., Liverpool. Sept. 14th, at Doncaster, aged 46, of fever, caught in the discharge of his duties as Medical Officer to the Doncaster Union Workhouse, Robert Storrs, Esq., M.R.C.S. Sept. 19th, at Honiton, aged 40, from tubercular deposition in the lungs, brought into action by an attack of typhus fever, James Campbell, Esq., M.D., Honiton. Sept. 19th, at Baltinglass, of fever, John Johnston, Esq., Medical Officer of the Union Workhouse and District Fever Hospital. Sept. 20th, at Perth, John Monteath, Esq., M.D. Sept. 26th, aged 26, from fever, contracted in the discharge of bis professional duties, John Oliver Curran, Esq., M.D., Dublin. Lately, at Athenry, of fever, L. S. M'Calman, Esq., M.R.C.S.E., Medical Attendant of Dispensary and Constabulary. PROVINCIAL MEDICAL AND SURGICAL ASSOCIATION. NOTICE TO MEMBERS. Gentlemen who have not paid their subscriptions for the current year, or who are in arrears, are requested to send the amount due to the Treasurer or the Secretary of the Association. ROBERT J. N. STREETEN, Secretary. METEOROLOGICAL JOURNALS FOR JUNE, 1847. Kept at Sidmouth, by W. H. CULLEN, M.D.; at Honiton, by Mr. ROGERS; at Romsey, Hants, by F. BUCKELL, Esq.; at Uckfield Sussex, by C. L. PRINCE, Esq.; and at Harrogate, by G. KENNION, M.D. PROVINCIAL MEDICAL & SURGICAL JOURNAL. A LECTURE ON THE ACCUMULATIVE ACTION | importance than this accumulative action of medicine, OF MEDICINES, WITH SOME REMARKS ON SLOW POISONING. By JAMES JOHNSTONE, M.D., Fellow of the Royal College of Physicians, Professor of Materia Medica and Therapeutics at the Queen's College, and Senior Physician to the General Hospital, Birmingham. (Delivered at Queen's College, Birmingham, Oct. 5, 1847, In the lectures on therapeutics which, during the last fifteen years, I have delivered at this Institution, I have frequently spoken of the accumulative action of medicines, or that power which they exercise over the animal économy by their continued operation when adminis. tered at short intervals, even in portions so small that no effect whatever would be produced by a single dose. To this subject, which has received less notice than it deserves from medical authors, I beg to call your attention. The difference in character, as well as intensity, between the effect of a single dose of a medicine, and that of the same quantity of it when divided into several doses, and given at short intervals, is in many cases as striking as if two different substances had been employed. Thus, ten grains of calomel in one dose is a cathartic too powerful for most disorders that occur in this country; while a single grain of calomel, administered every night and morning for several successive days, till even more than ten grains have been taken, is very often prescribed as an alterative without much affecting the bowels. Again, two grains of tartarized antimony seldom fail to excite vomiting, but if a quarter of a grain be given at intervals of three or four hours, the medicine soon ceases even to nauseate, and becomes a powerful sedative and expectorant, which is advantageously given for the relief of inflammatory affections of the lungs and other viscera. In these instances the larger doses do not usually act accumu. latively, because they irritate the intestinal canal, and therefore are not retained a sufficient time for that purpose. There are, however, other medicines of which the effect is increased, but not altered by their protracted operation: such are digitalis and iodine; the former being always sedative and diuretic, the latter a stimulant to the glandular and absorbent system, and an alterative. Nothing in the treatment of disease is of more No, 21, October 20, 1847. for while many disorders which do not soon or ever yield to the most active measures, may be cured by the gradual influence of remedies far more gentle in their first action, the physician is sometimes rather disconcerted at finding that his patient has been salivated by a few doses of mercury, which were intended to act upon the digestion only, or that the heart has almost ceased to beat, owing to the depression which digitalis, benefits which are now derived from the foxglove, were prescribed as a diuretic, may have caused. Indeed, the purchased at a cost of life by no means inconsiderable, before it was introduced into the "Materia Medica," and its power was properly estimated. The facts which I have stated are well known; and though the physiological explanation of them may admit of doubt, I believe that the accumulative action of a medicine is always dependent, either upon the chemical changes in the animal fluids which it may occasion when the system is loaded with it, or upon diminution of the nervous power, consequent on long continued depression of the nervous system. This classification might perhaps, with very little modification be applied to general therapeutics, for it is probable that most, if not all, of those medicines, which are not purely chemical agents, act primarily upon the nervous system; and I am inclined to think that the operation of some upon one organ especially, and others upon another, is owing to the peculiar sensibility of various sets of ganglionic and spinal nerves to appropriate stimulants-both natural and artificial, such as we know to exist in the cerebral system; so that in the same manner as the optic nerves are affected by the light alone, and the auditory nerves by sound, the nerves of the kidneys are excited by diuretics, those of the uterus by emmenagogues, and those of the intestines by cathartics, as well as by the ordinary secretions. Upon the same principle, the action of these organs is impaired when any substance which can stupefy their nerves may happen to come in contact with them. A medicine may enter an organ, and circulate through its vessels, but unless it either effect some chemical alteration, or be fitted to act upon its nerves, the functions of the part are not disturbed. Hence we find the colour and smell of rhubarb and other substances in secretions, which are neither thereby increased, nor otherwise materially changed; although other functions may be at that very time under the influence of these medicines. X I. CHEMICAL CHANGES EFFECTED IN THE ANIMAL pathologists was often bad, their theories were not so far wrong as Hoffman and Cullen imagined. FLUIDS, BY THE ACCUMULATIVE ACTION OF That certain medicinal substances are conveyed into the circulating system by absorption is an undoubted fact; for many of them, including salts of mercury, iron, silver, potassium, &c., have been detected in the blood itself, as well as in the secretions from it. The taste of iodine in the saliva, when it has been rubbed into the skin, a fact which I have often observed; the blue tint of the internal membranes, and the dark colour of the skin, of those who have taken nitrate of silver for a long period; the red bones of animals which have been fed upon madder, and numerous other instances of a similar nature, likewise evince the presence of mineral and vegetable medicines in the fluids and tissues. It does not, however, necessarily happen that medicines which are absorbed, act chemi. cally; for some of them when once deposited, either exert no apparent influence on the animal economy, or only on the nervous system, having during their passage through the alimentary canal, lacteals, and blood-vessels, undergone changes which rendered them ultimately inert; whereas, many others retaining the power which they previously possessed, prove benefi cial or prejudicial to health, as the case may be. Thus the continued use of alkalies in minute quantities, more effectually counteracts the disposition to form lithic acid than the largest doses occasionally administered; and upon the same principle, the invalid often derives more relief from habitually drinking the natural mineral waters, which hold in solution very small portions of various salts, than from any other medicine. By the accumulative action of such remedies, the constitution of the animal solids, as well as of the fluids, becomes gradually modified; and the morbid tendencies which may have previously existed, either remain for a time in abeyance, or are permanently removed. But as Of these changes in the animal fluids, the cure of those diseases which affect the functions of nutrition and secretion on the one hand, and on the other hand the tendency of some medicines, such as iodide of potassium, turpentine and copaiba, to induce cutaneous eruptions, are evidence; and this is corroborated by the experiments of several eminent physiolo. gists, who have shown, that when saline and other medicaments are mixed with blood, its colour and consistency undergo considerable alterations. Hewson very justly remarks, we must not conclude that the effects within the body, would be the same as out of it, and it must be admifted, that though we may be inclined to believe in the power of some preparations of iron to increase the quantity of globules in the blood, and to give credit to other instances of vital chemistry, equally interesting, yet such phenomena require further elucidation before we can claim an exact knowledge of them. Nevertheless enough has been done to prove that the efficacy of many medicines is dependent upon their chemical action, and that though in former times the practice of the humoral II. DIMINUTION OF THE NERVOUS POWER BY THE depends upon the chemical changes which they effect, it seems equally certain that the agency of others is entirely attributable to their diminishing the nervous power. The rapidity with which strychnine, and some of the other narcotic poisons, affect other animals, as well as man, can only be explained by the supposition that these substances possess a peculiar influence over the nervous matter, when brought into contact with it, and thus impair its functions. Changes in the structure of other parts of the body may, and often do, subsequently occur; but these I should, under such circumstances, regard as the result, and not the cause, of diminished nervous power. Indeed, the accumulative action of such medicines somewhat resembles the influence of long continued grief and anxiety of mind, which, by diminishing the energy of the nervous system, slowly, but surely, impede or pervert the organs of nutrition. In cases of this class, the loss of nervous power is the first and leading characteristic, whether the agent, being absorbed, come in contact with the nervous system through the medium of the circulation, or by a more direct application to the nerves; and there can scarcely be a better proof of the mode in which this kind of accumulative action is produced, than the tendency of some medicinal substances, to cause paralysis and convulsions, with which, in many instandes, the sufferer is afflicted for a considerable period afterwards. In a case related by Dr. Blackall, and mentioned by Dr. Christison, a person, while taking daily two drachms of an infusion of digitals, was attacked with pain over the eyes and confusion, followed in twenty-four hours by diarrhoea, delirium, convulsions, and insensibility, with extreme depression of the pulse. The convulsions continued to recur for three weeks, with intervals of delirium, and at length he died in a convulsive fit. The accumulative action of opinm, of hyoscyamus, and of narcotics in general, may be explained upon the same principle. In shaking palsy, which, though excited by the fumes of mercury, often continues long after the individual has been removed from their influence, the ordinary symptoms indicate disturbance of the nervous system; while in most cases there is no salivation, nor are there any of those signs of dis-. ordered secretion and nutrition, which the salts of mercury commonly occasion. So likewise in paralysis from lead, the general symptoms show derangement of the nervous system, the black line along the gums merely proving that the metallic salt has been absorbed. These examples are, perhaps, sufficient for my present purpose, for, though they exhibit the poisonous effects of mercury and of lead, the principle of their accumulative action is the same as of medicines. III.-OF SLOW POISONING. Besides these which I have mentioned, there is ON THE ACCUMULATIVE ACTION OF MEDICINES. another mode of accumulative action, by which medicinal substances have acted as most deadly poisons. Amidst the various means which have been devised to take away life, it was some centuries ago discovered, that by irritating the alimentary canal, and thus disordering the digestive function, the habitual use of certain drugs, many of which are now very commonly employed in a different manner, and for a far different purpose, even in very minute doses, proved fatal. This, however, is the action of poisons, not of medicines, and therefore does not properly form a part of our present subject; but since nothing can more strikingly illustrate the power which medicinal substances may gradually acquire, I shall mention some of the most remarkable examples of slow poisoning, for reference to the greater number of which, as well as for several of the circum. stances themselves, I am much indebted to the kindness of a very able and accomplished friend. 563 received, not merely by the vulgar, but by men of the highest literary attainments in the Roman empire, affords proof that such a mode of destroying life was known and practised nearly two thousand years ago. The deleterious properties of aconite, hemlock, and the poppy, which were the poisons most commonly employed, are well known at this day; and the ingenuity of more recent times, while adding to the catalogue of poisons as well as of crimes, has sanctioned the belief of the ancients in their fatal and imperceptible influence. The instances of slow poisoning which are on record from the fifteenth to the nineteenth century, are indeed so numerous, that I can only attempt a passing allusion to some of the most remarkable of them. Of all the adepts in this horrid science, none excelled Cæsar Borgia, who was born in the latter half of the fifteenth century, and died in 1507. Endowed with talents of the highest order, which he entirely devoted to the promotion of his own selfish views, Borgia unscrupulously removed all who might be obstacles to his ambition, or even to his slightest gratifications. For this purpose he sometimes had recourse to poison which was so insidious in its operation, and so indiscriminately employed, that he became an object of terror to those whom he called his friends, as well as to his open enemies. It is said that the poisons thus used were of two kinds, the one being a solid, white, mealy sub. stance, of which the composition is unknown; the other a solution of arsenic. It was believed, in the time of the Borgias, that the latter was the saliva collected during the dying agonies of a bear, which had been poisoned with arsenic; though this is not very probable, since that poison does not require such preparation to fit it for the destruction of man. last Cæsar Borgia himself nearly fell a sacrifice to his own machinations, and his father, Alexander VI., actually died in consequence of having drunk some poisoned wine which was intended for three Cardinals who were their guests. The convulsions with which they were almost instantly seized, must, however, have been caused by a very active agent; though the subsequent painful illness of Cæsar, who swallowed an antidote, might have been the effect of a small dose of arsenic, for those who have taken it, and do not die within a few days, seldom fail to suffer from irritation of the stomach during months and even years afterwards, and may never entirely recover. At From the works of Theophrastus and of Plutarch, it would appear that slow poisoning was practised both by the Greeks and by the Romans long before the Christian æra. In some cases the nervous power was destroyed by narcotics; in others the digestion was impaired by irritating or corrosive drugs. Theophrastus, who died 288 years before Christ, says, it is asserted that a poison can be prepared from aconite so as to cause death within a few months, or even after a longer period; and that Thrasyas, of Mantinea, who seems to have been his contemporary, was acquainted with a mode of preparing other plants, so that small doses of them occasioned an easy death, though they induced no weakness for a long time after they had been taken. We are told by Plutarch, that Philip, the son of Demetrius, and king of Macedonia, wishing to put to death Aratus, of Sicyon, who was a distinguished general, desired one of his friends to administer poison, of a kind which caused lingering beat or fever, with a slight cough and spitting of blood, followed by gradual decay. This occurred about 213 years before Christ, and a few years afterwards, according to Livy, poisoning became very common at Rome. Among others, so says Tacitus, the Emperor Claudius, and his son Britannicus, were destroyed by this means. In both cases a slow poison, prepared by the infamous Locusta, and intended gradually to destroy the mental as well as physical powers, was administered, but as the patience of the murderers was exhausted before it took effect, a stronger dose was given to each of the victims, and they speedily perished. To Claudius the poison was at first The Borgias being too powerful to fear punishment, given in a dish of mushrooms, but he was at last frequently had recourse to more speedy means of killed by a poisoned feather, which was put down his removing their victims than by slow poisoning; and throat under pretence of making him vomit. Since the the most remarkable examples of this secret murder slow poison was not allowed time thoroughly to operate occurred at a later period. In the seventeenth century, on these persons, it is doubtful what its effects might slow poisoning was carried on to such an extent in have been; and many of the symptoms which are Italy, that the public attention was attracted to the described by the Greek and Roman historians, so much subject; and two women, of the names of Spara and resemble those of some ordinary diseases, that in the Tofania, have acquired especial notoriety by their absence of corroborative evidence, it might have been skill. It is generally supposed that they made use of questioned whether the animal and vegetable sub-a solution of arsenic, but the Abbé Gagliani asserts stances that were used for this purpose really possessed the properties attributed to them. The fact; however, that the doctrine of slow poisoning was generally that Aqua Toffana was a mixture of cantharides and opium, which he adds is the surest of all slow poisons, and one which no one would avoid through suspicion, |