Antimonium tartaricum; Potassio-tartarate of antimony [K(SbO), C4H4O6]2 plus (H2O). Tartar Emetic.
TARTAR EMETIC is an irritant and depressant.
Its most prominent effect is indicated by its common name. The vomiting is partly due to the primary, direct, physiochemical effect of the drug on the lining of the stomach; secondarily it is absorbed and acts upon the medulla. Through the vagus nerves its depressant effects are continued. Lastly, some of the absorbed drug is re-excreted by various mucous membranes, upon which it exercises or renews an irritating effect. For the large bowel to be affected very large doses must have been taken, as much of the poison is vomited and a good deal is stored in the liver. It has thus a long-lasting effect and compared with some other emetics it is slow in starting.
It will cause its physiological effects swallowed or injected into the blood-stream or tissues.[Hypodermic injection causes great pain and is liable to be followed by sloughing of the tissues; this may follow even intramuscular injection, although the immediate pain is less. Intravenous injection with proper precautions is the method to be used where substantial doses are required.]
The nausea-complex is widespread one. Sinking illfeeling in chest and upper abdomen, with tendency to retch; yawning; feeling by a flush of heat passing off with slight perspiration, flow of saliva, lachrymation, dull fishy eyes, headache, pale pinched features, and loathing of food are the common features of nausea, which may lead on to vomiting. In most cases if the gastric irritation is not violent, or if the nausea is reflex, these symptoms may recur in spells or waves with varying intervals before vomiting ensues.
With the nausea and vomiting of antimony the depression of forces-feeling of weakness and illness-is severe, long-lasting, and not so prone to be paroxysmal as with other drugs. It is usually associated with abdominal features (pains, sensations of a lump or of coldness), eructations, diarrhoea or inclination to stool, with or without straining. The perspiration is soon cold with pronounced pallor of face. Other features, which serve to distinguish an antimony case, are: (1) anxiety with the vomiting; (2) drowsiness with or following it; (3) the vomiting is a great effort (ars.); (4) there is desire for acids, fruit, &c. (verat. alb.), – especially for apples; (5) the pulse soon begins to be slowed; (6) surface sensitiveness, especially epigastric (in gastritis &c.).
(1) Catarrhs.-The irritation of the mucosae caused by antimony is chiefly a catarrhal inflammation. In the alimentary canal this is supplemented (from the mouth to the jejunum) by occasional pustules somewhat like those on the skin, and (lower down) by enteritis. Through these mucous membranes, amongst many, antimony is excreted, whatever the side from which it is absorbed.
(2) Respiration.-At first somewhat accelerated, soon becomes irregular, with prolonged expiration and shortened, shallow inspiration. The drug is excreted through the respiratory mucous membranes, causing a catarrh which may amount, in the smaller tubes, to capillary bronchitis, and to symptoms clinically indistinguishable from broncho-pneumonia.
The respiratory depression of medullary origin makes the local catarrh more serious, and may induce a degree of asphyxia accounting, in chest cases, for the drowsiness of the patient.
Post-mortem examination shows that after accidental and experimental poisoning, a reddened consolidated condition of parts of the lungs has been produced. This has been acknowledged in this country by Ringer, and by Nothnagel, though it is ignored by some of the more recent text-books. The evidence supporting it seems to the writers to be complete.
No obvious involvement of the pleura has been recorded.
(3) Circulation.-Tartar emetic lessens the force and the frequency of the heart’s beat, which is arrested in diastole. This is due in part to a direct paralysing action on the muscular tissue of the heart and muscular coats of the blood-vessels. The blood-pressure is lowered. In further part the circulation is depressed along with the respiration as a result of medullary influence via the vagi.
(4) nerve-tissue function is also depressed, especially the spinal cord, reflex excitability being greatly lowered through the sensory columns. Muscular action is depressed and spasm consequently lessened. Lassitude, inability for mental and physical effort, drowsiness and torpor are partly primary and central, and partly secondary to nausea and vomiting.
(5) Excretion.-Besides the gastro-intestinal and respiratory mucosae already mentioned, excretion of tartar emetic takes place by way of the skin, breasts, kidneys and bile-ducts. Of these the kidneys are the most important; diuresis, albuminuria and haematuria may be induced-in short, nephritis. On the skin it acts as a diaphoretic, and on the bronchi as an expectorant (in medicinal doses).
On the liver one of its effects is to increase the flow of bile. Long-continued dosing with the drug may induce fatty changes in the liver and arrest of its glycogenic function. Very small doses, on the other hand, increase the glycogen and fat.
The view that the increased secretion brought about by antimony is but a part of the vomiting complex is hardly tenable, for repeated small doses will induce secretion quite apart from nausea. Tartar emetic irritates the skin, producing sweat, pustules (directly and indirectly), and cracks at various orifices and in the auditory meatus. If much perspiration be induces the secretion of urine will be correspondingly lessened.
(6) Temperature.-Large doses acting through the circulatory depressor apparatus lower the body temperature, and more directly by decreasing the amount of body heat produced.
(7) chronic antimonial poisoning is not common. It resembles arsenical poisoning in some of its features, but on the whole antimony is less irritating. What symptoms develop first depends on the dose employed. In any case there is some anorexia; nausea is soon induced; if the dose is a medical one, local (gastric) symptoms are soon manifested, e.g., malaise, heaviness and pain. If the dose is too small at once to beget local symptoms, headache, languor, vertigo, bodily and mental depression, confusion of ideas, impaired vision, followed by general weakness, loss of flesh and exhaustion develop. In the former class of cases diarrhoea may ensue, with backache, albuminuria, emaciation and collapse. As already mentioned, pustulation may be caused, even where the skin is not the site of entry of the poison.
ANTIMONIUM TARTARATUM is now little used as an emetic; if required and if it be the only emetic available, the dose of the wine is from 3ij to 3iv fl. Sulphate of copper and apomorphine act more quickly (for poison cases) and are less depressing.
Although the antipathic use of tartar emetic in pneumonia is abandoned, antimony has entered a fresh field where it is proving fruitful, namely, is some of the protozoal diseases of the tropics, e.g., relapsing fever, leishmaniasis, trypanosomiasis. It is used with much success in kala-azar, giving 90 per cent. of cures, and is the standard remedy for bilharziasis (schistosomiasis), killing the parent worm as well as the eggs; in leprosy (in the form of stibacetin), in filariasis, dracontiasis, &c. The action here is uncertain. Though substantial doses seem necessary it is not certain that the result is directly parasiticidal, for in vitro the parasites remain active in a solution even stronger than can be used medicinally. The drug should be administered intravenously with the usual precautions, beginning with doses of 1/2 gr. or less, gradually increased to a maximum of 2 gr.
HOMOEOTHERAPY.- Although the name tartar emetic suggests a primary gastro-intestinal sphere for the drug, therapeutically it is more valuable elsewhere. In capillary bronchitis and in pneumonia it had a reputation even before the days of homoeopathy. its abandonment was due to the unreasonably large doses used.
In bronchitis the chief indication is the presence of catarrhal products in the tubes in excessive quantity, causing a free, frothy expectoration. In children this dangerous condition is controlled by minute doses (3x to 6x) of antim. tart., facilitating expectoration and checking the catarrh. In pneumonias also-especially lobular-when resolution is setting in and the tubes are becoming choked with a similar frothy fluid, antim. tart acts beneficially. When the conditions is well marked, the patient (especially if a child), in addition to showing the strictly pneumonic or respiratory symptoms, diagnostic of the condition, is markedly pale with a tendency to a bluish hue (passing on, if unrelieved, to cyanosis); the face is cold and clammy, the nostrils are dilated, though not necessarily active. The breathing and the cough are rattling, and the latter results in very little expectoration though the chest seems full. Old people sit up or must sit up or must sit out of bed, their dyspnoea is so bad, and though chilly they want to be fanned to get more air and are worse in a warm, close room because they feel a lack of stimulating air-they are becoming asphyxiated. If thirsty, the patient likes sour drinks, but he can only take sips. if the patient be a child he is fearful; he wants to be carried about in the upright position and not to be interfered with, e.g, by being talked to or having his pulse felt, &c.-unless drowsiness, which sets in early, is sufficiently pronounced to make him indifferent to disturbances.
The kind of subject requiring antim. tart. is usually at one of the extremes of life, with feeble circulation and poor reaction, torpid and abnormally sensitive to damp. The temperature does not run high, even in febrile ailments. The patient is chilly, and his attack is likely to have been brought on by but slight exposure to cold or damp; if an adult he has probably always been very liable to “catch cold.’ Cold, wet weather and cold bathing aggravate or bring on relapses.
Digestive symptoms are not prominent, and may be overlooked, either because the patient is too young or too ill (and drowsy0 to draw attention to them. The mouth is sticky, the tongue pale and thickly coated white. The edges and papillae may be red; or red in streaks.
The patient is not usually thirsty, or if thirsty does not like to be bothered to drink. If he wishes for drinks it is for something acid or piquant to clean the mouth or “cut the phlegm.” Nausea and prostration may co-exist; the latter may depend upon the former or they may be independent features. In any case, prostration develops early. The patient is usually averse from milk, taking which adds to the nausea and may cause vomiting. This may be a temporary relief by bringing up thick stringy mucus, but it is difficult, associated with retching and straining; even water is vomited.
The nausea of antim. tart. (not specially in respiratory disorders) is a deep deadly loathing, and persists between the efforts of vomiting; it is something like that due to tabacum. Eructations like rotten eggs, flatulence and distension are present, the abdomen feels tight and “full of stones.” Antimonium tart. has been strongly recommended in choleraic diarrhoea, but other remedies are more likely. These complete the digestive symptoms.
Headache is a not uncommon concomitant. Besides general heaviness, worse in the morning, there is a constricted feeling- like a band tied round the bead. Or the pain may be unilateral- chiefly right-sided. The pains are worse on coughing.
The eyes and nose have few characteristic symptoms-they are mainly catarrhal-mucous discharges, dim vision and loss of taste and smell with coryza. This drug is useful for phlyctenular conjunctivitis and gonorrhoeal ophthalmia.
Urinary System.-As antim. tart. can cause acute nephritis so it may be a remedy for that condition, but it is not often called for. In addition to albumin and blood in the urine, bladder symptoms will be present if this drug is indicated-urging to urinate and burning during or after micturition. The urine is dark, scanty, reddish, and strongly smelling, reminding one of benzoic and nitric acid cases.
Back.-Associated with the kidney condition just mentioned or occurring independently of it there may be violent lumbo-sacral pain, worse from moving. Movement may cause retching and faintness.
Skin.-Severe backache and a pustular eruption are outstanding features of small-pox and of antim. tart. These two, backed up by other general symptoms common to drug and disease, have caused antim. tart. to be prescribed with advantage in variola and varicella. The benefit appears to accrue in the shape of moderated severity and lessened pitting. The remedy has been used prophylactically in epidemics, but it should not be relied on if vaccination is obtainable.
Papules and pustules on face and genitals-pustular acne, for example, may be indications for the drug; also ecthymatous spots and small chronic non-specific ulcers on the legs in debilitated subjects, or after severe illnesses in old people.
Extremities.-With small warrant from the pathogenesis, antim. tart. has been recommended in affections of the joints- gonorrhoeal rheumatism or gouty arthritis, with synovial effusions, or thickening of the ligamentous (fibrous) tissues of the joints. In gouty conditions, from habitual over-consumption of beer, with consequent catarrhal dyspepsia, antim. tart. may reasonably be expected to be of use. Arthritic conditions likely to require it, whatever their pathological cause, would be aggravated by cold, wet weather, by changes of weather, and by movement. The other symptoms of the limbs indicating the remedy are either nervous-“pins and needles,” twitchings of muscles, &c.-or are part of a general condition of weakness-trembling of limbs (upper or lower), feet “going to sleep” on sitting down, fingers cold and “dead,” &c.
The drowsiness of patients needing tartar emetic may be sign of combined exhaustion and asphyxia. In this case it will often be present in pulmonary disorders with deficient aeration of the blood and is common to most cases of the kind.
Drowsiness as an indication for antim. tart. need not have such causation. It is a feature running through the pathogenesis, of value in confirming the selection of the drug. Excessive sleepiness in all diseases; falling asleep in the day; eyes too heavy to keep open-thus the symptom is graphically described. it has led to the use of antimony in sleeping sickness (with a measure of benefit), quite apart from its use intravenously as a parasiticide. There are only a few other drugs having the symptoms so markedly-the most notable is opium. That drug causes heavy sleep with a red face, except in bad cases near the end, whereas the face is pale in tartar emetic cases. Nux moschata and apis also have great drowsiness in their pathogenesy.
Mental Symptoms.-A superficial consideration of the mental condition of antim. tart. patients would suggest a contradiction therein. The real state is one of irritability and restlessness. The patient, child or adult, resents interference or disturbance of any kind-wants to be let alone, is angry or moans on examination or when fed or given medicine. Passivity and indifference are foreign to him, and if present are but evidence of great prostration or drowsy hebetude from asphyxia, advancing to coma.
Of named diseases, whooping cough, bronchitis and broncho- pneumonia in old and young, gastric catarrh (of alcoholic) and gastro-enteritis and gonorrhoeal rheumatism and variola and varicella are the most common.
In other conditions the following features (few or many of them) should be present to warrant the use of antim. tart.
(1) Prostration whether due to nausea or not.
(2) All-pervading nausea, with the characters described.
(3) Rattling breathing, with deficient expectoration and cough.
(4) Distressed (Hippocratic) anxious countenance, clammy sweat and pallor or blueness, in acute cases.
(5) Alae nasi dilated rather than flapping.
(6) Dislike of warm rooms in dyspnoea.
(7) Thirstlessness is a notable feature, even in febrile cases, but see No.8.
(8) Craving for acid drinks or fruits.
(9) Drowsiness worse in the mornings.
(10) Irritability if disturbed.
(11) Thick white coating of the tongue, with red edges and papillae.
(12) Loathing of food, even the thought of it increases the nausea and dyspnoea.
(13) Tendency to dropsical swelling of legs (and even of abdomen) after acute maladies.
General (a) in cold damp weather; (b) when lying down; (c) from movement; (d) from being carried or looked at (children).
(a) From cool air (breathing); (b) from sitting up; (c) from lying on the right side (vomiting).