Acta med. scand. Vol. 199, p. 378, 1976


Toxicology in Clinical Medicine

The present number of the Acta contains seven papers all treating toxicological topics. This seems to me a very favourable sign of interest in these important problems. We have a number of other accepted manuscripts on similar topics that will appear in the next numbers of the journal. Without any doubt such communications will become increasingly relevant in the future, when the cornucopia of potent-and therefore potentially toxic-drugs will be steadily replenished. One of the difficulties inherent in this situation is the fact that the new drugs pose new problems for the doctor. It is quite clear that we need a continuing education of the medical profession in order to get acquainted with all the side-effects. Clinical pharmacology is one of the important new subjects in the medical curriculum but doctors, who were educated before this subject was introduced, will have to follow publications in medical journals. There are several excellent presentations such as the Medical Letter, The Medical Letter Inc., 56 Hamson Street, New Rochelle, N.Y. 1081, USA. One classical textbook, that appears in new editions with regular intervals is Sven Moeschlin’s “Klinik und Therapie der Vergiftungen”, Georg Thieme Verlag, Stuttgart, 1972. In a Skandia Symposium from 1972 “Suicide and attempted suicide” many toxicological problems are also treated. Another excellent source of information that may be used in acute situations is the Poison Information Center at the Karolinska Hospital in Stockholm. There is a day and night service on the direct telephone line 90000. During the 10 years this center has been active, the number of yearly calls has increased from 6000 to 27000 showing that the institution has become very popular. For many years I have stressed the point that a syndrome never described before is very probably iatrogenic. Toxic substances may cause quite bizarre symptoms and it is always important to take a very careful history of possible previous drug intake often with a real cross examination in such patients. Many recent presentations of this subject have stressed the fact that there is too much reliance on toxicity tests in animals. They may be quite misleading in several directions. Very often the doses given are much in excess of the dosage in human medicine. This may give a large number of false positives and delay the introduction of important and possibly life-saving new drugs. On the other hand, such experiments may also give false negatives as there is a great Acta mrd. scand. 199

difference in this respect between mice and men. Keen observers at the bed-side have often made fundamental new contributions thus saving thousands of lives, when their results-often much too slowly-have been accepted by the medical community. Striking such examples may be quoted from all fields of medicine. The mortality from agranulocytosis practically went down to zero, when it was found that aminopyrine (pyramidon) and similar drugs were the cause. The nephrotoxic effect of phenacetin was established from observations on patients. Another example is the death rate in acute porphyria that has been reduced to very low values since it became known that these patients are sensitive to a number of synthetic drugs. It is frightening to realize that we still see deaths from the administration of such drugs because doctors do not care to avoid them in sensitive patients. Also the fact that so many potent drugs are resting in drawers, where they can be found and consumed in large quantities for suicidal purposes, is another important aspect of toxicology and it becomes increasingly important for the physician to realize the possibility that several drugs may be combined in suicidal attempts. This makes the pattern difficult to recognize and increases the importance of a competent biochemical analysis. A wave of criticism against modern polypharmacy is at the present moment sweeping over the Western countries. This is a sound reaction against the combination of drugs that is often seen, especially in elderly patients, and there is no question that a large number of persons in modern society live in a state of slight chronic drug poisoning. The easy availability of drugs, especially economically, has favoured this development and the fact that such patients often get prescriptions from many doctors, who do not know about each other, is another factor. It would be a sound arrangement, if the doctor discusses the whole pharmaceutical arsenal in the patient’s home before he prescribes new drugs. The old dictum “primum nil nocere” is no longer valid. If a drug in normal dosage has therapeutic effects, it is very improbable that large doses are not in some way toxic. The editors of the Acta would like to collaborate in disseminating knowledge about toxic effects of drugs and the methods to recognize them. We shall be happy to print critical papers on these subjects and invite physicians to publish. Jan G . Waldenstrom

Editorial: Toxicology in clinical medicine.

Acta med. scand. Vol. 199, p. 378, 1976 EDITORIAL Toxicology in Clinical Medicine The present number of the Acta contains seven papers all treating...
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