Book. -F*/£ ! m. COPYRIGHT DEPOSm Elements of Active - Principle Therapeutics By J. M. FRENCH, M. D. I CHICAGO THE ABBOTT PRESS 1916 n ft* Copyright The Abbott Pres* 1916 &CtA43727i To Dr. Robert Gray By birth a Southern gentleman, by edu- cation a Parisian scholar, in early life a surgeon in the Confederate army, and now for many years a successful physician in tropical Mexico; whose successful applica- tion and enthusiastic advocacy of active- principle therapy has won him favorable recognition in many lands; to whom the writer is indebted for many personal and professional favors, and for whom, though never having seen him, he yet entertains a warm personal regard, this little volume is affectionately inscribed. INDEX PAGE The Development of Active-Principle Therapeutics . . 1 The Fundamental Laws of Active-Principle Thera- peutics 15 The Minor Peculiarities of Active-Principle Thera- peutics 33 The Materia Medica of Active-Principle Thera- peutics 49 The Active-Principle Treatment of Pneumonia 65 The Treatment of Typhoid Fever 79 The Treatment of Acute Infections 97 The Management of Chronic Maladies 113 PREFACE Nothing has ever been written — or at least nothing has ever come to my notice — which has seemed to me equal, as an introduction to the use of the active principles ac- cording to the method of the immortal Burggreave, to the first edition of Dr. Shaller's "Guide to Alkaloidal (Dosimetric) Medication." Especially did this work meet the wants of the times in which it was written, when the method described was a new one, and the physicians into whose hands the work might fall, needed to be enticed into the use of the new forms and ways by the skill of a master not only of medicine but of language. But now that the dosimetric method has been modi- fied, naturalized, and re-named, as a result of its intro- duction into and popularization in America by Dr. Abbott and his ever-increasing band of fellow workers, it seems desirable to have a re-statement of the old truths in the new forms. It is this which is attempted in the little work which is here presented — which is, in- deed, but a primer of its subject, and aims only to state the fundamentals of active-principle therapy as clearly, as definitely, and as briefly, as lies in the power of its author. John Marshall French, M. D. Milford, iMass., March, 1916. Elements of Active-Principle Therapeutics CHAPTER I The Development of Active-Principle Therapeutics \\T HEN I was a student in Dartmouth Medical ^ School, one of the professors told us a little story one afternoon, to while away an otherwise dull hour, which made so deep an impression on my mind that I have never forgotten it. It was the story of a young man who had been suffer- ing for a long time from some obscure disease and was steadily growing worse, while the attending physician gave little hope of his recovery. Finally, as a last re- sort, and at the request of the patient's father, a con- sultation was held, six of the ablest physicians in the vicinity being summoned to examine the sick man and consider what could be done for him. The doctors met, and each one made a thorough study of the patient and his symptoms, after which they retired to a private room for consultation. Meanwhile the anxious father, deter- mined to know the opinion of the consultants at first hand, and not as it might be doctored up and given out in the interests of the attending physician, had secreted himself in a closet in the room where the physicians were to meet and listened intently to the discussion which took place. One by one, beginning with the eldest and coming down to the youngest, as is duly provided by the code of ethics, these wise and scientific men delivered themselves each of his own opinion as to the diagnosis and pathology of this baffling case and each offered the best explana- tion he could present of the obscure and unusual symp- toms from which the patient was suffering. 2 ACTIVE-PRINCIPLE THERAPEUTICS The Thing of Most Interest— The Curo. Finally, when all the older men had spoken, it came the turn of the youngest and last of the six. ' ' Gentlemen, ' ' he began, "we have spent all our time thus far in con- sidering the nature of the disease from which this man is suffering. The thing which interests me most is, what will cure him." In the closet the listening father in his heart ap- plauded and quickly registered the vow, "This is the doctor that shall treat my son." So it is that men seek a physician to be cured of their diseases or be relieved of their pains; and he is a poor doctor, from their standpoint at least, who can not grant them the one boon or the other. To the physician the diagnosis is important and the pathology is essential; but to the poor victim and his friends the cure is every- thing. To the men and women who- employ us, who pay our bills and furnish us a living, we are simply doctors, and not scientific men ; curers, and not preventers of dis- ease. From their point of view, the doctor who, when called to attend a sick man, tells him at the outset that his disease is self -limited and must run its course, that it can not be aborted, cut short or modified in any way by medical treatment, is not worthy of the name of physician and has no excuse for pretending to treat the sick. And, frankly, when you come to think about it, how would you like that kind of a doctor to treat you when you are sick ? When that time comes, you will be likely to feel that the real business of a doctor is to cure you ; and if he does not know how, then his business is to find out how. You will be apt to realize then that the diag- nosis and pathology of disease are merely preliminaries to the all-important business of treating, and, if possi- ble, curing the sick person. ACTIVE-PRINCIPLE THERAPEUTICS 3 My good friend, your dean, suggested to me some months ago that he would like to have me give a few talks on some practical subject to the students of this college. When in response I proposed to talk to you about active-principle medication — than which I know of no more practical subject in medicine — he expressed a fear lest I might find it difficult to interest you in such a subject. I confess that I was somewhat surprised at this reply ; for I am unable to understand how it can be possible that you, who have undertaken to fit yourselves to prac- tice medicine, could fail to take a lively interest in the most important part of the curriculum, the treatment of disease. Surely, this can not be true — it is unthink- able. There are only two explanations which occur to me, .and the first is that my friend himself is not con- vinced of the practicability and superiority of the meth- ods which I shall advocate ; but from my long acquaint- ance with him I can not believe that such is the case. There remains only the alternative that the Doctor fears I may not be able to put the matter in such a way as to make it clear, and plain, and attractive to you. Well, that is up to me — and to you, to decide. Active-Principle Medication Not a "New System" Active-principle medication (which is also known as dosimetry, alkalometry, alkaloidal medication, active- principle therapeutics, and by various other names) is not, and does not claim to be a new system of medicine, but only a new method of employing drugs; and I be- lieve, and shall endeavor to convince you, that it is at once the most potent, the safest, the most convenient, and in every way the most satisfactory — both to patient and physician — of all known ways of using drugs for the cure of the sick. 4 ACTIVE-PRINCIPLE THERAPEUTICS It is. in no sense a school or a sect, and must not be so understood. Active-principle medication stands for therapeutic optimism, as opposed to the prevalent therapeutic nihil- ism of the day. The active-principle physician is a man who believes he can do things. He believes that remedial agents, when properly administered, positively do exert a favorable influence upon the course and termination of disease-processes. And not only does he hold this as an abstract truth, but he confidently affirms, as to a large class of cases, that he has found the drugs that will do the work, and has learned how and when to ad- minister them so as to obtain the desired result; while, as to the remainder, he is searching diligently for the means required, and confidently looks, day by day, for their discovery. There has been great progress in all departments of medicine during the last quarter of a. century, and not the least in the department of therapeutics. The change has included the forms of the medicines used, the meth- ods in which they are administered, and the indications for which they are employed. When I began to visit patients with my preceptor, he used to carry a big black trunk filled with nauseous pills and powders and liquid abominations. Today I can carry more kinds of drugs (and do vastly better work for my patients) in a pocket-case of 2-dram vials filled with clean, neat-looking granules or tablets. My preceptor gave saltpeter and "spirits of niter" to lower the temperature in typhoid fever, with pow- dered opium to lock up the secretions and relieve the pain, and brandy or whisky to start up the flagging pulse. I, today, go about it in a very different way. He did not care to begin the treatment until the symp- toms were well marked and the diagnosis evident. I want to see my patient at the earliest possible moment, ACTIVE-PRINCIPLE THERAPEUTICS 5 before I or anybody else can tell what is the nature of the fever from which he is suffering. His endeavor was to conduct the sick man safely through the various phases of the dreaded disease, and save his life by heroic measures, at the last, if necessary. My aim is to save him serious illness, if possible — and, if I can do it without permitting the development of symp- toms enough to warrant a definite diagnosis, I am so much the better pleased ; and so is the patient. A Mighty Progress: The Active-Principle Materia Medica Now, I do not mean to intimate that all the progress in therapeutics has been in the direction of the active principles, for that would be absurd. We have the syn- thetics, and the animal extracts, and the serums and antitoxins, electrotherapeutics, spondylotherapy, and other forms of physical therapy and many things equally important; and no one treats diseases as they were treated forty years ago. But it is my desire to interest you in the use of the active principles after the manner of Burggraeve and Abbott, and their followers. It was one of Boston's honored pharmacists, Mr. F. A. Davidson, president of the Theodore Metcalf Com- pany, who, on one occasion, said in the local medical society, of which I am a member, that the alkaloidal granule represented the highest development of the art of the pharmacist. And it was another of the most prominent pharmacists of the country, Mr. J. K. Lilly, of Indianapolis, president of the firm of Eli Lilly & Co., who in, a recent article in TJie Pharmaceutical Era upon the development of American pharmacy, after describ- ing some of the improvements which have already been made and still remain to be made in pharmacy and therapeutics, adds: "We further predict that even more radical changes will occur in the next quarter century ; that all the 6 ACTIVE-PRINCIPLE THERAPEUTICS progress of the one just closing will be as child's play compared to that which will be experienced between 1912 and 1937. Crude drugs will gradually disappear, to be replaced by active principles, synthetic products, and biologies. The practice of injecting intramuscu- larly and intravenously will increase. Punishing the stomach with large, frequent, and nauseous doses is bound to give way where possible to more refined and direct methods. Medicine will become less and less em- pirical, and more and more rigid demands will be made upon the manufacturer. We are profoundly convinced that these demands will be fully met. ' ' The Development of the New System Let me now sketch for you in brief outline the de- velopment of this new system, which can be traced in three successive steps, the first of which made the sys- tem possible, the second made it an accomplished fact, while the third made it an indispensable necessity to every progressive physician. The initial step consisted in the discovery of the alka- loids and other active principles of medicinal plants, thereby providing the necessary material. The first of the alkaloids to be brought to the knowl- edge of the medical profession was morphine, which was isolated and described by the apothecary Sertuerner, in the year 1816. Within the next sixteen years, strych- nine, brucine, quinine, eiiichoiiiiie, narcotine, codeine, vera.trine, coniine (or cicutine), atropine, nicotine, acon- itine, and hyoscyamine were discovered by different chemists, so that by the end of the first third of the nine- teenth century no less than thirteen alkaloids were known and prescribed by physicians. Since then numer- ous additions have been made to the list of active prin- ciples, which includes not only the alkaloids proper, but many rosins and gluoosidos, besides some misccllaneons ACTIVE-PRINCIPLE THERAPEUTICS 7 principles, and concentrations sufficiently potent to al- low them to be classed either as active principles or with them. Many of the latter class of remedies were up to a re- cent date manufactured by B. Keith & Co:, of New York, and by Lloyd Brothers, of Cincinnati. They were for a time enthusiastically advocated and largely em- ployed by the eclectics ; but most of these so-called resin- oids were later discarded by them, as a, school, in favor of what are called the "specific medicines" that were first introduced by Dr. Scudder, and afterward man- ufactured by the Lloyds and by Merrell. At present, along with these active vegetable derivatives — not, in- deed, similar to them in derivation, but similar in use — are included a considerable number of the more potent chemical synthetic and inorganic substances, which are largely used by the active-principle therapists. The Principle of Dosimetry: Minute, Frequent Dosage The second step in the development of active-principle therapeutics consisted in the establishment of certain general principles governing the use of the active prin- ciples as to methods, indications, and dosage, for the purpose of accomplishing certain definite therapeutic re- sults. This revolutionary step was brought about by the master-mind of Burggraeve, of Belgium, who conceived and elaborated the method which he named dosimetry. Dr. Burggraeve had seen the defects of the old sys- tems ,of therapeutics, in which the natural drugs were the sole medicinal resources of the doctor. These were administered mostly in their crude form or in the shape of voluminous mixtures, and were inconvenient to carry, unpleasant to take, very uncertain as to action, and de- cidedly unsatisfactory in their results. From such a combination eventually, and inevitably, there came into 8 ACTIVE-PRINCIPLE THERAPEUTICS being, on the one hand bald therapeutic nihilism and, on the other hand, blind faith in the various forms of sug- gestion. Adolph Burggraeve was born in Ghent, Belgium, in the year 1806. He died in 1902, after nearly a century of life spent in his chosen profession, the later years of his active life having been devoted to the development of the system of therapeutics, which is his masterpiece. He became professor of anatomy, and later of clinical sur- gery, in the University of Ghent ; also he was a member of the Royal Academy of Brussels. It was at the latter institution that he conceived and elaborated the system of dosimetric medication — an enduring foundation upon which his fame will ever rest. The Principles of Dosimetry, According to Burggraeve As stated by Burggraeve, dosimetric medicine rests essentially upon its power to jugidate those fevers in ivMcJi all acute maladies have their commencement. Its great end is to prevent anatomo-pathologic (this is Burg- graeve 's own wording) lesions, for these once established are above the resources of art. The study of morbid causes he declares to be indis- pensable, since without it medicine is little more than empirical. The dosimetric medicaments are simple,, never composite or amalgamated. The "dominant" treatment, as it is known in dosimetric practice, consists in attacking the morbid cause. The "variant" treat- ment is applied to those symptoms through which the diseased organism makes known its sufferings. To acute maladies, dosimetry opposes a sharp and ac- tive treatment, while chronic maladies are combated by more deliberate methods of treatment, That is to say, in acute maladies the treatment must proceed as rapidly as the disease, in order to prevent organic disturbances; ACTIVE-PRINCIPLE THERAPEUTICS 9 but in chronic maladies the treatment should proceed slowly, in proportion to the lengthened duration of the disease. The medicaments most commonly administered are the single, proximate principles, such as the alkaloids, which are given in divided doses, usually in the form of soluble granules. These are, in substance, the words of Burggraeve him- self and may be taken to represent accurately the spirit of dosimetric medicine as understood by its founder. It is worthy of note that he gives the place of first impor- tance to the object to be accomplished, and the second only to the medicaments to be prescribed. Although Burggraeve was able to show remarkable re- sults in the treatment of disease by his new method, yet he did not succeed in securing its adoption to any con- siderable extent, until after he had interested Chantaud, a noted pharmacist of Paris, in his undertaking, and formed an alliance with him, according to which the lat- ter thereafter devoted his great skill to the manufacture, of the highest grade of alkaloidal granules that had ever been produced, and in this way became the practical co- worker with Burggraeve in building up his new therapy. From this time on the dosimetric treatment of Burg- graeve spread rapidly, and especially did it begin to flourish in Belgium, France, Spain, Portugal, Italy, Hol- land, and Denmark. The next step in the evolution of modern active-prin- ciple medication consisted in certain modifications of the original system of dosimetry, and the broadening of its scope and methods, attendant upon its introduction into America. One of the first men in this country to become in- terested in the new system was Dr. W. T. Thackeray, who purchased an outfit for the manufacture of alka- loidal granules from Dr. Chartier, of Paris, and en- 10 ACTIVE-PRINCIPLE THERAPEUTICS deavored to persuade Messrs. Parke, Davis & Co., in whose employ he was, to engage in the business of man- ufacturing them. The firm,, however, declined to under- take it, considering the commercial difficulties in their introduction too great. Thereupon Dr. Thackeray him- self formed a company for the manufacture of the gran- ules, and started and issued a few numbers of a journal, which he called The Alkaloidal Clinic, devoted to the advocacy of dosimetric medication. However, he did not succeed in making a success of either branch of the undertaking, and the enterprise soon ended in failure. Abbott and Waugh Enter the Lists Not long after this, Dr. Wallace C. Abbott, then a young doctor from Vermont, who had been graduated from the Medical Department of the University of Mich- igan, and had located in the suburb of Ravenswood, of Chicago, who happened to have been for some time in- terested in the teachings of Burggraeve, began in a small way the manufacture of alkaloidal granules, in order to supply himself and also the friends whom he had inter- ested in this subject; and, in 1894, he began the issue of a new Alkaloidal Clinic. Dr. Abbott was a man of unbounded energy and de- termination, and his enthusiasm proved contagious and caused the alkaloidal idea to spread rapidly. I myself am one of those whom he interested early; and in my library I have preserved not only the first issue of Tlic Alkaloidal Clinic, but nearly every number that has fol- lowed. From that time onward, his has been the central figure in the propaganda for active-principle therapy in America, and his aphorism, "The smallest possible quantity of the best obtainable means to produce a de- sired therapeutic result," has been the slogan for rally- ing its forces to the battle. ACTIVE-PRINCIPLE THERAPEUTICS 11 Soon Dr. Abbott associated with himself Dr. William F. Waugh, an accomplished scholar, a successful physi- cian and medical teacher, and a versatile and forceful writer, and who has since then shared in the work of editing The Alkaloidal Clinic — the name of which later was changed to The American Journal of Clinical Medi- cine as the scope of the work was broadened. These two active and brilliant men were for a time also as- sociated in the manufacture of all the medicaments em- ployed in alkaloidal therapy, so called; a designation, however, which in the course of years grew much broader than the term would indicate, until it has finally come to include many remedies besides the alkaloids. The present status of the method may best be stated in the language of Dr. Abbott himself, who very properly may be called the father of American active-principle medication, as Burggraeve was the originator of the earlier form of dosimetry. These are the leading prin- ciples governing the newer, more positive, more definite way of combating disease: The Principles Governing Active-Principle Therapeutics "1. The administration of small doses of the most active and potent known remedies at short intervals, until either remedial effect or signs of drug-sufficiency, i. e., the full physiological effect, are secured. "2. The administration of such doses in the form of soluble granules or tablets each of which contains a defi- nite amount of the drug. "3.' The additional use of such solvents, eliminants, vital incitants, and local and systemic antiseptics as have proven of remedial value. "4. The use of any and all remedial agents in the most concentrated form available that will produce defi- nite results in recognized conditions. 12 ACTIVE-PRINCIPLE THERAPEUTICS "5. The avoidance of promiscuous combinations, problematical remedies, crude drugs, and nauseous, changeable alcoholic tinctures and fluid extracts when the active (remedial) principle of the drug can be ob- tained in its purity and given in effective, well-estab- lished doses." Many other honored names have been associated with those of Abbott and Waugh in the building of active- principle therapy in America — a structure which is still in the process of making. Among them are those of John M. Shaller, the author of the best manual of alka- loidal medication for beginners; E. M. Epstein, who may be termed the scholar of the method ; Coleman, the per- sistent advocate of systemic antisepsis in the prevention and treatment of the contagious fevers; Alfred S. Bur- dick, the present managing editor of Clinical Medicine ; and George F. Butler. Many more names might be mentioned, in fact one hardly knows where to stop. As to the present status of active-principle medication, it can be said that many thousand physicians are using the methods and medicaments referred to in their daily practice to a greater or less degree, and their number is each year increasing. Enthusiasm and optimism are the characteristics of these men as a class. They claim that they are better physicians because of the teachings of Burggraeve and his successors; that the principles and methods of dosimetry have enabled them to meet disease with greater confidence, and overcome its manifestations with greater certainty, than the}' were able to do with the old galenic methods. One of my own most intimate friends, the physician through whom I got my first introduction to this newer and better method, assures me that under the uncertain- ties of the old system of medication he had lost all en- thusiasm and nearly all interest in the practice of medi- cine, and was seriously contemplating changing his occu- ACTIVE-PRINCIPLE THERAPEUTICS 13 pation, when, thanks to Doctor Abbott and The Alka- loidal Clinic, he was ushered into a new world in his profession, given a new confidence in his ability to help the suffering, and filled with a new enthusiasm in the practice of medicine. And I can confidently affirm, from my own knowledge of this physician, that this op- timism has never left him, but that he is today a broad- minded, well-balanced, optimistic, and successful prac- titioner, a man who believes in himself and in his power to relieve suffering and to prevent and cure disease — and these are the things which every doctor needs to be- lieve and do. CHAPTER II The Fundamental Laws of Active-Principle Thera- peutics LAST week I described to you the origin and growth of active-principle medication in Europe and America. Today I desire to call your attention to the fundamental laws, general principles, or elementary teachings, upon which this method of therapeutics is based. According to my conception, these are three in num- ber, and these three embrace all the things which are strictly essential to the method, although many other and less important peculiarities and practices have grown up around them, and of these I shall speak in my next lecture. The Use of the Active Principles. The first law teaches the use of the active principles in the treatment of disease. The term "active principles," as here employed, is interpreted to include not only the alkaloids proper, but also many glucosides, resins, camphors, neutral prin- ciples, resinoids (so called), and concentrations of vege- table drugs, together with such definite chemical com- pounds as are sufficiently potent to produce positive re- sults in minute doses, and of sufficient medicinal virtue to render them desirable additions to the physician's armamentarium. This law has usually been considered not only as the first, but the most important of the three. The follow- ers of active-principle medication are ever ready to put it to the front, and defend it as the cardinal principle of their faith and practice. If you ask them for their rea- sons, they will point you to the acknowledged facts that 16 ACTIVE-PRINCIPLE THERAPEUTICS quinine is more active than Peruvian bark, atropine more positive in its effects than belladonna, morphine more definite and certain in its results than opium, pilocarpine more uniform in its effects than jaborandi, strychnine more efficient than nux vomica, and, in general, every active principle more potent, more uniform, and more reliable than the crude drug from which it is derived, or its galenic preparation. This being the case, he holds that it is manifestly bet- ter to employ these active principles and reject the bulky residue, the inert matter, the unknown and unre- liable substances whose effects cannot be predicted with any degree of certainty. For why should any part of a plant or of an animal or mineral substance which is not active be used in medicine ? Instead of choosing his rem- edies for their bulk, and possibly for their disagreeable qualities, as was apparently in some instances the cus- tom in olden times, he seeks for "the smallest possible quantity of the best obtainable means to secure a desired therapeutic result/ ' Arguments in Favor of Active Principles If we analyze the arguments in favor of the active principles, we shall find that they can be separated into three classes. First, because, as compared with the crude drugs and their galenic preparations, they are condensed in form, minute in dose, and positive in results; containing only the active remedial principle of the drugs which they represent, and rejecting the inert material. Secondly, because they are uniform in composition, containing, as a rule, but a single therapeutic principle, and therefore always to be be relied upon as producing the same remedial effect; whereas the crude drug may contain several unlike and even opposite principles, and FUNDAMENTAL LAWS 17 these may occur in different proportions in different specimens of the drug, so that one sample of a galenic may be much stronger than another which was prepared from the same formula, and different samples similarly labeled may produce entirely different and even con- flicting results. Recent analyses of standard tinctures on sale in the different drug stores of the same cities have shown a wide variation in strength, although all were supposed to contain the same percentage of the drug. The drug-strength of a plant is affected by the char- acter of the soil, the amount of sunshine, the tempera- ture, and many other conditions of environment. And these may change, not only the total amount of active principles in a plant, but the relative proportions of the different principles in the same plant. A good illustration of this fact is found in jaborandi, which contains two active principles, pilocarpine and jaborine, the one of which is the most potent of all our diaphoretics, while the other is the exact opposite, its effect being allied to that of atropine, drying up all the secretions. While under ordinary conditions the amount of jaborine is comparatively minute, and the drug jabor- andi is given to promote the secretions, cases have act- ually occurred where it has been found to produce the opposite and undesired effect of drying up the secre- tions. But, if pilocarpine is used instead of jaborandi, no such effect is possible. Keeping Qualities of These Drugs Thirdly, they are convenient to carry, taking up but little space, and having excellent keeping qualities. These qualities render them of especial value to the country doctor who is far from his base of supplies. Dr. Robert Gray, of Pichucalco, Chiapas, Mexico, an Ameri- can physician, who has practiced in the most unhealthy 18 ACTIVE-PRINCIPLE THERAPEUTICS belt on the continent, most of the time since the close of the Civil War, writes as follows of his own experience. "I carry one hundred and fifty-six active principles, weighing less than five pounds with case, the equivalent of which in galenic forms would load two mules. I am never ambushed by the enemy when suddenly confronted by some desperate emergency, no matter what the disease or the complications may be. I have the antidote while the time for medication still remains, and do not have to send prescriptions to a. distant drug store for uncertain remedies, a makeshif e often fatal to an imperiled life. ' ' As for the keeping qualities of the active-principle medicaments, they are due in part to the chemical quali- ties of the alkaloids themselves and in part to the man- ner in which they are held together in the standard granule, which is Well known to preserve the medica- ments much better, than any kind of coating that can be applied to a pill or a tablet. This is well seen in the case of calcium sulphide, a drug that is almost certain to de- teriorate by keeping when prepared in the ordinary tab- let or pill form. Here the superiority of the standard granules over the other preparations is very marked. While we believe in the superiority of the active prin- ciples, as a general rule, cases no doubt are encountered in which better results can be obtained from crude drugs and their galenical preparations, as well as from the coal- tar preparations and other chemical products. When this is so, they should be used without hesitation. In the words of Shaller, who is one of the first authorities on active-principle medication in America, "Any remedy that is good and that cures is used, no matter what its source or by what school it has been first advocated." The greatest need of the doctor is, not the active prin- ciples, but definite therapeutics, no matter whether it be in the direction of galenic medication, biochemistry, spe- cific medication, serum treatment, or glandular therapy. FUNDAMENTAL LAWS 19 Small Doses Frequently Repeated The second law teaches the administration of these remedies in minimum doses frequently repeated, until improvement is manifested or physiologic effects are pro- duced. This is known as the intensive method of dosage, or dosage for effect. I have said that the use of the active principles looms highest in popular estimation of all the characteristics of this method. But, if this were the only factor, it could never rise to the dignity of a system of therapeutics or even a method of administering drugs. The first law de- termines the tools to be used, the second explains the manner in which they should be used. The matter of dosage is one of the first importance to the physician. In the system in common use — which we may term massive dosage — there is a maximum and a minimum dose laid down, and these must be learned arbitrarily for each drug and every preparation. Very likely there may also be an average dose given, which is supposed to be the one most commonly used ; yet, if the doctor keeps within the limits of the maximum and the minimum dose, it is assumed that he is on the safe side and cannot be blamed, whether he fails to benefit the patient on the one hand or happens to kill him on the other — for has he not followed the dictum of the authori- ties and given the proper dose? Like the spelling book, the dose book usually takes up a good share of the student's time when in school, and like it, -again, is promptly laid on the shelf when school days are over. Of my two teachers of materia medica when I was in the medical school, from one of them I do not remember that I ever learned much of anything ex- cept doses — and I promptly forgot these as soon as I had passed my examinations. With many remedies, when a maximum dose is given, 20 ACTIVE-PRINCIPLE THERAPEUTICS it is supposed to produce the full effect of the drug, and a second is not to be given until the first is eliminated from the system. But whether or not it really does pro- duce the anticipated effect upon the system, depends upon so many factors that no one can foresee what the result really will be. If the patient is sensitive to the action of this particu- lar drug, he may be overwhelmed by a dose that would produce no noticeable effect upon another person, even though the two might seem to be counterparts. On the other hand, we often meet . with patients who are not easily affected by drugs of any kind, and hence require very large doses in order to secure results. How is the doctor to decide in the case of a new pa- tient whether the dose which he has administered will prove a poisonous one or will fail to produce any notice- able effect, either therapeutic or physiologic? This Method of Dosage Overcomes a Defect The defects of this system of dosage are frankly ad- mitted by our best therapeutists. Potter, in his excellent "Materia Medica, Pharmacy, and Therapeutics," says: "The dosage of medicine is the weakest part of the therapeutic armament, the flaw in our weapons which may be the cause of their failure at any moment, per- haps the most critical one for a life. If the accumulated rubbish of ages, which has been called therapeutic knowledge, is ever to be given scientific shape or placed in the process of becoming a science, the question of dosage must form one of the principal corner-stones in the foundation. ' ' Now, it is this weak spot which active-principle therapy has undertaken to strengthen, this chief corner- stone which it has set out to put in its proper place in the temple of scientific medicine. Already, in the process FUNDAMENTAL LAWS 21 of evolution, in the attempt to build our fragmentary therapeutic knowledge into a science, there has been for- mulated by the master-mind of Burggraeve and elabor- ated by the dosimetrists of Europe and their disciples in America, a system of dosage which avoids all the dan- gers mentioned and at the same time meets the require- ments of safety, accuracy, and convenience. This, as already mentioned, we call the intensive method, and its fundamental principle is dosage for effect. By this method, a minimum dose is given at the outset, and this is repeated at frequent intervals until the characteristic effect of the drug is secured, either therapeutic or physiologic; and then less frequently as long as it is desirable to maintain the effect. Granules of Minimum Dosage Employed As a matter of convenience, the medicaments used are nearly all prepared in granules of minimum dosage, so that the labor of learning the doses is entirely obviated, as the doctor never undertakes to put up his own gran- ules. This system is especially adapted to the more pow- erful drugs of whatever nature, which are the very ones that by the common method give rise to the most anxiety, lest ill results should follow their use in maximum dos- age, or no results be evident from their infrequent ex- hibition in minimum dosage. For example : If the doctor wishes to give aconitine in a case of fever, he gives one granule, preferably in solu- tion, every fifteen to sixty minutes, according to the in- tensity aconitine, veratrine, digitalin, strychnine — are the great active-principle remedies for fever. Singly or combined they meet most of the indi- cations, and do it with an ease and certainty not other- wise obtainable. To accomplish this more perfectly, two combinations have been added. The Defervescent Combinations The first of these is known as — The Dosimetric Trinity. The formula of this combi- nation is: crystalline aconitine, 1-800 grain; digitalin, 1-64 grain; strychnine arsenate, 1-128 grain. 54 ACTIVE-PRINCIPLE THERAPEUTICS The second of these is called — The Defervescent Compound, and its formula is: crystalline aconitine, 1-800 grain; veratrine hydro- chloride, 1-128 grain; digitalin, 1-64 grain. By the action of the dosimetric trinity, the heart is sustained and the nervous system toned up. I know it often is taught — and presumably you have been so taught — that tonics for the heart and nervous system should never be given in fever until there are evident manifestations of failure of these organs. That is to say, digitalis should not be given until there are signs of heart failure ; strychnine not until vital prostration su- pervenes. This seems to me like saying that a man should not go to work to earn any money until his means are entirely exhausted, or as if a doctor were to advocate going without food until serious weakness had set in. Let us take a case of serious febrile disease, pneumonia for example. If we know anything of the natural history of this disease, we know that its usual course is to go on until the vital forces are prostrated, and that the especial danger to be expected is from weakness of the heart, Is it, then, the wise course to employ no measures to guard against or to prevent this condition? Shaller, speaking of strychnine, says: "All schools of physicians use but one medicine to stimulate paralyzed nerves and to restore paralyzed muscles, and that medi- cine is strychnine. There is no other medicine but strychnine that can so effectually stimulate the vital functions and arouse nerve-force. If strychnine is a proper remedy to use to cure paralysis, it is also a proper remedy to use to prevent paralysis." The same or a similar argument may be advanced with reference to digitalin. Both these remedies many times are given in conditions of comparative health, and are considered the best tonics we possess for their respective purposes. Given, then, a fever which, if unchecked, is sure to produce the conditions calling for strychnine and digi- MATERIA MEDICA 55 talin, it seems to me that it is the part of wisdom to use them in minimum doses before the danger is imminent, and thereby prevent in many instances the urgent de- mand otherwise evidenced later in the disease. In the treatment of fever, then, the remedies at our command will be utilized in the various conditions some- what as follows: In the early stages of fevers not of a sthenic type, give aconitine; if markedly sthenic, veratrine; if the fever is high, the pulse full and bounding, and the patient a vigorous adult, the defervescent compound ; if the con- ditions are asthenic, and the patient not vigorous, or in any case where there is reason to anticipate heart weak- ness, and always in old persons, the trinity granule. As the fever progresses, change from the one to the other as conditions may indicate. And remember, that you do not need to wait for the diagnosis of typhoid fever or scarlet-fever or pneumonia before beginning this, the essential, treatment of the febrile process. A definite diagnosis, as it shows addi- tional symptoms and conditions, will call for additional remedies; but the essential fever is the same in all and requires the same treatment. Two Valuable Expectorants Apomorphine and Emetine, as expectorants and emetics, each with special indications for its use. As an emetic, apomorphine is best given hypodermical- ly, in doses of 1-16 to 1-10 grain. As an expectorant, it is specially indicated where the sputum is thick, viscid, and tenacious, when it may be given every fifteen min- utes until relief or nausea. It is well to bear in mind that apomorphine gradually turns to a light-green color this gradually deepening to a dark green, this being hastened when it is exposed to the air. This discoloration may be prevented by the 56 ACTIVE-PRINCIPLE THERAPEUTICS addition of a few drops of vinegar to the solution ; still, there is no evidence that the medicinal properties of the drug are at all affected. Emetine possesses to a certain extent the properties of ipecac, but is less irritating and causes less dis- turbance of the digestive tract. It is seldom used as an emetic. As an expectorant, it is indicated by deficient bronchial secretion, with tough and adherent sputum, and a dry, harsh cough. Emetine frequently is combined with apomorphine, and to these two may be added codeine, in similar dosage, more especially when there is an irritative cough. This makes one of the most effective and re- liable cough remedies of which I have knowledge, and it can be prepared in a few minutes at the bedside. A Group of Useful Laxatives Aloin, Calomel, and Podophyllin, to increase the se- cretions of the various portions of the intestinal tract. Standard granules: aloin, 1-12 grain and 1-6 grain; calomel (usually given in tablet form), 1-10 grain; podophyllin, 1-64, 1-12 and 1-6 grain. Saline Laxative, as a laxative and cathartic of al- most universal applicability. A granular effervescent preparation of sulphate of magnesium. An indispens- able aid in "cleaning out, cleaning up, and keeping clean" the intestinal canal. SalitMa, same as the above with the addition of one grain of lithium carbonate and 1-250 grain of colchicine to each 90 grains or full dose of the finished product. This is especially desirable in conditions showing the ' ' uric acid diathesis, ' ' and wherever a diuretic action is desired. Anticoiistipation (Waugh) is another compound granule of great efficacy in all forms of chronic consti- pation. Formula : MATERIA MEDICA 57 Aloin, gr. 1-25; strychnine sulphate, gr. 1-500; atro- pine sulphate, gr. 1-2500 ; capsicum oleoresin, gr. 1-500 ; emetoid, gr. 1-500 ; bilein, gr. 1-250. Should be given in sufficient number (three to six or more) three times a day before meals to produce one daily stool, continuing steadily and reducing very gradually as curative results are secured. Atropine, Hyoscy amine, and Hyoscine Hydrobromide, to combat spasm and to allay irritability. Standard granules: atropine, 1-500 grain and 1-250 grain; hyoscyamine sulphate, 1-1000 grain; hyoscine hydro- bromide, 1-1000 grain. All these belong to the mydri- atic group. Atropine is a cardiac and respiratory stimulant, re- laxing the minute capillaries and sending the blood to the surface. Hyoscyamine is mildly hypnotic and seda- tive. Hyoscine is more powerfully sedative and hypnot- ic, and is indicated in all motor excitation. Berberine and Quassin, as simple bitters of general applicability. Standard granules : berberine, 1-64 grain and 1-6 grain ; quassin, 1-64 grain. Berberine is the most, widely distributed bitter princi- ple in the plant-world. In addition to its valuable properties as a stomachic tonic, it possesses the property of constringing connective tissue, this rendering it of ex- ceptional value in all relaxed and catarrhal conditions of mucous membranes. Quassin is one of our best sto- machic tonics. Agaracin, grains 1-12 and 1-2, to arrest perspiration. Our best agent in night-sweats. Anemonin, grain 1-128, a camphor from anemone Pul- satilla, has a special action on the generative function in women, producing an increased menstrual flow when used near the menstrual period. Anodyne for Infants (Waugh) is used in the pain 58 ACTIVE-PRINCIPLE THERAPEUTICS and restlessness due to indigestion, teething, and other causes. As a remedy in diseases of children, it has a wide range of uses, and is one of the most popular of the compound granules. The formula is: Nickel bromide, gr. 1-128 ; codeine sulphate, gr. 1-64 ; emetine hydrochloride gr. 1-5000 ; lithium carbonate, gr. 1-16 ; oil of anise, q. s. Cactoid, a concentration from cactus grandinorus, as a valuable heart tonic. While of proven efficacy, cactus in medicinal dosage is without appreciable physiologic action, and for that reason condemned by so-called au- thorities. Cactoid is especially indicated in irregular pulse and nervous conditions of the heart. Standard granules, 1-128 grain and 1-64 grain. Caffeine, as an unequaled brain stimulant. It pro- motes the flow of thought and increases the mental activ- ities, without being followed to any considerable degree by depression. The salts (so called) of caffeine in vogue are the arsenate, benzoate, citrate, and valerate. Stand- ard granules of either : 1-64 grain and 1-6 grain. Very much larger doses may be given, though. The sudium benzoate is best adapted for hypodermic use, for which purpose the ordinary dose is 1 grain. Two Systemic Antiseptics Echinacea and Calcium Sulphide, as our best systemic antiseptics. Both drugs are of great value in averting and overcoming sepsis in its various forms. The stand- ard tablet of echinacea (echinacoid) is 1-2 grain; and the standard granule of calcium sulphide is 1-6 grain. Calcium sulphide, however, may be used freely in 1-2- and 1-grain doses. Nevertheless, Doctor Abbott claims, and experience amply has proven, that the granule form preserves the virtues of the sulphide far better than when made into tablets. Moreover, there is a vast dif- MATERIA MEDICA 59 ference in the quality of the various preparations offered the doctors — some being utterly worthless. Arsenic, in its several forms, as the great alterative. The salts of arsenic commonly employed are the bromide, iodide, and sulphide. Standard granule of either, 1-64 grain. Coniine (Cicutine) and Solanine, as antispasmodics and motor sedatives. Standard granules: coniine (cicu- tine) hydrobromide, 1-64 grain; solanine hydrochloride, 1-64 grain and 1-6 grain. Solanine is especially valu- able in some cases of epilepsy. Codeine and Morpliine, as anodynes. Standard granules: codeine, 1-64, 1-12, and 1-6 grain; morphine hydrobromide, 1-64 grain ; morphine hydrochloride, 1-64 grain, and 1-12 grain; morphine sulphate, 1-64, 1-12, and 1-4 grain. Codeine is especially valuable in irri- tative coughs. Copper Arsenite and Zinc Sulphocarbolate, as intes- tinal antiseptics and as antizymotics. Standard granules : copper arsenite, 1-1000 grain and 1-250 grain ; zinc sulphocarbolate 1-6 grain. Also, tablets of zinc sulphocarbolate ; 1, 2y 2 , and 5 grains. Ergotoid, Hydrastine, and Hydrastinine, to constringe unstriped muscle-fiber, as well as to quicken the heart. Standard soft mass pills of ergotoid, 1-6 grain. Stand- ard granules of hydrastine, 1-64 grain; of hydrastinine hydrochloride, 1-12 grain. Scutellaroid and Cypripedoid, concentrations of skullcap and lady 's-slip per, respectively, as mild seda- tives, anodynes and nervines. Standard granules: scutellaroid, 1-6 grain; cypripedoid, 1-6 grain. Iron, and its salts, to enrich the blood. Standard granules of the salts of iron, 1-64, 1-12, and 1-6 grain. Quinine, and its salts, to antidote malaria. Standard granules of quinine arsenate, which is the salt preferred by dosimetrists, 1-64 and 1-6 grain. Burggraeve claimed 60 ACTIVE-PRINCIPLE THERAPEUTICS that quinine heightens the tonicity of the tissues; and this perhaps, may account for its action in preventing and aborting colds. Nuclein and Lecithin, to strengthen the defensive forces of the system. Dose of nuclein, 1-2 to 2 drops ; of lecithin, 1-2 grain. Glonoin, to relax the capillaries and quicken the heart. Standard granule, 1-250 grain. This remedy acts very quickly when given by the mouth — more so when ab- sorbed from the buccal cavity. Arbutin, to remedy all catarrhal and suppurative conditions of the mucous membrane of the genitourinary system. Standard granules: 1-64 grain and 1-6 grain. Tablet, 1 grain. In small doses arbutin is diuretic and tonic to the mucous membranes ; in medium doses, useful in subacute and chronic cystitis and to restrain the loss of albumin in nephritis and pus in pyelitis and other forms of pyelitis. In large doses, a stimulating diuretic, and strongly antiseptic. Useful in cystitis. Aspidospermine, to relieve dyspnea of every kind: — bronchial, cardiac or nervous. This alkaloid from que- bracho sometimes is called "the digitalis of the respira- tory organs." Standard granules, 1-6-1 grain. Bryonin, to stimulate absorption and relieve pleuritic pains. A remedy for serous membranes. Standard granule, 1-64 grain. CantJiaridin, to overcome atony of the bladder. Stand- ard granule, 1-5000 grain. Gelseminine, to combat febrile conditions, when asso- ciated with bright eyes, flushed face and great nervous tension. A remedy especially in diseases of children. Standard granule, 1-250 grain. Pilocarpine, to produce diaphoresis. The most power- ful agent for this purpose that we possess. Standard granule (of the nitrate) 1-64 grain. Potassium DicJiromatc acts as an alterative to mucous MATERIA MEDICA 61 membranes, particularly of the respiratory tract. Standard granule, 1-64 grain. Sanguinarine acts as a general tonic and expectorant ; also is a sexual stimulant. Standard granule, 1-64 grain. Iodized Calcium (Calcidin), to combat membranous laryngitis (true croup), catarrhal laryngitis, and all forms of colds, especially those affecting the throat. Iodized calcium (Calcidin) also produces the systemic effects of iodine without giving rise to the phenomena of iodism. Standard tablets, 1-3, 1, 2% and 5 grains. Creosote, to serve as a respiratory antiseptic and an antituberculosis remedy. Standard granule, 1-64 grain. PJiytolaccoid acts as an alterative and absorbent in glandular enlargements. Standard granule, 1-6 grain. Salicin acts as a sexual sedative. Standard granule, 1-6 grain. A Few Reflections It will be observed that in a considerable proportion of the remedies named only one single use, either a, gen- eral or a special one, is named for each drug. This is in accordance with the belief that it is advisable to select the most important action of any given drug or the ob- ject which it serves in a more direct and positive way than does any other drug, and to make this the keynote for that remedy. Thus, for instance, we have "quinine, to antidote malaria." Now, quinine serves many other purposes, some of them quite important; but not^one of the un- named applications compares in importance with this particular one, while in no other condition are the re- sults so superior to those which can be secured by means of any other known drug as in this common and serious condition of malaria. Then there is glonoin, "to relax the capillaries and quicken the heart." In the case of this drug the purpose named is practically its only use, 62 ACTIVE-PRINCIPLE THERAPEUTICS but it fulfills that far better than any other known rem- edy, at least in an emergency. By adopting this plan, the principal use of a. drug is readily learned and quickly brought to mind when re- quired. Moreover, the other and minor uses will easily take their places as they are needed. Still other drugs are used practically for only one indication, and that a limited one. For example, agaricin is useful to pre- vent excessive perspiration (night-sweats) ; and this is the favorite, although there are other drugs for that condition. I am not aware that agaricin is prescribed for any other indication. It would seem, then, that the natural method of study- ing drugs is the best one. Find out first its most im- portant use, the purpose which it serves better than any other remedy. As other uses are developed, let them take their proper places. Sometimes, however, a more perfect knowledge les- sens, instead of increasing, the number of uses of a drug. Thus alcohol was formerly recommended for nearly every diseased condition known to man. It was thought to protect one from the cold of winter and from the heat of summer; it was used to strengthen the weak and to comfort the afflicted ; to increase the appetite and promote digestion; and to take the place of food and prevent the pangs of hunger; to relieve pain, assuage grief, overcome melancholy; to prevent heart failure, bring about reaction in shock, bridge over the crisis in fevers, destroy the germs of infectious disease. But of late years physicians have gone more closely into the physiologic action of alcohol, while they also have learned more of other substances to produce the various results formerly thought to be secured by this one; with the result that the internal remedial uses of alcohol are now practically limited, among up to date scientific physicians, to two — to dilate the capillaries MATERIA MEDICA 63 and quicken the heart, in small doses, and to benumb the sense of pain and produce easy death, in larger ones. But even here the first-mentioned use is better met by nitroglycerin, and the second by morphine. We now have perhaps a dozen drugs, each of which takes the place of alcohol in some one of its uses, and does that work better ; no one of them, though, will accomplish all the results ascribed to alcohol. The Value of Experimentation As practitioners of medicine, after passing your ex- aminations, it will be your privilege, and, I believe, your duty as well, to be real students of the action of drugs. You should not only learn what the books have to tell you of these things, but you should try to enlarge to some extent the bounds of knowledge. To illustrate how you can do this. For the last ten years I have been studying experi- mentally the properties of a little-known drug, the ver- bena hastata. This is not a very important drug — it is not even entitled to be called a drug of the second class. Most of the uses which formerly were ascribed to it by the few -books mentioning it at all are better met by other remedies. But I learned, a dozen or more years ago, that someone had used this humble herb-^the blue vervain — with apparent success in certain cases of epi- lepsy. Now, epilepsy is a disease in the treatment of which a large number of remedies have been tried, but not one of them with any great satisfaction (even the bromjides often do more harm than good), and so it seemed to me that the claim was worth trying out. Just to what forms of this malady the herb was best adapted, no one seemed to know — and this, then, was the prob- lem which I set for myself to solve. I began to prescribe the verbena hastata for a woman who just then had been made distinctly worse after a course of the well-known "compound-bromide treat- 64 ACTIVE-PRINCIPLE THERAPEUTICS ment." The result of my experiment was favora.ble — so favorable, indeed, that the patient has continued the use of the verbenin from that day to this, for the reason that, while it did not wholly cure her, it has enabled her to control the manifestations of the malady more fully than any other treatment she has ever tried, and that with absolutely no unpleasant by-effects. I then tried this remedy in the case of another patient, who had been somewhat improved under the bromide treatment, but desired to avoid the very unpleasant incidental effects of that drug. Here verbenin not only failed entirely, but made the patient distinctly worse. As a result, I adopted tentatively as my first indica- tion for giving verbenin: "when patients have been made worse rather than better by the bromides. ' ' That was a broad rule, but the experience in ten years of fur- ther trial of the remedy has confirmed it. Meanwhile I have continued my study of the action of the drug in similar cases, until I now have five indications by which to judge as to its applicability ; and further use will, no doubt, develop others, and perhaps modify some of these five. In the meantime I came upon another drug — solanum carolinense — of greater power, but very unlike in action, which I have found to fit in a large number of those cases in which the patients were not helped by verbe- noid; so that in these two drugs, verbena hastata and solanum carolinense, or their representatives, I have been able to benefit a large proportion of all the epi^ leptic patients who have come under my care. But, in all my use of these remedies, it has been my constant study to determine the special indications, or, if you please, the particular class of cases, for which each one was fitted. It is in this way, it seems to me, that every physician can and should do his part in broadening the common knowledge of our profession. CHAPTER V The Active-Principle Treatment of Pneumonia PERHAPS I can conclude what I have to say to you about active-principle therapeutics in no better way than in giving you a few practical illustrations of its application to everyday disease ; and in doing this, I am going to begin with that most common, serious and fatal of all our acute diseases, pneumonia. My reasons for this are, first, that I know of no disease which it is more important for you to be able to approach with confidence and handle with success; and, secondly, that the treatment which I shall describe has in this disease won its finest laurels. "Pneumonia is a self -limited disease and runs its course uninfluenced in any way by medicine. It can neither be aborted nor cut short by any known means at our command." Such is the dictum of Osier, who is perhaps the most widely known English-speaking med- ical teacher in the world; and through the influence of his great name it has obtained wide circulation and a very general acceptance. However, this idea is the emanation of the rankest drug-nihilism, pure theory from the prince of drug- nihilists. It reduces the doctor to the position of a very inferior grade of head nurse, whose duty it is to watch the patient's symptoms while he is dying and then to certify solemnly that there was no help for him. The active-principle doctor does not accept this dic- tum, does not believe this theory. He believes that it is his duty to do something in the sick-room. More than that, he believes that it is in his power, not only to les- Isen suffering, but to modify disease and to lengthen life. He is the kind of doctor whom I want to attend me when I am sick. I leave it for you to settle it for yourselves whether or not you agree with me. 66 ACTIVE-PRINCIPLE THERAPEUTICS The way in which the theory of Osier works out in practice is well illustrated by a. story told by a well- known physician at a medical meeting in my home town, some years ago, when the members present were discuss- ing the different methods of treating pneumonia. A Personal Experience When this doctor was a senior medical student and was just entering upon the first day of his service as interne in a large hospital he was confronted by what he diagnosed as a severe case of pneumonia, and he naturally felt in a quandary as to what he should do for it. Not being able to settle the question to his own sat- isfaction, he waited with some impatience the coming of his instructor on his daily rounds. This worthy soon made his appearance and questioned our novice as to the nature of this patient's disease. The young interne re- plied that he thought it was a case of pneumonia, and he anxiously asked what he ought to do. "Hm-m-m," was all the learned professor vouch- safed, passing on to his next patient. Fearful that something was wrong, the interne fol- lowed after him and repeated his question. ''Hm-m-m," again hummed the instructor, as he ap- peared to be wholly absorbed in the case at that moment before him. Seeing that it was impossible for him to get any sat- isfaction at this time, the young doctor waited until the professor had finished his rounds and was about to take his departure, when he screwed up his courage and ap- proached him once more, repeating the inquiry, what he should do for his pneumonia patient. "Y-y-young m-m-man," replied the professor, who was an inveterate stammerer, "it m-m-makes such a d-d-d-damned little d-d-difference what you d-d-d-do in TREATMENT OF PNEUMONIA G7 these cases that I have d-d-d-decided to let you exp-p- periment for you-you-yourself . " ' ' And, ' ' added the doctor as he told us the story, ' ' I have been experimenting ever since." If, now, young ladies and gentlemen, you can get some ideas that will enable you to approach your first case of pneumonia with something of a definite idea of what you want to do, and how it can be done, you will find that this frame of mind will give you a. great ad- vantage over that of the man who accepts the Oslerian doctrine that it makes no difference what you do. You will have confidence in yourself; and this will get you the confidence of your patient and his friends. These two combined will prove to be the fulcrum upon which you can rest your lever of active-principle medication and move the world. For to you, to cure your patient, is to move the world. In the treatment of pneumonia (or, for that matter, of any other disease), you have to consider three things: (1) the patient, because no two persons are alike in ap- pearance and constitution or in physical vigor and the power of resisting disease; (2) the disease, because the severity of a disease depends in part upon the intensity of the infection, and the same disease varies in its man- ifestations at different times and under different condi- tions; (3) the treatment, because no two persons re- quire exactly the same treatment, even when the symp- toms are practically the same; and, also because similar results often may be produced by different methods of treatment. Use the Best Obtainable Remedies And right here let me say that, while I am advocat- ing what we call the active-principle treatment of dis- ease, it is no part of my purpose to urge you to confine yourselves strictly to the use of the so-called active prin- 68 ACTIVE-PRINCIPLE THERAPEUTICS ciples. What we want is, not so much active principles, as the best obtainable remedies. We advocate this treatment because we believe that in the main, not only the remedies used, but the manner in which they are employed, are such as will produce better results than any others with which we are ac- quainted. But we do not confine ourselves strictly to any one class of remedies, nor do I advise you to do so. We are practicing medicine, and our business is to cure our patients. If you can find any remedies that will pro- duce better results — any medicinal principles more po- tent for good — than those I have described, by all means use them. It is only in this spirit that we can have any prog- ress in medicine. You must mix your remedies — "with brains, ' ' as the great painter mixed his colors ; you must treat your patients with the aid of common sense and good judgment, remembering that "circumstances alter cases. ' ' The first essential for the most successful treatment of pneumonia is that the physician should be called early — before the case is fully developed or all the classic symptoms have made their appearance. Nor, under those circumstances, should he wait for the further de- velopment before beginning active measures of treat- ment. To wait until it is possible to make a positive diagnosis, is greatly to lessen your chances of success. Remember the teaching of Burggraeve, that the great end of dosimetric medicine is "the prevention of ana- tomic-pathologic lesions, for these, once established, are above the resources of art." Put this over against the dictum of Osier — and choose for yourselves. A positive diagnosis can be made only when the symptoms are typical or the disease is well advanced. The early chill is characteristic, but in twenty percent TREATMENT OF PNEUMONIA 69 of the cases it does riot occur. Rapid respiration is com- mon; still, the variation in this respect is so great that it is not safe to rely upon it. The quick pulse is not found in every instance. Even high temperature is not always present, and its absence has come to be recognized as a distinctly unfavorable symptom. Many patients have little or no pain in the chest from first to last, and sometimes there is almost no cough, even the rusty spu- tum being absent in a considerable number, especially in the aged. The crepitant rale, when well marked and persistent, is considered almost pathognomonic, but this sign sometimes is absent. So, do not wait for the occurrence of all these classic symptoms, but, when you find enough to indicate con- gestion of the lungs with fever, go to work at once to prevent, if possible, that further progress of the disease which alone will render a positive diagnosis possible. If there is a feeling of oppression and tightness across the chest, with pain and difficulty of breathing, I know of no better remedy than a mustard poultice ap- plied to the affected part and allowed to remain until pain is relieved and the breathing easier, when it may be replaced by an antiphlogistine poultice or a cotton jacke + If there is no pain or difficulty of breathing, the antipnlogistine — or any other "clay poultice" — may be applied at first. Under these conditions, many physi- cians prefer not to make use of any external applica- tions whatever. In nearly all cases of pneumonia a thorough clearing out of the intestinal canal at the outset is desirable. In cases characterized by constipation, nausea, and a coat- ed tongue, you may give 1-6 grain each of calomel and podophyllin every half hour until a grain has been taken, and follow in two hours with a heaping tablespoonful of a laxative saline. Or, if the case comes into your hands at night, you may give a single dose of 70 ACTIVE-PRINCIPLE THERAPEUTICS a suitable purgative, such as the ' ' triplex pill, ' ' com- posed of aloes, blue mass, and podophyllin; and in the morning follow with the usual dose of the saline laxa- tive. In either of these ways, or in various others, you will be pretty sure to secure thorough elimination, which is an important point. After this, the bowels should be kept clean, securing at least one free movement each day, and for this purpose the saline laxative is often sufficient. To Reduce High Temperature and Relieve Congestion We come next to measures for the reduction of the temperature and the relief of congestion, using for this purpose remedies acting through the vasomotor nervous system. The great active-principle vascular sedatives are aconitine and veratrine, either alone or combined with the tonic alkaloids strychnine and veratrine, as in the dosimetric trinity and the defervescent compound. In children, in delicate women, in the weak, the aged, the debilitated, and in all patients showing a tendency to asthenia, the preferred remedy is aconitine. So far a,s the pulse is concerned, the special indication for acon- itine is the small and frequent pulse. Veratrine, on the other hand, is the remedy of choice in strong and vigorous adults, and in all subjects show- ing symptoms of a markedly sthenic character. Its special indication is a. rapid, full, and bounding pulse. In the same case veratrine may be required at one stage of the fever, while aconitine is called for at another. Both these remedies are of the greatest utility in the early stages of fever, and as a rule neither one should be given in the later stages, or in any stage of cases marked by great debility and lack of vitality, except as guarded by one or both of the tonic alkaloids, strychnine and digitalin. Indeed, knowing that if the disease runs its TREATMENT OF PNEUMONIA 71 course the greatest danger in pneumonia arises from the strain upon the heart, the alkaloidist deems it wise to guard against any weakness in this direction from the first, and therefore often prefers to use the dosimetric- trinity granule from the first in all severe and markedly asthenic cases, and the defervescent granule in sthenic cases. The standard granule of aconitine hydrobromide is 1-800 of a grain, and of veratrine, 1-128 grain. These are the minimum adult doses, and are best given dis- solved in a teaspoonful of hot water. If the fever is 103° F. or higher, this dose may be given every fifteen minutes for a few times, then every half hour until the fever begins to lessen, as shown by the tongue becoming moist, the pulse softer and slower, and the temperature lower. When this effect has been produced, the remedy may be given every hour as long as it is considered necessary to continue the effect. If the initial fever is below 102° F., give the dose only half -hourly from the first. These are general directions, to enable you to make a beginning. But always remember that there is no fixed or arbitrary dose or frequency of admin- istration, the only object being to produce tlie desired effect. Some patients are affected very easily, others only with great difficulty. Some people are very hard to sweat, but I have noticed that even in these cases the fever generally declines in about the usual time under the influence of these remedies. Strychnine and digitalin are tonic remedies and their use is well understood by medical men of all schools. Strychnine is the great nerve tonic, and is especially indicated where there is imperfect or en- feebled respiration or a condition of general relaxation of the whole system. Digitalin is the great cardiac tonic, strengthening the heart and slowing the pulse. When 72 ACTIVE-PRINCIPLE THERAPEUTICS given alone in considerable doses, it may sometimes be objectionable on account of its tendency to increase the blood pressure, but when combined with aconitine and strychnine, as in the trinity granule, this effect is pre- vented. The standard granule of strychnine arsenate is 1-128 grain, and of digitalin, 1-64 grain; and these doses may be given with perfect safety in the same fre- quency as the aconitine and veratrine, when combined with these drugs. There is one other active principle which I have learned to use in those cases of pneumonia which are complicated with pleurisy, as shown by a sharp "catch- ing" pain in one or the other side when breathing. This is bryonin, a glucoside derived from bryonia alba, a rem- edy of which you probably know very little. It is a remedy for serous membranes, and is especially indi- cated in pneumonia when there is felt a sharp, cutting or stabbing pain in the side, made Worse by motion. I will mention one other remedy which I have used with much success in the treatment of pneumonia, and which I desire to recommend to your favorable attention, although I do not claim that active-principle therapy has any mortgage on it. General Antiseptic Treatment in Pneumonia If pneumonia is a germ disease, as is now universally accepted to be the case, then nothing can be more ap- propriate than an antiseptic treatment. For this pur- pose I know of no more effective agent than creosote, which is eliminated largely by the lungs, and is entitled to be termed a respiratory antiseptic. Sajous declares that creosote is as nearly a specific in pneumonia as is quinine in malaria, Beverley Robinson, of New York. was one of the first to advocate its use in lung disease. Van Zandt, of Texas, has been especially prominent in recommending its use in pneumonia. He has found it to TREATMENT OF PNEUMONIA 73 abort a considerable proportion of cases, to modify fa- vorably the symptoms and shorten the course of a still larger proportion, and only in a small proportion to fail of influencing it in any way. Creosote carbonate is the preparation commonly used. Sajous gives it in 10- and 15-grain doses every two or three hours. Van Zandt gives two and one-half drams in twenty-four hours as an average adult dose, and divides this amount into either two or four doses. My own experience has been with the preparation known as thiocol. This is a made-in-Germany, patented prep- aration, chemically known as the guaiacol sulphonate of potassium. The main advantage which I find in this, over the cruder preparations of creosote, is the fact that it has very little taste, and may be given in any desired dose without disturbing the stomach. A great disadvantage is that it is still sold at the high price of patented prep- arations. I give it in 5-grain tablets, two tablets every four, three, or even two hours to an adult, and I have never had any bad symptoms. It is a valuable addition. Reasons for Failures in Practice With the treatment thus briefly outlined, it is pos- sible to abort a considerable proportion of cases. That this result cannot be secured in all cases, is due to one or more of the three following causes : 1. Lack of vitality in the individual, so that the system does not react favorably to the medicine. 2. Unusual intensity of the infection, such that the vital forces are overwhelmed by the first onset of the poison. 3. Late beginning of the treatment or lack of thor- oughness in carrying it out. But even when the fever is not aborted, the course of the inflammation is almost always favorably modified. 74 ACTIVE-PRINCIPLE THERAPEUTICS and it runs a shorter course than when left to nature, with fewer alarming symptoms and far less danger of failure of the vital forces than is seen when the coal-tar products and other depressing remedies are used. After the crisis is passed and the fever is gone, only a condition of weakness and depression remaining, it is better to omit the aconitine from the dosimetric trinity and to rely upon the tonic effects of strychnine and digitalin alone. You will observe that from the beginning we have guarded against danger from, weakness of the heart, using for that purpose the tonic remedies strychnine and digitalin. Add one other needed drug, and most of the cardiac dangers in pneumonia may be satisfactorily met. Glonoin, or nitroglycerin, is the great emergency remedy, relaxing the tense arterioles, and letting the blood go free when the heart is overburdened. With the active-principle therapist this drug takes the place of alcohol, in a very large degree, compared with which he finds it quicker in action, freer from danger, and more satisfactory in results. Instead of the usual dose of 1-100 grain, he prefers the dose of 1-250 grain, in gran- ule, repeating this as may be needed to secure the de- sired result. This is one drug which is said to act more quickly when absorbed from the mouth than when in- jected subcutaneously. When properly used, it works wonders. Treatment of the Cough The cough of pneumonia seldom requires more than four drugs, and these are emetine, apomorphine, codeine, and calcium sulphide. Emetine is especially indicated by deficient secretion; apomorphine by a thick, viscid, and tenacious secretion; codeine by the cough of irrita- tion as distinguished from the cough of expectoration ; and calcium sulphide by a hoarse, harsh, hard cough, TREATMENT OF PNEUMONIA 75 with putrid secretion. The dose of emetine and apo- morphine each is 1-64 grain, and that of codeine may be 1-64 or 1-12 grain, according to the nature of the case. They may be given either separately or combined, in aqueous solution, every fifteen to sixty minutes, as in- dicated. I have come to depend upon this mixture, which I call the A-C-E mixture, for use at the bedside, to loosen a tight cough, to the exclusion of almost everything else. The calcium sulphide is especially useful in the cough of bronchopneumonia, measles, whooping-cough, and the like. It is best given in 1-6-grain granules every hour, and may be given without dissolving, care being taken to take a few swallows of water with each dose. I can only give you the outlines of the use of any of the remedies named. You must learn their more inti- mate uses from your own experience, by getting used to them. Then you will know Avhat they will do. You will see that my idea of a drug to be used in the treatment of disease is something like that of a friend whom you depend on for help and comfort in the work of life. You must get acquainted with your drugs be- fore you can use them to advantage, before you know what they will do, and how long they will last. If they are the real thing, the more intimate your acquaintance with them the better you will like them, and the more you will learn to depend upon them. If they are only shams, you will soon find it out, and the sooner you get clear of them the better. Drugs are like friends in another respect. It is bet- ter to have a few good ones, old friends that you know and can depend upon, than a host of new ones, passing acquaintances, "said to be good," "highly recom- mended, ' ' but not known to you from your own experi- ence. I have not spoken of the importance of fresh air and 76 ACTIVE-PRINCIPLE THERAPEUTICS plenty of it, of bathing, good nursing, propeV nourish- ment, and many other things essential to the proper treatment of pneumonia, because their importance is recognized by all physicians, and their use is not con- fined to one school of medicine or system of practice. These things play an important part in determining is- sues of life and death. Now — to sum up : The active-principle treatment of pneumonia should begin early. Its first aim is to abort the disease. For the digestive tract: "Clean out, clean up, and keep clean." Calomel, podophyllin, and salines are the preferred laxatives. Give liquid nourishment. "Keep on the right side of the stomach at all hazards. ' ' For the pulmonary congestion : Counter-irritation by mustard ; depletion by antiphlogistine. For the fever and the heart: Aconitine and vera- trine ; strychnine and digitalin ; glonoin. For the cough : Apomorphine, codeine, emetine, cal- cium sulphide. For pain : If slight, counter-irritation, codeine, bry- onin; if severe, morphine hypodermically. Watch the patient. Dosage to effect. No alcohol. A Word in Conclusion In finishing this course of lectures, young gentlemen, let me say to you that the different diseases which we have considered have been selected only as illustrations of the methods of applying the therapeutics of the active principles. They are not necessarily the most common, or even the most important that could have been se- lected. They are simply those in which I have bad a fair share of experience, and for which 1 have somewhat definite ideas and methods of treatment to suggest. Lot me urge upon you, as yon go out to begin your work in caring for the sick, the importance of making use of the TREATMENT OF PNEUMONIA 77 most definite, positive, and dependable means and meth- ods at your command. It is a far cry from the herb teas and powdered roots of our grandfathers to the potent chemicals and active principles which are at our own command today. The old therapeutics Avas a mass of undigested facts, mostly clinical, dealing with remedies uncertain in their action, and not to be depended on as to their results. The new consists of a compact body of knowledge, both clinical and physiologic, relating to drugs which are definite in their action, and whose effects are well ascer- tained and always to be relied upon. The old remedies were bulky and largely inert, the new are concentrated and always active. The old were unpleasant in appear- ance and nauseous to the taste, the new are attractive to the eye, and either- tasteless or may easily be admin- istered so as to conceal the taste. The old were danger- ous because of their unknown potency and massive dose, the new are absolutely safe because of their definite ef- fects and the ease with which their action can be con- trolled when administered by the intensive method of dosage. The form and concentration of the active principles enables the practitioner in the cities and larger towns to have with him at all times the more important rem- edies, and to be able to administer them at a moment's warning when needed in case of an emergency. Their importance to the physician practicing in the country, or who is distant from his base of supplies, is well expressed by Dr. Robert Gray, who is himself one of the most remarkable figures in the medical history of our day, and who has practiced medicine for most of the time since the close of our Civil War in one of the southern provinces of Mexico. He writes as follows : "I carry 156 active principles, weighing in all less than five pounds with case, the equivalent of which in 78 ACTIVE-PRINCIPLE THERAPEUTICS galenic forms would load two mules. I am never am- bushed by the enemy, when suddenly confronted by some desperate emergency, no matter what the disease or the emergency may be. I have the antidote while time for medication yet remains, and do not have to send prescriptions to a distant drug store for uncertain rem- edies, a makeshift often fatal to an imperiled life. ' ' CHAPTER VI The Treatment of Typhoid Fever ASA FURTHER illustration of the application of **■ active-principle therapeutics, I shall speak to you today of the rational treatment of typhoid fever. But I do not wish you to understand that there is any recog- nized method of treating this or any other disease which is limited to the exclusive use of the active principles of plant-remedies. Rather, I desire to call your atten- tion once more to the fact that the use of the active principles in the treatment of disease does not, in itself, make a physician an active-principle therapist; but neither does the use of other remedies in addition pre- vent his being such. Indeed, as I have already told you more than once in substance, the active-principle therapeutist as a rule is not a secterian, or a faddist, or an extremist in any direction. He uses the active principles and conforms to the other fundamentals of the method in most cases, for the reason that he has become convinced that the best results can be secured in this manner. But, in any case where experience or observation or testimony has convinced him that the cure of the patient can best be brought about in some other manner, he unhesitatingly departs from the tenets of strict active-principle medi- cation and uses that which to him seems the best method. Not methods, but results are the things to be sought after. You will find that typhoid fever does not always pre- sent itself in the sick-room as it is pictured in the lec- ture-room or in the text-book. I once heard a physician say that, although he had been in practice for ten years, he never had seen but one typical case of any disease. By which he meant that he had seen but one case which 80 ACTIVE-PRINCIPLE THERAPEUTICS corresponded closely with the descriptions given in the books. He had learned the lesson that, while the teacher must describe the type, just as the artist must make his sketch a composite picture, in actual life no one case corresponds exactly with the type, no one individual perfectly resembles the composite picture. The Importance of Accurate Diagnosis It is not within my province to dwell upon the diag- nosis of typhoid fever ; your professor of practical medi- cine no doubt has instructed you carefully in this re- spect. Very likely he has told you that, while sometimes the diagnosis is easy and can be made early in the dis- ease, it is difficult in others, and much valuable time may elapse before one is quite sure as to the real nature of the disease. This was true to a much greater degree when I began the practice of medicine than it is today, and, hence, the need of such instruction may no longer be felt. For. by the aid of the methods of modern laboratory diag- nosis, the number of uncertain cases is reduced to a minimum. Especially is this true if it is your fortune to practice in or near a large city, where you can avail yourselves of the advantages now uniformly found in large hospitals, you will be able to rely to a great extent upon these methods to aid you in diagnosis ; and your results will, without doubt, be far more accurate and satisfactory because of these aids. And, indeed, you will need to avail yourselves of the latest and best methods which science has placed at your command, in order that you may do your whole duty, meet successfully the sharp competition to which you will be subjected, and bring the largest possible pro- portion of your patients safely back to health. But, if, on the other hand, it should fall to your lot TREATMENT OF TYPHOID FEVER 81 to find your work in a sparsely settled country, where you are out of easy reach of the helps of which I have spoken, do not be downcast or discouraged because of these things. There are no advantages without corre- sponding disadvantages. Always when one end of the seesaw board goes down the other end goes up. In the country, you will be farther away from help, and, thus, will be obliged to depend upon your own re- sources. But, in compensation, you will develop self- reliance, independence of action, and an all-around ver- satility that does not characterize the specialist or the laboratory physician. Therefore, I say, develop yourself according to your opportunities, and you will be able to meet the responsi- bilities of life as they come to you. And this means that you should gain a thorough understanding of the most improved methods of diagnosis as well as of thera- peutics, and that in the treatment of disease you should bring to your aid every means within your reach. The Old and the New Idea Contrasted Typhoid fever is a specific disease, and its cause is a specific germ, the typhoid bacillus. The symptoms really are due to the presence of the bacilli in the blood — what might be termed a bacillemia. This condition is found at a very early stage and is continued through- out the disease. The intestinal lesions are centralized in the Peyer glands, but also are found in various parts of the intestinal tract. The glands in question are the site of entrance of the germs, just as the glands of the throat are the site of entrance of the bacilli of diph- theria; in either case the principal lesions existing at the point of entrance. ' The fever is the most constant, as it is the most im- portant, of the constitutional symptoms, and is present 82 ACTIVE-PRINCIPLE THERAPEUTICS in virtually all cases, making its appearance*" at an early stage, often as the first symptom attracting the atten- tion of the patient. Usually, however, the intestinal symptoms are early manifested, and these and the aci- demia precede, and they also cause, the fever in every instance. For the reasons named, remedies directed to the fever itself can not be relied upon to check it as long as the specific germs retain their activity. And, as the removal of the morbific cause is always more important than the treatment of the resulting symptoms, it is even more material that we should strike at the germ than to combat the fever. A friend of mine, who was graduated from Harvard the year after I was from the University of Vermont, took for the subject of his graduating thesis "Typhoid Fever;" and in discussing the treatment he wrote as follows — this sentiment, he tells us, embodying the sub- stance of the teachings he had received on this point : "The treatment of typhoid fever is devoted to one end. namely, to keep up the patient's strength till the disease has run its course. There is no drug which will lessen, cure or cut short the disease. ' ' This statement has a most familiar sound and calls to mind the similar words of Osier with respect to pneu- monia; raising, indeed, the question as to whether Osier took his ideas from Harvard or Harvard and Osier both drank from the same fount of knowledge. Undoubtedlv the statement quoted represents the consensus of medical opinion of a generation ago. As for my friend, I am glad to be able to tell you that he has entirely repudiated those ideas and now advocates and practices something quite opposite to those pessimistic notions. Expectant Versus Prompt Treatment Perhaps the worst result of these teachings was the state of mind they engendered, leading, as they did. the TREATMENT OF TYPHOID FEVER 83 practitioner of that day to make no endeavor to do any- thing for a fever, except to watch and wait until the disease was fully developed; and then the symptoms were treated, and the symptoms only, since according to the prevailing theory nothing could be done for the disease itself, either to cut it short, to cure it or even to lessen its intensity. But, glory be! No such hopeless dogma hampers the action of the active-principle physician. The main de- sire of such a practitioner is, to get at the disease early — and the earlier the better. He does not even wait until the diagnosis is final and complete before beginning the treatment, but treats the symptoms as he finds them. It is true that he still has difficulty in getting his cases as early as could be desired, but, thanks to his persistent teachings in this respect, he certainly does get called to his patient much earlier than did the fathers. Right here I want to impress upon your minds this one point, namely, that the most important point, the one thing which more than any other characterizes the active-principle treatment of typhoid fever and of all other acute disease, is the early beginning of treatment. This is in strict accord with the principles laid down by Burggraeve, the founder of dosimetry, who declared that ' ' dosimetric medicine rests essentially upon its power to jugulate those fevers in which all acute maladies have their inception." But only at their start can these maladies be aborted. Therefore, begin early. Now, I do not claim that all cases of typhoid fever can be aborted, or even most of them — in the stage in which they usually reach us. But I do believe in the abortability of fevers and other acute diseases ; and that not merely as an ideal to be aimed at, but as a fact which can be actually accomplished in a considerable proportion of cases. And when we cannot succeed in cutting short the disease by early treatment, we can at 84 ACTIVE-PRINCIPLE THERAPEUTICS least favorably modify the symptoms, prevent dangerous complications, shorten the duration, and lessen the mor- tality. If I did not believe this much, I should not have the courage to undertake the practice of my profession. Great Promise in Bacterin Treatment The vaccine, or bacterin, treatment of typhoid fever is one which promises great results, and although there is not yet a universal agreement as to the degree of its efficiency, from all indications it seems probable that with the further development of the method its value will be increasingly recognized. As a preventive measure, its importance certainly is well established. Dr. George M. Gould declares that it renders an individual practically immune to typhoid fever for at least two years, is attended by no danger and by practically no inconvenience, and that exhaustive experimentation has proven it reliable. This is gen- erally accepted as true, and it follows that antityphoid vaccine should be used in all epidemics, and also by all persons who are likely to be exposed to infection, such as are travelers in countries where pure water can not be obtained, as also soldiers and sailors in general. Indeed, it is largely through the experience of these latter classes that its value has been established. As a means of treating the disease once it is established, the place of the vaccine is not so firmly fixed, but seems, with each year, to be increasingly recognized. It does not interfere with other medical treatment, and when properly used it seldom does harm. For these reasons it seems to me advisable, when the diagnosis of typhoid fever has been made, to admin- ister the proper dose of typho-bacterin, and repeat the same at proper intervals throughout the course of the disease; meanwhile continuing the usual medical treat- TREATMENT OF TYPHOID FEVER 85 ment. And here again we see the importance of begin- ning early ; for all authorities are agreed that the earlier this measure is employed, the greater is the benefit likely to be derived from it. The Essentials of the Treatment The essential treatment which is relied on by the active-principle physician combines three elements : it is eliminative, antiseptic, and defervescent. 1. The treatment is eliminative, in order that the decaying and septic material in the intestinal tract, and throughout the system, may be removed, so far as pos- sible. 2. It is antiseptic, in order that the entire intestinal tract as also the system in general may be rendered a less fertile soil for the growth and development of the specific germs. Many sneers, without justification, have been thrown at the antiseptic treatment of typhoid fever, on the ground of the evident impossibility of securing abso- lute asepsis of the intestinal canal. But no friend of intestinal antisepsis, however ardent, has ever claimed that such a thing is possible. On the other hand, however, no one has ever shown that the digestive tract, if it is cleared out at the begin- ning of the disease, and kept reasonably clear of the products of decay, and in addition is saturated and kept saturated with a nonpoisonous antiseptic agent, fur- nishes as good a soil for the growth and development of the typhoid or any other pathogenic germ as when these conditions are reversed. And this is all that the most enthusiastic friend of intestinal antisepsis ever has claimed. 3. It is defervescent, not only because the fever is a source of danger in itself, but because the rise of 86 ACTIVE-PRINCIPLE THERAPEUTICS temperature is an indication of the severity of the infec- tion; and, if it can be kept at a reasonable point, the danger is greatly lessened. Remember that each case must be treated on its own merits. The patient himself must be treated as well as the disease, and no two are alike. The symptoms also must guide in the treatment, as showing where the most vulnerable points are to be found, which need the most urgent attention, and to which the greatest care must be given. There should be no such thing as a routine treatment ; still, there needs must be a general plan, but which must be modified as conditions may seem to demand. It is this general plan of treatment which I shall try to lay down, one which is adapted to the average case and can be modified as may be needed. But, like the doctor who had seen only one typical case, you also may never see but one — or not even one — case to which the treatment I shall describe may seem the best adapted. A General Plan of Treatment Outlined The first thing needed is thorough elimination — clean- ing out. If the patient is seen early, begin with a tablet containingl-6 grain of calomel, 1-6 grain of podophyllin and 1-12 grain of bilein. Give this every half hour for six doses. Two hours after the last dose has been taken give a full dose of a laxative saline. If needed repeat this every two hours until the bowels have been thor- oughly cleaned out, ending with loose watery discharges. If there has been a preliminary diarrhea, it will take less to produce this result than when there has been con stipation. But the clearing out is needed under either circumstance. As for the dose, the effect is what is needed. If much is required, give much; if little, give little. TREATMENT OF TYPHOID FEVER 87 When this result has been thoroughly secured, it is time for the next step, which is, to secure intestinal asepsis to the greatest extent possible. Here the agents to be employed, and which experience has shown to be the most effective, the safest, and the most reliable, are the sulphocarbolates of zinc, calcium, and sodium. These salts may be given either singly or, as more often desir- able, the three combined. This remedy should be given in doses of from 10 to 30 grains every two to four hours, according to the severity of the attack. It is best given in solution, with a plenty of water. Or the tablet may be crushed or even given whole in some cases, but always with plenty of water to insure ready dissolution in the stomach. Shaller says in regard to this procedure: "Where the evacuations are frequent and foul, 5- to 10- grain doses of any of the three sulphocarbolates or of the com- bined intestinal antiseptics not only checks the offensive- ness of the stools, but lessens their number. As the pres- ence of the sulphocarbolates in the intestine checks and prevents fermentative action, the high temperature of typhoid fever begins to decline and can be kept down by the administration of these remedies throughout the disease. . . . Treated on the above plan, typhoid fever will be of shorter duration than usual. Instead or running three weeks or more, patients are frequently up and about within two weeks. If this treatment is begun very early, the probabilities are that very few cases can run their full three weeks' course. Calomel and the sulphocarbolates do certainly abort many cases of typhoid fever." Abbott writes: "Not all cases pursue an eminently satisfactory course under the antiseptic method ; but the severe forms become scarce, the abortive cases frequent, and the disease puts on a milder aspect. The sooner the antiseptic method is put in practice, the more decidedly 88 ACTIVE-PRINCIPLE THERAPEUTICS will its good effects be manifested. If the case is not treated until ulceration has occurred or until the patient's condition is desperate, and the believer in anti- septics is then called on to demonstrate his miracles, failure is probable. The sulphocarbolates will usually prevent the dangerous conditions of the third week, but there are better remedies to promote the healing of ulcers, prevent perforation, and stop hemorrhage; also to combat pneumonia. But when they are given early in the attack, in the manner described, there is little to be apprehended in the way of complications and sequels. ' ' Here again (pardon me for harping so persistently on one string) let me call attention to the stress which is placed upon beginning treatment early. When this is done, the dreaded complications seldom occur, while the doctor will be credited with having had to deal with only a light case of typhoid fever, or perhaps no typhoid infection at all. However, your patient gets the benefit, after all. The laxative treatment should be repeated in full every few days, and a sufficient dose of saline laxative should be given every morning to secure one or two loose movements each day. Steps in Combating the Febrile Condition The next thing to be considered is the treatment of the fever. It should not be inferred, of course, that the institution of this treatment is to be delayed until the eliminatives and antiseptics have accomplished their work; rather, it sometimes is the first form of treat- ment to be undertaken, and, moreover, always to be begun early. Thus, the different forms of treatment are to be carried on together or the one or the other may have the precedence, according to the symptoms in each particular case. TREATMENT OF TYPHOID FEVER 89 The principal drugs to be relied upon for this pur- pose are : aconitine, veratrine, digitalin, and strychnine. It is sometimes objected that the first two of these drugs are sedatives and depressants, while the last two are tonics and stimulants — the two classes seeming to be antagonistic in their effects. However, you will remember that in a previous lec- ture I explained the selective action of the cells through- out the system, whereby each cell selects from the gen- eral blood stream those things which are needed for its building up, and rejects those which are foreign to its needs; that, while this is true when only enough ma- terial for proper nourishment is absorbed, it neverthe- less is possible to overwhelm or poison the blood-cells by an overdose, which forces them to take up more than the proper amount ; that this rule holds with regard to medi- cines as well as to foods; and that in this way it is possible to use to the greatest advantage remedies of unlike and even to some extent opposing properties, pro- vided only minimum doses are employed. ' Fever and the Vasomotors Along with this, you will remember the theory of the relation of fever to the vasomotor nervous system, as explained by Doctor Waugh, which was explained in the same lecture as the foregoing. He tells us that ''acute inflammatory attacks begin with a disturbance of the circulatory equilibrium. The affected part fills up with blood, which distends the capillaries, whose walls, relax- ing under the increased pressure, afford an example of relative vasomotor paresis, being abnormally weak in proportion to the pressure to which they are subjected. But, as there is no reason to suppose that the actual quantity of blood in the body has been increased, this overplus of blood in the distended capillary area indi- 90 ACTIVE-PRINCIPLE THERAPEUTICS cates that there is too little blood in some other part of the vascular system. In other words, the vasomotor paresis in the hyperemia area is exactly compensated by a vasomotor spasm in some other vascular area." Now, the normal equilibrium of the circulation in these cases may be restored in either or both of two ways : by increasing the tonicity of the dilated vessels or by causing those which are contracted and comparatively empty to relax and dilate, or by both acting together. But, this is just what we undertake to do in the treat- ment of fever by the methods that are adopted by the active-principle medicationists. Contraction in the dilated areas is secured by means of the vasomotor ten- sors, strychnine and digitalin ; and relaxation in the con- tracted areas is obtained by the vasomotor relaxants, aconitine and digitalin. By either of these means, but best by both carried on together, the restoration of cir- culatory equilibrium is secured — and this is the great object to be attained. The basic prescription for fever, therefore, would con- sist of aconitine and digitalin. Aconitine inhibits the rapid action of the heart, slows and regulates the pulse, lessens the vascular tension, and lowers the temperature. Digitalin also inhibits the action of the heart, which it slows and strengthens, meanwhile restoring vascular ten- sion where it is wanting. To these two agents, Burg- graeve added strychnine, which is the most powerful vital incitant we possess, energizing every organ ami function of the body, and especially combating that ten- dency to weakness and debility which is common to all febrile diseases and increases with each day of their continuance. This happy combination of drugs is known as the dosimetric trinity, and is especially adapted to the asthenic form and stages of fever. To the basic prescription of aconitine and digitalin, Abbott added vera trine, constituting what is known as TREATMENT OF TYPHOID FEVER 91 the defervescent compound. This addition of veratrine increases the inhibitory power of the combination, slows the pulse, and opens every door of elimination, so that it is one of the most effective agents for the removal from the body of the various toxic products, whether of infectious agents, morbid metabolism or from absorp- tion from the alimentary canal. When Aconitine, When Veratine? As an agent in the treatment of fever, aconitine is the preferred remedy in children, in ephemeral fevers, and in the earliest stages of fevers in asthenic forms. Veratrine is the remedy of choice when the case is sthenic in its nature and the pulse full and bounding. But when the patient is debilitated, markedly asthenic or the disease is one which in its ordinary course leads to great weakness and debility, especially heart weak- ness, then the trinity granule of aconitine, digitalin, and strychnine is to be used from first to last. But in a disease like pneumonia, when it is desired to secure quick results and the patient is plethoric and full-blooded, then the defervescent granule is the thing. Furthermore, in the different stages of the disease, we often change from the one to the other combina- tion as the symptoms may change. Moreover, when it is especially important to reduce the fever quickly in a patient who has a good heart and is not debilitated, this result may be obtained by the use of the coal-tar pro- ducts acetanilid or acetphenetidin more quickly, although with greater danger and less permanently, than with the defervescent alkaloids. Remember that the doses of the tonic alkaloids, strych- nine and digitalin, are not such as to stimulate power- fully, not such as to serve as a whip to the tired horse, but rather such as to afford proper support and prevent 92 ACTIVE-PRINCIPLE THERAPEUTICS exhaustion of the vital forces. Much can be done by the proper use of these remedies to prevent the more dan- gerous complications and sequels which under other cir- cumstances often make their appearance and sap the vitality of the patient. The trinity granule may be given with safety every hour as long as may be needed. The aim should be to keep the temperature below 102 degrees or as little above that figure as possible. And when the fever is gone, and the aconitine, therefore, no longer is needed, while sup- port for the heart and nervous system is still indicated, then drop the single granule, and substitute in its place the granules of strychnine and digitalin, every hour or two hours for as long as may be needed. I believe that this treatment, thus briefly outlined, is superior to any other with which I am acquainted for the essential fever process under whatever circum- stances occurring. Of course, other agents may be added as indicated, and other methods may, in rare instances, be preferred. It is, however, a method simple, easy of application, and satisfactory in result to a greater de- gree than any other I have ever made use of. We now have considered the medicinal treatment of typhoid fever under the four heads of bacterial vac- cines, eliminative treatment, antiseptic treatment, and antiphlogistic, or febrifuge, treatment. It remains to consider the general care of the patient. General Management of the Typhoid Patient From the onset of the illness, the patient should be confined to the bed, which when possible should be in a large, well-aired and pleasant room. No room in the house is too good for the sick-room. "Walking cases" of typhoid fever, so called, are proverbially dangerous; the danger arising largely from the exposure and undue TREATMENT OF TYPHOID FEVER 93 exertion necessarily involved as well as from the lack of proper care in other respects. Strict cleanliness should be observed in all things. Disinfection of the room itself, the bed, bedding, and all the clothing, as well as of the discharges, should be scrupulously carried out. Many agents are used for this purpose, but perhaps no single one better meets the requirements in most instances than chloride of lime.- It is the practice of most physicians to restrict the patient to a liquid diet during the continuance of the fever. This may include milk, rice- and barley-water, fruit- juices, bovine, beef -juice, white of egg, malted milk, and so on. Baths should be administered both for cleanliness and for the comfort of the patient. They may be hot, cold or tepid, according to the judgment of the physi- cian or the desire of the patient. The use of cold baths to control the fever is highly recommended by good authorities, but as a matter of fact, they are better adapted to institutional work than to private practice, and have never been as much used in this country as in Germany. Aiding the Defense Nuclein may be used with advantage to strengthen the defensive forces of the system, and echinacea to aid in bringing about systemic asepsis. In the severer forms, and especially where treatment is begun late, baptisoid sometimes is a valuable remedy. The special indication for this drug is a brown or purplish discoloration of the tongue and mucous membrane of the mouth, with a con- gested face and deep-red tongue. Quinine arsenate some- times is desirable for its tonic effect. Caffeine acts as a valuable diuretic and brain and nerve stimulant. Codeine may be needed to quiet irritated nerves and 94 ACTIVE-PRINCIPLE THERAPEUTICS induce sleep. In exceptional instances, morphine, hypo- dermically, may be required for the relief of severe pain. In the active-principle treatment of typhoid fever there is no place for alcohol. When ulceration has occurred and serious symptoms are present — usually about the third week — threatening perforation, oil of turpentine is the standard remedy. When this is given in 5-drop doses every two to four hours, in capsule or in an egg emulsion, it is a usual thing to see the tympanites quickly subside, the tongue become moist, and the stools assume a healthier char- acter. For hemorrhage, the best remedies are: ice to the abdomen, silver nitrate in small doses up to 1 grain in a day, and atropine hypodermically, in 1-100- to 1-50- grain doses and repeated so as to keep the blood at the surface. Emetine hydrochloride, in 1-2- to 2-3-grain doses, hypodermically, has recently been advised for the treatment of hemorrhage and deserves a careful trial. Perforation of the intestine is perhaps the most dan- gerous of all the complications and calls for the prompt opening of the abdomen and resection of the diseased portion of the intestine. But when the case is treated antiseptically from the start, perforation seldom will occur. The same is true of the various other serious complications. I feel that I ought to ask your forbearance for so constantly iterating and reiterating, with what must seem persistent and needless frequency, the laws of active-principle therapeutics — to which, you may think I have been paying more attention in this talk than I have to the treatment of typhoid fever. The reason is. that I am not teaching you the practice of medicine, for I know that you will get better instruction from your regular professors than I could give you if I were to attempt it. What I am endeavoring to do is, to im- TREATMENT OF TYPHOID FEVER 95 press upon your minds, in a way to last for the rest of your lives, the more striking features of a method of therapeutics which is comparatively new to most of you and concerning which you look to me to tell you more than you will be likely to get from anyone else in your present studies. You will note that I have not attempted to discuss the use of bacterins in the treatment of typhoid fever; this is not because I lack faith in these agencies, nor is it be- cause the active-principle men do not employ them — for the exact contrary is true. In this little book I have lim- ited myself in the main to medicinal therapy, and this is my theme. The truth is, that Doctor Abbott and his associates are warm advocates of the prophylactic bac- terin, and believe that even in the treatment of devel- oped cases of typhoid fever the typhoid bacterin has dis- tinct though limited value. May I add that another alkaloid, emetine, has recently been used by Frazier and others for the treatment of typhoid fever with alleged good results ? It is too early to say, as yet, just how great its value is or what its limitations are. CHAPTER VII The Treatment of Acute Infections DRW. H. BURGESS, of Tennessee— the man who invented one thousand new uses for epsom salt — reduced all known diseases to five, which he named Retention, Invasion, Enervation, Trauma, and Poison. If you will look upon these as five original types with which all diseases may be compared, or as five great classes in one or another of which all known maladies may be placed, you will see that Burgess was a man who thought for himself, even though his ideas do not run in the beaten tracks. The acute infections, to which I shall call your atten- tion today, all belong to Burgess' second class. They are invasions. To use the Doctor's own words, " there is an enemy present, and this whole array of symptoms is an invasion." Under the general head of acute infections, it is cus- tomary to consider all of the eruptive fevers — such as measles, scarlet-fever, small-pox, chicken-pox — with diphtheria, influenza, whooping-cough, mumps, and others of a similar nature, most of which commonly are regarded as diseases of children, for the reason that, being of a highly contagious nature, most persons con- tract them before arriving at the years of adult life. To these may be added a formidable list of other dis- eases, including pneumonia, typhoid fever, erysipelas,. and meningitis, all of which are acute infections. But to make up the class in this way would be to include in it an unduly large proportion of all the diseases the physician is called upon to treat, consequently I shall limit the term acute infections to the diseases first named. 98 ACTIVE-PRINCIPLE THERAPEUTICS A General Consideration Let us first consider them as a class and see wherein they resemble the type, which is a composite of the whole. In the first place, they are all acute diseases and, beginning with a greater or less degree of fever, require special treatment for the hypertherma; except in those light cases in which only care, watching, and proper restraint are needed for restoration to health. Reduc- tion of temperature is best accomplished by means of the defervescent alkaloids aconitine and veratrine, aided when necessary by the tonic remedies strychnine and digitalin, according to the general method already de- scribed by me in dealing with pneumonia and typhoid fever. To the remedies named, some others may be added under special conditions. Each remedy has its special indication, and the remedies and combinations selected are varied with all the changing conditions of the patient and phases of the disease. With this under- standing, it is safe to say that the treatment for * ' fever, ' ' once learned, is learned, in its general outlines, for all classes of patients and every named disease. In the second place, since these diseases are all in- vasions of the body by an enemy from without, they are all benefited by some form of eliminative treatment, whereby the enemy may be driven from the system — or, if not driven out, at least rendered unable to thrive and grow, because the resisting power of the body has been raised and the natural immunity of the system to dis- ease, which is reduced by fecal toxins and retained waste, has been increased. Hence, elimination is an essential step in the treatment. Here again, the general principles to be followed are substantially the same as those which were laid down under the head of eliminative treatment in typhoid fever. There is, however, a variety of other drugs and TREATMENT OF ACUTE INFECTIONS 99 remedial measures that may be called in aid, among them, calomel, podophyllin, bilein — small doses, singly or combined — followed by the saline laxative; or, in some cases, the old-fashioned remedy castor-oil may be superior to any of the others. Of course, other appro- priate remedies may be called for, while sometimes a laxative enema is advisable. There is plenty of oppor- tunity for intelligent choice. But, whatever is given, give it in small doses to effect. The doctrine of clean out, clean up, and keep clean is strictly applicable in all invasions — that is, acute infections. All Are "Septic" Diseases In the third place, they are all septic diseases, due to some poison introduced into the body from without. These poisons are believed to be living germs, each one specific to the disease which it produces. In nearly all of these diseases, this germ has been discovered and its habits studied. In others, this has not yet been done, but in all probability soon will be. And, since it is impossible to eliminate the poison completely, an anti- septic is also needed, whereby the sepsis may be over- come and the germ destroyed ; or, when this is not prac- ticable, at least its vitality may be sapped and the soil in which it exists rendered infertile, so that its growth may be hindered or prevented. These results may usually be accomplished by means of chemical antisep- tics, employed both internally and externally. When taken into the system, these germicides in many cases show an affinity for some particular organ or tissue. Thus, calcium sulphide exerts its characteristic effects upon the blood ; the sulphocarbolates, upon the intestinal canal; creosote, upon the respiratory organs; hexa- methylenamine, upon the urinary organs; and so on through the list. Salvarsan acts specifically in syphilis ; 100 ACTIVE-PRINCIPLE THERAPEUTICS quinine, in malaria; emetine, in dysentery. The par- ticular remedy to be employed will, therefore, be de- termined by the nature of the disease and the organs and tissues which are chiefly affected thereby. This form of therapeutics sometimes is referred to as chemo- therapy. In the fourth place, since they are all specific dis- eases and produced by definite living germs, each one propagating only its own kind, it follows as at least a probability that each one may be successfully treated with some form of serum, vaccine or bacterin admin- istration. As a matter of fact, this form of treatment has been developed and is being employed with success in some of the acute infections ; in others it is being de- veloped and is now on trial; while in still others the specific germ has not yet been isolated and no progress has been made at the therapeutic end of the problem, though even here it seems likely that the near future will see great progress in this direction. Thus, vaccination was first employed in smallpox, antitoxin has won its greatest laurels in diphtheria, bacterins are used with considerable success in typhoid fever, while in measles, up to the latest of my information, the microorganism had not yet been discovered. Four Different Methods of Treatment We find, then, four different methods of treatment that are common to most or all of the acute infections; these being: the defervescent treatment, the eliminative treatment, the antiseptic treatment, and the biologic treatment. And it seems to me that you can get a more practical knowledge of this subject, that you will be better prepared to treat these cases when you meet them in your practice, if you will familiarize yourselves with the general nature and specific applications of each TREATMENT OF ACUTE INFECTIONS 101 of these different methods as well as the class of cases to which they are adapted, once for all, rather than to take rip the individual diseases separately and learn a separate treatment for each one. By this I do not mean to teach you that any two of these diseases are to be treated in the same way, or even that any two cases of the same disease are to be so treated; but only that there are certain general prin- ciples and conditions which are the same in each, and these may be learned once for all. You will be struck by the fact that these four forms of treatment are in general the same as those which I presented to you the other day in speaking of the treat- ment of typhoid fever. This arises from the fact, to which I have already alluded, that typhoid fever, strictly speaking, is a member of this class, an invasion, an acute infection. As a matter of convenience and because of its great importance, it has been considered by itself. But the general principles are the same as in the other members of the class. In addition to the four forms of treatment already referred to, it is necessary to make mention of at least one other, namely, symptomatic treatment. In this, as a sort of miscellaneous class, we may place all the meas- ures and remedies not already enumerated that are re- quired in the treatment of special symptoms, and which may or may not occur in any of the cases mentioned; which, though, when so occurring, are in the main not essential, but only incidental to the disease considered. Symptomatic Treatment An illustration of this is found in the use of morphine, which may be called for in almost any disease, at times, for the relief of severe pain ; but it is really no part of the treatment of the disease, being employed only for the relief of a symptom. Under this head, we use also 102 ACTIVE-PRINCIPLE THERAPEUTICS heart and nerve stimulants and sedatives; remedies to aid digestion and improve nutrition; remedies that re- lieve local anemias and congestions, either by local or general action; and remedies that attack local foci of disease. We will now proceed to take up a few of the diseases individually, but only very briefly. My aim is not to exhaust the treatment, but only to suggest a few rem- edies for special diseases, and leave the rest to be treated according to the general principles which we have already considered. The Treatment of Measles Rubeola, or measles, is perhaps the most common and one of the most contagious of the eruptive fevers, few children escaping it. The symptoms and diagnosis are important, but it is not for me to dwell upon these. The first essential of treatment is, to begin early. The second is, to have full control of your patient and the family. Given these two things, and the responsibility is yours. Failing of these, the responsibility is divided, as is equally the probability of recovery. Treat the fever on general principles. Keep the bowels open and the intestinal canal reasonably aseptic. Saturate the patient with calcium sulphide. I shall give this last advice so often, it may be well to tell you just how to proceed. In the first place, you must remember that calcium sulphide is a somewhat unstable drug and that many of the preparations on the market are utterly without value, because of the fact that they have lost their strength. No preparation which does not reveal itself by the smell of sulphureted hydrogen soon after it has been ingested, is of any medicinal value whatever. So, when you are taking either the granules, pills or tablets TREATMENT OF ACUTE INFECTIONS 103 of this substance, if you do not smell "rotten eggs" shortly afterward, your drug is of little value. As a matter of fact, judging from what information I can obtain, much of the calcium sulphide sold is of little value. This fact accounts for the widely differing opin- ions of different physicians concerning the value of this drug, some being enthusiasts in its favor, others declar- ing that they have never found it of the slightest value. The very first thing, then, is, to be sure you have a good drug. Some coated tablets keep their strength fairly well, but the granule seems to preserve its virtues better than other pharmaceutic forms. My own experience has been mostly with 1-grain tab- lets and 1-6-grain granules of proven reliability. Of these, the granules undoubtedly are to be preferred, and a 1-6-grain granule taken every hour will do more than a 1-grain tablet every four hours. Nevertheless, since many adult patients, especially if not seriously ill, will not take a small granule every hour, when they will take a large tablet every four hours, we sometimes must give the tablet or else order several granules at a single dose. But, whichever preparation is employed, be sure that it is active — that is to say, that it "smells the real thing." Whether or not the use of this remedy previous to ex- posure will render one immune to the disease, I am not prepared to say with any degree of certainty. I do believe, however, that such a saturation established either previous to exposure or during the stage of in- cubation would either prevent, abort or largely modify the symptoms of the disease; and I should use it with confidence for this purpose. In addition to this use as an antiseptic, the sulphide of calcium is also the best remedy for the cough of measles, which is hard, harsh, and hoarse. Indeed, for this kind of cough, no matter in what disease it occurs, 104 ACTIVE-PRINCIPLE THERAPEUTICS there is. no better remedy than calcium, sulphide. Here the granules may be given every one or two hours or the tablets every two to four hours. At the same time you are prosecuting the germicidal treatment look out for elimination, by giving 1-10-grain calomel every half hour for ten doses, following this in an hour with the proper dose of saline laxative. If there is obstinate constipation or intestinal autointoxication, add to the calomel an equal quantity of podophyllin or else use the compound granule containing 1-6-grain each of calomel and podophyllin, giving six doses only. Re- peat the saline laxative, if necessary, in an hour or two, until free movements result. Or it may be advisable to give an enema. Meantime the child should be bathed in a carbolized solution of epsom salt, made by dissolving an ounce of the salt in a quart of hot water and adding 10 minims of carbolic acid. This is an excellent lotion to use for sponging the patient in all cases of the eruptive fevers, these bathings to be repeated once or twice daily through- out the course of the sickness. Aconitine may be prescribed for the fever, in the usual doses. That is to say, to 24 teaspoonfuls of hot water in a cup, add 1 granule for each year of the child's age and one additional granule. This is the general rule for active-principle dosage in the case of children, and is known as Shaller's rule. The frequency of the dosage is regulated by the height of the fever, the aim being to keep the temperature below 102 degrees. But, when elimination and antisepsis have been carefully attended to, in a large proportion of the cases the fever will be but slight and little, if any, treatment for it will be u coded. In the case of children, some practitioners prefer to substitute gelseminine for aconitine when there is present the special indication for the former remedy, namely. TREATMENT OF ACUTE INFECTIONS 105 a flushed face, bright eyes, contracted pupils, and in- creased heat of the head. When this is prescribed, the same rules as to dosage prevail. Except in severe and long-continued cases, it is seldom necessary, when dealing with children in these diseases, to resort to the combination known as the trinity and the defervescent granules. When the eruption does not come out promptly, a hot bath, hot drinks, sponging with water containing mustard, or hot-packs on the chest will usually aid ma- terially in producing the desired result. This is im- portant, as there is always danger in the delayed erup- tion. The mouth, nostrils, and throat should be cleansed carefully with some alkaline antiseptic solution and the ears syringed with warm boric-acid solution once or twice a day. The bronchial symptoms may be largely controlled by means of inhalations, once in four hours, of a medi- cated vapor made by adding 20 drops each of oil of eucalyptus and oil of turpentine to a quart of boiling water. The diet should be light, consisting mainly of broths, gruels, fruit- juices, and the like. Special symptoms must be met as they arise. The Treatment of Scarlet Fever Here again the standard antiseptic is calcium sul- phide, and this should be given, not only to the patient, but to all exposed persons who have not had the disease. My own experience has convinced me of its great value. I will mention but one instance. A woman of thirty-five was taken down with scarlet- fever, which ran a fairly typical and moderately severe course. During her illness, the house was strictly quar- 106 ACTIVE-PRINCIPLE THERAPEUTICS antined, and in it, besides herself, were confined her hus- band, her own little daughter of seven or eight years, and her husband's sister — none of whom ever had had the disease. From the very onset of the disease, I saturated all four persons with calcium sulphide, in the manner de- scribed under the head of measles. The smell of the sulphureted hydrogen gas was obvious in the breath of each one — and this is essential to securing the desired results. This treatment was continued until the patient recovered and the quarantine was removed. Neither of the exposed persons contracted the disease. This per- haps was not strange in the case of the adults, but that the child should escape certainly is suggestive. The three well persons in the house went freely in and out of the room where the sick woman was confined, no restraint being put upon them. I am aware that this one case proves little or nothing. Still, as one of a considerable number of similar cases occurring in my own practice and in that of my friends, it serves to confirm me in placing much reliance upon this drug as a preventive of scarlet-fever and to think that perhaps it acts the same in the other contagious fevers — though my experience with the latter has been less extensive in this respect. Another method of prophylaxis worthy of trial and likely to prove of value, although it has not as yet won general adoption, is the use of the scarlatina prophy- lactic bacterin. Further experience with this is desir- able. The treatment of the disease, when developed, is simi- lar in some respects to that of measles. Howovoi', here the temperature is higher and the general symptoms are more severe, while the local symptoms call for close attention. Carbolated epsom bath and general antiseptic treat- TREATMENT OF ACUTE INFECTIONS 107 ment are of value here as in measles. The mouth and throat should be sprayed or gargled freely with a solu- tion of Seller's tablets, camphomenthol, borothyme, or some similar preparation, in proper dilution. Anoint- ing the entire body with cacao-butter or camphorated oil does much to relieve the extreme itching; also to lessen the contagiousness, if, as is generally taught, the contagious element is found in the scales which flake off the body. Intestinal antisepsis may be observed, with good results, from first to last. When desquamation is complete, the patient should take a hot bath in some antiseptic solution, then put on sterile clothing; while the rooms must be disinfected with formalin gas. The Treatment of Diphtheria Diphtheria is due to the Klebs-Loeffler bacillus, and this malady, previous to the discovery of antitoxin, was the most dreaded of all the acute infections. But now it has been largely shorn of its terrors, thanks to the antitoxin, and is now less to be feared than scarlatina or measles. You whose memory does not reach back beyond the days of antitoxin cannot realize the wonderful change which this remedy has brought about in the prognosis of this disease. For myself, I well remember my first experience with it, and the radical transformation it wrought in my own outlook. It was in the afternoon of December 27, 1895, when an Italian girl seven years of age was seen by a brother practitioner and, being found to have well-marked diph- theritic membrane in the throat, was duly reported to the board of health. As this physician was called away that night, he left the patient in my charge. When I saw the girl the next morning, I found her throat liter- ally filled and packed with diphtheritic membrane and 108 ACTIVE-PRINCIPLE THERAPEUTICS realized at once that, situated as she was and good care- taking impossible, there was almost no chance for her recovery with the usual treatment. Antitoxin being a new remedy and much praised, I determined to try it ; but, the next day being a holiday, I had great difficulty in getting the antitoxin from Boston. However, I finally succeeded, and at 7 o'clock in the evening I injected 1000 units of the remedy; this being the dosage then prescribed. That was Thurs- day evening. On Sunday morning the child's throat was entirely free from false membrane and she was sitting up and writing on her slate. On the following Tuesday recovery was nearly complete and I paid my last visit. This result cannot seem as marvelous to you as it did to me at that time • for, you are used to seeing diphtheria treated in this way, and with similar results, while I at that time was not. The general experience with antitoxin therapy — and which should guide us — is that, if given on the first day of the disease, the mortality is almost nil, while for each day wasted the death rate is largely increased. Another score for the early beginning of treatment. Along with antitoxin, the usual antiseptic precautions should be scrupulously observed, not only as to the patient, but for the furniture, rooms, and all individuals. All exposed persons should be immunized by receiving a minimum dose of antitoxin. Use the concentrated antitoxin (globulin solutions) only. Internally, calcium sulphide, echinacea, nuclein, and calcidin are valuable remedies; and right here I want to add that while antitoxin is the specific remedy for diphtheria, there are many other useful remedies that should be used to meet special indications, some of which have just been mentioned. Of special importance is attention to the heart, which suffers severely. Watch TREATMENT OF ACUTE INFECTIONS 109 it carefully, giving strychnine, digitalin, and other remedies as indicated. The principal source of infection is the diphtheria " carrier" — the individual who has had diphtheria (per- haps in such a light form that it was not properly diagnosed) and still harbors the Klebs-Loeffler bacillus in his throat. After clinical recovery be sure that the throat is free from this germ. If it lingers, clean it up by using sprays containing suspensions of the bacillus bulgaricus. The same local treatment is useful during the course of the disease; but, of course, no antiseptics should be used when these cultures are employed locally. In diphtheritic croup, intubation or tracheotomy some- times becomes necessary. My only fatal case of diph- theria treated with antitoxin was one of laryngeal croup. In cases of croup which is not membranous, calcidin proves successful in nearly all cases. The Treatment of Grip The grip, or influenza, is a disease of many forms and a great variety of symptoms. The violence of the dis- ease may fall upon almost any of the organs or systems of the body. The most common form is that in which the respiratory organs bear the brunt of the attack. Or, this may fall upon the digestive organs or upon the nervous system. Probably these three are the most com- mon forms. But when you have learned the grip from one angle — how it looks and how to deal with it — it is likely, in the next case to which you are called, to strike in a new way and at different organs; so that it is really a difficult matter to get on intimate terms with this protean monster. It is not a pleasant matter, either. And when there are so many forms and such varying symptoms it is not strange that the treatment varies greatly with 1.10 ACTIVE-PRINCIPLE THERAPEUTICS different men and that there is as yet no general agree- ment. Nevertheless, in all its forms, there is one invariable characteristic of influenza, and that is the great depres- sion. If there is a weak spot in the system, the grip is sure to find it out and force an entrance at that spot. I might go a step further and say that, if there is no such weak spot when the grip attacks a man, there is sure to be such a one when it leaves him. Therefore, every form of treatment should aim at supporting the patient; the vital powers must be sustained in every possible way. Beyond this, the treatment is largely symptomatic. Alcohol, opium, and all narcotics are to be avoided, because of their secondary depressing effects. Also the coal-tar products are looked upon with suspicion by the best therapists. Strychnine and digitalin frequently will be found necessary. For the fever, I have no better plan to offer than the usual dosimetric method, with which by this time you ought to be getting somewhat familiar. Aconitine in the early stages perhaps, but more likely the trinity granule from the beginning. Always fortify the heart. Do not wait for the symptoms of depression to manifest them- selves, but anticipate them and think yourself fortunate if you are able to forestall them. Heat is a valuable adjunct to the treatment. The hot bath, hot-water-bags, hot drinks, hot capsicum-tea — all these are good. Rest in bed is essential while the extreme depression lasts; and this is true in all forms of the disease. Highly nutritious and easily digested food, such as turtle-soup, clam-broth, raw oysters, milk and eggs, fruit- juices, coffee, and the predigested foods, may be given in small quantities every two or three hours and pushed to the limit of the digestive capacity. TREATMENT OF ACUTE INFECTIONS 111 In the respiratory form of the attack, it is well to syringe the ears and irrigate the nasal passages with the alkaline antiseptic solutions, and to spray the nose and throat with campho-menthol or a standard anti- septic oil. Cresoline, oil of eucalyptus, and similar sub- stances may be vaporized, to fill the room with antiseptic vapor. For internal use in this form of influenza, iodized calcium is an especially valuable remedy. Another peculiarity of grip is that it is liable to lead to all sorts of complications. One of the most common and dangerous of these is pneumonia — and the pneu- monias of influenza are mixed infections, and always dangerous. We are still lacking in the knowledge of any specific antiseptic. We cannot yet with confidence attack the bacillus of influenza, either with a chemical product or with a bacterial vaccine. These things will come, we confidently hope and expect ; but as yet the treatment is largely symptomatic. Grip is a tricky devil, and the best way to meet him is to be clothed in the armor of good health and be guarded by the best of care ; and, if attacked, to give support at every avenue. To recapitulate briefly: In an epidemic of grip or when exposed to conditions which favor its approach, 1. Live simply, guarding your health on every hand ; especially, look out for colds, be careful of your diet, and spare your nerves. 2. If attacked, eliminate poisons and tissue waste by means of the usual measures in those circumstances ; support the system by proper nourishment and tonic medication; treat symptoms as they occur; avoid ano- dynes and narcotics. 3. Look out for complications. Much more might be said, both of this and the other diseases of this class, but the hour is up and I must postpone further discussion until the next time. CHAPTER VIII The Management of Chronic Maladies UP TO this time we have considered only the treat- ment of acute diseases. In these conditions the needs of the patient are urgent. The treatment must begin early, and be pushed to effect. In the words of Burggraeve: "To acute maladies we must oppose a sharp and active treatment; that is to say, the treat- ment must proceed as rapidly as the disease." It must be remembered that in these cases the result to be sought for is speedy recovery, the thing most to be feared being death. This afternoon, however, we are to consider the general principles that should be followed in the management of chronic maladies, where the progress of the disease is slower, and where improve- ment and comparative comfort of the patient often is the best that reasonably may be anticipated, and where death is not always the worst thing to be feared. Some chronic diseases are curable under proper man- agement, while others are incurable under any manage- ment or any form of treatment. You may ask me, "If a disease is acknowledged to be incurable, why treat it?" The point is well taken; the answer, however, is plain. Suppose you yourself have a well-marked valvular disease of the heart. You may be quite sure that your affection never will be cured, never can be cured; still, is that any reason why you should be abandoned by your physician and left to suffer the worst that nature can bring upon you? Certainly not! For, with proper care and such treatment as may be indicated, you can in all probability go on for twenty years or longer in comfort and good health, scarcely knowing that you have leaky valves, save as it is revealed to you by the 114 ACTIVE-PRINCIPLE THERAPEUTICS stethoscope of the medical examiner; while without ap- propriate treatment life would soon become a burden and death a welcome relief. It is told of a noted divine that he once gave a very remarkable prescription for the attainment of long life. Listen, and take note of it, for there surely is something in it. This is how to attain long life: "Have an in- curable disease — and take care of it." I do not, indeed, advise that you should follow liter- ally this suggestion, especially the first part of it ; and, yet, I think that if you will read between the lines you will see that it is one of the best prescriptions for lon- gevity that ever was given. For you may have noticed that it is the bluff and hearty athlete, the man who seems always well and active, the bon vivant who enjoys his food and thinks he can eat anything, because he has a cast-iron stomach — it is this kind of a man who has a way of dropping off suddenly in time of stress or strain or of dying quite unexpectedly at an age not past middle life. On the other hand, the man who has found his limi- tations, and who found them early in life; who knows that he has disabilities and weaknesses, and where they are to be found — and who then guards his weak spots with zealous care — this is the man who lives to a re- spectable old age (though perhaps not to extreme old age) and who does his full share of the best work of the world. The reason is that he has learned to take care of himself. And so it is with many chronic maladies: if early recognized and properly cared for they are fully compatible with length of days, a useful life, and per- sonal enjoyment. These things are worth remembering when we are considering the management of chronic dis- eases. Another difference between acute and chronic ail- ments is that when a person is ill with an acute disease, JMANAGEMENT OF CHRONIC MALADIES 115 if the tide is turned and recovery sets in he expects to be well in a short time, able to stop all medical treatment, forget all thought of taking care of himself, and drop back into his old habits of living. But many times the chronic patient must content himself with something less than this — must make up his mind to keep a close watch over himself all his life, and it may be take more or less medicine as long as he lives — that is, if he wants to live long or be of any use in the world or enjoy him- self while he lives. It must be remembered that there are many abnormal conditions which, while not classed as diseases but merely as "diatheses," yet, are the cause of great discomfort and much suffering and meanwhile prepare the way for serious and even fatal diseases. For example, there is the condition — alas, all too common — of chronic consti- pation, which results in autointoxication, arteriosclerosis, rheumatism, neuralgia, and unnumbered other forms of suffering. Chronic Constipation Chronic constipation has many causes, all of which may be included under the two heads of inherited ten- dencies and acquired habits. It can be avoided in most instances by correct habits, provided they are formed in early childhood; and even after it has become in a measure fixed much may be done to relieve and correct it by proper diet, hygiene, and remedial measures of various kinds. I do not know of any medicine which can be depended on to cure constipation. In fact, very few confirmed victims are ever really cured at all, although they may be greatly relieved. However, the combination that has given me more help than any other, and which comes nearer to being a cure for chronic constipation than any 116 ACTIVE-PRINCIPLE THERAPEUTICS other combination of drugs of which I have any knowl- edge, is the little anticonstipation granule devised by Doctor Waugh. In this granule a number of drugs are combined with great skill for the purpose, and the fin- ished product possesses the unusual property of produc- ing the desired effect in gradually and constantly re- duced doses, until at last, when taken in strict accord with the directions which Doctor Waugh has given, the remedy can finally be dropped entirely; and, with proper care, the constipation will not return. That is to say, this is the way it works in favorable cases. However, in order to secure the result named, it is not enough merely to swallow a certain number of granules at a given time each day. Like the great painter's colors, the granules must be "mixed with brains." Burggraeve's directions again apply here: "To chronic maladies, we must oppose a deliberate method of treatment. That is to say, the treatment should proceed slowly, in proportion to the lengthened duration of the disease. ' ' Many cases of chronic consti- pation fail to be cured because of the too rapid with- drawal and too early discontinuance of the remedy. Acidemia Then there is the condition known as acidemia, which is closely related to the so-called uric-acid diathesis and the various manifestations of rheumatism. As among its early indications may be mentioned fermentation in the different portions of the alimentary canal, with eructation of gas, sour stomach, heartburn, and an un- duly acid urine. This latter is easily discovered by Har- rower's method. When this acidity is found greatly to exceed the normal, it may be corrected, either by the administration of alkalis, to neutralize the acid ; or by means of eliminatives designed to stimulate the glan- MANAGEMENT OF CHRONIC MALADIES 117 dular organs to greater activity, whereby the acid de- posits may be removed from the system ; or by a combina- tion of both of the two methods, in conjunction with such a regulation of the diet and general habits as will prevent or at least lessen the liability to similar deposits in the future. One of the best remedies for this purpose is Sodoxy- lin, containing sodium bicarbonate and sulphocarbolate, colchicine, juglandoid, and xanthoxyloid, besides sodium chloride and aromatics. This is put up in the form of a coarse granular powder, is readily soluble in hot water, and is not unpleasant to the taste. The most reliable indication for the use of this combination, and one in which I have never known it to fail of being useful, is a high urinary acidity. The simplest way with which I am acquainted of determining this acidity is by means of Harrower 's sodium-hydroxide test. When the urinary acidity, as thus indicated, goes up, from the normal of from 30 to 40 degrees, as indicated by the acidimeter, to 60 or 80 degrees or more, as often happens, then you may safely prescribe this remedy, with the confident assurance that it will bring help and comfort to your patient, besides the reasonable probability of a cure; provided, of course, this remedy is properly used and continued for a sufficient length of time. The patients to whom I first administered this mixture were selected because they showed a high degree of acidity of the urine, and their perspiration was so acid that it would tarnish chains and rings and gold and silver watches, and the like. One was a case of arthritis deformans of long standing in an elderly woman, and the other, one of alimentary glycosuria in a young man. I prescribed calomel, podophyllin, and the bile salts to be taken at night, with a sufficient dose of a saline laxa- tive in the morning to insure free movements of the bowels. This treatment was attended by great benefit 118 ACTIVE-PRINCIPLE THERAPEUTICS and improvement in each patient, but both were obliged to continue it almost uninterruptedly for two or three years in order to keep up this improvement. In due time, however, conditions so changed that the improve- ment became virtually permanent, and it only was neces- sary for them to resort to the remedies in the occasional relapses occurring from unfavorable circumstances or lack of proper care. Of course, the arthritis deformans of these persons is not cured, nor ever will be; but the patient has been made vastly more comfortable and ex- istence rendered more enjoyable by means of the remedy. Another remedy of a somewhat similar nature, espe- cially useful in chronic rheumatism, is calcalith, com- posed of calcium carbonate, lithium carbonate, and colchicine, with aromatics. My personal experi- ence with this combination has not been extensive, but it is considered a most effective remedy for many of the common manifestations of the uric-acid diathesis, such as lithemia, gout, lumbago, certain forms of eczema, and so on, in addition to the common forms of articular rheumatism. There is nothing secret in these combinations, and the physician may write his own prescriptions, adapting the drug and the dose to each particular case, if he pleases. There are decided advantages in this lat- ter method ; the only disadvantage occurring to me being that most physicians cannot write offhand, and many druggists cannot compound prescriptions that will pre- sent the desired remedies in a form compact, convenient, and pleasant for use as those which have been prepared in large quantities by skilled pharmacists. By the rational employment of these and other rem- edies of the class, much may be done for the abatement of acidemias. The indications are not difficult to de- termine, nor are the remedies unpleasant to take — an important matter in chronic conditions, where the treat- MANAGEMENT OF CHRONIC MALADIES 119 ment must be long-continued. When in your practice you are confronted by conditions of this nature, you will find them worth trying ; and, if you try them faith- fully, making an intelligent application of the general principles which I have suggested and follow the special directions which you will find laid down in the books of active-principle practice, you may rest assured that you will accomplish much good for your patients. Tuberculosis Great headway has been made in recent years in the control and prevention of tuberculosis, and the present death rate is less than half as great as it was not longer than fifty years ago. According to the modern management of tuberculosis, as practiced in sanitariums throughout the country, the three great fundamentals of treatment are: (1) fresh air; (2) rest; (3) forced feeding. Remember — air, rest, food. However, even these commonplace agents require care and discretion in their employment, and much harm may be done by their injudicious application. Thus, even fresh air may be of the wrong temperature or humidity or in other properties, or it may be managed injuriously, as in the case of drafts when a patient is in a state of perspiration, or being cold air when he is heated. Many persons undoubtedly have taken cold and had their lives shortened by the routine but injudicious use of fresh air, without regard to other conditions. So even rest should not be absolute, save in extreme conditions, but it needs to be mixed with a proper but variable amount of exercise (plus "brains")- Forced feeding is far from being an unmixed blessing, and I believe it to be in many instances a very unsafe pro- ceeding, if not directly harmful. Not what is taken 120 ACTIVE-PRINCIPLE THERAPEUTICS into the stomach, but what is digested and assimilated, is the measure of improvement. Each patient needs individual study, in order that the treatment may be adapted to his personal needs. I am one of those who still hold to the old-fashioned notion that there are various medicinal agents that will aid greatly in the treatment of tuberculosis. Measures for the improvement of digestion frequently are called for, and when rightly used are of great value. Espe- cially are they likely to be needed when forced feeding is the rule. Pepsin, pancreatin, papain, and the various compound digestants many times are called for. Nuclein and lecithin are of value in strengthening the defensive forces of the system and in building up the nervous system. Iodine in its various forms, but oftenest (as a matter of preference) in the form of iodized calcium, benefits in many cases. A remedy in which I personally have great confidence is creosote. I can say this the more freely and strongly, because this is a remedy which has never been monop- olized or even specially advocated by the active-prin- ciple medicationists. To my mind, creosote is to the respiratory organs what calcium sulphide is to the blood and tissues generally, the sulphocarbolates to the intes- tinal tract, hexamethylenamine to the urinary organs, and so forth. It is both an antiseptic and an expec- torant. It is of value in pneumonia in all its forms, in bronchitis, both acute and chronic, influenza, and tuber^ culosis. It loosens and lessens the cough, relieves irrita- tion and promotes resolution and healing. I have prescribed creosote in various forms, including plain creosote in pill and tablet, as carbonate of creosote (or creosotal), guaiacol, potassium sulphonate of guaia- col (or thiocol), and calcium creosote (or calcreose). Some of these are proprietary or patented preparations, and, hence, are open to boycott by the ethical purists. I MANAGEMENT OF CHRONIC MALADIES 121 do not like patented preparations, and I do not like trade- names of drugs ; but, I can see that each of them has its advantages, and when I have found a remedy which benefits my patients, that fact alone outweighs all ques- tions of ethics with me. And when a remedy has once established its usefulness in certain definite conditions of disease I prefer the original, even though it be a proprietary. The use of creosote in tuberculosis is as old as the hills and is vouched for by a long line of our best thera- peutists, from Reichenbach in 1833 down to the present time. Potter says of it that "in pulmonary tuber- culosis, when well borne by the stomach and continued over a long period of time, it has probably proved more efficient than any other remedy. ' ' Sajous states that "creosote is a valuable remedy in the first and second stages of tuberculosis, excepting those cases in which asthenia is to any degree marked. ' ' Thompson says: "The creosote treatment of tubercu- losis is a curious revival, after more than sixty years, of the use of a drug which fell into disfavor after its original trial. It is, on the whole, the most satisfactory drug for tuberculosis. ' ' Bartholow writes : ' ' Internally, also, creosote and carbolic acid, especially the former, have been used with conspicuously good results in the treatment of the several forms of consumption, except phthisis florida." Even Osier, who is very nearly a therapeutic nihilist, agrees that it "is an old remedy, strongly recommended by Addison; and the reports of Jaccoud, Fraentzel, and many others, show that it has a positive value in the disease." I have had considerable experience in the use of thiocol ( which is chemically the potassium sulphonate of guaia- col) , principally in the treatment of pneumonia and the other acute diseases of the respiratory organs ; and have come to think very highly of it. The special point in. 122 ACTIVE-PRINCIPLE THERAPEUTICS which it excels the cruder preparations is that it is not unpleasant to take and that it will be borne by the stomach in any desired dosage without creating any dis- turbance. I do not claim that it has any virtues other than those of creosote or its active ingredient, guaiacol ; still, I consider it as one of the best, if not the best, of the preparations and derivatives of creosote. The only drawback to the use of thiocol is its high price (owing to the German patent, which must now be nearly ex- pired). As for calcium creosote, or calcreose, my experience with it has been much shorter and less extended. As to- this preparation, however, there undoubtedly is an ad- vantage derived from the calcium with which the creo- sote is combined. Clinical workers have seemingly dem- onstrated the theory that calcium starvation is a prime factor in the causation of tuberculosis. Lime-starved dogs fall easy victims to bovine tuberculosis, while the addition of calcium compounds to their diet cuts short the progress of the disease and they gain weight and are restored to health. (See Van Giesen and Lynah, Med- ical Record, Nov. 27, 1908, and July 1, 1909.) It is well known that calcium is essential to the formation of the fibrin element in the blood, and also that the healing of tuberculosis foci is largely a calcification process. In these facts I find the reason why calcium creosote acts so favorably in tuberculosis. My attention was called to calcium creosote not very long ago by a medical friend who himself is a victim of tuberculosis, having suffered from repeated hemorrhages, but who still continues to do a good general practice in one of our New England cities. This doctor assured me at that time that he did not think he would still be alive were it not for the benefit which he had derived from the use of calcium creosote. So strongly was I impressed by this remark, coming from a man in whose judgment MANAGEMENT OF CHRONIC MALADIES 123 I had great confidence, that I at once began prescribing it for my own patients; and I have found it of great value. One other method of treatment for tuberculosis re- mains to be spoken of, one which has been strongly advo- cated and as strongly condemned. This is the vaccine, or bacterin, treatment; that is, the use of the various preparations and cultures of the bacillus tuberculosis. The pendulum has swung high and swung low in rela- tion to this much debated subject, from the days of Koch and his tuberculin, down to those of Friedman and his turtle-serum; and the question is still unsettled, with much difference of opinion yet existing. On the whole, however, it may be said that the advocates of the biologic therapy are steadily increasing; and it seems probable that, with future improvement in the preparation and technique, this method will be generally accepted as one of the most important aids to the medical treatment of tuberculosis. Epilepsy The last of the chronic diseases to which I shall call your attention is epilepsy. This is a chronic nervous dis- ease, characterized by recurrent general paroxysms ap- pearing at variable intervals, and attended by loss of consciousness and sensation. Its principal forms are the grand-mal, or major epilepsy; petit-mal, or minor epi- lepsy, and Jacksonian, or cortical, epilepsy. The theory of epilepsy generally accepted assumes the existence of a convulsion-center at the base of the brain, irritation of which will produce an epileptiform con- vulsion. The irritation may come from many different sources; but when once convulsions have been induced, no matter by what cause, they will be brought on more easily with each succeeding attack, until finally such 124 ACTIVE-PRINCIPLE THERAPEUTICS changes have been wrought in the convulsion-center itself that thereafter the seizures occur at irregular in- tervals, without the intervention of any apparent cause. Epilepsy does not belong to the class of self-limited, or spontaneously curable diseases. Its natural course is from bad to worse, until a fatal result ensues, either as a direct result of the disease or, more likely, from the many complications following in its wake. It is esti- mated that not more than ten per cent of all victims are curable by any known method of treatment, while not more than fifty per cent are benefited in any appreciable degree even by prolonged treatment. You will see that these unfavorable statistics render the question of treatment of all the greater importance, and any plan of treatment which offers hope, even in selected cases, worthy of careful attention. In all cases of epilepsy, the first thing to be done is, to discover the primary source or cause of the irritation, and to remove or modify this as far as may be possible. The most frequent exciting causes are to be looked for in influences arising from one of three directions: the digestive organs, the sexual system, the mental func- tions. Look out carefully for all possible sources of irri- tation in each of these three directions. Time will not allow me to go into detail. If the cause can be determined, the next thing is, to remove it if possible, or, when this can not be done, to modify its effects or to render it comparatively inactive. In mild and incipient cases, no further measures may be needed to restore the patient to health ; and in a large proportion of cases there will be more or less marked improvement, either permanent or temporary. If no cause can be detected (and this is often the case), we arc accustomed to label such cases as idiopathic — although, strictly speaking, there probably are no idiopathic cases of epilepsy. MANAGEMENT OF CHRONIC MALADIES 125 The second thing to be done is, to lead the patient into right habits of living, both as to diet and general hygiene. To do this, it is essential to secure the full cooperation of the patient himself. The food must be plain, simple, and easily digested, and the ordinary rules of hygiene as to diet must be scrupulously observed. Proteids should be allowed only in very limited amounts ; still, I do not believe that they should be prohibited entirely. The saltless diet is now very generally recommended for epileptics, but I have never seen any wholly satis- factory explanation of the benefits claimed for it. In- deed, in some patients it has been found that, while the paroxysms were measurably held in check by salt ex- clusion, yet, this was accompanied by a grave nervous condition, characterized by delirium and suicidal im- pulses, and all of which passed away when salt was restored to the diet. My own practice has been a com- promise between the two extremes. I direct that no salt be used as a condiment, but I do require that the food be prepared strictly without salt. This plan works satis- factorily for the patient, and saves much trouble for the family. Moderate exercise, both physical and mental, is de- sirable, but all severe labor of body or mind should be strictly prohibited. The third indication consists in providing proper med- ical treatment. This includes general and symptomatic medication, of which I shall not speak further, as it is conducted wholly on general principles and needs no special description. It also includes, in those patients having a distinct aura, provision for some quickly act- ing means of relaxing the vasomotor spasm, overcom- ing the muscular contraction, and thus preventing the occurrence of the convulsion ; the means to be employed at the first approach of the aura. The remedy most com- 126 ACTIVE-PRINCIPLE THERAPEUTICS raonly employed for this purpose is the nitrite of amyl (preferably from perles, which may be carried in the pocket), this to be inhaled at the earliest indication of the oncoming of the paroxysm. However, the essential and important thing is, to over- come or to lessen the abnormal irritability of the con- vulsion-center. For this purpose, a multitude of drugs have been employed and are still being recommended. The one remedy which is almost universally used is the bromide of potassium or some other compound of bro- mine. But, while in some cases this is very beneficial in restraining the paroxysm, its secondary or incidental effects are unpleasant and injurious, producing depres- sion, dulness, and mental hebetude, with partial or com- plete loss of mental power ; while in a considerable pro- portion of cases no benefit is derived, the convulsions either not being affected or, not seldom, being made worse. Under these circumstances, a study of other remedies is essential, and I shall introduce to your attention two drugs which I believe to be far superior to the bromides, as has been proved by the experience of numerous phy- sicians during the past few years. These are, verbena hastata, commonly known as blue vervain ; and solanum carolinense, the common horse-nettle. Of verbena, I can speak from an experience extending over some twelve years or more. It is clearly a nerve tonic, and one of its earliest effects is in most cases to brighten up the mental powers of the patients and give them a more cheerful aspect. This is in marked contrast to the bromides. The class of cases in which I have found verbena to be especially beneficial includes, first, those in which the action of the bromides is distinctly unfavorable, render- ing the patient worse instead of better; and, secondly, the comparatively mild cases, in which the convulsions MANAGEMENT OP CHRONIC MALADIES 127 are not extremely frequent or severe, nor are the mental faculties greatly impaired. This class includes most of the curable and a large portion of the improvable cases. As to the preparation used, all my experience has been with the concentration, known as verbenin or (of late) verbenoid. This is prepared in tablets of 1-3 grain each, representing about 15 grains of the crude drug. Begin- ning with one, two or three tablets at a dose, give this dose before each meal and at bedtime. Increase by one tablet each a day {not one at each dose), continuing until either the convulsions are measurably controlled or signs of ill or unpleasant effects from the drug become mani- fest. I carry this augmented dosage, without hesitation, up to as much as six tablets four times a day, and have never met with untoward effects. In one or two cases, I have observed another result; namely, that the patient was not improved by this course, but actually grew worse. This, of course, is an indication for dropping the drug. When this occurs, I change to solanum caro- linense. Solanum carolinense is a powerful antispasmodic and nerve sedative, and, unlike verbena, in large doses pro- duces potent physiological effects. The general indica- tions for its use I find in those cases where the bromides exert a beneficial effect on the convulsions (although at the same time producing secondary unpleasant effects) ; and, further, in all cases which resist the comparatively mild action of verbenoid. Theoretically, solanum should be of more value than the former remedy; but in prac- tice I have found it far less frequently applicable; or perhaps I should say, I have found it to be distinctly helpful in far fewer cases than verbena. I have given this drug in two forms; namely, the "specific medicine" of the Eclectics, and the more exact alkaloid, solanine hydrochloride. The dose of the "specific medicine" varies from 5 to 30 or more 128 i ACTIVE-PRINCIPLE THERAPEUTK !S drops, to be taken before meals and at bedtime. The alkaloid is prepared in granules of 1-64 grain, and the dose of these ranges from three to eight or more, taken four times a day. The rule of dosage is the same as for the other active principles: begin with the minimum dosage and increase until the desired effect is produced. I have given only the briefest outline of the treat- ment which I recommend. Should any of you desire more complete details, I shall be pleased to send you reprints containing a fuller discussion and more definite instructions. In closing, let me say, Remember that epilepsy seldom is cured. Do not expect too much. When you have found a remedy which exercises a reasonable degree of control over the convulsive attacks, do not forget that it should be continued indefinitely, varied as to dose accord- ing to the needs of the case. Never pronounce a patient cured until at least two years have passed without any return of the paroxysms. >•■} M-. •£>.>* "i:.:-- LIBRARY OF CONGRESS 0D0Et3lDE315 '-•:■■('■■■ ■•'■' : -'l : »w8l&88 SS&ftKSetf 888 ^^gg