oaQQamMg Jfflggffffggfl I s3S8 WS8§§§88S :•:,.■•,■..'■::■:'.•'•:.'•.. SS :: ' : - ■••■ ■ r'y' :■'■:■. . ■ \ ?■:..■■■:;•.•:■••■■.•;:■.•:•:•:■:••'•..• ass LIBRARY. OF CONGRESS. S^ap..— :,- ©ijp^riglt 5§o. Shelf. _HSA_A'5'2- J0s UNITED STATES OF AMERICA. APPROVAL OF THE DOSIMETRIC INSTITUTE OF MEDICINE OF PARIS, 1886 FIRST (BURGGRAEVE) PRIZE, AMOUNT 2,000 FRANCS ELEMENTS OF THERAPEUTICS AND PRACTICE ACCORDING TO THE DOSIMETRIC SYSTEM J BY / DR. D'OLIVEIRA CASTRO NEW YORK D. APPLETON AND COMPANY 1888 & <&% p' ^ Copyright, 1888, By D. APPLETON AND COMPANY. THE AUTHOR DEDICATES THIS WORK TO THE ILLUSTRIOUS DR. BURGGRAEVE, AUTHOR OF THE DOSIMETRIC SYSTEM OF MEDICINE, Officer of the Order of Leopold of Belgium and of the Order of Christ of Portugal, Commander of the Order of Charles III of Spain, Professor Emeritus of the University and Principal Honorary Surgeon of the Civil Hospital of Gand ; Titulary Member of the Academy of Medicine of Belgium, Honorary Member of the Society of Russian Physicians of St. Petersburg ; Corresponding Member of the Society of Surgery of Moscow, of the National Society of Surgery of Paris, of the Royal Academy of Medicine of Madrid ; Foreign Associate Member of the Academy of Sciences of Lisbon, Corresponding Member of the Society of the Medical Sciences of Lisbon, Corresponding Member of the Imperial Academy of Rio de Janeiro, Original Member of the Society of Medicine of Gand, Corresponding Member of different Medical Societies of Belgium, etc. Civic Cross for fifty years of public services. TO M. CHARLES CHANTEAUD, Chevalier of Charles III, Commander of Isabella the Catholic, Commander of the Order of Christ of Portugal, Pharmacist of the First Class in Paris, Sole Preparer of Dosimetric Medicaments. PREFACE TO THE AMERICAN EDITION. Tins translation has been made for several laymen of New York and Boston who, having derived great benefit themselves from the daily nse of the alkaloids as recommended by Dr. Burggraeve, are desirous of bringing this admirable book to the knowledge of the physicians of the United States. The new method of treatment of disease described in this book is called Dosimetry — that is, the medicine of small doses mathematically measured. The gran- ules contain accurately weighed quantities of simple substances whose chemical composition is invariable, whose effects are always the same, and are such that they can be calculated with great certainty in advance. These substances are the active principles of the plants, and are, for the most part, crystallized alka- loids. Dr. Burggraeve, an eminent professor of the Univer- sity of Ghent, is the author of this new method of medical treatment. He was the chief surgeon of the Hospital of Ghent, and many years ago was deeply impressed by the great mortality among those who had been operated upon. He found that about two thirds of them died in consequence either of trauma- tism or of purulent infection. Later the antiseptic dressings of Lister reduced the mortality to fifteen and vi PREFACE TO THE AMERICAN EDITION. twenty per cent. Subsequently Dr. Burggraeve, by his alkaloido-therapeutic treatment, both preventive and curative, brought the mortality down to two and a half and 1iYe per cent, where it has since been maintained. He judged that the traumatic fever was due to a stoppage of blood in the capillaries, caused by a pa- ralysis or a fatigue of the vaso-motor nerves which control the circulation. He thought that, by restoring to these nerves their tone and improving their vitality, he would bring back the circulation to its normal condition and put a stop to that stagnation of the blood which is at first a source of heat and then of inflammation, and thus be- comes the origin of congestion, changes of texture, and finally of lesions. He recalled to mind a successful treatment of inter- mittent fever and cholera in Russia, in 1832, by Dr. Mandt, of St. Petersburg, described in a memoir upon Indian cholera, which was read in 1854 by Dr. Everard before the Royal Academy of Medicine of Belgium. The Academicians paid no attention to this memoir, they did not even discuss it, the cholera epidemic hav- ing ceased. Dr. Burggraeve, however, found in this memoir material for serious study, and he decided to apply Dr. Mandt's methods to the fever cases which came under his charge in the Hospital of Ghent. He, however, substituted alkaloids for the substances of the plants which Mandt had used. He gave to his patients strychnine in small doses, repeated at short intervals, to give tone to the vaso-motor nerves, and thus to re-establish the circulation of the blood. At the same time with the strychnine he gave small doses of aconitine and veratrine, to lower the temperature PREFACE TO THE AMERICAN- EDITION. vii and stop the fever. He thus made the discovery that it is sometimes possible to prevent the fever, very often to jugulate it, and always to check the fever syndrome. Encouraged by this success, he studied upon him- self and others the effects of the different alkaloids which he thought suitable to introduce into therapeu- tics. In his " Manuel di Pharmacodynamic " he describes, in a summary manner, the physiological and thera- peutic action of the principal agents employed in dosimetry. He also established some simple rules of treatment, simple in form but of the greatest value in practice. In each disease he distinguishes two peri- ods : the first, dynamic, presenting only functional disturbance ; the second, organic, accompanied by a change of tissue. It is in the first period that the physician should use the most active means possible to jugulate the disease, or cause it to abort. From this Dr. Burggraeve educed his rule to give to an acute attack an acute treatment, and to repeat the small doses until the desired effect is obtained, independ- ently of the quantity of medicine administered, thus doing away with the ideas of maxima and minima, which have been regarded as axioms (especially when employing the alkaloids), and which are as great hin- drances to success as are the massive doses which are currently employed for certain drugs. Small doses facilitate the absorption of the medi- cine, and make it certain that the needed quantity shall not be exceeded. The disease may be considered as a resistance to the remedy, or a resistance of the human organism, in a state of disease, to the remedy. The dose should v iii PREFACE TO TEE AMERICAN- EDITIOK therefore be adapted to the morbid resistance. This adaptation can not be known beforehand : the organ- ism and the condition of the patient can alone indicate it. The dosimetric physician has thus the route he is to follow clearly traced before him by the imperious indications of the facts in the case. He is in no danger of an imprudence by giving too much of the remedy, because he stops it or gives it less frequently when the useful effect he aims at begins to be accomplished ; and, on the other hand, he is not held back in his treatment by timidity, for he is guided by Dr. Burg- graeve's invaluable rule to continue giving the remedy until a useful or sufficient effect is obtained ; that is, a result which is sensible to the patient or appreciable by the physician. One granule too few may prevent the desired effect; one granule too many, by increasing that effect a little, can not do harm. As Prof. Laura says, in his "Journal Dosime- tria" : " Observation and experimentation are thus the two masters that never deceive. The experimental method has become the sovereign method in medicine." There can be no exact treatment without an exact clinical knowledge and an exact remedy. The exact remedy can only be had in the simple principles of the medicinal plants, i. e., in their alkaloids. Dr. Burg- graeve found that, by administering the necessarily small doses in a liquid form, there was a too rapid ab- sorption by the mucous membranes of the throat, etc. ; he therefore adopted the form of the granule, and he applied to a well-known and very skillful pharmacist, M. Ch. Chanteaud, of Paris, to assist him. M. Chan- teaud prepared the granules containing the different alkaloids. They are easily soluble, and are unalterable PREFACE TO THE AMERICAN- EDITION. \ x except when exposed to dampness. Each granule con- tains, according to the case, a half-milligramme, or one milligramme, or one centigramme of the active sub- stance. These quantities correspond to j^-, and ^ and about \ of a grain English. These granules are composed solely of the alkaloids mixed with and protected by sugar of milk. They are rapidly dissolved by the juices of the stomach, and are absorbed within ten or fifteen minutes, so there is no possibility of an accumulation, as sometimes happens with pills ; especially as there is, in the dosimetric treatment, a lavage intestinale every morning by taking a teaspoonful or less of Sedlitz Chanteaud (neutral sulphate of magnesia), which has the triple good effect of acting on the digestive tube, on the kidneys, and on the skin. D'Oliveira Castro writes (in another book) that the dosimetric granules are of such purity and so regular in their action that too great praise can not be given to M. Chanteaud for the courage with which he de- voted himself to the reform of Dr. Burggraeve, but still more for the constancy with which he has maintained the purity of his products. There are, unfortunately, many imitations, and some very poor ones, now offered for sale both in Europe and America ; and their use would bring discredit upon dosimetric treatment. The sole agents in the United States for the Chanteaud granules are Fougera & Co., of 30 North William Street, New York. These granules do not deteriorate if kept from humidity. D'Oliveira Castro states that some of them which he had on hand for six years preserved intact all their organoleptic and therapeutic properties. x PREFACE TO TEE AMERICAN EDITION. The hesitation which, many physicians show to using the alkaloids in their general practice seems strange when we consider that, for their hypodermic injections, they employ exclusively these active sub- stances that are chemically defined ; and that, for this purpose, they never use extracts, decoctions, or elec- tuaries. Why should the cellular tissue be given the prerogative of a treatment by simple substances, easily absorbable, while the intestinal mucous membranes are rudely attacked by gross and irritating substances, whose absorption is often difficult % If their hesitation proceeds from the fact that they regard these alkaloids as poisons, this may be justified to some extent, for the reason that in allopathic prac- tice there are numerous examples of poisoning by their use ; but not one case can be cited in dosimetric prac- tice. There are now in Europe more than three thousand physicians who use the dosimetric treatment ; many of them have done so for several years, and, in the thou- sands of cases which they have reported in the dosi- metric journals, there is not one case of poisoning by the alkaloids. As Prof. Laura says: "In dosimetry, poisoning is materially impossible." The dosimetric medicaments should always be given by small successive doses, proportioning the dose to the tolerance of the patient, and they are to be sus- pended or given less frequently as soon as the physio- therapeutic effect is obtained ; consequently, a toxic effect is never reached. Dr. Burggraeve says it is only the abuse of these medicaments which provokes a toxic action. Dr. D'Oliveira Castro shows elsewhere how a patient PREFACE TO TEE AMERICAN EDITION. xi may take successively or at proper intervals more than sixty granules of aconitine without feeling the physio- logical effect, and still less any toxic effect, or more than toxic. In order that therapeutics should derive the great- est benefit from the use of the active principles of plants, it was necessary that Dr. Burggraeve should teach the profession how to use them, not only with- out danger, but in the most profitable way. He has thus deserved the title of Reformer of Therapeutics. About fourteen years ago he founded a monthly journal in Paris, "Le repertoire universelle de mede- cine dosimetrique." It contains the report of cases treated dosimetric- ally by allopathic and other physicians in all parts of France and of some other countries. There have subsequently appeared similar dosi- metric journals in Italy, Spain, Portugal, England, and Holland, and very recently in New York. Dr. Burggraeve has written many important books on the subject ; a list of some of them is given in this work ; and, although now in his eighty-second year, he is still an indefatigable writer and a hard worker. A most useful book is the " Compendium de Mede- cine Dosimetrique," by Dr. Van Renterghem, of Goes, Zealand. It is chiefly devoted to the therapeutics of the active principles of plants. Prof. Laura, of the School of Medicine of Paris, has in press a treatise of " Pharmacodynamie Comparee." He says that his life for twenty -five years has been devoted to the hospitals, to instruction, and to his private practice. During eighteen years of this time xii PREFACE TO TEE AMERICAN EDITION. he followed the rules of the regular school of medi- cine, but for the past seven years he has devoted him- self to the study and practice of dosimetry exclusively. This work, treating of comparative pharmacology, is the fruit of his professional career. He compares the results of his later years with the earlier period of his practice. He says that he is profoundly and seriously con- vinced that this new dosimetric method is a grand progress in the science and art of medicine, that it re- stores to the physician an abiding faith in the curative powers of his art, while it spares him the dangers of an excessive treatment, and that it renders to suffer- ing humanity services much superior to those of ordi- nary medicine. The dosimetric method contains the germ of a per- fection which time and science will develop from year to year. Happy are those who are young in the medi- cal profession : they will see some marvelous things in therapeutics ! The present translation has been revised by Dr. Jules Grand, an eminent physician of the Ecole de Medecine de Paris, who has for some years followed the dosimetric practice. It has also been read and approved by the author, Dr. D'Oliveira Castro, who is a good English scholar. TABLE OF CONTENTS. PAGE Introduction (Dr. Burggraeve's preface) 1 Prologue 7 Prolegomena \ 11 Life 13 Disease — Causes of Disease — Morbid Symptoms or Effects — Morbid Elements 23 Medicaments — Impressionability — Dosage — Concerning Curative Action 36 The Therapeutic Plan 67 Pharmacological Memorial of the Dosimetric Medicaments, with the Indication for Dosage, together with their Principal Properties and Applications 77 Memorial of Diseases and the Principal Morbid Elements, with Indi- cations for the Corresponding Dosimetric Medicaments which would be most Useful 99 Elements of Practice in Accordance with the Dosimetric System . 113 ALPHABETICAL TABLE OF DISEASES. Abscess of the Liver. (See Suppurative Hepatitis, under H.) . .115 Adenitis 115 Albuminuria. (See Nephritis.) 116 Alienation, Mental 116 Amenorrhcea 119 Amygdalitis 120 Anaemia 123 Anaemia, Cerebral 128 Angina Pectoris. (See Valvular Lesions of the Heart, under H.) . 130 Angina, Pseudo-Membranous. (See Diphtheria.) .... 130 Aphthae. (See Aphthous Stomatitis, under S.) Apoplexy, Cerebral. (See Cerebral Haemorrhage, under H.) . . 130 Apoplexy, Serous. (See Hydrocephalus.) 130 Asthma 130 Asystolia (Asystole). (See Cardiectasis.) 134 Athrepsis. (See Pultaceous Stomatitis, under S.) .... 134 xiv TABLE OF CONTENTS. PAGE Balanitis 134 Beri-beri 136 Blennorrhagia. (See Urethritis.) . 137 Bronchitis . 137 Bronchitis, Capillary 142 Bronchorrhagia. (See Broncho-Pulmonary Haemorrhage, under H.) . 144 Bubo. (See Syphilis.) 144 Cancer of the Stomach 144 Cancer of the Uterus 146 Cardiectasis 146 Catalepsy 148 Catarrh, Epidemic 150 Chancre, Infecting or Hard. (See Syphilis.) 152 Chancre, Simple or Soft. (See Syphilis.) 152 Cholera Morbus 152 Chorea 174 Cirrhosis, Hepatic. (See Interstitial Hepatitis, under H.) . . .176 Colic, Hepatic. (See Biliary Lithiasis, under L.) 176 Congestion, Cerebral 176 Congestion of the Liver 180 Congestion of the Uterus 188 Congestion and (Edema, Pulmonary . . . . . . . 185 Constipation 189 Coryza. (See Rhinitis.) 194 Croup. (See Diphtheria.) 194 Cystitis 197 Cysts, Hydatid, of Liver 197 Delirium Tremens 198 Dermatoses * . . 203 Diabetes 207 Diarrhoea 210 Diphtheria 215 Disease, Addison's 219 Disease, Basedow's. (See Goitre, Exophthalmic) 286 Disease, Tuberculous 221 Dysentery 225 Dysmenorrhea . 230 Dyspepsia 232 Emphysema, Pulmonary 238 Encephalitis, Acute 239 Encephalitis, Chronic 241 Endocarditis. (See Pericarditis.) 243 Enteritis .... 243 TABLE OF CONTENTS. xv PAGE Epilepsy, 246 Epistaxis .'..... 249 Erysipelas 251 Fever, Intermittent 257 Fever, Puerperal 257 Fever, Traumatic 262 Fever, Typhoid . 265 Fever, Yellow 273 Gangrene, Pulmonary 275 Gastralgia 276 Gastritis, Acute 279 Gastritis, Catarrhal 281 Gastritis, Chronic 283 Glossitis 285 Goitre, Exophthalmic 286 Gout 288 Haemoptysis. (See Broncho-Pulmonary Haemorrhage, under H.) . 293 Haemorrhage, Broncho-Pulmonary 293 Haemorrhage, Cerebral 295 Haemorrhoids 299 Heart, Dilatation of the 301 Heart, Valvular Lesions of the 301 Helminthiasis 310 Hemicrania 312 Hepatitis, Interstitial 321 Hepatitis, Suppurative 325 Hydrocephalus 327 Hydrophobia 329 Hyperaemia, Meningo-spinal . 332 Hyperkinesia, Cardiac s , 333 Hypertrophy, Cardiac 336 Hysteria .338 Icterus 340 Incontinence, Urinary 343 Indigestion 347 Infection, Paludal 348 Infection, Purulent. (See Traumatic Fever, under F.) 350 Laryngitis, Acute Catarrhal 350 Laryngitis, Chronic 352 Laryngitis, Stridulous. (See Acute Catarrhal Laryngitis, under L.) . 354 Leucocythaemia 354 TABLE OF CONTESTS. PAGE Leucorrhcea 356 Lithiasis, Biliary 358 Lithiasis, Renal . . 361 Lumbago. (See Rheumatism.) 364 Malaria. (See Intermittent Fever, under F.) 364 Meningitis, Cerebral 364 Meningitis, Spinal 368 Metritis . , 369 Metrorrhagia 372 Migraine. (Same as Hemicrania, q. v.) 312 Muguet. (See Pultaceous Stomatitis, under S.) 451 Myelitis 374 Nephritis 378 Neuralgia 382 Obliteration of the Arteries of the Brain 385 Occlusion, Intestinal 387 CEdema of the Glottis 391 (Edema, Pulmonary 392 CEsophagismus 392 (Esophagitis . 393 Orchitis 395 Ovaritis 397 Ozaena. (See Rhinitis.) 399 Palpitations of the Heart. (See Cardiac Hyperkinesia, under H.) . 399 Pancreatitis 399 Parotitis 400 Pericarditis and Endocarditis 401 Peritonitis 404 Phthisis. (See Tuberculous Disease, under D.) 406 Plethora 406 Pleuritis 407 Pleurodynia. (See Rheumatism.) 413 Pneumonia 413 Pneumorrhagia. (See Broncho-Pulmonary Haemorrhage, under H.) . 419 Pollutions. (See Spermatorrhoea.) 419 Pseudo-Croup 419 Purpura Hemorrhagica. (See Scorbutus.) 419 Rhachitis 419 Rheumatism 421 Rhinitis 428 Rubeola 431 TABLE OF CONTENTS. X vii PAGE Scarlatina 435 Sclerosis of the Brain. (See Chronic Encephalitis, under E.) . . 438 Scorbutus 438 Scrofula .440 Septicaemia. (See Traumatic Fever, under F.) ... 442 Spasm of the Glottis 442 Spermatorrhoea 443 Splenitis 446 Stomach, Cancer of the. (See Cancer of the Stomach.) . . . 144 Stomatitis, Aphthous 446 Stomatitis, Catarrhal 448 Stomatitis, Mercurial 449 Stomatitis, Pultaceous 451 Stomatitis, Ulcero-membranous 454 Syphilis ' 455 Tetanus 459 Tuberculosis. (See Tuberculous Disease, under D.) . . . .461 Ulcer, Gastric 461 Urethritis 463 Uterus, Cancer of the 465 Uterus, Congestion of the 188 Vaginitis. (See Urethritis.) 466 Variola 466 Vesania. (See Mental Alienation, under A.) 482 Vulvitis 482 Whooping-Cough 483 INTRODUCTION The work of Dr. d'Oliveira Castro, which received the grand prize of the Dosimetric Institute for 1885, is the complement of the prize essays of Dr. Laura and Dr. Van Renterghem. Prizes were awarded to each of these three works : to the first, in connection with thera- peutics ; to the other two, in connection with materia medica. Together they form the ways and means of a well-adjusted medical budget. Practitioners will find in them all necessary directions for the treatment of acute and chronic diseases according to the dosimetric system. With such guides they should never have oc- casion to hesitate ; and they will escape the contradic- tions which the classic authors experience — of whom one might say, tot capita, tot census (as many opinions as there are individuals), if, like Julius C?esar, they give as an excuse the famous "Veni, vidi, mcV (I came, I saw, I conquered). The adversaries of the dosimetric system decry the simplicity of its means: " Always strychnine! aconi- tine ! veratrine ! digitaline ! hyoscyamine ! " As if the dosimetric medicaments were like the allopathic ones. With the latter the prescription must constantly be changed, because for the natural malady it substitutes an artificial one, as the word allopathy indicates. Do- simetry has also been reproached with the charge that it merely regarded symptoms, as if disease were an entity for which there were specifics — mercury standing for syphilis, salicylate of soda for articular rheumatism, etc. 1 2 ELEMENTS OF THERAPEUTICS AND PRACTICE, In dosimetry we regard the dominating and the varying — in other words, it is the treatment of causes and effects. If the first are often obscure, so that one might say, " Felix qui rerum poterit cognoscere causas " (happy he who will be able to comprehend the causes of things) ; the second, the effects, are constant. Symp- toms are the basis of treatment, as was well expressed by the celebrated author of ' ' Symptomatology, or Mor- bid Conditions " — " It is so unusual to cure, while it is always urgent to relieve." By the dosimetric system suffering can always be relieved and fever subdued, and it is upon this " jugulation " that the system is based. Munaret has said of it that it is an old fashion of the Greeks renewed, for it dated back to Hippocrates. If one shall object, ' ' How can one fight with an unknown enemy % " the answer would be, we are doing that most of the time, and this is the cause of the differences which prevail among classic authors. Open the work of Prof. Spring, for example, and you will see that, where he believed he was making the history of the medical science, he was pronouncing a criticism which was the truer because it was unconscious, for Spring, as a professor, was faithful to the "magister dixit" and he died of variola, a victim to his convictions that this disease can only be combated in its symptoms. D'Oliveira Castro, on the contrary, proves that the poi- soning of the blood in this disease may be combated, as the source of the trouble, by the sulphide of calcium as the dominant, and the defervescing alkaloids as the variant. That there are parasites, microbes, we do not deny ; but are they cause or effect ? In typhoid fever there are also proto-organisms ; will anyone say that this fever can not be arrested in its evolution % Where can these infinitely small organisms not be found % An enthusiast on the subject of microbes set up his microscope on a street-corner in London, and for a penny allowed each new-comer to examine a drop of water which, to the naked eye, was pure and limpid. INTRODUCTION. 3 Under the microscope it swarmed with monsters which attacked and devoured each other. It was a sermon to the crowd against water, as effective as Father Mathew's sermons against gin. Could not one tell an equally alarming tale concerning the liquids of the allopathic pharmacies, covered with mold and in active fermenta- tion? Thus, to the microbes of the disease one must add the microbes of the remedy, while the alkaloids of the dosimetric system destroy both. The duration of the treatment is not a matter of im- portance ; that which is important is, that the patient run no risks. In dosimetry crises are not recognized, because vital reactions are battles in which the results are uncertain and contain an element of chance. These are the views which have guided Dr. D'Oli- veira Castro in the composition of his book. Being addressed to practitioners, it is sparing of theories, pre- ferring to go straight to the facts. Let us also believe that this book, as well as those of Laura and Van Ren- terghem, will be found upon the table of every physi- cian who desires to succeed in his cases, cito, tuto, et jucunde (quickly, safely, and agreeably). Dr. Burggkaeve. PROLEGOMENA. LIFE— DISEASE— MEDICAMENTS— CUKATIVE ACTION— THE THERAPEUTIC PLAN. PROLOGUE. WHE!sr a man takes the trouble to write a book, and has the courage to publish it, it must be to carry out a motive of some kind or other, whether it be the hope of applause, the desire to be useful, or the necessity of satisfying the conscience, in filling what one believes to be an important lacuna in literature. In the author's case, it is not an urgent desire to write which is responsible for this book, for he has had hardly time to experience any joy or satisfaction in writing ; nor has it been a desire for glory, for he is quite conscious of his insufficiency. It is a recognized fact, however, that there is in dosi- metric literature a lacuna of considerable dimensions. When the physician brought up in the precepts of the schools, but losing their illusions at each step in his practical career, feels skepticism and unbelief surround- ing him, clouding his faith in science, dampening his enthusiasm for struggling, and strangling that zeal which is an earnest of victory, he looks around in search of a plank for safety in the midst of this wreck — for a light which alone may illumine the most difficult and the least agreeable of all the professions. Outside of the walls of classic medicine appear, on one side, the structure of Hahnemann, battered and almost demolished by positive criticism, or expectation, seeking in vain to conceal its deplorable weakness ; and, on the other, the reform of Burggraeve, growing and filled with sap, ingrafted upon the experimental method, and nourished by the purest juices of chemistry and physiology. Under all these circumstances the physi- 8 ELEMENTS OF THERAPEUTICS AND PRACTICE. cian finds himself drawn along by reason, and compelled to yield to necessity ; but the novelty of the principles of the reform, the energy of its means, the strangeness of its results, all these arrest his attention and impose upon him a prudent reserve. The most natural way to inform one's self in regard to the practice of dosimetric medicine would be to read the books which contain its doctrines. But the truth is, that the dosimetric library still wants a treatise which shall teach the practitioner to draw practical consequences from the principles formulated by the venerable head of the dosimetric school. The "New Manual," written in 1877, is not only too much abridged on certain points, but is no longer on a level with the progress which has been reached by cer- tain disciples of this school, whose most effective work has been conceived and given to the world since the manual was published. Books on therapeutics age quickly, however positive their teaching may be ; for, whatever the utility of a medication or the efficiency of a medicament may be, improvements are always supposable. The new substances introduced into the therapeutic arsenal, or medicaments more effective than those al- ready known, new modes of administration, unforeseen results from combinations hitherto untried — all these constitute an important capital of forces which one can use against disease, and which the practitioner can not and ought not allow to remain unproductive. Periodi- cal publications appear and are forgotten, and do not always present the fruit of experience in its maturity. To be first on the ground, one is often content with a hastily prepared exposition. Besides, practitioners can not read everything, nor submit every novelty to the test of experiment. Hence the necessity of condensing everything which is worth preserving in print, and that is the plan which we have followed. Using alkaloids every day, we have employed them in all the diseases PROLOGUE. 9 which we have been called upon to treat. This book is therefore only the exact reproduction of our daily practice, with the exception of certain rare diseases which we have had no occasion to treat, but for which we have formulated treatment in accord with the rules and indications of Burggraeve, or his most esteemed followers. Written from day to day, between profes- sional calls, this book is ever the narrative of our practice ; in that alone is its unity. We have always endeavored to be clear and truthful, though we might be neither wise nor learned. We hope that this effect will not be without some useful result, and we shall be satisfied if we shall be able to guide the first steps of those who desire to fol- low the paths of dosimetry after having left other schools with their illusions. Our satisfaction will be complete if this effort shall stimulate some one more competent than ourself to produce a more perfect and meritorious book. We do not dread criticisms, nor do we hope for eulogies ; our only ambition has been to be useful, and in pursuance of this end we have en- deavored to show the indications in each form of dis- ease, without any other regard for style than that of clearness. The plan of the book is a simple one. In the first part we give certain general considerations, to warn the neophyte against the astonishment which may be caused by the novelty of certain applications, or the boldness of certain principles which are far different from anything which he has hitherto been taught. In the second part we refer to the principal indications which are ordinarily presented in different diseases, and the means for satisfying them. In each chapter we insist upon the particular agents which are most useful to know, in such a way that the book may perhaps be considered as intermediate between a dictionary with- out the complete want of connection in the parts which a dictionary presupposes, and a treatise without the 10 ELEMENTS OF THERAPEUTICS AND PRACTICE. regular method of such a work. It is for this reason that the title of "Elements" has been chosen, in order to indicate that our ambition has been to serve as a guide for beginners, and a stimulus to those who can produce a more complete work than ours. This book is not intended to instruct beginners in medical studies, but only to enlighten the physician who desires to become acquainted with dosimetric treat- ment. All that is common to this system and regular practice is omitted, only the differences in the two therapeutic methods being described. The kind in- dulgence of the reader is desired. Dr. d'Oliveira Castro. Deqa de Palmeira, August 12, 1885. PROLEGOMENA. The disposition of the physician is to neglect the study of the philosophic problems which surround his science. It tends, on the other hand, to regard exclu- sively their practical application in so far as they are sanctioned by his own experience and that of others. Although he endeavors to disregard all speculative notions as to the origin of the phenomena which he encounters at every step, yet he can not help reflecting upon the principal points of his science, and investi- gating the phenomena which arrest his attention, and sharpen his curiosity in search of their first cause. The reasoning faculty, that endowment of all men, but especially of those who cultivate science, is as necessary to intellectual life as digestion to vegetative life. Bowed over the cadaver with scalpel in hand, opening and dissecting the tissues to seek in their changes for the causes of death, the physician must inquire in vain, must pursue his investigations in vain, for the supreme object of his search, life ; this has gone, never to be found. His inquiry as to what it is will never be satisfied. The lesions which have changed the tissues, the pro- found ravages which the organs have suffered, the strange degenerations which have altered their forms and their relations — these may explain the disease, with- out giving the supreme reason for death. Between the last moment of life and the first sign of death, what is going on which so condemns to decay a body which is endowed with motion, which stills forever a voice whose tender farewells break our hearts ? At this last 12 ELEMENTS OF THERAPEUTICS AND PRACTICE. moment have the lesions become so exaggerated as to destroy vitality, and to render the final struggle with the death-agony unsuccessful ? The physician who, at the pillow of the dying man, follows with painful curiosity the progress of this final scene, watching the heaving of the chest, the contrac- tions of the countenance, the convulsions of the limbs, the fall of the pulse, the elevation of the temperature, suddenly sees the chest at rest, the countenance calm, the limbs motionless ; the heart ceases to beat, and the body becomes cold. But can he, with the aid of all these phenomena, declare the secret of life, and the meaning of death % No, he can hear and observe, but in vain. The study of causes belongs to the reasoning faculty ; the discovery of the nature of causes to the domain of reason, aided and directed by logic. The clinician and the therapeutist can not be indif- ferent to the knowledge which pertains to life, for from this the knowledge which pertains to disease is derived, as well as that which pertains to health, and the means for restoring it. But it is the philosopher more than all others who should occupy himself with this study, for it embraces all nature, not being limited to man in a state of disease. But the physician is also a philoso- pher. He can not be disinterested in all the questions which are debated in the field of pure science. It is not only a satisfaction to his mind, always eager for truth, but it is a necessity for his practical work, which is never so bold nor so free as when it is illuminated by the light of wisdom and judgment. Empiricism may guide him for want of something better, but it is a blind guide, which leads now to a precipice, and again to an obstacle which can not be overcome. Unfortunately, when he interrogates science con- cerning life, he receives so many answers that his igno- rance is unenlightened. Opinions the most divergent, and schools the most opposed, have had their proselytes and their proficient advocates. But the independent LIFE. 13 mind is not satisfied with any of them, nor is it content with following any. We would like to make an end of these divergences, once for all, and, with that end in view, to present an opinion which will defy all donbt, respond to all objections, explain all phenomena, and embrace all facts. Unfortunately, this can not be done ; and if we discuss the subject of life it is not with the pretension that we shall fully illuminate the subject, for even the greatest geniuses have failed in that re- spect ; it is only to keep our promise, and express our views sincerely and loyally. Before entering upon the subject of therapeutics, it is indispensable to have some sort of an opinion con- cerning life, disease, and medical agents. What we shall say, then, will be nothing but the expression of our views upon these subjects. The reader will accord to them whatever considera- tion they may seem to merit. LIFE. Life surpasses definition. One knows when he ex- periences it, and there is no one who does not know the difference between a living and a dead body. It would be useless work for a physician to probe such questions very deeply, were it not that a more accurate and com- plete knowledge of the nature of life than is ordinarily possessed fits him the better to interfere in connection with its phenomena. Pathology is a particular manifestation of physiol- ogy, just as therapeutics is of pharmaco-dynamics. To understand disease, and to be able to establish a rational and effective method of treatment, we ought clearly to understand the fundamental object of physiology, since upon this notion are based all those with which a phy- sician has to do. In order to give a precise idea of the nature of life, it will be necessary to take as a point of 14: ELEMENTS OF THERAPEUTICS AND PRACTICE. departure certain facts and principles which are recog- nized as axioms which do not require discussion. The best method, then, will consist in studying the most simple facts, and transferring the results of such study to conditions which are more complex. Whenever we can discover life, we shall always find that fundamental body, the cell, and an essential func- tion, nutrition, and these are definitely manifested by motion. Growth, assimilation, and elimination do not exist and can not be conceived of without the displace- ment of the matter of which these rudimentary organ- isms are composed. But as matter can not exist with- out motion, as everything in nature, from the vast stars which shine at the extremities of the universe to the invisible atoms which are agitated in the smallest grain of sand, is animated by motion, as everything lives, one might say that matter is the essential factor of life. Matter, some one will say, is inert ; but this inert- ness of matter ought not to be understood in the sense of immobility, but as the impossibility with which mat- ter finds itself endowed of changing, by its own power, its motion. We can conceive, without too great mental repug- nance, that an atom of matter can be in a condition of complete repose, but that which our reason refuses to admit is, that there can be bodies and forms, except as their inherent matter is unceasingly in motion. Imag- ine, for once, that motion ceases, and all nature will be destroyed, everything will return to chaos. The vast and eternal monotony of the desert would universally prevail, without a breath of air stirring a grain of sand, or a ray of light which would enable one to distinguish between the nearest object and the most distant star. We can conceive a void, but, while matter exists, we are compelled to allow it the property of motion, which is as inherent to its nature as substantiality, impenetra- bility, and inertia. LIFE. 15 The notion of force results from that of motion. A force can not exist without motion, but it is rather the result and the effect than the cause of motion. Therein lies the apparently important difference which creates confusion between the idea of force and that of motion. Motion, being transmissible, has no need for the inter- vention of force as a cause ; but forces ought to be con- sidered as effects, which are also motions, for motions alone can produce motions. And just as motions are only causes of motion, so the effects of a motion are causes of other motions, from which it follows that forces may appear to be at once cause or effect of mo- tion. Matter can not be destroyed or annihilated. Matter always preserves the same mass and the same quality. The motions which animate this matter, and are sus- ceptible of modification, of augmenting energy, and of being transformed into new modes of motion, give way to new forms, to new molecular constitutions, to differ- ent chemical and physical properties. The force of in- ertia may be considered as true motion, as the essential quality of matter, and it should, preferably, bear the name of vibratility. All other motions are ingrafted upon this, being susceptible of augmenting it, but not of destroying it, because it is essential. The others are transmitted, augmented, diminished, decomposed, transformed. It remains permanent, while all the oth- ers come to an end and disappear. If, then, vibratility is the essential property of all matter, not alone of liv- ing matter, it must be concluded that the particular motion which characterizes life is an accessory contin- gent motion, of which we ought to search the origin out of that which constitutes matter itself. In consid- eration of what has been said, and what is to be said, we can eliminate from the vital principle all idea of force. In life there are no forces, there are motions. Still less ought we to admit the existence of a foreign substance in the organism which presides over vital 16 ELEMENTS OF THERAPEUTICS AND PRACTICE. acts, and born before the accomplishment of these acts, which it directs according to its fancy. The vital phe- nomena which we see can only be the resultant of vital movements which transpire in the inmost parts of or- ganized matter. Otherwise, conld it be comprehended how life conld be transported npon a minute portion of epidermis ; could leave one organism and be ingrafted upon another % Could one comprehend how a portion of tissue could be completely removed from an animal and, reapplied somewhere else, could resume its exist- ence as before % The transplantations of periosteum, teeth, of fragments of the skeleton, transfusion of blood, etc., would also be inexplicable if the foregoing propo- sition were not true. When one considers, on the other hand, that man, born from a simple cell, does not entirely die at one and the same instant ; that there is a capital difference be- tween the suspension of life in the noble organs and a similar condition in the less vital ones ; that in spite of the fact that the heart has ceased to beat, the lungs to respire, and the brain to think, the muscles may still be made to contract, the liver may persist in its work of assimilation, and other organs in their function of elimination, one can not help declaring that life is the sum of the elementary lives of the cells, all joined by the intervention of means of communication which se- cure all the cellular elements to each other, these means being principally the intercellular substance and the nervous system. Nevertheless, the problem thus sim- plified is not yet solved with sufficient clearness. It still remains under the same form, namely, what is the nature of the motion which determines vital phenom- ena, which is observed in the most simple organism — the cell % Let us see whether in the mineral kingdom we shall be able to find any analogous or similar phenomena, which will aid us in forming an approximate idea of what is meant by vital motion. LIFE. 17 Suppose we take a bar of magnetic iron. Would, some say that there are in it currents and motions? Nevertheless, such is the case, for, wherever polarized forces exist, this polarization can only be accounted for by motions which are exerted in a x>redetermined way. If iron filings are distributed near each of its two poles, we can see them move and arrange themselves in more or less concentric lines around the two poles, forming a definite figure. To what is this result due % To a force independent of the iron which animates the entire bar \ No ; for, if we cut the bar, each of its fragments will reproduce the same phenomena as the original, with an intensity which is clearly the same. The force, therefore, resulted from a particular motion in each molecule of iron, the sum of the vibrations producing currents in a way which has been determined. The motion which accomplishes this result is not observed in all bodies, nor yet always in the same substance. On the contrary, a difference in temperature, a modifi- cation of the medium, an alteration in the chemical constitution of the bar, or the influence of motions of another kind, will suffice to augment or diminish the magnetic motion, and with it the motions of the bodies submitted to its action. This motion may even cease entirely, the material constitution of the body remain- ing the same, or, on the other hand, being altered by new chemical combinations. To the particular mode of motion which acts upon molecules of iron the name magnetism or magnetic vibrations is given without ex- plaining the way in which this motion differs from electricity, heat, or light. And this is sufficient, be- cause motion, being a property and not a substance, has no nature or essence. Vibrations may be counted or measured, but science has not yet been able to define them or otherwise to characterize them. Start a current in a voltaic pile, in the presence of a magnet, and what will be the re- sult % The electrical motion will stimulate the magnetic 2 18 ELEMENTS OF THERAPEUTICS AND PRACTICE. motion ; the affinities of the substances which supply the current for the pile will be modified ; and if this motion be transmitted to an animal, it will have an in- fluence upon his power of contractility and sensibility. After a certain length of time it will be necessary to replace the constituents of the pile, and then it will be observed that crystallizations have occurred, the re- sults of chemical combinations and decompositions — phenomena which would not have occurred had elec- tric motion not excited them. Therefore, it will not be very difficult to understand how the phenomena of nutrition, of assimilation, and elimination, are pro- duced — phenomena which constitute the most univer- sal function of all living beings. It will suffice to conclude that matter in certain appropriate chemical and physical conditions is ani- mated by a certain motion to realize all these phenom- ena, the ensemble of which appears so incomprehensible to us. Life, then, is only an atomic vibration, a par- ticular modality of motion in matter. As in magnetism, electricity, heat, etc., we ignore the characters of this modality, and distinguish it only by its results, which we call vital, the ensemble of which bears the name of life, just as the simultaneous cessation of the most im- portant of them is called death. Around this opinion rally certain homoeopaths, certain organo-vitalists, and Burggraeve, the head of the dosimetric school, all of them regarding life as an organism animated by a par- ticular dynamic influence. What is the origin of vital motion, and what are the conditions which determine it % If life is a vibratory motion, and if matter is inert, vital motion can not begin to appear without first being transmitted. Now, the vibrations of bodies can only be produced in two ways : by transmission from other vibrating bodies, the motion of which passes into new bodies ; or by motions of another kind, which in consequence of certain resistances are transformed into vibratory mo- LIFE. 19 tions. The laws of molecular vibrations are unknown, but it may be regarded as certain that they are under the influence of the medium, the matter, the dimen- sions, and the action of other motions. Thus we see friction converted into heat, and that into light, elec- tricity, magnetism, sensation, contraction, and work. Vital motion is transmitted to substances ingested in the process of alimentation, and incorporated by as- similation, and this is accomplished with the more readiness according to their vibratory power. Oxygen, one of the most magnetic of bodies, is indispensable both to animals and vegetables. The latter form the basis of alimentation for man, who could with difficulty adjust himself to a mineral regime, although this regime could contain all the chemical substances which he loses by assimilation. Vital motion in the individual is sustained by alimentation, which supplies it not only with the elements necessary to renew and increase the tissues, but also with strength, whether it be the direct strength which it carries within itself, or the indirect which it occasions by chemical combinations and de- compositions. Thus, fermentations constitute the first degree of that mtaUzation which animates the ingesta of the body, and which ought to facilitate their incor- poration into the organism. Vital motion is preserved in the species by the elimination of a living portion of the individual, which is animated with the vibrations characteristic of such species. Thus is explained, not only the perpetuity of species, but also heredity in races and families. The necessity for the participation of the two sexes in the accomplishment of reproduction is another argument in favor of the opinion which has been advanced with respect to life. The ovule is a simple organism which must be fecundated — that is, must receive an addition of vital motion, in order to be developed and become a complex being. Hybrid formations can not be con- ceived of as resulting from two vital principles which 20 ELEMENTS OF THERAPEUTICS AND PRACTICE. are blent in each other, but rather as the result of a vibratory motion which is different from the ordinary one. Life is a motion of the same nature as other physico-chemical forces, but different from forces stud- ied in connection with physics and chemistry. It should not be confounded with heat, electricity, or affinity, from which, however, it does not differ essen- tially. There are as many different modalities of vibra- tory motion in matter as in the ether interposed between the atoms of matter. Otherwise, how can one compre- hend that the seeds of plants and the eggs of birds must have certain conditions of medium and temperature, in order to germinate and be developed 1 How, also, that life in hibernating animals is suspended until that de- gree of external temperature returns which will again start into action their different organs and apparatuses ? How, too, the consecutive death of the different tissues in the same animal ? How can one explain the influence, which is so apparent, of a great number of external and internal agents upon living beings— an influence which is so profound 1 From the foregoing the following definition of life may be accepted as a conclusion : Life is a particular vibration of matter giving rise to particular forms, and manifesting itself by functions which are only the phenomenal expression of this vibration, transformed into physical, chemical, mechanical, or psychical mo- tions. When this transformation is carried on rapidly in almost every part of the living individual, convert- ing vital motion into physico-chemical motions, it is called death. The elements in which life had been preserved die because they are not surrounded by the conditions which are essential to the performance of their functions. Life is not destroyed, however; its motion is not lost. Matter is disorganized, forms new combinations, and vital motion is converted into other forms of motion, viz., affinity, fermentation, liquefac- tion, etc. Consequently, death is the transformation of LIFE. 21 that form of vibratory motion which is peculiar to life into other modalities of motion. Having thus ex- plained the origins of life, we can get for ourselves a clearer idea of vital phenomena. Vital motion, which animates each atom of a living substance, determines a certain polarization in the molecules, and hence it is not difficult to understand how cells are formed. As these are composed of different substances, their motion undergoes modifications which correspond to the sub- stances, and gives rise to functions which also differ. But motion is not located in the cell alone ; it also ani- mates the surrounding medium, its vibrations being transmitted to contiguous matter with a facility which varies with its vibratile power, and with the resem- blance which it has to the element which we are con- sidering abstractly. Therefore, a group of cells forming a more or less homogeneous tissue, may have a common life without the existence of any particular means of relation and communication between their different elements. Just as the particles of iron filings transmit to each other, by simple contact, the vibrations of the magnet to which they adhere, so the cells are in vital communi- cation by simple contact. But when the vibrations are modified, the motion no longer has a medium which so readily transmits its influence. There must, therefore, be special organs to receive the different vibrations, and convert them into motion of another kind, through the influence of a difference in material composition, and consequently of dynamic action, and thus institute the various functions. As the intervention of rheophores is necessary to convert magnetism into electricity, so the nervous system must intervene to transform nutri- tive motion, or the vibrations which result from it, into other vibrations which give rise to impression and sen- sation. Contractility, then, is nothing but the property which certain tissues possess of transforming vital mo- 22 ELEMENTS OF THERAPEUTICS AND PRACTICE. tion into mechanical work. In the physical world do we not see, in the same way, how heat produces expan- sion in bodies, which is made use of in so many ways to accomplish work of the greatest variety both as to its nature and its energy 1 Vitality is the sum of the motions which are peculiar to each vital element. It, therefore, bears a direct ratio to the number of those elements for each tissue. But as these motions can be converted into mental and mechanical work, into heat, affinities, etc., it follows that vitality diminishes in proportion to the work accomplished. In order that equilibrium be maintained, it is necessary that it be furnished with new potentialities of dynamic force — in other words, with elements which are susceptible of receiving a reserve supply of the vital influx for which they will be the more fitted as their energies approach the nearer, in point of resemblance, to the organism in which they are about to enter. Among the vital phenomena we shall also find psychological ones, but for the present we shall not enter this labyrinth, and the more willingly, inasmuch as the physician may put such obscure questions aside, without suffering in his practical work. The nature of these phenomena is most complex. The brain is the particular organ which concentrates all the activities, and which has the power of transforming all sensations into perceptions, into consciousness. It is, in a certain way, the general organ of the senses. Thought, the will, are thus the wonderful and incomprehensible result of vital vibra- tions, just as the electric light is the soul of electricity ; a light of the original mode of which we are ignorant, a light which is different from all other lights, a vibra- tion different from all other vibrations. The brain can think and perform its functions only under certain physical conditions. A slight change in its circulation, an imperceptible lesion in its structure, may modify all the psychical phenomena. The concentration of all transmitted motions, the conflict of all these modi- DISEASE. 23 fied vibrations in the track of nervous conductors, give as a result a particular motion, which is called the soul. Just as a lens, concentrating rays of light, pro- duces at its focus wonderful phenomena, so the brain can be conceived of as a concave mirror, where all cen- tripetal impressions are focalized, and upon which are reflected and radiated all centrifugal vibrations. DISEASE. After the foregoing statements, it is easy to under- stand that each cellular element lives, not only in its own life, but also in that which animates all the other elements which are near enough to be moved in the same sphere of activity, and even in those which are remote, with which it has certain communications. There is, then, a reciprocal action of element upon ele- ment, of such a character that, when one is perturbed, its echo is perceived in all the others. Life, considered as a force composed of the entire ensemble — that is to say, vitality — is therefore the resultant of elementary energies, and the elementary energies are, in their turn, resultants in which the general resultant appears as a factor. But, as the organism can not escape from in- fluences exerted upon its vitality by the external me- dium, which is constantly varying, and the internal medium, which is equally inconstant ; as, on the other hand, vital phenomena are constantly changing the co- efficient of vitality of the organism which serves for their field of operation ; as, finally, vital motion varies necessarily with the inconstant material constitution of the anatomical elements — it follows that vitality changes every instant under the influence of as many different causes as act upon it in a modifying manner. The first law of living bodies is, therefore, the con- tinual absence of equilibrium. But, in spite of all the influences which necessarily modify the coefficient of 24: ELEMENTS OF THERAPEUTICS AND PRACTICE. vitality, the want of equilibrium is so little manifested that neither in living matter, nor in the motion which animates it, does it give rise to trouble which is per- ceptible to the individual. Thus, the functions are executed with regularity, notwithstanding the more or less periodical oscillations which characterize all vital acts, the ensemble preserving an apparent equilibrium ; for not all the functions are either in action or at rest at the same time. This apparent equilibrium consti- tutes the condition of health. When a function is performed with an expenditure of an excess of vital motion, and in such a way that other functions are prejudiced, or when its work re- quires too much time for its accomplishment, equilib- rium can no longer be maintained, the coefficient of vitality diminishes, and we have the beginning of dis- ease. Between health and disease there is, primarily, no other difference than a marked want of equilibrium, which can not be quickly restored ; the question is one of degree and of time. Disease, at its beginning, is therefore a notable and permanent diminution of the vital motion which ani- mates the organism. All the causes which antagonize the production of this motion are causes of disease. But as motion can never increase, except for a very short time, without a material substratum, it follows that all diseases have an asthenic element. When an augmentation of vital vibrations is produced by any cause whatsoever, the excess is immediately trans- formed into other mechanical, chemical, or physical motions, and equilibrium is rapidly restored. The easiest way to produce a notable increase of vitality would be to excite strychnism. This is manifested by convulsions — that is to say, an excess of vital motion is transformed into mechanical work, heat, and chemical reactions, which immediately consume the excess of vitality, and re-establish equilibrium, or may even DISEASE. 25 produce a want of equilibrium of an opposite char- acter. Those who admit the existence of hypersthenic dis- eases are victims of an illusion, and mistake the appar- ent for the real. Living matter may be incited and excited. Incitability is the property which it possesses of increasing, to a certain point, the number or the in- tensity of its vibrations. This functional impulse re- sults in a growth of substance, which establishes, in a permanent manner, this gift of vitality. Incitation is joroduced in a slow and secret manner, but yields a lasting result. It can only be realized by alimentation, and by weak but prolonged hygienico- therapeutic means. Excitability is the power of displacing vital motion, which increases with excess at some points, while it diminishes at contiguous ones. Excitation is not an increase of force, nor a means of profit nor of wealth. It is a loan which is made by one part of the organism to others. And, as this increase of motion is rapid, and as matter can not sustain it, because it has not augmented to a parallel degree, it is transformed into other modalities of motion, in order to re-establish equilibrium. The borrower is no richer than before, while the lender is impoverished, because nothing is given back. The final result of excitation is conse- quently, in all cases, an impoverishment of vitality and hyposthenia, and the diseases which show a great ex- penditure of force are the result of excitation, and are never characterized by hypersthenia. The sum of vital motion appertaining to each indi- vidual being insusceptible of rapid augmentation, un- less the substance which is to receive the excess under- goes organization, it follows that all diseases signify diminution of vitality. Consequently, everything which causes a diminution of vital motion is also a cause of disease. Now, as this motion diminishes by the removal of material substance, by its transformation into other 26 ELEMENTS OF THERAPEUTICS AND PRACTICE. motions, and by certain modifications of the medium in which, it is accomplished, it follows that vitality may be attacked by losses of material — for example, haemor- rhages, mucous and purulent discharges, etc.; by the various modes of transformation of motion — for exam- ple, exercise, hyperthermia, moral emotions, intellectual work ; by meteorological perturbations of all kinds, such as barometric, hygrometric, therm ometric changes, etc. The organism, though exposed to so many influ- ences, feels them all, and, if the want of equilibrium is not pronounced and is soon re-established, it will con- tinue to thrive, being governed by their intensity and its own coefficient of vitality, or, if the test be very long or very severe, it will show a tendency to weakness ; and it will become actually sick if the derangement be too great to remain unnoticed. It is surprising, indeed, that the organism is not oftener diseased, exposed as it is to so many vicissi- tudes, and that it almost always recovers its equilib- rium. Experience has taught man how to attenuate the most of the causes of disease, and to prevent their effects. Hygiene, which we all follow mechanically, and the mobility of the vital energies, which rapidly restores harmony among the vital forces, distributing them with regularity, explain how man can resist so many causes, both internal and external, which constantly threaten his health. From the foregoing considerations it may be con- cluded that disease, in its initial phase, is always a perturbation, or rather a diminution, of the dynamic influence which animates the organism. But this dynamic perturbation compels an alteration in the molecular constitution, in the atomic grouping of the living matter. Modifications of nutrition coin- cide with this alteration of matter, changing the form DISEASE. 27 and the work of the cells. The elements first attacked influence those which are contiguous, and these, in their turn, influence the general vitality. This altera- tion is resented by the nervous centers, which, on their part, react upon the entire organism, sending out ab- normal vibrations which further disturb the regularity of the intimate phenomena of life, and give, as a final result, lesions of substance and structure which modify the local life and the general vitality. Therefore, no perturbation can remain local or simple. It soon be- comes the cause of a circle of perturbations, which are constantly increasing in number and in complexity. The most insignificant cause, hardly able at the begin- ning to produce a dynamic perturbation, may become the point of departure for numerous dynamic and so- matic morbid effects. Diseases, then, are primarily dynamic, but soon be- come material, because the dynamic influence can not be isolated from matter, and because its modalities forcibly influence the organism. There are, therefore, dynamic and somatic diseases. All diseases must be of both kinds, and in all there is only a predominance either of dynamic perturbations over the material ones, or the reverse. In the first phase of acute diseases, per- turbations of vital motion predominate, the material lesions being still insignificant. If the equilibrium is not re-established, the vital per- turbations are superseded by modifications of structure, and organic lesions are constituted. As lesions develop from other lesions, however, and as the changes in vital motion engender other changes, disease is not entirely established, as long as this ascending progression of morbid dynamico-somatic effects lasts, and also this first period of abnormal evolution in which the organ- ism finds itself, and which does not end without estab- lishing an equilibrium — that is to say, a stationary period. But this equilibrium, which is out of harmony with the natural arrangement of the organism, and with 28 ELEMENTS OF THERAPEUTICS AND PRACTICE. the influences of external agents, is quickly disturbed, and then a new phase of difficulty is seen, the evolution of which may be accomplished in the direction of dis- ease, which may become aggravated and complicated, until it results in death ; or in the direction of health, which improves as the ensemble of the perturbations is simplified and diminished. When equilibrium is re- stored, convalescence begins, which is equivalent to the incorporation of a new substance, this process continu- ing until the organism has recovered its normal sub- stance and vitality. Five periods can be recognized in disease — the dy- namic, the preparatory, the constitutive, the period of reparation or of disorganization, and the period of con- valescence or of death. The dynamic period lasts from the first perturbation of the vital motion until the ap- pearance of perceptible lesions in the organized matter ; it becomes preparatory when these lesions evolve, call- ing forth secondary, tertiary lesions, etc.; it is constitu- tive when this evolution is completed, as long as this state of abnormal equilibrium persists ; the fourth pe- riod begins when the abnormal equilibrium is destroyed, the perturbations now increasing until they become incompatible with life, now diminishing until there is a return to stable equilibrium, compatible with health. CAUSES OF DISEASE. Diminution of the vital motion constitutes the first act in the morbid series, the essential primordial cause of all disease. But, as this diminution may be excited in different ways, the causes of disease may be classi- fied into different categories or groups, which are all reducible to three. The first group includes all the dynamic agents, whether chemical, physical, mechanical, or vital, which have an influence upon the organic dynamic principle. Therefore, heat, light, sound, muscular work, the work of the intellect and emotions, may all influence vitality, DISEASE. 29 by giving rise to different diseases characterized by the morbid effects which are successively produced. Almost all the acute diseases belong to this group. The second group includes material agents, and, in addition, those which primarily excite modifications in the material composition of the organism. So the want of proportion between the elements which are neces- sary to the organism, and the quantity of the elements of repair which is furnished to them ; the defective elimination of certain products, the incorporation of certain insoluble and non-assimilable substances, trans- form the material constitution of the organism, produc- ing alterations which are now imperceptible in the vibratory motion, but which sooner or later become appreciable when alterations of matter are extended or multiplied. This is the genesis of many of the chronic diseases. The third group embraces the dynamico- material causes — that is, that class of agents the ac- tivity of which is exercised not only by their presence in the tissues, but by the dynamic modifications which they cause there. The invasion of the organism by living agents, whether animal or vegetable microbes, bacteria, the entire class of parasites, realizes this two- fold order of perturbations. In this last category may be classed the alkaloids and other principles which do not merely change the material constitution of the tissues in which they are deposited, but excite di- rect dynamic perturbations by virtue of their energy. Among all these causes, some act instantaneously or within a short period, and give rise to a simple vital perturbation which either disappears on account of com- pensatory action by other motions, or is transformed into successive effects, and produces a disease which retains no trace of the nature of the exciting agent. Such are the diseases which are caused by cold, inso- lations, results of moral emotions, etc. Others, on the contrary, continue for a very long time, and give rise to successive perturbations which change their form 30 ELEMENTS OF THERAPEUTICS AND PRACTICE. and physiognomy according as the susceptibility of the individual is modified by the first perturbations. These perturbations always preserve, among their con- stitutive elements, the causal one — in other words, among the secondary, tertiary, etc. , morbid effects, the primary perturbation can always be recognized, being maintained by the permanence of the cause. This con- stant element, or this permanent perturbation, which is excited by the cause, is antagonized, in dosimetry, by the dominant, appropriate action being based upon the aphorism sublata causa, tollitur effectus (when the cause is removed, the effect will disappear). The truth of this proposition is well seen in the parasitic diseases, for example, in indigestions, etc., diseases in which it is necessary to destroy the cause in order that the primary effects may cease, and with them the sec- ondary, tertiary, etc., ones. There are diseases in which it is impossible to over- come the persistency of the cause, and in which, then, one must counterbalance the primary effects. For ex- ample, since we are unable to dissolve a urinary cal- culus, we must endeavor to annul the spasm, the pain, the congestion, etc., which are due to the presence of the calculus ; and we must establish the dominant, not against the calculus itself, but against the causes which have made it grow. In other cases, after the disap- pearance of the original cause, there remains a perma- nent effect, which acts as the origin of all the others. Disease, being a chain of effects, may lose its first links, without any treatment which is directly aimed at them. Thus, an amygdalitis may be produced by cold, heat, fatigue, or by contact of an irritating substance. These causes will produce an inflammation which will persist long after the causes have disappeared. The dominant can have nothing to do with the original cause, which has disappeared from the scene of the disease, but it will operate upon the effect which remains, which is the cause of all the other effects. It will antagonize DISEASE. 31 the element of inflammation, of which the cause may have been cold, or a direct irritation. The effects of these causes become in their turn the source of new perturbations, and the latter in their turn give rise to new morbid phenomena, which again are multiplied ; so that the disease, which started from nothing, is transformed after a longer or shorter period of time into an ensemble of diseases, of which the his- tory almost always involves difficulties which are in- extricable. Disease, therefore, is not a distinct entity of the organism in which it is established, though it may determine reactions which tend to destroy it. Disease is an ensemble of phenomena, created, either mediately or immediately, by a primary perturbation of the vital motion, or the matter in which it is located. This succession of phenomena obeys laws which control the resultant of forces or of motions. If the organism, having arrived at its greatest development, were in such a condition that assimilation and disassimilation exactly compensated each other ; if its work were al- ways the same, not exceeding what it could produce without disturbing the organo- vital equilibrium ; if external agents always operated upon it in the same way, and in a way which would be suitable for it — it certainly would never have diseases ; and not only would such an organism be without pain, but it would live indefinitely, as long as this ensemble of conditions was not disturbed. Unfortunately, life is, itself, one cause of disease, because, with its work constantly vary- ing, it is impossible to furnish to the organism the exact quantity of the elements of repair which are necessary. The organisms which have the most uni- form lives are also the ones which preserve it the longest, which explains the fact that certain forms of vegetation reach an age that man can never experience. In order that animal life be preserved for the longest possible period, vital motion must be almost suspended, 32 ELEMENTS OF THERAPEUTICS AND PRACTICE. and the organism be kept as free as possible from external influences. An hibernating animal, which realizes these conditions, to a greater or less degree, could remain in a condition of lethargy for a long period without any apparent modification of a morbid character. But is hibernation life? No, life is not repose nor immobility, but a conflict of motions ; life is motion. This is why disease is a modality of logic, and death a necessary consequence of life. SYMPTOMS AND MORBID EFFECTS. Whatever be the perturbation of the vibratory mo- tion which animates organized matter, it gives birth to alterations in the organic and dynamic state of the individual. These alterations may be compensated, and then the loss of equilibrium is unnoticed. But if com- pensation does not take place, they will engender new perturbations, secondary effects of the primary causes of the initial perturbation which the vital dynamic in- fluence has experienced. All these effects, as well as those which follow them, are morbid effects, but are not symptoms. The latter are morbid effects of which the sick person is conscious, or which are discovered by the physician in his examination. A symptom, then, is always engendered by a per- turbation of dynamic influence ; and just as the effect of motion is likewise cause of motion, so symptoms give birth to others, and these in their turn to yet others ; so that we ought to consider symptoms not only in themselves, but also, and above all, in their natural consequences. The first symptom of a morbid condition is a source of many others, and as this first symptom is the expression of a lesion which is rather dynamic than material, it becomes evident that it is principally at the beginning of morbid conditions that therapeutics has the best opportunity to interfere suc- cessfully, for it is more difficult for it to cure than to prevent. DISEASE. 33 Besides, we always see certain symx^toms accom- panied by certain others, and we observe, in general, a constant succession in certain groups of symptoms. Does the frequent occurrence of this simultaneity and this order of succession, maintained by the invariability of physiological laws, justify the classification of these natural series of groups of symptoms into different species of diseases, as if they were entities characterized by typical properties ? Such a notion is entirely a false one. Disease is nothing but a new manner of being of the organs, which present either new phenomena or different modalities of normal ones. Herein lies the difference between clinical medicine and pathology : the latter shows us the species and genera of disease ; the former compels us to bear in mind that it is not disease, but diseased persons, with whom we have to deal. The morbid phenomena determined by numerous and different conditions vary unceasingly, according to the varying combinations of these conditions ; it is, therefore, impossible to refer diseased conditions to certain types which shall be invariable and uniform. If all individuals had organs constituted in the same manner, and endowed with the same dynamic energy, if climacteric conditions were the same for all, and all could be subjected to the same physico-psychical life, the same perturbation would then produce the same effects in all, in the same invariable order of succes- sion. In such a case there would be as many diseases as there are varieties of initial perturbations, and they could be classified as one classifies chemical reactions. But this equality does not and can not exist ; each case has its particular physiognomy, which distin- guishes it from all the others, and therefore justifies the clinical aphorism which has been referred to. Disease is made up of morbid symptoms and effects. But the relation of causality and dependence which unites these elements often requires that a system of 34: ELEMENTS OF THERAPEUTICS AND PRACTICE. treatment should take cognizance principally of symp- toms, not so much on account of the value of the symptom in itself, as on account of the other symp- toms which depend upon it, and the morbid effects which it may produce. Symptomatic therapeutics, which in dosimetry bears the name of the variant, is more important and more useful than many people im- agine. In annulling a symptom one does not confine himself to destroying its effect, and to simplifying the morbid condition, for by this means many others can be avoided, which would naturally and physiologically follow from the existence of the one which was to be suppressed. Symptomatic therapeutics is, therefore, not only curative of a portion of the disease, but pre- ventive, besides, of ulterior morbid phenomena, compli- cations, and aggravations. MORBID ELEMENTS. For the observant physician, disease is a combina- tion of symptoms which are linked together, distributed in groups, and determined by their filiations and their dependence. Every symptom represents a constituent element of disease, but all symptoms have not the same hierarchi- cal value, and do not all deserve to be placed in the class of morbid elements. There are principal and pri- mary symptoms, which give birth to others less impor- tant, which readily disappear with them. So pain, which may be only a simple symptom, is very often a true morbid element, since pain frequently engenders spasm, congestion, immobility, hyperthermia, insomnia, anorexia, etc. Remove the pain, and all its attendants will disappear. It is clear, therefore, that morbid elements are al- ways the basis of a therapeutic indication, since with them disappear also a great number of perturbations, and by simplifying disease we avoid ulterior complica- tions, diminish its gravity, and, at the same time, re- DISEASE. 35 lieve the discomfort of the patient. The difficulty con- sists in recognizing, among so many perturbations, those which are the mothers of others, and, in the midst of groups of symptoms which subdivide in various ramifi- cations, to distinguish them by their families, in order to attack each one separately, at the time of the pri- mordial perturbation. One is therefore brought face to face with different and manifold indications which must be satisfied at the same time, not by favoring polypharmacy — that is, making use of many drugs for one disease — but, on the contrary, by using a single remedy for several elementary diseases, whenever it can be done, or at least a single remedy for each of their morbid elements. Suppose we have a case of congestive neuralgia. In connection with it there are two principal morbid elements which give rise to two independent series of symptoms — the pain which produces spasm, insomnia, etc., and the congestion which produces heat, oedema, and hypersecretions. If we simply antagonize the pain with morphine, the neuralgia itself will offer resistance, or will reappear after a short time ; but if we add aconi- tine, by which the congested condition is dissipated, we shall obtain a rapid and effective cure. This exam- ple well demonstrates the capital difference between polypharmacy, or the excessive use of drugs, which we condemn, and the proper association of medicaments which we must approve and advise. The morbid element is the cause of symptoms. But whether the symptoms are determined by a morbific cause, or by other symptoms, it often happens that the best way to antagonize the morbid element is to extir- pate or to neutralize the cause. It is, therefore, the causal or pathogenic element, the primordial one, which we ought to annul, as soon as it is recognized, and we have the means of destroying it. But, as the cause is not always present with its effects, as at other times we may fail to recognize it, 36 ELEMENTS OF THERAPEUTICS AND PRACTICE. and at others we may not know how to antagonize it successfully, we shall at times be limited to exerting our efforts against its first effects, its principal morbid elements. These are always, at the beginning, rather of a dynamic than a material character. Thus fever, pain, spasm, exaggeration of the work of elimination, excessive sensibility or contractility, are so many func- tional dynamic perturbations. They are so many phe- nomena of excitation and accumulation of vital mo- tion at the expense of certain parts, and from them follow hyposthenias, impoverishment of vitality (in the form of adynamias, anaesthesias, and paralyses), which we might easily avoid', were we to interfere as soon as they make their appearance, by means of def ervescents, calmatives, and antispasmodics, which are the principal agents for overpowering (jugulating) disease in its dy- namic and preparatory stage, before it is fully devel- oped, and before the dynamic perturbations are super- seded by material lesions. The study of symptoms, their hierarchical classifi- cation, their physiological interpretations — for some of them are the manifestation of latent though real morbid effects — will enable us to accurately determine the morbid elements, and to select those which should serve as the object of hygienic or therapeutic indications. Our practical work will always be more profitable in consequence of this work of analysis and synthesis, without which our system of therapeutics is tossed about at the mercy of a deceitful inspiration. It ought always to be based upon physiological premises fur- nished by minute study and reflection upon each case. MEDICAMENTS. Theee has been much discussion to establish a characteristic difference between foods, medicines, and poisons. This distinction has not yet been established, MEDICAMENTS. 37 in spite of the most subtile reasoning, and it is impossi- ble to give an exact definition of each of these classes in such a way as to determine their differential charac- ters. In fact, just as it is difficult to accurately distin- guish health from disease, the entire difference residing in a different modality of the same phenomena, in di- versity of energy, and in the intensity of the vital acts, so between foods, medicaments, and poisons there is no other distinction than that which follows from the diversity of energy of their effects, and the intention with which they are employed. Foods, like medicaments and poisons, act upon liv- ing matter by their material and dynamic properties. Health is preserved so long as there is equilibrium of the vital motion ; but, in order to preserve this equilib- rium, it is necessary to compensate the losses which the motion sustains by means of other motions which be- come confused with it, and to re-establish the changed dynamic influence. Foods act to accomplish this end, and they have no other role than to furnish the sub- stance and force which the organism expends in accom- plishing vital acts. If they are not furnished in suit- able form, and at the proper time, the equilibrium is not re-established, the vital motion becomes insufficient, and an abnormal and morbid state is established, which may be readily remedied by alimentation, if its con- tinuance has not been too prolonged. Food, then, is, as it were, the proper medicament for those normal states in which there is want of equilibrium ; but it may also act as a poison if it is administered inopportunely and with excess. Disease, which is a condition of extraordinary want of equilibrium, therefore requires extraordinary means to restore equilibrium. From this point of view medica- ments are simply foods for the morbid state, for their sole object is to furnish the organism, either directly or indirectly, with means for preventing loss of equilib- rium, or for restoring it after it has been lost. Medica- 38 ELEMENTS OF THERAPEUTICS AND PRACTICE. ments which in their action exceed the requirements of the organism, increase the want of equilibrium already- existing, by increasing the perturbations, and so become an actual poison, just as would have occurred had a poisonous dose been given in the state of health. The medicament which accomplishes the desired end is, therefore, a substance which can furnish the diseased organism with the vital energy which is requisite for the restoration of the normal equilibrium. Just as foods are of different kinds, each kind being intended to satisfy a certain physiological want, or to determine certain modalities of motion, so will medica- ments vary with the diseases for which they are re- quired — that is, with the character of the dynamico- somatic alterations which the diseases produce. What essential difference is there between the phos- phorus which is taken into the stomach with the food, supplying nutriment "to the bones and the nervous sys- tem, and the phosphorus which is contained in the hypophosphites, and prescribed for such conditions as rachitis and nervous prostration ? What essential difference is there between the coffee which we drink every day to support the vital motion of the nervous system, and the strychnia which is given to stimulate the vitality depressed by disease \ In all these cases is there not a demand for an agent which shall satisfy a necessity of the organism % As all matter is animated by motion, and all motion can be translated into other forms, within certain de- fined limits, every substance and every motion may alike become a medicament. The secret of the action of drugs consists, then, in a conversion or transforma- tion of motions. Since vital motion appears to be limited to the or- ganism, and not transmissible by the ether, it is neces- sary, in order that there may be action on the part of medicaments, that they be in contact with living mat- ter. The latter animated by its special motion, and the MEDICAMENTS. 39 former by their specific motion, as they conflict, give a resultant which is determined by the primitive action of each substance. But, as in all the tissues and all the organic elements we find neither the same material constitution nor the same vitality, it follows that the same medicament, in traversing all the tissues and all the elements, will not give the same results nor the same effects in all. Thus the elective action of medicaments is ex- plained, and the property which each possesses of pro- ducing an impression upon some organs or systems, and not upon others. Vital motion is modified by every substance which comes in contact with living matter. It is for that reason that alimentation does not differ essentially from medication. A more definite difference is that, while alimentation is always material, medication may be exclusively dynamic. Alimentation implies repair of expended substance ; medication implies at one time assimilation of matter, at another only modification of dynamic influence. Since dynamic changes constitute the primary character of diseases, medicaments ought to be modifying agents of vital motion, bound to re- store to it its original intensity. If medicaments, in- stead of simply modifying this motion, transform it into others, the loss of equilibrium will increase, and a toxic instead of a salutary effect will follow. The same substance, endowed with its peculiar energy, will at one time produce modification, and at another per- turbation. If the changed vital motion can utilize all the energy of the medicament, and transform it into vital vibrations, the vital motion will be modified as it becomes stronger ; but if the energy of the medica- ment, whether from its nature or the quantity used, transforms the vital motion into other forms, vitality will diminish and new perturbations will be developed. There is always, therefore, a limit to the action of a medicament beyond which toxic effect is apparent. 40 ELEMENTS OF THERAPEUTICS AND PRACTICE. Within this limit the action of the medicament is pro- portional to the quantity used ; beyond it new modes of motion are developed, and the proportion is no longer preserved. Since all organic elements are interdependent, the primary action of a medicament npon a certain group of elements will be modified in a reflex manner by the influence of other groups. Therefore, the action of a medicament is not the same at the moment when it is first felt as it is subsequently. The modifications which are first effected have a bearing upon those which fol- low, and produce different results, according as new factors are introduced. The effect of the medicaments which depends altogether upon the substance used, and the dynamic condition of the organic elements upon which they are employed, differs, not only with different individuals, but even with the same individ- ual, according to the time of its application. Medica- ments may be classified into three groups : in the first, some, incorporating themselves in the living tissues, act indirectly upon the vital motion by the material modification which they produce upon the organism, since every alteration of substance causes an alteration of force ; while others, analogous to foods, by being assimilated sooner or later, increase the total of matter in -the individual ; yet others, which are true poisons, destroy a portion of the living matter, and only be- come useful by the disturbing modifications which they cause. The second group includes substances which, with- out becoming incorporated in the tissues, act only by contact, by the power of their dynamic properties, upon the motion which is peculiar to living matter. Some of them are dynamogenic, and increase the co- efficient of vital motion ; others are inhibitory, and diminish or suspend vitality. The third group includes all substances w T hich act like those of both the preceding groups. MEDICAMENTS. 41 To the first group belong the metals, to the second the alkaloids, to the third the metalloids and the vac- cines (vaccins). As the vitality of the different tissues varies greatly, and as the want of equilibrium in the vital motion is not the same in each of them, it follows that the effects of medicaments are not felt in the same way in all parts of the organism, and that there may even be opposite effects in the different groups of organic elements. Therefore, it is not unusual to meet with dynamogenic effects by the side of inhibitory ones, so that one can obtain similar results by different means, and by effects which at the beginning are absolutely contrary to each other. In order to estimate an effect, it will not suffice to calculate the coefficient of general vitality ; it will be indispensable, in addition, to appreciate the particu- lar vitality of each organic element, in each of its factors, during the entire time in which the action of the medicament continues, and during the time in which this action is continued by successive vital modifications. These differences constitute impres- sionability. The action of medicaments being the result of their dynamic influence upon the vital motion of the organs with which they come in contact, and this result being appreciable or latent, manifest or invisible (although an effect is a result which is always susceptible of veri fication), it appears that the action of a medicament differs from its effect. The latter proceeds from the former, though this filiation or production may not always be direct. The action of a medicament may have ceased when its effect begins to be manifested. For example, a purgative effect may follow the admin- istration of belladonna or atropine long after their anti- spasmodic and exciting action upon the longitudinal muscular fibers of the intestine has disappeared. The action of a medicament always exists, whatever be the 42 ELEMENTS OF THERAPEUTICS AND PRACTICE. impressionability of the patient, but trie effect depends upon the impressionability of the subject, and the in- tensity of action of the medicament. In practical therapeutics one seeks only to obtain results. Since the conditions for obtaining them de- pend upon the agent which is used, the impression- ability of the patient, and the intensity of effect of the medicament, the therapeutic problem is resolved into its simplest expression : (1) By understanding the im- pressionability of the element upon which it is pro- posed to act ; (2) by determining the quality and inten- sity of the impression which is desired ; (3) by choosing the substance which is suitable for the production of this kind of impression, and calculating its activity — that is, bringing the necessary quantity into contact with the organ to produce the desired impression with the proper intensity. Therefore, the results depend essentially upon three factors — the patient, the medicating agent, and the dose. But, as one only uses those substances of which the medicinal properties are more or less well known, if one desires to effect a cure, one must determine, above all things, in each case : (1) The impressionabil- ity of the patient, (2) the proper dose which is required. IMPEESSIO^" ABILITY. In order to be cognizant of the entire impressiona- bility of the patient, we should know with exactness the impressionability of each tissue, in particular of each element upon which the medicament is about to act. But, as each element is in relation and communi- cation with many other elements, if not with all of them, the modification which is exerted by the medica- ment will differ at each instant, on account of the re- ciprocal influences which are established between the different animated elements. Hence the impossibility of determining, a priori, for the same medicinal unit, the resultant of the modifications which this unit will MEDICAMENTS. 43 produce in a given element, and still more in the entire economy. Sick people, showing as they do the greatest variety both in their material constitution and their dynamism {dynamisme), may be said to have no characteristic which is equal in all ; more than that, the same sick person is not the same in successive moments. Trous- seau and Pidoux have related the experience which they had with antimonial preparations in 1831. In that year it seemed to be impossible to use them in large doses in the treatment of pneumonia. JSTot more than a gramme of the white oxide of antimony could be given with safety, and kermes mineral produced terrible accidents, in doses no larger than three to five decigrammes. Tartar emetic, however administered and attenuated as to the dose, could not be borne. Subsequently, this mysterious impressionability disap- peared, and sixteen grammes of the white oxide of an- timony, daily, were frequently given from the first day of the disease, two to three grammes of the kermes mineral, or one gramme of the tartar emetic, without associating with them any substance to mitigate their effect. In this way we can explain the different results which a substance produces, which may vary with the individuals and with the particular moment of life for each individual, without any regard to the dose. So extensive are the considerations upon this subject that opposite results are obtained from w^hat would ordinarily be expected. Bouchut comments upon this fact in the following manner : ' ' Medicinal properties are not, in fact, in the medicinal sub- stances themselves, as is commonly supposed. They represent the action of their particular characteristics in conflict with the living nature of each individual. Now, while this nature has general resemblances, it also has marked particular differences ; consequently, a medicament, which is always the same in its nature, will frequently meet organisms with different reactions, 44 ELEMENTS OF THERAPEUTICS AND PRACTICE. and will, therefore, furnish different curative reactions. Furthermore, it follows that medicaments do not always have the same results — for example, that which is a tonic for one person may not be for another. On the other hand, a remedy which we consider to be endowed with tonic properties, because by its use strength is increased and the tone of diseased organs improved, may cease to have those effects after a very short time, and may even exercise a debilitating action upon vital activity." (" Nouveaux Elements de Pathologie gene- rale," p. 124.) Fonsagrives expresses himself quite as positively : "A dose of a given drug may be tolerated to-day, and eight days hence it will not be. The dif- ference doubtless depends upon the different powers of absorption on the two occasions, and the different chemical conditions of the fluids in which the drug is dissolved, but above all upon the varying conditions of the nervous system. . . . And yet how many causes operate to complicate the physiological action of drugs, to attenuate or to increase it, to mask it or even to transform it altogether ! The different ages (of life) are not impressed in the same manner by the same drug — its different effect upon the different sexes is also no- ticeable. The temperament or the primary formula of health, the constitution, or its actual form, also effect modifications in the action of a drug. Besides, we must take into account the manner of life, the custom- ary food, the habits, etc. I do not mention, in addi- tion to these, conditions of a moral character which play an important part in the production of these infi- nite modalities, which an analysis, however skillful and delicate it may be, can not include in its ensemble" ("Principes de Therapeutique generale," pp. 35 and 281.) The same author continues : "One child's reac- tion may be represented by 1, if you give him a drop of laudanum, while another will, under the same cir- cumstances, be represented by 10. Every moment we are meeting with examples of this apathy on the one MEDICAMENTS. 45 hand, and erethism on the other, with respect to every medicinal substance, which demonstrates that the weight of the body is an imperfect basis for establish- ing any rule of dosage. Impressionability to the action of medicines takes no account of the scales ; it rests upon facts of sensibility and life which are eminently idiosyncratic, which are measured in practice only by the results of the substances used, and for which there can be no arithmetical calculation. " ( " Traite de Thera- peutique appliquee," pp. 527 and 532.) The genuine homceopathists are troubled with this same difficulty, and La Pommerais says: "The question as to doses which will have a medicinal effect can not be estab- lished by a general principle, because it is subjected to an infinitude of individual conditions, from the most simple idiosyncrasy, to the best regulated constitution ; from the most lively sensibility, the most marked im- pressionability, to a sensibility the most dull, and sen- sations the most obtuse. In default of a fixed and invariable rule in respect to doses and the administra- tion of medicaments, which would be an impossibility in view of the variety of sick persons and sicknesses, the duty and the mission of every physician are to ap- peal to his own inspiration." The agreement is therefore unanimous. Experience confirms the conclusions which we have propounded, and we can assert that it is impossible to determine, a priori, tlie impressionability of a sick person. DOSES. What is a dose ? This term is usually accepted in two senses. It may mean the quantity of a medicine taken at once, or the quantity taken in twenty-four hours. To neither of these acceptations must there be rigorous adhesion. For, if it is impossible to ^k as a dose the quantity of chloroform which is taken with each inspiration, or the quantity of mercurial ointment which is absorbed by each act of friction, or the exact 46 ELEMENTS OF THERAPEUTICS AND PRACTICE. quantity of a purgative agent in each glass of purgative lemonade, we can not understand, on the other hand, why the accumulated doses should be estimated for each twenty-four hours, rather than for each forty- eight or each twelve hours. For active remedies the term is usually understood in the first of the two definitions ; but the confusion that exists well shows the want of precision and of clear knowledge which is indicated by the term. Not- withstanding this, there is nothing that is more impor- tant, for all therapeutics depends upon posology, and without it we should run the risk of going astray into the ethereal regions of the homoeopathic myth, or into the dangerous confines of toxicology. The only definition which can harmonize these two conflicting ideas is one which considers a dose as the quantity of a medicament which is intended to pro- duce a precise effect. Even this definition is somewhat vague, especially if we consider the necessity of expressing it in units of weight and measure. In fact, not only may the end for which the medicament was given fail of achieve- ment, but the effect may not be apparent, for that effect depends essentially upon the dose. There is, therefore, a vicious circle, in which one seeks to determine the effect by the dose, and the dose by the effect, a problem in which the product only serves to indicate to us the factors. This method of considering the dose is, there- fore, very arbitrary — in other words, is incompatible with the strictness which its object requires. But, in accepting it provisionally, suppose that one administers a dose of a certain substance in order to produce a cer- tain effect, and that the quantity which is necessary to obtain that result could be calculated in advance, would the effect appear, of necessity ; would the result be produced with certainty? Certainly not, even if we admit that the economy would always act in the same manner. As a matter of fact, there can be, and there MEDICAMENTS. 47 always is, a considerable difference between the quan- tity of the medicament which is taken and that which acts at any given moment upon the part to which it is directed. There are, then, differences as to the degree with which medicines are retained, differences as to their solubility : there are those which take place at the time of absorption, and those which occur within the circulation, or while the medicament is en route. As to the first, we find that in certain cases of gastric irritability the whole, or nearly the whole, of the dose may be ejected by the act of vomiting. We know also that often, in such diseases as typhus fever or enteritis, the remedy may traverse the entire digestive canal without undergoing the least alteration, as has been recently stated, in a memorable discussion in connection with typhoid fever, before the Academy of Medicine of Paris, and as I have observed in some cases. The solubility of the dose is a matter of no less in- constancy, and one often finds at autopsies, in the folds of the intestines, large portions of medicinal substances which have failed as to the first condition in order to absorption. (Dr. Crassot, " Encyclopedic Medico-phar- maceutique," 1883, p. 708.) " There is a want of toler- ance," says Jaumes, " when a substance which has been taken in a solid form, the form of a pill, becomes so hard that it resists the dissolving action of liquids." ("Traite de Pathologie et de Therapeutique generale," 1869, p. 1096.) Absorption is eminently a variable con- dition, and it is only the fact that it is dependent upon life which makes it different from the phenomena of osmosis, and prevents us from counting upon identity as to results. It varies with the condition of the ab- sorbing surfaces, the density of the solution, the state of relative fullness or emptiness of the vessels, the de- gree of saturation of the secretions, etc. Finally, the passage of medicaments to their field of operation also varies with circumstances which it is not necessary to mention in detail. 48 ELEMENTS OF THERAPEUTICS AND PRACTICE. We learn, therefore, that medicaments, being com- pelled to experience so many vicissitudes before reach- ing their destination, can never have an effect which is proportional to the dose absorbed. Between the quan- tity of the dose which is employed and that which is used with advantage there is such a difference, and such a varying one, that, if we consider the dose as the quantity of medicine which is administered, we expose ourselves to the unlooked for, the uncertain, and the erroneous. Can we foretell with accuracy all the circumstances in nature which will have a bearing upon medicaments, so that we can estimate the loss which is experienced by the dose which is given % Can we in the most simple condition — vomiting, for example — estimate the quan- tity of the medicament which has been rejected, so as to replace it, and complete the necessary dose % And, if the result need not be mentioned in so simple a con- dition, what shall we do in the more obscure and com- plex ones % Nothing, and it would be foolish to attempt anything of the kind. What, then, is a dose, in its most rigorous acceptation % After what has been said, it is plain that it must be simply that portion of the medicament which acts. Now, as the object of administering a remedy is always to obtain a certain result, it may be said that the therapeutic dose is that portion of a medicament introduced into the blood which is capable of produc- ing a determined action. It would be absurd to admit that a result can be produced, whatever be the dose of the substance. Reason and observation show that the result always depends upon the dose. The homoeopathists them- selves seek a manifest result in their medication, for it is impossible to remove the dynamic influence (dyna- misme) of matter itself. Says La Pommerais: "The frequency of repetition should always depend upon the intensity of the morbid phenomena ; the more rapid MEDICAMENTS. 49 the course of a disease, the greater the necessity for repeating the medicament until a result of a decided character is manifested." (" Cours d'Homceopathie.") One may be deceived in the interpretation of phe- nomena which are observed, but it is certain that one gives no remedy without hoping for some result from it. We have seen that every modification produced in the organism by a medicinal agent is called the action of a medicament. Whether this action be latent or visible, mild or violent, useful or harmful, it always exists when an agent enters into relation with a living element. It differs, then, from the effect. The effect is the action of a medicament carried to a certain de- gree, or intensity, and always giving rise to an apparent modification, whether that be physical, chemical, vital, or — with reference to results — curative. The effect, therefore, depends directly upon the dose. Without stopping to consider the effect in the element alone, we will study it in the organism, and, as the vehicle of the medicament is almost always the blood, and as most medicinal actions are accomplished by a modification of the nervous system, we may, in general terms, offer this principle : the effect depends upon the quantity of the remedy which affects the vitality of one or more nerve-cells, the remedy being transmitted by means of the blood- current. Thus we shall the better under- stand that, in addition to determining the effective portion of the dose, we ought also to take into consid- eration that portion of the medicament which is elimi- nated, and consequently can not affect a second time the cells to which it was carried by the blood before elimination occurred. In reality the dose varies with each systolic movement of the heart, because it de- pends partly upon the quantity absorbed and partly upon the quantity eliminated. Suppose a single dose to be introduced into the stomach, absorption does not take place all at once ; there will therefore be received by the blood a series of doses which will differ at each 4 50 ELEMENTS OF THERAPEUTICS AND PRACTICE. moment as absorption goes on. If elimination is equal to absorption, the dose will be constant ; if the former be less active, the quantity of the medicament in the blood will increase as long as any of the substance originally ingested is not absorbed. If, on the con- trary, elimination is more active than absorption, the dose of the medicament in the blood will gradually diminish. If we can not calculate in advance the quantity of the medicament which will be absorbed, no more shall we be able, for similar reasons, to estimate that which is eliminated. As the active portion of the dose depends directly upon the two factors of absorption and elimination, and as these are absolutely indeterminable, the propo- sition is justifiable that it is impossible to calculate the active portion of any dose whatsoever. Experience is in accord with this conclusion. We know that at each step practitioners meet with sur- prises and with unforeseen results from inability to adapt the doses which have been prescribed to the ab- normal necessities of the patients. " That which will soothe one patient will excite another ; that which overheats may also refresh, just as that which refreshes may overheat. It is in this way that the same drug combines several properties. In support of this state- ment, let me call to your attention the tartrate of anti- mony, which is now purgative, now emetic, now dia- phoretic, in spite of posological precautions." (Muna- ret, "Le Medecin des Yilles et des Campagnes," 1862, p. 276.) " Other testimony could be added, but it will suffice to refer to the different idiosyncrasies, which are simply cases in which there is now great impressionability, and again an accumulation of doses ; extraordinary cases of tolerance, in which one or two grammes of opium have been given with impunity within a short space of time, or the wine of colchicum by the glassful at once." MEDICAMENTS. 51 (Forget, ' ' De quelques Medicaments actif s administres a des Doses extraordinaires.") Such, is the extreme uncertainty as to the results which are to be obtained even with moderate doses, and also the variety as to the opinions concerning the prop- erties attributed to medicinal substances. There can, therefore, no longer be any doubt as to the perfect agreement of the teaching which is drawn from facts with the conclusions drawn from the principles which have been enunciated. We may, therefore, consider that the so-called maxi- mum and minimum doses have undergone condemna- tion. The facts which have been cited should long since have convinced physicians by their eloquent ob- stinacy that the principle of the maximum and mini- mum could not be considered the true rule for dosage. Common sense ought long since to have told us that the doses prescribed in the formularies are only based upon experience in certain cases, or upon experimenta- tion made upon animals. From such data, however, the first author who wrote upon the posology of different substances started, and others have simply copied after the first. If any fact went beyond the well-defined limits, it was wont to be explained by the defective quality or method of preparation of the drug, or by an idiosyncrasy so rare that one would not even take the pains to investigate the matter and see if it were really less rare than had been believed. It has been already remarked that a drop of lauda- num may have an effect in one person which might be represented by 1 and in another by 10; it has been observed that an occasional insufficiency of the elimina- tive organs multiplies the energy of the substances ab- sorbed, that poisoning may take place from minimum doses, and no appreciable effect be received from maxi- mum ones ; but, notwithstanding these facts, we seem to persist in preferring old methods, and in refusing to seek for the true significance of these numerous excep- 52 ELEMENTS OF THERAPEUTICS AND PRACTICE. tions. The bad results of this form of practice finally became so manifest that it was no longer possible that a remedy for such a degree of uncertainty should re- main undiscovered. What is that remedy \ Nothing could be more sim- ple : it is the old case of the egg of Columbus. If one desires to obtain the effect of a medicament, it must simply be given to the point when that effect is ob- tained. This discovery, which is so simple that it scarcely seemed a discovery, with an importance which is supreme, belongs to Burggraeve. Whether it is the fruit of genius or of common sense will be decided in the future ; perhaps it may be due to both. The entire system of Burggraeve starts from that point. But, in order that the effect may be produced, it is necessary that the desired intensity of the medi- cative action be not exceeded ; it is also necessary that the quantity of the drug in the circulation should not vary, by too much or too little, from the desired quan- tity. Furthermore, the absorption should be rapid, elimination readily accomplished, and the result promptly obtained. Hence the necessity of using small quantities, perfectly uniform in character, of energetic medicaments, which shall be readily soluble and per- fectly tolerated ; which, being introduced into the cir- culation, shall gradually accumulate in the blood until the active dose is reached. Hence the choice of alka- loids and other fixed principles, and of the granular form as a vehicle, in order that the patient may experi- ence the minimum of annoyance in the administration of small and frequent quantities. Clearly effect, under these conditions, means a result which is perceived by the patient or appreciable to the physician. Any other result must be illusory. Apart from this rule, there is only imagination ; there is nothing which is positive and mensurable but that which we can see and feel. Fonssagrives, whom we are pleased to quote, on account of his position, his MEDICAMENTS. 53 age, his experience, his knowledge, and his critical spirit, qualities which establish his authority beyond conjecture and make him the representative of official science, repudiates the study of those intimate actions which are the most mysterious, for the reason that they are obscure and indeterminable, and advises that we attach importance only to those actions which are mani- fest or phenomenal, which have a result which can be perceived by the senses. ("Traite de Therapeutique appliquee," vol. ii, p. 506.) In ordinary practice doses are frequently measured without accuracy, and repeated without regard to any rule ; they often accumulate in the intestine, enter the circulation without our knowledge, or are eliminated without having produced any effect. Everything, in ordinary practice, conduces to such results. The vol- ume of the drug may be considerable, and it may be of a complex character, and not readily soluble. Its ab- sorption, therefore, is often irregular and illusory, while the large size of the dose may readily cause an accumu- lation in the blood, with serious and perhaps irrepara- ble consequences, if elimination is imperfectly accom- plished. This is the reason why many patients are sufferers from the use of substances which are appar- ently inoffensive, notwithstanding the fact that the most active substances will sometimes traverse the economy without producing the slightest perturba- tion. The most harmless substances have sometimes been objected to on the ground that they have a poisonous action. This is certainly true of them in some cases in which the physician has neglected to take into con- sideration the condition of the eliminative organs. In yet other cases the condition of these organs could not be foretold. The sulphate of soda, the salicylate and the nitrate of potash, which are usually regarded as harmless drugs, may give rise to the most unfortunate surprises. (See Fonssagrives, u Principes de Therapeu- 54 ELEMENTS OF THERAPEUTICS AND PRACTICE. tique generale," p. 148; J. Perreira, "Materia Medica and Therapeutics," vol. i, p. 504.) On the other hand, apparently toxic quantities of alkaloids are sometimes absorbed by patients without producing violent effects, in spite of the dread which is felt by those who dare not use them, and who forget that mildness and energy may go hand in hand. This irregularity in the effect of the alkaloids in some cases which are characterized by a very slight impressionability, or by an unusual readiness of the eliminative functions, can only be ex- plained by the method followed in administering them. The stupefaction which is manifested by those who do not practice dosimetry, at the effect of doses which are far superior to those which they have been in the habit of using, is not a new phenomenon. "It was a singular spectacle," says Jaumes, "for the practitioners who assisted the first dosimetrists, that a patient could endure without detriment and with positive profit considerable quantities of tartrate of antimony, the digestive function remaining almost undisturbed." ("Traite de Pathologie et de Therapeu- tique generale," p. 1102.) The same, or an analogous spectacle, is seen every day, but our adversaries do not seem to profit by the teachings of history. We must not lose sight of the fact that the dose is the quantity of the remedy which is present in the blood at any given moment, and that, for the same impressionability, the effect depends upon that dose. Let us now see what is meant by accumulation and saturation. Accumulation may be the result of the total quan- tity of the doses taken, or of the quantity of the doses which is used with profit by the economy. Accumulation by means of the doses taken is a result which can not be foreseen ; it may happen that several doses, given perhaps at long intervals, are added one to another, and retained in the digestive canal, where MEDICAMENTS. 55 they may be absorbed or eliminated, entirely or in part. If absorption is total and continuous, the effect will exceed the calculations which have been made ; if the accumulated doses are rejected entirely, there will be no effect ; in yet other cases, the effect will depend upon the proportion between absorption and the activity of elimination. Accumulation from doses which have been efficient results from elimination which is insuffi- cient as compared with absorption. The activity of these two functions, however, is not susceptible of cal- culation ; we must, therefore, always proceed with very small doses, in order that accumulation may never be- come perilous. The medicament, as it accumulates little by little in the blood, will produce an intensity of action gradually noticeable, which will increase by de- grees until the effect — that is, the point for which we are striving — is obtained. When this effect has been obtained, it is time to suspend or to diminish the doses ; and, as the doses are very small, soluble, and readily absorbable, absorption will cease when the adminis- tration of the medicaments is interrupted ; likewise accumulation in the blood will be arrested, and the corresponding energetic action of the medicaments. Elimination continuing, the activity of the dose will continue to diminish until the remedy is entirely re- moved from the organism. It is, therefore, evident that, while in allopathic practice accumulation is an undesirable event, in dosimetry it is an advantage, and an indispensable one, because by it alone can the effect be obtained ; and, according as this effect is appreciable and proportionable to the accumulation, shall we be able to excite, increase, or diminish it, as the indica- tions present themselves. Aside from the accumulation of the doses, we may admit also an accumulation of effects, or medicinal erethism, in cases in which, the active dose remaining constant, the impression produced is maintained or is 56 ELEMENTS OF THERAPEUTICS AND PRACTICE. exaggerated by a repetition of the impressions cansed by the agent. In snch a case, also, dosimetry offers perfect security, because the effect is increased only to the necessary limit, since absorption is continually equal to elimination ; and, at the moment when absorp- tion ceases, the elimination continues, and the active dose is diminished in its turn, so the partial effects can no longer be increased. If, on the contrary, absorption exceeds evacuation, the accumulated effects will only produce the total effect more speedily. Saturation can be understood in only two ways : 1. Either it is the accumulation of the medicament in the blood in such quantity that its accumulation is no longer possible, from which one of two things happens : (a) an insufficient effect is produced (for, if it had been sufficient, the doses would not have been repeated until saturation), which will remain stationary, because the active dose can not be increased, absorption being sus- pended, and then this effect will indicate, ipso facto, that new doses would be of no use ; or (b) no effect is produced, and, as saturation prevents further absorp- tion of the medicament, we are reminded that we must try some other substance as a synergist. 2. Or satura- tion exists in the effects produced — that is to say, it is useless to increase the dose — the organism will no long- er react to its influence, and the medicinal energy will not reach a degree sufficient to produce the desired effect, still less to produce any phenomenon of an alarming character. But, though this element has given negative conclu- sions, some other element will respond to the indica- tions, and we shall thus be warned not to insist upon it. The effect that we seek after has not been pro- duced, it is true, but we are thus warned to be upon our guard. When this saturation of effects occurs, it may give rise to failure of a dosimetric treatment as well as of an allopathic dose. However, if the desired useful MEDICAMENTS. 57 effect is not produced, but some unusual manifestation is apparent in its stead, which method will have shown the less foresight? Will it be dosimetry, which pro- duces an effect little by little with gradually increasing intensity of medicinal action, or the allopathic method, which roughly provokes it with all the force of its powerful doses? If this effect, which could not be foreseen, is an evil, under what condition shall we be able to control it with the greater facility \ Will it be when it exists at its maximum from the beginning, or when the evil presents itself slowly, and is aggravated only by our obstinacy and obtuseness ? The difference between the two methods is too evident for further com- ment. The only way, therefore, to proceed with accu- racy, with assurance, and without danger, is to give, at short intervals, small doses of simple substances which are readily soluble, and have clear and precise effects. In this way we can correct any possible variability in the given pharmaceutical preparation, uncertainty as to the activity of absorption, ignorance as to the state of elimination, and we can compensate for inconstancy in the vital impressionability. The different conditions may vary as much as they will, but we shall always reach the effect. Can this effect be injurious? We have already seen that it can not, for, in place of fol- lowing any arbitrary rule, in place of calculating the dose in accordance with the inflexible indications of the formularies, or our own vague inspirations, we allow ourselves to be guided by vitality itself. This element does not tell us how much of the medicament must be given in order to arrive at a precise result, but it does tell us to stop when the end has been attained. So a fireman, though he may be ignorant as to the quantity of coal which the furnace of his locomotive will burn, does not give himself concern on that ac- count, for he intrusts the regulation of that matter to his infallible manometer. When the desired pressure of steam is indicated, he ceases to apply fuel, conscious 58 ELEMENTS OF THERAPEUTICS AND PRACTICE. that he has used only what was indispensable, whether much or little has been burned. When it is stated that the administration of drugs by the dosimetric method can never produce harmful results, it is, of course, pre- supposed that the result will be such as would be ex- pected from the attentions of a physician who is skill- ful and experienced in the use of drugs. If a physician has administered an emetic to the point at which it produces vomiting, and bad results follow the act of vomiting, would it be right to say that the effect of the medicament has been harmful ? Assuredly not. The fault has been in the method of interpreting the indica- tions. A medicament which gives exactly the result which is expected from it, neither more nor less, is a medica- ment which has been accurately administered. Such results constitute the great merit and the incomparable value of the method of Burggraeve. It is the only one by which the caprices of vitality are subjected to the intelligent will of a physician. And not only is this method exempt from dangers, but it is the only means which allopathic practitioners have for avoiding dan- gers. It is not difficult to show that, whenever the regular practitioners desire to combine efficiency with innocuity, the dosimetric method of administration is the one which is employed. Xow, as it is impossi- ble to correctly understand therapeutics if these two conditions are separated — in other words, a remedy ought to be always effective, never harmful — one must always turn to dosimetry if one desires to make him- self truly useful in his medical attendance. In ordinary practice, when one wishes that a drug should be effect- ive, an attempt is made to render it active by giving it in small and repeated doses until the required effect is attained, and one should not be satisfied with the com- mon method of giving now and then any dose which the inspiration of the moment may suggest. If, for example, the case be to obtain anaesthesia from the use MEDICAMENTS. 59 of ether or chloroform, to treat a threatening asystole, to combat the effects of inanition, to calm a violent pain, to dispel a spasm which threatens life — if the question be to excite vomiting, or to produce a diaphoretic or hypnotic effect — do we not have recourse to the use of small doses, which are repeated until the effect is pro- duced % Do not our adversaries recognize that there is danger from the uncertainty of their doses, from their erroneous calculation, in a word, from the absence of dosimetry % Has not Fonssagrives said that " the dan- gers of mercury are not peculiar to it, but belong to all active medicaments, when they are used without particular indication, without accurate measurement, and without regard for the rules by which they are rendered inoffensive "? (" Traite de Therapeutique ap- pliquee," vol. ii, p. 190.) Does not Dujardin-Beaumetz say : "Heart tonics, like all other medicaments, present two distinct aspects : if the dose is carefully measured, good therapeutic results will follow ; if it is excessive, the scene will change, and a toxic effect will appear " % ("Lecons de Clinique therapeutique," p. 60.) And, on the other hand, when the regular practi- tioners do not dare to meet the dangers which they believe are found in the dosimetric system, is it gener- ally known what plan they follow % Let us see what they say upon this point : According to Fonssagrives, " the most active alkaloids — digitaline, veratrine, strych- nine, even aconitine, the salts of arsenic, etc. — may be used as well for the treatment of children as for adults, and any therapeutist who would deprive himself of their usefulness would be deficient in good judgment. Everything depends upon the doses, which should he 'very small at the beginning, and gradually increased, according to the effects observed, so they will yield all the desirable probabilities associated with innocuity. "Every medicament, however great its activity, is applicable to practice among children, not excepting those medicaments to the action of which children show 60 ELEMENTS OF THERAPEUTICS AND PRACTICE. the greatest susceptibility ; opium and tartrate of anti- mony, for example, need not be absolutely excluded from such practice. Everything depends upon the ap- propriate indication and graduation of the doses. "The principle of administering the antispasmodics in minute doses clears away all difficulty, and enables us to obtain satisfactory results. "Finally, having taken the precaution of beginning with the smallest dose (of strychnine), of watching its effects, and of increasing or diminishing the fractional doses, as circumstances demand, we can feel secure from all risk of accidents." ("Traite* de Therapeutique ap- pliquee," 1882, pp. 527, 572, 577.) The great dangers of dosimetry, therefore, are re- duced to this : these are the great crimes of which it is accused ; these are the reasons which prevent our ad- versaries from adopting our method. This is the retort which we give to the accusation against the system, viz., dosimetry is effective without ceasing to be inof- fensive ; it is inoffensive without ceasing to be effective. We are therefore warranted in offering the following conclusions : 1. Therapeutics always aims at a result. 2. The result can only be obtained by a dose which shall be sufficient. 3. The sufficient dose can not be established in advance either by calculation, by experience, or by inspiration ; we must give the remedy until the suffi- cient result is obtained, without especial regard to the quantity taken, but only to the objective and subjective modifications which an examination of the patient will indicate. Experience and calculation can only aid us in establishing the initial or typical dose, the fractional part of a complete dose which should serve to initiate the medicative action, and which, when repeated with suitable frequency, will constitute the sufficient accu- mulated dose. The initial dose should never be capable of producing any toxic effect, for, if it did, we would MEDICAMENTS. 61 fall into the clangers of the allopathic practitioners, and thus the dosimetric system would lose the characteris- tics which give to it all its value and all safety. CUEATIVE ACTION. Since living matter can be modified in its dynamism, and in its material constitution, and since substances which are foreign to the organization may be the agents of this modification, it is easy to understand that the mechanism by which morbid phenomena are produced is the same as that by which the action of medicaments is realized. Both the former and the latter are the result- ant of physico-chemical movements struggUng with the vital motion. There is no difference between the modi- fications which are produced upon the body in its nor- mal condition by morbific agents, and those which are effected in the pathological condition by therapeutic agents, if we consider them in their essence. If there are any differences at all, they arise entirely from a diversity of causes — a diversity which may result from their particular quality, their degree of intensity, the duration of their action, or the time at which they are produced. Pathology has chapters in common with pharma- cology and therapeutics. Saturnism, hydrargyrism, narcotism, ergotism, or accidents from lightning, are morbid conditions which are distinguished from ordi- nary medication with lead, mercury, opium, ergot, or electricity, only by the degree of intensity or the dura- tion of the action of the agent which produces modifica- tion of the vital phenomena. The laws which govern the two classes of phenomena are common and identical ; the results differ with the differences in the conditions, which it is impossible not to take into consideration in our calculations. It should not be a matter of surprise that hygiene and therapeutics — the two sciences which teach us as to the means which will have a favorable effect upon 62 ELEMENTS OF THERAPEUTICS AND PRACTICE. the organism in health and the organism in disease — should really exist as sciences. Indeed, their existence conld only be denied by minds which are systematically preoccupied in wrong directions, or are totally devoid of every faculty of observation. But, after having shown that intervention by thera- peutic means is possible, it remains for us to determine the conditions which shall render them useful and effective. It has already been stated in general terms how curative action by means of medicaments is accom- plished ; but, if we were to descend to particulars, and to the particular reaction of each medicament and each morbid element, the problem would become insoluble, because we are entirely ignorant of the exact means for determining phenomena which change the condition of health ; neither do we know the cause of the differences which exist in the force which is exercised by certain substances, among which substances we must include medicative agents. The results from the intimate action of a remedy can scarcely be ascertained by analysis. Only a comparison of these results of the most simple action of remedies with the most simple vital perturba- tions enable us to conclude that the curative action is exercised in opposition to primary or secondary results. The old principle, contraria contrariis curantur, is still the one which explains the greater number, if not all cases. Not that it was a difficult matter to explain them by the contrary principle, similia similibus cu- rantur, for, as we have already seen, the principle of vital equiponderations teaches us that a divergence in one sense is always balanced by a divergence in a con- trary sense. If there be a congestion in one organ which is caused by vascular tension in a neighboring organ, if spasm is always accompanied by a compen- satory paralysis, if, in a word, life retains its equi- librium only by means of antagonisms which are ad- mirably adjusted, any displacement whatsoever of force or of matter must necessarily result in a want of equi- MEDICAMENTS. 63 librium of antagonistic forces, which can neither be limited nor prevented. But the formula of the homoeo- paths fails to satisfy according as physiology opens to us new horizons and explains pathological phenomena. Between the old idea concerning inflammation and that which follows from the results of physiological analysis — which attributes the primary cause of the phlogosis to vaso-motor paralysis — there is so much difference that the scientific basis of the reform which was insti- tuted by Hahnemann seems likely to fall, and in its fall it must include the entire system which was constructed by the founder of the homoeopathic doctrine. But, instead of dwelling upon these sub til ties, it will be more profitable for us to inquire exclusively as to the indications which an examination of a sick person pre- sents to us, in order that we may relieve the urgent necessities of the organism which has been invaded. In many cases the analysis of a diseased element will enable us to judge as to the proper antagonistic modi- fications which we should at once employ in order to restore readily and quickly the equilibrium. For ex- ample, in a case of dysuria, we will find spasm of the neck of the bladder, associated with paralysis of the body. The indication will, therefore, be to administer an anti- spasmodic — hyosciamine, for example — in order to overcome the spasm ; at the same time we should use a nerve - stimulant — for example, strychnine — in order to overcome the paralysis, and give to the longi- tudinal muscular fibers the tonicity in which they are deficient, either because it is concentrated in the sphinc- ter or has been wasted in repeated contractions. In accomplishing this end, should we follow the principle contraria contrariis, or the opposite one, similia simili- busf Apparently both ; but our treatment, though it could appear to be contradictory, is, in reality, physio- logical, for we seek to overcome the want of equi- librium, and to antagonize merely the aberrations of 64: ELEMENTS OF THERAPEUTICS AND PRACTICE. the physiological mode. Therefore, whenever we are able to discover the primary, elementary morbid change, our efforts to produce a cure must follow the principle contraria contr arils. This is the clearest, most nat- ural, the most simple, and the most logical method. We readily admit that the disease will disappear only after another disease has been artificially produced. While we admit that all medicative action is only a modification of the organo-dynamic condition, and that diseases are only the different modalities of matter ani- mated by vital dynamism, we find that every cure is the result of a morbific action, which is more or less intense and more or less fleeting. But it is by no means necessary that this artificial disease should correspond to the original one either by intensity or by nature ; indeed, in most cases, the cure can only be explained by the opposition between the modifications effected by the remedy, and those which were caused by the disease. The cures which are accomplished by means of the attenuated and infinitesimal doses of homoeopathy, and which are attributed by many to medicative force, nat- urally lead to the consideration of the worth of this force as a curative agent. If this force exists, its effects should be most clear and manifest in the simplest cases — that is, in those which would tend to recovery with- out the intervention of therapeutic means. Suppose we take a very simple case of congestion ; what has occurred % Blood has accumulated in a ves- sel, its pressure has increased, its walls have been dis- tended and made thin, and, should the pressure grad- ually continue, the elasticity of the vessel will be over- come, its force of cohesion will be vitiated, its walls will be torn, and the result will be a haemorrhage of greater or less volume. As the blood is discharged, the pressure is relieved, the walls come together again, the congestion disappears, the blood is coagulated at the point of rupture, and the haemorrhage ceases, or, on MEDICAMENTS. 65 the other hand, it continues to flow, and the use of a haemostatic becomes necessary. Do we not see in this process a series of successive modifications in perfect relation, and dependent, each upon the other? And is it not thus that morbid phenomena are evolved when the disease gets more severe and the supposed medica- tive force is ineffective? Is there any cause for the supposed intervention of any special force differing from the forces which result from physical, chemical, and vital movements, in order to explain the cessation of the congestion? But, if the walls of the vessel in the supposed case of congestion do not yield to the excess of pressure, how can the medicative force inter- fere so as to overcome the cohesion of the walls of the vessels? Moreover, if it overcomes this cohesion, it must, in destroying one disease, give rise to another, which will be longer in duration and more severe ; and, should haemorrhage take place in a very sensitive area — in the brain, for example — death itself might be caused by the use of the agent which had developed a great or even fatal lesion out of a slight perturbation of the physical forces. In order that a force be medicative, it should act suitably upon associated morbid phenomena with due and clear reference to their cause ; it should foresee and calculate the consequences as well as the opportunity of its intervention ; it should act with suitable intensity upon succeeding phases of the disease for the cure of which it is given ; and it should seem to exercise a kind of selection as to the means and the place of its appli- cation. A force of this character should, of necessity, be intelligent, omniscient, and omnipotent — in a word, it should be divine. But, if it has these qualities, it should also know how to vary the method of treatment, as a haemorrhage of the brain is not a haemorrhage of the intestines or of the lungs. But observation teaches us that there is no intelligence of any character which presides over natural crises ; that the force which is at 5 6Q ELEMENTS OF THERAPEUTICS AND PRACTICE. work is blind, inconsiderate, and absurd ; and that its action may be limited to insignificant cases, or that it may aggravate cases of the greatest gravity ; we may, therefore, conclude that this force has no real existence, and that it is folly to rely upon it for the amelioration of any disease whatsoever. The notion of a medicative force (vis medicatrix naturce) has originated from numerous instances in which cure has resulted either without the aid of a physician or even in spite of un- suitable interference on his part. This is not suffi- cient to establish our belief in the existence of any force which could be of advantage to the sick. As well might we say that there is a medicative force in time, for we see the sun succeed the storm ; or that there is a force in the earth which preserves it, since the convulsions of the globe do not last ; and volcanoes become quiet after a period of efferves- cence, and after they have vomited up their incandes- cent lava. The medicative force is therefore a myth — an ex- pression which has no meaning, further than that a great many cases of disease get well spontaneously. The getting well is not effected by means of a particular force ; it is the result of a transformation of effects, in a curative sense, which is caused by the condition of the organs involved, by the external medium, by ali- mentation, or by the state of the functions which have remained unaffected, or the trouble of which tends nat- urally to diminish by itself. It is only by reasoning in this way that we can understand how a disease which is benignant at its outset suddenly becomes dangerous under the influence of some agent or other, which prevents an evolution in the direction of health, in spite of the illusion of a medicative force. Therefore, since this force has no real existence, while the force of medicative agents does exist, therapeutic intervention becomes an indispensa- ble obligation, which is laid upon the physician from MEDICAMENTS. 67 the time when the first abnormal phenomenon appears until the patient has ceased to live. SYSTEMATIC THERAPEUTICS. The treatment of a disease is a warfare, a campaign in which the physician studies to find out the strength and the tactics of his enemy, the theatre of his opera- tions, and the troops at his disposal, before he elabo- rates a plan for his own offensive and defensive conduct. As soon as he has joined battle, he should not only think of victory, but should seek to cut off the retreat of the vanquished, follow up fugitives, repress disorder, clear away that which has been destroyed, establish peace and harmony, arouse prosperity anew, and re- store that which has been devastated by war. Disease is a very complicated ensemble of phe- nomena, which follow each other without interruption, from the moment when the cause begins to act, until its last effects are terminated either by a return to health or by death. Therapeutics constitutes an arsenal of arms of various kinds, each one of which may be han- dled in a thousand different ways. Between the mo- ment when we find ourselves in the presence of a sick person, and that in which we are required to draw up a plan of treatment, a period of time, usually very short, will elapse, in which this plan must be outlined. It is, therefore, desirable that we have some method which will abbreviate our work as much as possible, and habituate us to the detachment of the leading in- dications and the choice of the best agents, and which will enable us, in a word, to trace the general lines of a therapeutic system. The classification of diseases has an advantage : it is, that the presence of certain symptoms leads us to anticipate others, and that their order of succession reveals to us the existence of latent perturbations, as well as the nature of the causes which have aroused them. 68 ELEMENTS OF THERAPEUTICS AND PRACTICE. A particular diagnosis in the various cases of disease is a necessity, but, without being limited to the de- termination of the locality of the principal morbid con- dition, we should also not neglect the ascertaining of the nature of the primordial perturbations and their original causes. This point is the more important, be- cause, if we can settle it in the dynamic or preparatory phases of diseases, and then know how to interfere effectively, we can cut short the subsequent phases. In variola, for example, we can not diagnosticate that the disease is localized at any one point ; we merely observe fever and other uncertain and temporary symp- toms. But, if we are able to recognize the nature of the disease and its main cause by destroying the lat- ter, we can arrest the natural evolution of the morbid processes, and reduce the duration of the disease to a very few days ; while, if left to take its course, it would reach its end only after the patient had suffered for a long time, and had lost much strength. If we are called to investigate any morbid condition whatsoever, our first thought should be to discover the cause of disease. That cause, when discovered, will either be still in existence or will have passed away. If it still exists, we must fight it with the greatest en- ergy, in order to destroy it, to neutralize it, or to pre- vent its results. If the original cause has disappeared, we can no longer operate upon it, but we can and should direct our efforts upon its results. These results may be primary, secondary, tertiary, etc., and it will be our duty to fight them in the order in which they were developed, choosing for particular attention, among those which appeared at the same period, the ones which are the most grave, the most perturbant, and the most insupportable. The medicaments which are directed toward the principal element, which is the origin of all the other morbid elements, constitute what is called the domi- nant, whether that element be a pathogenic cause or MEDIOAMENTS. C9 only the cause of a group of secondary symptoms. When these primary perturbations are cured, it some- times happens that some of their effects remain. The dominant will vary, in that case, according as different morbid elements preponderate. The symptoms which have arisen from a principal morbid element, which can not disappear rapidly, may give rise to suffering, and act unfavorably upon the course of the disease by giv- ing rise to new series of symptoms, or by perverting the action of the medicaments, or by increasing the primary want of equilibrium. These symptoms must be antagonized, whatever be their hierarchical position. Remedies which are occu- pied with this function constitute what is called the variant. Therapeutics has only diseases to fight, and, as diseases are always accompanied by changes in the vital phenomena, we can not introduce into therapeu- tics, nor call by the name of medicaments, the neutral- izing chemical bodies which are intended to prevent the sad results which attend the action of poisonous substances. Before the absorption of the poison, or before its action upon the surface of the organs, no vital modification is possible, no disease has been pro- duced. The antidote acts as it would act in a beaker in the laboratory ; its effects are purely physical or chemical, and, indeed, there is no medicative action without the intervention of vitality. It is only after the poison has acted upon the tissues or the functions that disease actually exists, and therapeutics can interfere. The confusion between chemistry and therapeutics originated in the classical languages, and has been retained by pious tradition. The intervention which follows the ingestion of a poison, and which is certainly indispensable to prevent the results which would other- wise follow, certainly belongs to the domain of medi- cine, but it belongs rather to the department of hygiene than to therapeutics. The latter is limited in its func- tion to curing ; it neither encroaches upon physics nor 70 ELEMENTS OF THERAPEUTICS AND PEAGTICE. upon chemistry, excepting in those cases in which it is preventive. It is self-evident, however, that a phy- sician can not fail to be interested in the action of anti- dotes, in order that he may ward off the action of poi- sons upon the organism in every way. What has been said about antidotes is equally true about certain medi- cations which have for their sole object the modification of fermentations, the absorption of gases, and the elimi- nation of foreign bodies. It is indispensable that the causes of disease disappear if we are to effect a cure ; but true curative therapeutics is concerned with the results of causes, and not with the causes themselves. That is why the physician must bring to bear precise and rapid agents for the destruction or the elimination of the cause. He will choose these means from chemi- cal and physical agents, parasiticides, and eliminators, limiting his action to the nature of the cause, to the means at his control, and to the tolerance of his pa- tients, whose organism should remain at least neutral upon its own territory in this struggle, which is carried on in its behalf. It is only after one has been attacked and injured that he has a right to demand the services of a physi- cian, who will come to his aid, and will serve, as he ought, as an ally of Nature. When the organism passes from the defensive to the offensive, with its con- sequences, the time has arrived for putting the thera- peutic system into operation. This system will have for its objective point the pre- vention of the prolongation and multiplication of the existing troubles which engender others. We shall be able to control the latter the more easily by strangling the rebellion in its incipient state as rapidly as possible. The jugulation of diseases is one of the most important duties which are imposed upon the physician. In order to accomplish it he must lose no time, but begin the struggle forthwith. In the dynamic stage of diseases, jugulation (cutting off, as by strangling) is relatively MEDICAMENTS. 71 easy ; in the preparatory stage there is more difficulty, and it is sometimes insurmountable when the disease is completely under way. In that period we may be able to prevent the progressive evolution of the disease, but it will be impossible for us to repair, in a few hours, the injuries of substance which have been ef- fected ; for, while it is possible to correct in an instant disturbances of motion, modifications of substance al- ways require time for their accomplishment. Accord- ing as the nature of an injury is dynamic or material shall we conclude as to the activity of the medication which is required. The rule is as follows : For every acute disease, acute treatment ; for every chronic dis- ease, chronic treatment. But, in order to establish this acuity or this chronicity, it is not the progress of the disease in its ensemble which must be considered, but rather the rapidity with which the morbid elements are established which are to be antagonized. An hysterical paralysis may be chronic ; it may have lasted several months or even years, and yet require acute treatment, because, as it was established quickly, it may also dis- appear quickly, perhaps in a moment, or even from the influence of a moral impression. But, if this is to be accomplished, there must be no appreciable modifica- tions of tissue, for the cure of such conditions is a mat- ter of nutrition, and all the means at our disposal for the modification of nutrition are feeble, slow in their action, and not precise. In a word, the plan of treat- ment should be more acute, as the morbid element which it aims to correct is more essentially dynamic ; and the more chronic, as the dynamic perturbations have been transformed into lesions of substance. The best rule will be to investigate the nature of the princi- pal morbid elements and their filiation or succession in the primary perturbations. For example, paralysis which results from cerebral haemorrhage always comes on suddenly, without presenting any indication for the acute plan of treatment for paralysis. 72 ELEMENTS OF THERAPEUTICS AND PRACTICE. This element is, in effect, already secondary ; the in- dication is to combat the primordial dynamic lesion — that is to say, the vascular atony — which has allowed the haemorrhage to take place. It will also be necessary to administer ergo tine in the most acute manner possi- ble, because this medicament, by increasing the con- tractibility, causes the haemorrhage to cease, and pre- vents its recurrence. The necessity for acute medication being granted, it still remains to estimate its degree of acuity. In this respect we should be governed by cir- cumstances. We aim at obtaining as rapid an effect as possible, in so far as therapeutic action can be ac- complished without harm to the patient. Herein lies the question of dosage and of graduated effects, upon which it is useless to insist. The dose is determined, in general, by the quantity of the medicament which is contained in each granule — a quantity which may serve for the average in most cases. However, the most active alkaloids — like strychnine, morphine, hyoscia- mine, atropine, daturine, colchicine, etc. — should be given in fractions of granules when the administration of the first granule gives evidence of an excessive im- pressionability on the part of the patient, or when his age leads one to fear intolerance of the medicament after the first few doses have been given. It is often necessary, however, to double or treble the fractions of doses in order to produce an effect ; that is, to give two, three, or even more granules at once when we wish to lengthen the intervals, to bring on the effects more rapidly, to overcome some apathy to the action of drugs, or any morbid resistance of an excep- tional character. In the chronic diseases, which call for a plan of chronic treatment, we can proceed in two ways : we can either give the same dose on each occa- sion, increasing it at long intervals, and relying upon time and the persistence of slight effects to obtain the desired result, or we can increase the quantity of the drug at each dose until a perceptible effect is obtained. MEDICAMENTS. 73 Suppose we take for an example an atonic condition of the stomach, for which strychnine is indicated. We will administer one or two granules before each meal for a long time. In some cases no effect will appear, the dose being insufficient ; in others, these small doses will go on accumulating until their useful effect is ap- parent, and then the effects of the drug will remain concealed, while the curative effects will be the only ones which are evident. But, in place of administering this constant dose of strychnine, we may give one granule on the first day, two on the second, then three, four, five, six, or more at a time, until the curative effect is obtained, or an important physiological one. This latter method of administration is especially fitting in the chronic organo-dynamic diseases ; the for- mer in those chronic diseases in which the organic le- sions constitute almost entirely the disease, while the dynamic troubles are of very little account. The variability of individual impressionability, which may change from one day to another, renders the latter method of administration the less safe, and limits its use to those cases in which the indications are very clear, and in which medication is addressed to a morbid element of great genealogical importance. This plan of treatment can not be continued for a very long time, but, as the doses are increased very grad- ually, the dangers of a result which was not anticipated are not great. After the effect has been obtained, we should con- tinue the use of the same agent, but in gradually de- creasing doses. It should be understood that dosime- try, the principle of which is that there is no sufficient effect without a sufficient dose, supplies all the means for testing the impressionability, so as to be able to accomplish much with safety in a small period of time. When the disease reaches its stage of reparation, the physician must still interfere, but rather to furnish that 74 ELEMENTS OF THERAPEUTICS AND PRACTICE. which the organism lacks than to modify it. It is a kind of expectation of a protective character, which, while allowing Nature to pursue her course, and trans- form morbid results into healthful processes, furnishes her in an intelligent manner with a liberal supply of the substances which are necessary for organic repair, such as iron, arsenic, phosphorus, and lime, which are complementary to alimentation, and, by means of the dynamophores (caffeine, guaranine, brucine, strychnine), increases the sum of vital energy, which is necessary for the complete repair of the tissues and forces. What we are about to say in our "Elements of Clinical Thera- peutics," and what has been already expressed in other works on dosimetric medicine, will give the physician the instruction and the confidence which he requires to treat the different varieties of disease. The pharmaco- logical memorial and the list of the principal morbid elements, and the most useful medicaments which are appropriate for them, will greatly facilitate the arduous task of elaborating a therapeutical system which shall answer the principal necessities of the sick. PHARMACOLOGICAL MEMORIAL OF THE DRUGS WHICH ARE IN USE IN DOSIMETRIC MEDICINE, WITH A STATEMENT AS TO THEIR DOSES, THEIR PRINCIPAL PROPERTIES, AND THEIR MODE OF USE. PHARMACOLOGICAL MEMORIAL. Acid, Arsenious. — In granules of one milligramme each. This drug acts as a restorer of the nutrition, and has a great influence upon the blood- and heat-produc- ing functions. It is indicated in chloro- anaemia, leu- corrhcea, the ataxo-adynamic fevers, cholera, purulent cachexias, in certain cutaneous affections, such as ele- phantiasis, psoriasis, icthyosis, etc. It is a febrifuge, and may be used as a succedaneum or an auxiliary to quinine in the treatment of malarial fever. In acute conditions, one granule every half -hour or hour may be given, according to the intensity of the disease, until an effect is produced ; in chronic conditions, from ten to twenty daily may be used. Acid, Benzoic. — In granules of one milligramme each. This is the immediate principle which is found in all the balsams. When introduced into the organ- ism, it transforms uric into hippuric acid, which, when combined with the ordinary bases of organic fluids, forms soluble salts. It is indicated in gravel, gout, etc. It also has stimulating properties, and favors expectora- tion ; but, as it is only slightly soluble, it is better to administer it in the form of salts — for example, benzo- ate of ammonia, soda, or lithia. It is often used in the subacute and chronic forms of bronchitis among children, and is also suitable for cases of laryngeal catarrh with hoarseness. Dose, two granules every hour, or three granules three or four times a day. 78 ELEMENTS OF THERAPEUTICS AND PRACTICE. Acid, Phosphoric. — In granules of one milli- gramme. It is an hsemogenic excitant, which is used, with strychnine, in the first period of inflammations, in all algid affections, and in depraved conditions of the nervous system. Phosphoric acid has been used suc- cessfully in the scrofulous disorders of children. Dose, eight to twenty granules a day. Acid, Salicylic. — In granules containing one cen- tigramme. It is antiputrescent, antiseptic, and anti- febrile. It is indicated in all zymotic diseases, espe- cially in diphtheria, malaria, eruptive fevers, etc. It is also appropriate in different forms of dyspepsia, especially those in which there are fetid eructations. Dose, one to three granules at a time, at shorter or longer intervals, according to the case. It is also use- ful as a topical application in all forms of epithelial degenerations. Acid, Tannic {Tannin). — In granules containing one centigramme. Indicated, on account of its astrin- gent properties, in all conditions in which there is marked relaxation of the tissues. It is useful for haem- orrhage, and for discharges of a mucous character, for the atonic diarrhoeas of children, and as a topical appli- cation (chewing the granules) for chronic forms of gin- givitis, amygdalitis, and pharyngitis, or, dissolved in water, for subacute forms of conjunctivitis. Dose, two or three granules three to five times daily. It should never be given with the alkaloids, nor with the greater number of the metallic salts, since it forms insoluble compounds with them. Aconitine. — In granules of one half of a milli- gramme. This is a valuable anti-congestive, and the best of the antiphlogistics. It is indicated for all febrile and inflammatory conditions to moderate the fever and reduce vascular tension. It is useful in all gastro-intestinal irritations, and in those of the respira- tory apparatus. It possesses decided cholagogic prop- erties, and is a diuretic and sudorific. It should be PHARMACOLOGICAL MEMORIAL. 79 associated with digitaline and veratrine in intense feb- rile conditions, and with strychnine when there is a depressed condition of vitality. Dose, in the acnte state, one granule every fifteen minutes or every half-hour, or larger doses may be given if the case demands it. In the chronic condition two granules may be given three or four times a day. The thermometer should always serve as a guide in the use of aconitine. Agaricine. — The active principle of agaric. The granules contain one milligramme each. It is an excel- lent active succedaneum with atropine in the treatment of nocturnal sweating. The dose is three to six granules daily. Anemonine. — The volatile, crystallizable principle which is obtained from the anemone Pulsatilla. Each granule contains one milligramme. This alkaloid is a decided irritant, and has a physiological action analo- gous to that of aconitine, but with this difference — that it stimulates the nervous centers. It may be used in paralysis, whooping-cough, and constipation. It is a medicament which is not very well known, but is capa- ble of giving excellent results. The dose is two gran- ules three to five times daily. Apomorphine. — In granules of one milligramme. It is a useful expectorant in cases of bronchitis and pneumonia in children. It is a tonic to the respiratory apparatus, and for this reason is indicated in capillary bronchitis in connection with brucine. When used hypodermatically in doses of one centigramme, it acts as an emetic. The dose is one to two granules every hour, or more may be given if necessary. Arbutine. — A glucoside, in granules containing one milligramme, which is obtained from the arbutus. It is to be given in doses of two to three granules, three or five times daily, in chronic affections of the bladder and urethra. It is also given to increase the flow of urine. 80 ELEMENTS OF THERAPEUTICS AND PRACTICE. In rebellious cases of bronchitis in lymphatic indi- viduals, arbutine is also indicated. Arseniate of Antimony.— In granules of one mil- ligramme. It modifies the vitality and the nutrition of the organs which are innervated by the pneumo- gastric nerve. Used as an expectorant, it has the dis- advantage of diminishing the appetite. The dose is one to two granules every two hours. It is also used to modify disordered conditions of the heart, in doses of one to six granules daily. Arseniate of Caffeine. — In granules of one milli- gramme. It is indicated in the condition of cerebral torpor which attends infectious diseases, and in cases in which the energy of the heart is weakened. In peri- odical cephalalgia and hepatic congestions of malarial origin, its prolonged use is beneficial. Two granules may be given every two hours. Arseniate of Iron. — In granules of one milli- gramme. It is the best regenerator of the blood in chloro-ansemia, in conditions of convalescence, and in haemophilia. It is also useful in the dermatoses of lymphatic persons, and in leucorrhcea. Dose, six to twelve granules daily. Arseniate of Manganese. — In granules of one milligramme. It is used in the same doses and for the same purposes as the similar salt of iron, when the lat- ter can not be tolerated. Arseniate of Potash.— In granules of one milli- gramme. Dose, six to ten granules daily. To be used for various affections of the skin, digestive disorders, and liver troubles. Arseniate of Quinine. — In granules containing one milligramme each. It is used in doses of six to twenty granules daily to counteract the element of periodicity which is present as a complication in certain diseases. It is also useful in affections of the skin which have evening exacerbations, and for lesions of the liver and spleen which are the result of malarial poisoning. PHARMACOLOGICAL MEMORIAL. 81 Arseniate of Soda. — In granules of one milli- gramme each. An agent which modifies the nutrition in general, and that of epithelial tissues in particular. It is useful in diseases of an herpetic character, and in all the chronic engorgements. When associated with iodoform, it modifies the work of suppuration. Dose, six to twelve granules daily. Arseniate of Strychnine. — In granules contain- ing one half a milligramme each. This is the neuro- sthenic par excellence, and the best vital incitant. It may be used with profit in almost all diseases, but especially in those which are accompanied with paraly- sis or atony. It should be administered in the initial stage of all pyrexias, to antagonize vaso-motor paraly- sis, and should be associated with phosphoric acid. In cases in which defer vescents are badly tolerated, a com- bination of them with strychnine will enable us to use them until their effect is produced. In the spasmodic affections, it assists in establishing the physiological equilibrium by combating the paralysis, while hyoscia- mine attacks the spasm. It is a tonic for all the apparatuses and for all the functions, and one of the principal means for produc- ing longevity. Dose, one to two granules, at intervals which must be governed by the acuteness of the disease and the degree of diminution of the vitality. Asparagine. — In granules containing one milli- gramme each. It is the active principle of asparagus. It has a feeble diuretic action, and is calmative to the urinary passages. It is useful in the first stage of urethritis and cystitis. Dose, ten to twenty granules, repeated several times. Atropine. — In granules containing one half a milli- gramme each. An alkaloid which is obtained from belladonna. Its principal action consists in contractil- ity and in diminishing secretions. It may be employed in all conditions of spasm, and for that reason it is 82 ELEMENTS OF THERAPEUTICS AND PRACTICE. useful in tetanus, hydrophobia, photophobia, internal strangulations, gastralgia, and the neuroses, such as hysteria, chorea, and epilepsy. It is also given to facilitate parturition, because it dilates the neck of the womb and regulates its contractions. It is useful for ptyalism, nocturnal sweating, and incontinence of urine. Dose, one granule every half -hour, in very acute cases ; in others, one granule every hour, every two hours, or less frequently, according to the condition of the disease or the tolerance of the patient. Atropine is borne by children better, relatively speaking, than by adults. Benzoate of Ammonia. — In granules of one centi- gramme each. It is a mild stimulant to the catarrhal, urinary, and sudoral secretions. It is very useful in apyretic forms of bronchitis in children, to facilitate and then to diminish expectoration ; also, in atonic forms of cystitis. Dose, ten to twenty granules daily. Benzoate of Lithine. — In granules containing one centigramme. It is indicated in all the lithiases and gouty troubles, and also in affections of the urinary passages. Likewise is it useful in pyrosis, and dys- pepsia from excessive secretion of acid. Dose, ten to twenty granules daily. Benzoate of Soda. — In granules containing one centigramme. Its indications and doses are the same as those of the two preceding salts. Biniodide of Mercury. — In granules containing one milligramme. It is to be used in the same cases in which the protoiodide of mercury is indicated, for all the phenomena which are connected with the syphi- litic diathesis. Dose, three to twelve granules daily. Brucine. — A very bitter alkaloid obtained from nux vomica and false angostura. Each granule con- tains one half a milligramme. It has properties analo-* gous to those of strychnine, but without the intensity of the latter. It is usually substituted for strychnine in the treatment of disease in children, and is useful PHARMACOLOGICAL MEMORIAL. 83 and almost indispensable in capillary bronchitis, in paralysis, and in atonic forms of dyspepsia. It has also been used in rachitis, and, in general, in all the affections in which the vitality is lowered or threatened. Dose, one to two grannies every half -hour, in acute cases ; six to twenty granules a day in chronic cases. Bryonine. — In granules containing one milli- gramme. It is regarded as a tonic to the large intes- tine and the respiratory apparatus. It is useful in typhoid fever, in pneumo- typhus, in constipation, and in recto- vesical paralyses. Dose, one to two granules every two hours, in the acute stage ; six to ten daily in the chronic stage. Caffeine. — An alkaloid, which is one of the dyna- mophores, and is derived from coffee. The granules contain one milligramme each. It excites the cerebral functions and dissipates congestive and comatose con- ditions. It is a heart tonic, and, as a result of such action, increases diuresis. It is useful in the various forms of neuralgia, in vertigo, and in asystolia. Dose, in the acute conditions, one or two granules every half- hour ; in the chronic, six to twenty daily. Calomel (Protochloride of Mercury). — In granules containing one milligramme each. It is generally given as a vermifuge, six to twenty granules being given at once. It is also used as a cholagogue, and with advantage in icterus, dysentery, etc. Dose, one to two granules every hour. Carbonate of Lithia. — In granules containing one centigramme. It dissolves uric acid, and is therefore useful in all forms of lithiasis. Dose, from six to twenty granules daily. Cicutine. — In granules containing one half a milli- gramme. It is a calmative to sensory and motor de- rangements, and a moderator of reflex excitability. It is indicated in the diseases of the cord, in many forms of neuralgia, in conditions in which there are lancinat- ing pains, in insomnia and in neuropathic excitement. 84: ELEMENTS OF THERAPEUTICS AND PRACTICE. Dose, in acute cases, one granule every half -hour, until the effect is produced ; in chronic cases, six to ten granules daily. Citrate of Caffeine. — In granules containing one milligramme. It is weaker than caffeine, and is ap- plicable for the same conditions. Cocaine. — In granules containing one half a milli- gramme. This alkaloid is a dynamophore obtained from ErytJiroxylon coca. It devascularizes and anaes- thetizes those tissues with which it is brought in con- tact. It relieves congestion of the brain, and preserves the nutritive forces. It is very useful when dissolved upon the tongue in relieving inflammations of the mouth, tonsils, and pharynx. For these conditions it should be given in doses of from two to three granules every hour or every two or three hoars. In gastralgia, oesophagismus, etc., one or two granules may be given every quarter of an hour until the desired effect is obtained. Codeine. — In granules containing one milligramme. As a calmative it is weaker but safer than morphine. It is used at the beginning of cases of bronchitis, laryn- gitis, and tracheitis, combined with iodoform. It may also be given in enteritis, enteralgia, in dentition, etc. Dose, one to three granules every quarter of an hour, or less frequently if necessary. Colchicine. — In granules containing one half a milligramme. It is diuretic, analgesic, and cholagogue. It has emetic or purgative properties which never fail, if its use is sufficiently prolonged. It is the drug par excellence for the treatment of rheumatism and gout. Dose, one or two granules every half-hour, in acute cases, until the physiological effect has been produced ; six to ten granules daily in chronic cases. Colocynthine. — In granules containing one half a milligramme. It is tonic and stimulant to gastro- intestinal contractility. It is useful in cases of atonic dyspepsia, in intestinal torpor, and in habitual consti- PHARMACOLOGICAL MEMORIAL. 85 pation. It is also useful as a vermifuge. Dose, three to five granules two to three times daily. Cotoine. — A principle which is obtained from the bark of coto, a plant which is a native of Bolivia. The granules contain one milligramme. This alkaloid has antifermentative and antipyretic qualities. It is prob- ably analogous to guaranine, and gives excellent results in different affections of the digestive apparatus. It can be tried to relieve vomiting, dysentery, loss of ap- petite, etc. Dose, three granules three to five times daily. Croton Chloral. — In granules containing one centi- gramme. It soothes hyperesthesia and reflex excita- bility. It is indicated in myelitis, nervous cough, neuralgia, etc. Dose, two granules every half-hour until the effect is obtained. Cnbebine. — In granules containing one milli- gramme. It is eliminated by the mucous membranes, and is therefore useful in cystitis, blennorrhagia, bron- chitis, etc. Owing to its stimulant properties, it is also applicable in anorexia and apyretic conditions of gas- tric disorders. The dose is three to five granules three to ten times daily. Cyanide of Zinc. — In granules containing one milligramme. This salt soothes and settles disturbed conditions of the nervous system. It is useful in gas- tralgia, epilepsy, etc. It is also advised for affections of a rheumatic character. Dose, six to twelve granules daily. Cyclamine. — In granules containing one milli- gramme. It is laxative and cholagogue, but its exact properties and indications are not yet well defined. The dose is six to ten granules daily. Daturineo— In granules containing one half a milli- gramme. Its action is calmative and antispasmodic, analogous to but more energetic than atropine and hyoscyamine. It is sometimes substituted in ophthal- mic practice for atropine, being used in solution by instillation. It is of service in photophobia and ocular 86 ELEMENTS OF THERAPEUTICS AND PRACTICE. neuralgia, in asthma, nterine colic, etc. [Dose not stated.— Teans.] Diastase. — In grannies containing one centi- gramme. It serves to replace pty aline in buccal and intestinal forms of dyspepsia. The dose is one to Hve granules with each meal. Digitaline. — In granules containing one milli- gramme. This alkaloid has a particular action upon the heart, increasing its contractility by a moderat- ing and regulating influence, and producing a tonic effect. It diminishes the number of pulsations when they are exaggerated, increases the number when the systole is incomplete, and equalizes the pulsations when their rhythm is disturbed. It is used for cardiac excitement, for all febrile and congestive diseases, and for the chronic affections of the heart. It may be used daily to regulate the cardiac forces and to contribute to longevity. Dose, in acute conditions, one granule every half- hour, or less frequently, as the case requires ; in chronic conditions, two to four granules daily may be given. Elaterine. — In granules containing one milli- gramme. It is obtained from elaterium, and possesses drastic and emmenagogue properties. It may be used for the treatment of constipation and hemorrhoidal or catamenial suppression. Dose, one to three gran- ules two or three times daily. Emetic. — In granules containing one centigramme. An emetic, purgative, contra-stimulant, and expecto- rant, according to the size and frequency of the doses. It is used in bronchitis, dyspepsia, pneumonia, and as a modifier of cardiac nutrition. Dose, for emetic pur- poses, two granules in water, every ten minutes, until the desired effect is obtained ; as a purgative, one granule every half -hour until the effect is produced ; as an expectorant, one granule every two hours. Emetine. — In granules containing one milli- gramme. An emetic suitable for children, an expec- PHARMA COL GIGAL 'MEMORIAL. 87 torant, contra-stimulant, and antispasmodic. It is useful in bronchitis, pneumonia, whooping-cough, dys- entery, etc. Dose, as an emetic, two to three granules every ten minutes, dissolved in a teaspoonful of water ; as an expectorant and antispasmodic, one granule every two or three hours. Ergotine. — In granules containing one centi- gramme. It is used as an excito-motor to smooth muscular fibers, in haemorrhages, atony, and inertia of the uterus. It is also useful in adynamia and in atonic affections of the respiratory apparatus. Dose, three to five granules every quarter of an hour, as a haemo- static ; two granules every two hours to excite muscu- lar action. Euonymine. — In granules containing one milli- gramme. A tonic to the digestive apparatus and a cholagogue. It is useful in hepatic disorders, icterus, and dyspepsia. Dose, three to ten granules two or three times daily. Gelseinine. — In granules containing one half a milligramme. It is antispasmodic and antineuralgic. It is used in odontalgia, sciatica, for intercostal pains, and, in general, for all pain which is more tenacious than severe. Dose, one granule every quarter of an hour, until the desired effect is obtained. Gregory's Salt.— In granules containing one milli- gramme. It is a double chloride of morphine and strychnine. Its action is calmative, hypnotic, and anodyne. It may be used for insomnia, simple coughs, abdominal pains, diarrhoea, etc. Dose, one to three granules every quarter of an hour, until the effect has been obtained. G-uaranine, — In granules containing one milli- gramme. It is a dynamophore which is obtained from Paullinia sorMlis. It increases vitality, and is useful in all forms of adynamia. It is also useful for neural- gia and migraine. Dose, three granules, three to five times daily. 88 ELEMENTS OF THERAPEUTICS AND PRACTICE. Helenine. — In granules containing one centi- gramme. A crystallizable principle which is analo- gous to camphor, and is obtained from Inula Helenium. It is antiseptic, antispasmodic, and stimulant to ca- tarrhal secretions. It is useful in atonic and putrid forms of dyspepsia, in flatulence, in hysterical condi- tions, and in catarrhal troubles of the bronchi, larynx, and bladder. It may also be used with advantage in whooping-cough, phthisis, and blennorrhagia in its final stage. Dose, one to three granules three to five times daily. Hydrastine. — In granules containing one milli- gramme. It is a cholagogue, and a tonic to the digest- ive apparatus. It is very effective in cases in which there is suppression of the biliary excretion and secre- tion, and equally so in treatment which is directed against the carcinomatous diathesis. Dose, ten to twenty granules daily. Hydriodate of Morphine. — In granules contain- ing one milligramme. Its properties are those which are common to the other salts of morphine, but it is especially indicated in cough which arises from irrita- tion of the bronchi, in laryngitis of rheumatic origin, and for osteocopic pains. The dose is one or two granules every quarter of an hour until the effect is obtained. Hydrobromate of Cicutine. — In granules con- taining one milligramme. It is a calmative for nerv- ous, vascular, or muscular excitement. It is without some of the inconveniences of morphine, but has not the force of the latter as an antagonist to pain. It is useful in nervous irritability of all kinds, in cough, in meningo-myelitis, in cystalgia, myalgia, etc. Dose, one to two granules every quarter of an hour, in acute conditions, until the effect is produced ; and six to twenty granules a day in chronic conditions. Hydrobromate of Quinine. — In granules con- taining one milligramme. It is indicated in cases in PHARMACOLOGICAL MEMORIAL. 89 which, the element of pain is associated with that of spasm. Dose, ten to twenty grannies, or more, once or more frequently, according to the course of the attack. Hydro chlorate of Morphine. — In granules con- taining one milligramme. It is narcotic and anodyne, and is indicated in all forms of neuralgia and nervous irritation ; also at the beginning of all forms of inflam- mation, being usually associated with hyoscyamine, because pain rarely fails to provoke spasm. It is use- ful in catarrhal affections, and in all exaggerated con- ditions of sensibility. Dose, one to two granules every quarter of an hour until the effect is produced. Hydroferrocyanate of Quinine. — In granules containing one milligramme. This salt is antiperiodic like all the salts of quinine ; but has, in addition, a particular calmative action which it owes to the hydro- cyanic acid, and tonic properties which it owes to the iron in its constitution. It is useful in all diseases in which exacerbations occur, and also during the remit- tent period of all the pyrexias. Hyoscyamine. — The alkaloid of hyoscyamus. In granules containing one half a milligramme. It is anti- spasmodic, calmative, and analgesic. It is useful in all nervous affections in which there is excessive con- tractility. It gives good results in constipation, stran- gulated hernia, intestinal occlusion, enteralgia, gastral- gia, photophobia, dysuria, etc. It diminishes the secre- tions of the mucous and sweat glands, and for that reason is useful in bronchitis, bronchorrhcea, ptyalism, tuberculosis, etc. Dose, one granule every half-hour until the desired result is obtained ; or, one granule three to five times daily, according to the severity of the case. Hypophosphite of Lime. — In granules contain- ing one centigramme. It is a means of alimentation for the bony and nervous systems. In rachitis and all affections in which vitality is lowered, and in cases in which the hypophosphite of strychnine is too ener- 90 ELEMENTS OF THERAPEUTICS AND PRACTICE. getic a stimulant, this salt is indicated. The dose is ten to twenty granules daily. Hypopliosphite of Sodium. — In granules con- taining one centigramme. The doses and indications are the same as the foregoing. Hypopliosphite of Strychnine. — In granules containing one half a milligramme. It is a tonic and stimulant to the nervous system, improving its func- tional action and nutrition. It is useful in all cases of vital depression caused by overwork, age, or disease. It is indispensable in pneumonia in the aged, in all adynamic affections, in rachitis, chloro-ansemia, and in the prostration which accompanies convalescence from severe diseases. Dose, six to forty granules daily. Iodoform. — In granules containing one milli- gramme. It is a disinfectant with a calmative action, and a modifier of nutrition, especially with reference to the lymphatic system. It is useful in bronchitis, pulmonary gangrene, offensive breath, the lymphatic diathesis, and syphilis. It is also useful for the pain and congestion which accompany rheumatism. Dose, one to three granules every half -hour, for acute condi- tions ; three to five granules from three to live times daily in chronic conditions. Iridine. — In granules containing one milligramme. It is a cholagogue and exciter of intestinal con- tractility. It is useful in cases in which there is suppression of the biliary excretion, in icterus, and in hepatic cirrhosis ; diuretic effects have also been ascribed to it. Dose, two granules five to ten times daily. Jalapine. — In granules containing one milli- gramme. Its action is tonic upon the small intestine. In small doses its action as a purgative is uncertain ; in large doses it is a drastic cathartic. Dose, six to twenty granules daily. Juglandine. — In granules containing one milli- gramme. Vermifuge, depurative, and antisyphilitic PHARMACOLOGICAL MEMORIAL. 91 action has been attributed to this drug. It has been used with success for scrofula and weaknesses in which the torpid element predominates. Dose, six to twelve granules daily. Eermes Mineral. — In granules containing one centigramme. This drug has a modifying influence upon the respiratory apparatus and the cardiac nutri- tion. It is useful as an expectorant, and also in chronic diseases of the heart in the hypertrophic stage. Dose, six to twenty granules daily. Kousseine. — In granules containing one milli- gramme. A vermifuge, particularly for children. Dose, one to five tubes in the course of an hour. .Lactate of Iron. — In granules containing one centigramme. An iron salt, which is usually well tolerated, even by those who have stomachs which are sensitive to the astringent action of iron. It may be used in chlorosis, anaemia, atonic diarrhoeas, etc. Dose, three to ten granules daily. Leptandrine. — In granules containing one milli- gramme. It is cholagogue and tonic to the organs of the digestive apparatus. It is useful in the hepatic diseases, in enteritis, in choleriform diarrhoea, etc. Dose, six to twenty granules daily. Lobeline. — In granules containing one half a milli- gramme. It is expectorant and antispasmodic, is use- ful in acute and chronic affections of the respiratory apparatus, especially in those of children. Dose, four to twelve granules daily. Lycopine. — In granules containing one milli- gramme. A narcotic and astringent action has been attributed to it, which would make it useful in cases of convulsive cough and other pulmonary affections. Dose, six to ten granules daily. Monobroniate of Camphor {Bromide of Cam- phor). — In granules containing one centigramme. It is antispasmodic and calmative to the nervous system. It possesses also antithermic and hypnotic properties. 92 ELEMENTS OF THERAPEUTICS AND PRACTICE. It is indicated in convulsions, hysteria, insomnia, epi- lepsy, tetanus, palpitations, etc. It is also very useful in bronchitis in cases in which the catarrhal element is associated with a spasmodic one. Dose, one to three granules, at suitable intervals, according to circum- stances. Narceine, — In granules containing one milli- gramme. Calmative, antispasmodic. Its uses are the same as those of codeine. Dose, six to twenty gran- ules daily. Mtrate of Pilocarpine. — In gran ales containing one milligramme. It is diaphoretic, sialogogue, and diuretic. It is useful in bronchitis, pleuritis, coryza, asthma, stomatitis, and pharyngitis. Dose, ten to thirty granules daily. Pepsin, — In granules containing one centigramme. An aid to digestion, which is given with the aim of supplying the deficiency as to gastric juice, or to aid the gastric forces. It is useful in dyspepsia, enteritis, etc. Dose, two to four granules with each meal. Phosphate of Iron, — In granules containing one centigramme. By virtue of the iron it acts as a tonic to the blood, and by the phosphorus to the bones and nervous system. It is useful in chloro-ansemia, in rachitis, in the lymphatic diathesis, during convales- cence, etc. Dose, six to twelve granules daily. Phosphite of Zinc. — In granules containing one milligramme. A tonic to the nervous system. It is useful in all the forms of nervous debility, in scrofula, tuberculosis, etc. Dose, five to fifteen granules daily. Picrotoxine. — In granules containing one half a milligramme. It has a calmative effect upon the bul- bar centers, and is a stimulant to therm ogenesis, being manifested by symptoms of congestion upon the face. It is applicable in different spasmodic affections of the respiratory centers, of which asthma, whooping-cough, etc., will serve as examples. In cases in which there is pleuritic effusion, it also relieves dyspnoea and favors PHARMACOLOGICAL MEMORIAL. 93 the resorption of the effusion. Dose, in acute condi- tions, one granule every hour until the effect is ob- tained ; in chronic conditions, two to three granules two to three times daily. Piperine. — In granules containing one milli- gramme. It stimulates the digestive functions, and those of mucous membranes as well. It is useful in anorexia, blennorrhoea, and chronic bronchitis. It is contra-indicated in irritative conditions of the gastro- intestinal canal. Dose, one to two granules three to five times daily. Podophyllin. — In granules containing one centi- gramme. Its cholagogue and purgative action can be relied upon, though it comes on slowly and without the production of colicky pains. It is of use in consti- pation, intestinal occlusion, gastritis, and icterus. Dose, in acute cases, three granules every hour until the de- sired result is obtained ; in chronic cases, three to five granules before going to bed at night. As a purgative, five granules may be given every half-hour, for three or four doses. Protiodide of Mercury. — In granules containing one centigramme. It is cholagogue and antisyphilitic. Dose, three to fifteen granules daily. Quassine. — In granules containing one milli- gramme. It is a bitter tonic, stomachic, and regulator of the biliary excretion. It is useful in all conditions of weakness and atony, in anorexia, and in most forms of dyspepsia, in conditions of convalescence, and as a stimulant to digestion, especially if there is a tendency to a hypersecretion of mucus on the part of the gas- tric glands. When combined with hyoscyamine or morphine, it mitigates the stupefying action of those alkaloids. It is very useful in that form of gastric catarrh to which drunkards are subject, in cough, in palpitations, and in that form of headache which is of gastric origin. Dose, one to five granules before each meal. 94 ELEMENTS OF THERAPEUTICS AND PRACTICE. Salicylate of Ammonia. — In granules containing one centigramme. It is a most valuable antiseptic, and is of use in rheumatism and in all infectious and septi- cemic conditions. It is of use in cases in which there has been inoculation with poison, and for a fetid con- dition of the breath. Dose, one to three granules every two hours, or every hour in acute cases. Salicylate of Iron. — In granules containing one centigramme. It restores the blood to a healthy con- dition, and prevents decomposition. It is useful in chloro-ansemic conditions complicated with rheuma- tism, in dyspepsia attended with fermentation, in scor- butus, purpura, etc. Dose, two to three granules three to five times daily. Salicylate of Quinine. — In granules containing one centigramme. It is useful for the periodic symp- toms of all rheumatic and infectious diseases. Dose, ten to forty granules once or several times daily. Salicylate of Sodium. — In granules containing one centigramme. It is useful for rheumatic condi- tions, gout, and dyspepsia which is accompanied with fermentation. Dose, three to five granules two to three times daily. Santonine. — In granules containing one centi- gramme. It is the active principle of the semen contra, and is used to destroy intestinal parasites. Dose, six to fifteen granules for one or two evenings, in connec- tion with two to four granules of podophyllin, or with a Sedlitz powder. Scillitine. — In granules containing one milli- gramme. It is diuretic and expectorant in its action, and tends to diminish the viscosity of mucous dis- charges. It is employed in bronchitis of the dry form, in whooping-cough, and in heart-disease in which there is diminished flow of urine. Dose, one to two gran- ules every two hours, or less frequently in chronic cases. Sedlitz (effervescent). — A saline purgative com- bined with sugar, in a granular form. A small tea- PHARMACOLOGICAL MEMORIAL. 95 spoonful may be taken daily as a mild cathartic ; or, as a purgative, a dessertspoonful may be taken every two hours in cold water until the desired effect is ob- tained. It may be used as an ordinary drink during the latter end of pyrexial troubles and infectious dis- eases. Subnitrate of Bismuth. — In granules containing one centigramme. It is an absorbent, an antispasmodic, and a disinfectant to the digestive apparatus. It is used in gastralgic forms of dyspepsia, in the chronic diarrhoea of children, and for eructations of an offensive character. Dose, five to ten granules, before eating. Sulphate of Atropine. — In granules containing one half a milligramme. Its action is the same as, though feebler than, that of atropine, and it is used in similar cases. Dose, one granule every half -hour until the desired effect is produced ; or, two to three gran- ules once or twice daily for incontinence of urine, epi- lepsy, the sweating of phthisis, etc. Sulphate of Calabarine. — In granules containing one half a milligramme. It increases the energy of contractility of the circular fibers ; it is useful in atonic conditions of the intestines. Dose, six to twelve gran- ules daily. Sulphate of Quinine. — In granules containing one centigramme. It is an antiperiodic which is useful in all paroxysmal diseases, but especially in the inter- mittent fevers. It has a tonic action upon contractil- ity. Dose, six to twenty granules, or more, daily. Sulphate of Strychnine. — In granules containing one half a milligramme. Its properties, uses, and doses are the same as those of the arseniate of strychnine. The sulphate is to be preferred if it is desired to obtain simply a neurosthenic effect. Sulphide of Calcium. — In granules containing one centigramme. It is the best of the parasiticides. It is indispensable in the treatment of all infectious diseases ; for example, croup, measles, variola, erysipe- 96 ELEMENTS OF THERAPEUTICS AND PRACTICE. las, cholera, etc. It is equally useful in catarrhal troubles, particularly in those of the respiratory appa- ratus. It is also of use in different dermatoses. Dose, one granule every quarter of an hour, in the acute stage ; two to five, three times a day, in the chronic. Tannate of Cannabine. — In granules containing one milligramme. It is obtained from Indian hemp, and is a valuable drug on account of its calmative and analgesic properties, while it has not the disadvantages of morphine. It may be used in gastralgia, and for all pains of a spasmodic character, when it is desirable to soothe and avoid excitation. Dose, for acute conditions, two granules every quarter of an hour until the effect is produced ; for chronic conditions, three granules three to five times daily. Tannate of Pelletierine. — In granules contain- ing one milligramme. If it is to be used as a tsenif uge, the granules should contain a centigramme. When used for the latter indication, ten to fifteen tubes may be taken in water at once, or at frequent intervals, and the dosage continued until twenty-five to thirty centi- grammes of the drug have been taken, this being the quantity which is requisite to expel the tsenia. It may also be used in certain congestive forms of headache. The dose for headache is five granules hourly until the effect is produced. In cases in which it is taken as a tsenifuge, a purgative should follow after a short period to facilitate the effect. Valerianate of Atropine. — In granules contain- ing one half a milligramme. It is antispasmodic, and is particularly indicated in neuroses of a convulsive character, and in cerebral ansemia. It is also effective in the different forms of vesania. Dose, one granule every half -hour until the desired effect is produced, in acute conditions ; two granules two or three times daily in chronic. Valerianate of Caffeine. — In granules containing one milligramme. It has an antispasmodic and anti- PHARMACOLOGICAL MEMORIAL. 97 congestive action npon the brain. It may be used in headache, vertigo, cerebral torpor, etc. Dose, one to three granules every half-hour. Valerianate of Iron. — In granules containing one centigramme. It is useful in neuroses, chloro-ansemia, and those forms of ansemia which are accompanied by gastralgia and headache. Dose, one to three granules three times daily. Valerianate of Quinine. — In granules containing one centigramme. Its action is antiperiodic and anti- spasmodic. It is particularly useful in malarial or intermittent affections with nervous phenomena. It is an excellent tonic. Dose, two to five granules three to five times daily. Valerianate of Zinc. — In granules containing one centigramme. It is antispasmodic, and checks nervous mobility. It is useful in neuropathies in cases in which iron is contra-indicated. Dose, six to twenty granules daily. Veratrine. — In granules containing one half a milligramme. It is a calmative of muscular contrac- tility, a defervescent, and a contra-stimulant. It is of use in rheumatism, congestive dermatoses, chorea, and all febrile conditions in which the pulse is hard and full. In gastric troubles it tends to excite the ap- petite. For children it serves as an excellent emetic. Dose, one to three granules at suitable intervals, ac- cording to the case. LIST OF DISEASES AND CONSPICUOUS MOEBID ELEMENTS, WITH THE INDICATIONS FOR THOSE DOSIMETRIC DRUGS WHICH WOULD BE MOST APPLICABLE TO THE GIVEN CASES. LIST OF DISEASES AND CONSPICUOUS MORBID ELEMENTS. Accidents at the critical period Acne Acne sebacea . Acrinia, pancreatic Action, nervous Adynamia Agalaktia . Agony Albuminuria Algidity . Alienation, mental Alkalescence . ! Stimulants Depressants ( Increased ( Depressed Amaurosis Amenorrhoea Plethoric Anaemic Spasmodic Tonic . Amnesia . Amygdalitis Aconitine. Sedlitz. Veratrine. Sulphide of calcium. Arsenious acid. Arseniates. Nitrate of pilocarpine. Calomel. Aconitine, hyoscyamine. Phosphoric acid,' strychnine. Sulphate of strychnine. Salicylate of ammonia. Arseniate of iron. Phosphate of iron. Hydrochlorate of morphine. Arseniate of strychnine. Aconitine. Digitaline. Hypophosphite of strychnine. Phosphoric acid. Tannate of cannabine. Hyoscyamine, digitaline. Salicylic acid. Tannic acid. Tannic acid. Aconitine. Tannic acid. Strychnine. Sulphate of strychnine. Anemonine. Aconitine, veratrine. Iron, strychnine. Hyoscyamine. Ergotine. { Cubebine. ( Atropine. < Aconitine. ( Cocaine. 102 ELEMENTS OF THERAPEUTICS AND PRACTICE. Anaemia . Anaesthesia Anaphrodisia . Anasarca (dropsy), acute Aneurism Angina pectoris Anginae, acute . Anosuria . Apepsia . Apoplexia Appetite, for food Appetite, sexual Increased Diminished Increased { Diminished Arrest of growth in children . Arthritis, chronic Ascites Asialorrhcea Asphyxia Asthenia Asthma . Asystolia . Ataxia Ataxia, partial muscular . Ataxia, progressive locomotor Ataxisystolia Arseniate of iron. Arseniate of manganese. j Hypophosphite of strychnine, ( Phosphoric acid. j Strychnine. ( Phosphide of zinc. Aconitine. Digitaline. j Digitaline. ( Ergotine. ( Daturine. ( Brucine. Aconitine. Cocaine. Veratrine. Pepsin. j Ergotine. ( Caffeine. Hyoscyamine. Quassine. Bromide of camphor. Strychnine. i Carbonate of lithia. ■< Hypophosphites of lime and ( sodium. Iodoform. Arseniate of strychnine. Nitrate of pilocarpine. Nitrate of pilocarpine. Quassine. Strychnine. Sulphate of strychnine, j Hyoscyamine. ( Sulphide of calcium. j Digitaline. ( Caffeine. j Bromide of camphor. ( Gelsemine. Veratrine. Atropine. Phosphite and zinc. Digitaline. valerianate of Biliousness Blennorrhagia Blennorrhcea Sedlitz Chanteaud. Podophyllin. Aconitine. Helenine. Helenine. Strychnine. DISEASES AND REMEDIES. 103 Bodies, foreign, in the oesophagus . . Emetic. -r. r • ( Hyoscvamine. Bouhmia } Morphine. ( Aconitine. Bronchitis •< Morphine. ( Apomorphine. Bronchorrhcea \ ggj** •**»• Cachexiae .... Calculi, biliary and urinary Cancer Cancerous diarrhoea Carus Catarrh, dry pulmonary Catarrh of the stomach Catarrh, suffocative . Catarrhal affections . Cephalalgia Cephalalgia, rheumatismal Chlorosis . Cholera . Cholera, infantile Cholerine . Chorea Chyluria . Colic, hepatic . Colic, lead Arseniate of strychnine. Arseniate of iron. Benzoate of lithia. Hyoscyamine. Hydrastine. Cicutine. Salicylate of iron. Pepsin. Caffeine. Strychnine. Scillitine. Emetine. Veratrine. Quassine. Hypophosphite of strychnine. Piperine. Nitrate of pilocarpine. Atropine. Caffeine. Guaranine. Colchicine. Cyanide of zinc. Arseniate of iron. Arseniate of manganese. Phosphoric acid. Strychnine. Sulphide of calcium. Codeine, brucine. Hydrochlorate of morphine. Sedlitz. Brucine, morphine. Veratrine. Hyoscyamine. Strychnine. Quassine, Hyoscyamine. Salts of lithia. Podophyllin. Strychnine. Atropine. 104 ELEMENTS OF THERAPEUTICS AND PRACTICE. Congestion, atonic, of the brain Congestions Conjunctivitis, chronic Constipation . Contractures . Convulsions Convulsive state Cough, whooping Cramps Croup Cystinuria Cystitis, chronic Cystitis, from use of cantharidcs Deafness . Delirium, alcoholic . Dentition, painful . Depression, nervous Dermalgia Diarrhoea . Diathesis, hemorrhagic Diathesis, purulent . Diphtheria Dry tetter Dysentery Dysmenorrhoea Dyspepsia 1) ( Nitrate of pilocarpine. \ Strychnine. Aconitine. Sedlitz. j Arsenious acid. { Iodoform. j Podophyllin. \ Sedlitz Chanteaud. j Hyoscyamine. \ Croton chloral. j Phosphoric acid. I Gelsemine. Hyoscyamine. Bromide of camphor. j Sulphide of calcium. ( Helenine. Bromide of camphor. Hyoscyamine. j Sulphide of calcium. ( Salicylate of ammonia. Juglandine. ( Arbutine. ( Helenine. { Bromide of camphor. ( Hyoscyamine. Aconitine. Cocaine, j Strychnine. ( Digitaline. Cocaine. Codeine. j Phosphoric acid. I Sulphate of strychnine. Cicutine. Tannate of cannabine. j Morphine. ( Strychnine. Ergotine. Arseniate of iron. Iodoform. Arseniate of sodium. Sulphide of calcium, j Arsenious acid. { Arseniates. ( Emetine. ] Hyoscyamine. j Veratrine. I Hyoscyamine. j Pepsin. 1 Diastase. DISEASES AND REMEDIES. 105 Dyspnoea . ( Picrotoxine. ( Hydrobromate of cicutine ( Atropine. Dysuria -j Strychnine. ( Bromide of camphor. Eclampsia, infantile E j Phosphoric acid. 1 Hydrobromate of quinine. Eclampsia, puerperal j Morphia. ( Bromide of camphor. Ecthyma, chronic j Juglandine. ( Arseniate of potash. Eczema, chronic ( Sulphide of calcium. ( Arseniate of soda. Engorgement, chronic j Iodoform. ' ( Arseniate of iron. Ephidrosis j Atropine. \ Strychnine. Epilepsy . j Atropine. ( Bromide of camphor. Epistaxis . j Ergotine. ' ( Tannic acid. Epizoaries Sulphide of calcium. Erethism, cerebral . ( Aconitine. { Digitaline. Erethism, sexual j Cicutine. ( Bromide of camphor. Eruptions, recurrent j Sulphide of calcium. "j Picrotoxine. Erysipelas Sulphide of calcium. Esthiomene (rodent ulcer^ ( Juglandine. 1 Phosphate of iron. Excrescences, epidermic Salicylic acid. Expectoration, viscous j Scillitine. | Helenine. F Favus Sulphide of calcium. ( Aconitine. Fever •< Veratrine. ( Digitaline. Fever, eruptive Sulphide of calcium. Fever, intermittent . j Arsenious acid. ' ( Arseniate of quinine. Fever, mucous . j Nitrate of pilocarpine. ' I Sedlitz Chanteaud. Fever, pernicious j Sulphate of quinine. ' { Arseniate of strychnine. Fever, puerperal j Aconitine. ( Salicylate of quinine. 106 ELEMENTS OF THERAPEUTICS AND PRACTICE. Fever, typhoid . ( Aconitine. " I Arseniate of strychnine. Fever, urethral j Aconitine. ' ( Hydrobromate of quinine. Fever, yellow . ( Aconitine. ( Sulphide of calcium. Finger, numbness in Hypophosphite of strychnine. Fissures, anal . Daturine. Fistulas, anal . j Iodoform. ( Arseniate of iron. Flatulence j Sulphate of strychnine. 1 Euonymine. Flowers, white (leucorrha ja) . j Iodoform. ( Arseniate of iron. Flux, menstrual j Excessive \ Deficient Ergotine. Veratrine. Galactorrhcea . G j Phosphate of iron. ' ( Arseniate of strychnine. Gangrene, senile Hypophosphite of strychnine Gas, gastro-intestinal Nitrate of bismuth. Gastralgia j Tannate of cannabine. ( Hydrobromate of morphine. Gastrodynia j Veratrine. ( Quinine. Glossitis . Aconitine. Glycosuria j Cocaine. ( Benzoic acid. Gout H j Salicylate of lithine. ( Colchicine. Haemateinesis . Ergotine. Hemoptysis j Ergotine. ( Veratrine. Haemorrhage . j Ergotine. ( Sulphate of strychnine. Haemorrhaphilia j Ergotine. ( Arseniate of iron. Haemorrhoids . j Aconitine. ( Strychnine. Hernia, strangulated j Atropine. ( Podophyllin. Herpes circinatus . Sulphide of calcium. Herpetism j Arseniate of soda. ] Sulphide of calcium. j Lactate of iron. Hydraemia 1 Arsenious acid. DISEASES AND REMEDIES. 107 Hydropsy . Hydrorrhachis Hydrothorax Hyperacusis Hyperosmia Hypersecretion Hypersystolia Hyperthermia Hypnosis . Hypoglobulia Hysteralgia Hysteria . pancreati j Digitaline. ( Strychnine. Iodoform. Ergotine. Nitrate of pilocarpine. j Valerianate of quinine. I Narceine. Hydrobromate of morphine. j Morphine. ( Hyoscyamine. Digitaline. Aconitine. Valerianate of atropine. Valerianate of caffeine. Arseniate of iron. Gelsemine. Hyoscyamine. Bromide of camphor. Valerianate of atropine. Ichthyosis . Impetigo, chronic . Incontinence of urine, nocturnal Indigestion Inertia, uterine Inflammations . Insomnia . Intertrigo . Arsenious acid. j Phosphoric acid. ( Sulphide of calcium. (, Atropine. I Brucine. ^ Emetic. ( Pepsin. j Ergotine. ( Strychnine. ( Aconitine. \ Strychnine. Hydrochlorate of morphine. Tannate of cannabine. \ Tannic acid. ( Veratrine. Laryngitis stridulus Leucocythoemia Leucorrhcea Lumbrici . Lupus Lymphatic diathesis Sulphide of calcium. Benzoic acid. Hydroferrocyanate of quinine. Arseniate of iron. Phosphate of iron. Iodoform. Santonine. Calomel. Iodoform. \ Juglandine. | Iodoform. 108 ELEMENTS OF THERAPEUTICS AND PRACTICE. M Meningitis, granular j Iodoform. * I Arseniate of quinine. Meningitis, infantile j Aconitine. * ( Hyoscyamine. Mentagra ( Arseniate of potash. * ( Biniodide of mercury. Metritis, puerperal . j Aconitine. * I Salicylate of quinine. Metritis, simple j Aconitine. * ( Ergotine. Metrorrhagia .... j Ergotine. * ( Strychnine. Miasm j Sulphide of calcium. ' ( Salicylic acid. j Quassine. ' ( Caffeine. Migraine ..... Morphine, poisoning by . j Hyoscyamine. ' l Caffeine. Muscarine, poisoning by . ( Atropine. * ( Dat urine. Naevi materni .... N Ergotine. Nausea ..... { Quassine. * 1 Codeine. Neuralgia .... j Aconitine. ' l Hydrobromate of morphine. Neuralgia, cranial . j Cocaine. * ( Croton chloral. Neuralgia, general . j Cicutine. ' ( Tannate of cannabine. Neuralgia, paludal . j Hydrobromate of quinine. * ( Valerianate of caffeine. Neuralgia, vesical . j Bromide of camphor. ' I Helenine. Neuroses j Hyoscyamine. * ( Strychnine. Nicotine, poisoning by j Caffeine. * } Strychnine. Obesity j Strychnine. " ( Iodoform. (Edema . j Sulphate of strychnine. * I Digitaline. Oligsemia j Arseniate of iron. ' ( Phosphoric acid. Oligocholia ..*... j Podophyllin. * ] Colchicine. Oliguria j Asparagine. ' ( Arbutine. DISEASES AND REMEDIES. 109 Ophthalmia, scrofulous Orgasm, sexual Osteitis, scrofulous Osteomalacia . Otalgia Oxaluria . Ozaena j Arseniate of soda. I Iodoform. j Bromide of camphor. ( Cicutine. \ Iodoform. I Hypophosphites. j Hypophosphite of lime. ( Hypophosphite of soda. Hydrobromate of morphine. Cocaine. j Sedlitz Chanteaud. ( Phosphoric acid. j Iodoform. I Sulphide of calcium. Pains Pains, spasmodic Palpitations Paludal poisoning Paralyses . Paraplegia Parasites . Peritonitis, puerperal Phlegmorrhagia Phosphaturia . Photophobia Pityriasis . Plethora . Pneumatosis Pneumonia Pollutions Polycholia Polyhsemia j Morphine. ( Tannate of cannabine. j Bromide of camphor. ( Hyoscyamine. Digitaline. Aconitine. Arseniate of quinine. Arseniate of caffeine. ( Strychnine. ( Phosphoric acid, f Phosphide of zinc. { Colocynthine. ( Sulphide of calcium. I Salicylates. Aconitine. Salicylate of quinine. j Atropine. ( Morphine. i Sedlitz Chanteaud. } Asparagine. Daturine. Gelsemine. j Sulphide of calcium. ( Arsenious acid. j Aconitine. "I Sedlitz Chanteaud. ( Strychnine. } Quassine. Aconitine. Nitrate of pilocarpine, j Strychnine. ~( Hydrobromate of cicutine. j Leptandrin. ( Sedlitz Chanteaud. Aconitine. Sedlitz Chanteaud. 110 ELEMENTS OF THERAPEUTICS AND PRACTICE. Polyuria . Priapism . Prolapsus . Prosopalgia Pruritus vulvae Purpura . Pustule, malignant Putridity . Hydrochlorate of morphine. Gregory's salt. Bromide of camphor. Hyoscyamine. Ergotine. Sulphate of strychnine. Aconitine. Phosphide of zinc. Cicutine. Gelsemine. Ergotine. Valerianate of iron. Sulphide of calcium. Salicylate of ammonia. Salicylate of ammonia. Salicylic acid. R Rectum, inflammation of Rhachitis . . . . Rheumatic diathesis Rheumatism, acute . Rubeola (measles) . \ Daturine. \ Emetine. j Hypophosphite of lime. I Phosphate of iron. j Colchicine. \ Salicylate of soda. Colchicine. Veratrine. j Sulphide of calcium. ( Salicylate of quinine. Scarlatina Sciatica . Scorbutic diathesis Scrofula . Secretions, biliary Secretions, gastric Secretions, intestinal Secretions, salivary Sensibility Septicaemia Excessive . Insufficient . Excessive . Insufficient . Excessive . Insufficient . Excessive . Insufficient . Increased . Diminished. j Sulphide of calcium. ( Veratrine. Aconitine. Gelsemine. j Arseniate of iron. ( Ergotine. j Juglandine. \ Iodoform. Sedlitz Chanteaud. Podophylline. Benzoate of lithia. Pepsin. Hydrochlorate of morphine. Elaterine. Sulphate of atropine. Nitrate of pilocarpine. Tannate of cannabine. Phosphoric acid. ( Salicylate of ammonia. | Salicylate of quinine. DISEASES AND REMEDIES. Ill Sialorrhoea Somnolence Soporous habit . Spasm Spermatorrhoea Spleen, hypertrophy of Strychnine, poisoning by Suppuration . Sweating . Swellings, white Sycosis Syncope . Syphilitic eruptions Syphilis . Increased Diminished j Hyoscyamine. ( Tannic acid. Caffeine. ( Caffeine. \ Cocaine. j Valerianate of atropine. \ Bromide of camphor, j Hypophosphite of strychnine. ( Hydrobromate of cicutine. j Sulphate of quinine. ( Ergotine. j Hyoscyamine. { Tannic acid. j Iodoform. ( Arseniate of soda. j Sulphate of atropine. I Agaricine. j Aconitine. ( Sulphide of calcium, j Juglandine. ( Iodoform. ( Arseniate of potash. \ Biniodide of mercury. ( Phosphoric acid. I Sulphate of strychnia. { Arsenious acid. ( Protiodide of mercury. ( Biniodide of mercury. \ Protiodide of mercury. Tenesmus . Terrors, nocturnal Tetany . Thermogenesis . Thirst Tic-douloureux Tic, indolent . Torpor, hepatic Trismus, of the newly Tuberculosis . Increased Diminished born Hyoscyamine. Emetine. Bromide of camphor. Valerianate of atropine. Bromide of camphor. Croton chloral. Aconitine. Picrotoxine. Quassine. Aconitine. Atropine. Aconitine. j Sulphate of strychnine. ( Valerianate of zinc. j Jalapine. ( Podophylline. Bromide of camphor. Gelsemine. Iodoform. Arseniate of iron. 112 ELEMENTS OF THERAPEUTICS AND PRACTICE. U j Arseniate of strychnine. Ulcers ....... -j phosphoric acid. TT . ( Sedlitz Chanteaud. Uraemia ....... -j B enzoate of lithia. tt it. m." 1. i Helenine. Urethritis, chronic j ^routine. V TT . . ( Daturine. Vaginismus ] Bromide of camphor. TX . ... \ Aconitine. Vaginitis } Helenine. __ . . ( Sulphide of calcium. Variola } Salicylates. ( Caffeine. Vertigo -j "Valerianate of atropine. ( Sulphide of calcium. Virus ( Salicylate of ammonia. . . ( Colchicine. Visceralgia j Aconitine. , r , , ( Podophyllin. Volvulus } Hyoscyamine. iQuassine. Sulphide of strychnine. Codeine. ELEMENTS OF DOSIMETRIC THERAPEUTICS. DOSIMETRIC PRACTICE. ELEMENTS OF DOSIMETRIC PRACTICE. Abscess of the Liver. — See Suppurative Hepatitis (under Hepatitis). Adenitis. — Adenitis, or ganglitis, is a very common disease, and is due to a great variety of causes which tend to irritate the tissues of lymphatic glands. What- ever its cause, the common effect is an inflammation ; therefore the dominant should consist in the use of aconitine to overcome the inflammatory element. When- ever the disease is due to the presence in the circula- tion of infectious material, as in erysipelas, variola, etc., it is better to discard the mode of treatment which regards only the local accident, and seek to obtain a cure by means of efficient pathogenic medication. The more intense the local inflammatory symptoms, and the more elevated the fever, the more frequently should aconitine be administered. After the fever has somewhat subsided, one granule every two hours will suffice. The induration due to congestion, which char- acterizes the first stage, should be combated with en- ergy in order to prevent its evolution during the subse- quent periods. Should we see the case in its earliest stage, we should aim to abort the disease ; and, with this end in view, should give one granule of aconitine every hour until the desired effect is obtained. Emol- lient and absorbent local applications are suitable for this condition, to facilitate the disappearance of hyper- semia. Among the resolvents we prefer iodoform dis- solved in collodion, and applied in such a way as to cover the affected gland. This formula might be used : 116 ELEMENTS OF THERAPEUTICS AND PRACTICE. 5 lodoformi 2 grammes. Collodii elastici 30 u The pain which accompanies suppuration may be quieted by the hydrobromate of cicutine, two granules being given every half-hour until a sedative effect is obtained. For the fever give hydrobromate of quinine, in addition to aconitine, to combat the intermittent character which is usually present ; three to five gran- ules may be given every two hours. After the gland has suppurated, iodoform associated with arseniate of soda may be given in doses of two granules of each, four times daily. Chronic induration, which almost always follows scrofula or inflammation of the lym- phatic glands, will require the use of juglandine and of iodoform, three granules being given three or four times daily. Topically, iodoform and collodion may be used as already prescribed. Dominant. Inflammatory element . . Aconitine. ' Congestive induration . . Aconitine. Pain Hydrobromate of cicutine. Fever Hvdrobromate of quinine. (Suppuration. . . • | It^e of soda. Chronic induration . . j ^Une. Albuminuria. — See Nephritis. Alienation, Mental (Vesania, Phrenopatliies). — For obvious reasons, it will be impossible to indicate the particular treatment for each variety of phrenopa- thy. The practitioner should always observe with the most careful attention the mental perturbations which result from material injuries to the brain, and should distinguish them from those which are purely functional, whether the vitality of the psychical organ is directly affected, or whether it is modified by the in- termediate influence of organs which are not directly associated with the work of the brain. In the first instance, those agents which modify nutrition, the iodides, iodoform, the arseniates, phosphides, zinc, iron, etc., will give desirable results only on condition ELEMEXTS OF DOSIMETRIC PRACTICE. \\% that the treatment is continued for a long time ; in the second case, the dynamic modifiers, if well selected, will give resnlts which are much more prompt and more manifest. The difficulty consists in defining with accuracy the essential quality and direction of the dynamic perturbation, and this difficulty is often in- surmountable, because the complication and multi- plicity of nervous phenomena do not readily permit an absolute detection of the want of primary equilibrium. If this elementary diagnosis is impossible, and we are unable to make trial of the entire series of vital modi- fiers until that one is found which will correct the want of equilibrium, we must begin by giving one of the principal agents of this series, either strychnine or hyoscyamine, until an effect is produced. If the action of strychnine, as far as its therapeutic effect is con- cerned, appears inappropriate, we must substitute hy- oscyamine for it, and vice versa. This is a kind of interrogation or exploration which is entirely prudent, and Dr. Burggraeve has very justly called it the touchstone method. However skillful the physician may be, he will often be obliged to resort to this method in order to find out accurately the way he should follow. The dosimetric method, by giving us the means of obtaining gradually effects which are progressive, is the only one which pursues this cau- tious plan of diagnosis without any risk to the patient. As the circulation has a great influence upon the brain, greater indeed than upon any other organ, we are compelled to resort to agents which will regulate it, for the phrenopathies may depend upon a mild con- gestion, or upon anaemia of some encephalic region. We should therefore give aconitine to combat hypere- mia ; morphine, strychnine, phosphoric acid, and arse- niate of iron to relieve anaemia ; and digitaline or caf- feine to regulate the distribution of the blood. These are the drugs which we will have occasion to use in obscure cases for the purpose of modifying nervous vitality. 118 ELEMENTS OF THERAPEUTICS AND PRACTICE. The mobility of nervous phenomena may cause us to lose, in a short period of time, the advantage of pro- longed treatment ; for the same reason, anaemia may be rapidly changed into congestion, or spasm trans- formed into paralysis. The inefficiency of treatment for many cases of vesania, which could be easily cured if proper regard were paid to anatomical condi- tions, can only be explained by the extreme facility with which dynamic troubles are transformed into those of an opposite character, thus giving rise to in- numerable combinations, by means of which the normal equilibrium may be disturbed. This mobility is to be combated by the cyanide, the phosphide, or the vale- rianate of zinc, joined with strychnine or brucine, selec- tion from these drugs to be made according as the phenomena of excitation or of depression predominate. If the effect of strychnine or brucine is of an exciting character, they may be replaced by caffeine, cocaine, or guaranine, which regulate the vital actions, and are therefore excellent modifiers of the cerebral func- tions. We will refrain from prescribing fixed doses for these different indications, for that can be estab- lished only by the study of each particular case. At one time it will be necessary to force the dosage until there is an extraordinary accumulation ; at another, to reduce it to proportions which are almost homoeopathic. We should observe, however, that this delay or even absence of effect after frequently repeated doses is due to a kind of apathy, or an inhibition, as to the action of drugs, in the given case ; on the other hand, in other cases, very small doses will quickly produce decided effects on account of an erethism with respect to the action of drugs. But as these modalities are very variable, it may happen that before increasing the doses the moment may be suddenly reached in which the dosage becomes efficient or even excessive. Hence the necessity of proceeding with great prudence, and of interrogating the vitality continually, in order that it may ELEMENTS OF DOSIMETRIC PRACTICE. 119 indicate to us with certainty the modifications which should be introduced into the therapeutic arrangement. ^Hyperasmia Anaemia . ^ ('Dominant. Want of nervous equilibrium m Variant. Nervous mobility Spasms . Atony and paralysis Encephalopathies . j Arseniate of strychnine. ' Hyoscyamine. Aconitine. Digitaline. Arseniate of iron. Morphine, f Caffeine. J Guaranine. 1 Cyanide of zinc. [ Valerianate of zinc. j Valerianate of atropine. ( Gelsemine. Phosphoric acid. Ergotine. Iodides. Arseniates. Phosphides. Amenorrhoea. — The absence of menstruation may be accompanied by morbid phenomena, more or less complex in character ; or it may produce neither symp- tom nor inconvenience. It may be either permanent or transitory, and may depend upon organic lesions of the sexual organs, or upon a constitutional state. In the first case, haemorrhage from the cavity of the uterus is prevented by atresia of the genital organs ; in the sec- ond case there is no haemorrhage, and consequently no retention of blood. In the cases of atresia or obtura- tion of the cervix uteri, nothing can be done by the use of drugs, except to soothe the irritability of the uterus, which is caused by the permanent contact of the men- strual fluid, this irritability being especially marked at the menstrual epoch. We may give, then, cicutine and tannate of cannabine, three granules at a time, as often as seems necessary ; and, if there are painful contrac- tions with reflex phenomena, we can give one granule of hyoscyamine every half -hour. Changes in the constitutional condition sometimes give rise to amenorrhoea of a transient character. Such cases may be associated with chlorosis, in which iron would be indicated ; with tuberculosis, for which we would give iodoform ; with syphilis, for which we would 120 ELEMENTS OF THERAPEUTICS AND PRACTICE. give mercury ; with, polysarcia, for which we would pre- scribe suitable diet, exercise, and strychnine. The em- menagogues are contra-indicated in this condition. <$ t Permanent g /Dominant. J f Chlorosis . W ( TranmVnt J Tuberculosis 03 J lransient < Polysarcia< [ Syphilis I Spasm I Pain . Variant 1 Irritability Congestion Surgical measures. Iron. Iodine. Strychnine. Mercury. Tannate of cannabine. Hyoscyamine. Cicutine. Aeonitine. Amygdalitis. — The following remarks apply par- ticularly to the simple form of acute amygdalitis, which is the most frequent of all forms ; but we shall indicate, also, the differences in treatment which are imposed by morbid diathetic elements, which not only complicate the disease, but also render its medical treatment more complex. The disease is generally benign, but its treat- ment differs according to its duration and the presence of complications which aggravate the prognosis and make the disease itself less tolerable to the patient. A short time ago the proper treatment of this angina was believed to consist in the use of leeches and emollient or astringent gargles. These means are sometimes in- effective, if not actually harmful. The result of deple- tion is to weaken the tonsils, and consequently to pre- dispose to the development of the disease into a chronic form, and to frequent recurrence — though the imme- diate result is to soothe the patient, the final one is to prolong the disease. Gargles are objectionable, because they excite the inflamed organs to movements of a harm- ful character, and one can hardly hope that the tran- sient contact of not very active fluids will have much influence upon the progress of the morbid process. The rational treatment will necessarily consist in at- tacking the constitutional elements of the disease, in combating them wherever they show themselves, and in destroying those which cause the most suffering, or which have the greatest influence in producing and ELEMENTS OF DOSIMETRIC PRACTICE. 121 maintaining the lesions of the disease. As in other diseases, therefore, we shall deal with the dominant and the variant. Chronic amygdalitis generally de- pends upon a morbid diathesis of some kind, and we ought, first of all, therefore, to aim at an alteration of the constitution, of such a character as shall affect the cause of the disease. The herpetic diathesis should be treated with the arseniates of soda or iron, or with arsenious acid, six to ten granules being given daily ; the syphilitic diathesis with the protiodide or biniodide of mercury ; the rheu- matic diathesis by the salicylates, by colchicine, or by iodoform, in doses of two granules, three or four times daily ; the scrofulous diathesis by hygienic means and by mineral waters, by juglandine, iodoform, arseniate of soda, and arseniate of iron ; the tuberculous diathe- sis, which usually depends upon a condition of leucocy- thsemia, by iodoform, arseniate of strychnine, and the ferruginous preparations. The acute forms of angina, of parasitic origin, are all curable by means of the sulphide of calcium, and even the diphtheritic form may be included in the list of curable diseases, thanks to the labors of Fontaine. For these forms of disease the sulphide of calcium can not be dispensed with. It may be associated with bru- cine, if there is adynamia ; with salicylate of quinine, if it occurs in periodical paroxysms ; with aconitine, if the fever is very high ; and with emetine, if the pres- ence of false membranes renders suffocation imminent. Simple tonsilar or acute catarrhal angina is best treated, as a rule, with aconitine. Its action is often remark- able, not only in reducing the temperature, but in re- lieving local hyperemia. The patient should be directed to allow the granules to dissolve slowly in the mouth, as the local effect upon the inflamed tonsils is thus increased. Thus, "taken at as frequent intervals as is indicated by the temperature, these granules take the place of both leeches and gargles, and are without their 122 ELEMENTS OF THERAPEUTICS AND PRACTICE. inconveniences. If the fever is not sufficiently high to require aconitine, cocaine may be used instead, three granules being taken every hour or two, according to the indications. Pain, which is often the first symptom, can be met satisfactorily with hyoscyamine, given in half-granule doses every quarter of an hour, until the desired effect upon the throat is produced. If the pain should not be present until after the fever has manifested itself, the aconitine or the cocaine will be sufficient to relieve it. Dryness of the throat will also be relieved by the aconitine or by the nitrate of pilocarpine, of which three granules may be given every half-hour. The gastric catarrh which often accompanies this disease may be treated with Sedlitz Chanteaud. After the in- flammation has become established and exudation has occurred, the fever must still be treated with aconitine. During the remissions hydroferrocyanate of quinine may be given. Codeine, two granules every quarter of an hour, will relieve the nausea accompanying this dis- ease ; while the ptyalism should be treated with small doses of atropine, repeated until the desired effect is obtained. In the third period, when the inflammation terminates by suppuration — a termination which will rarely occur, however, if the treatment of the disease be begun within the first twenty-four hours of its his- tory — the occurrence of chills will indicate the use of arseniate of quinine, one granule every hour, and ady- namia will call for a liberal use of tonics, especially strychnine. After the patient has recovered, we should endeavor to prevent all predisposition to renewed at- tacks by the use of strychnine and cold baths, if the tendency is to simple angina ; and by a prolonged anti- diabetic system of treatment, if the tendency is due to a morbid constitutional condition. The foregoing ob- servations will serve as a guide to the practitioner in the choice of suitable remedies for combating the different conditions which may arise in the course of this disease. ELEMENTS OF DOSIMETRIC PRACTICE. 123 CO I— I H Dominant. Herpetic diathesis Syphilitic diathesis . Rheumatic diathesis . Scrofulous diathesis . Tuberculous diathesis y Parasitic infection (diphtheria, measles, erysipelas, variola, etc.) ( Pain Variant. / 1st period : Congestion. 2d period : \ Inflammation. 3d period : ^Suppuration. •< Dryness . ( Gastric catarrh Fever 1 Nausea . [_ Ptyalism ( Chills . ( Adynamia Arseniate of soda or iron. Arsenious acid, j Protiodide of mercury. ( Biniodide of mercury. j Salicylate of quinine. "( Colchicine. {Arseniate of soda or iron. Iodoform. ( Iodoform. -j Arseniate of strych- ( nine. j Sulphide of calcium. ( Salicylate of quinine. Hyoscyamine, cocaine. Aconitine. Sedlitz Chanteaud. j Aconitine, hydroferro- ( cyanate of quinine. Codeine. Atropine. ( Arseniate of quinine. < Arseniate of strych- r nine. Aiisemia. — Clinically, anaemia may be considered under three distinct and well-defined forms. First, anaemia proper, in which the condition is due to the loss of a greater or smaller quantity of blood by haemorrhage. Second, cachectic ancemia, which is the result of the introduction into the blood of principles which are for- eign to it, or of the insufficient elimination from it of substances which should be excreted. In both cases a modification in the composition of the blood, of the nature of a dyscrasia, is effected, and, consequently, a defective alimentation of the red globules. Third, essential anamia, or chlorosis, which is a disease of the red globules themselves, or of the organs which produce them. Anaemia proper is quickly transformed into hydre- mia. The cause being removed, the patient will get well spontaneously, in a longer or briefer period, ac- cording to the condition of the digestive functions, if he has offered successful resistance up to that point. Our aim should therefore be to preserve and excite the appetite, by stimulating the contractility of the intes- 124: ELEMENTS OF THERAPEUTICS AND PRACTICE. tinal tube by the use of quassine and strychnine, and facilitating digestion artificially, by the use of pepsin and diastase. With an active stomach and the use of proper food, the normal state of the blood will be read- ily re-established, and there will be no occasion for em- barrassing the digestive functions by the administration of iron, which is contained in the food in sufficient quantity to meet the exigencies of the case. In cachec- tic anaemia the cause must be treated ; the daily use of Sedlitz Chanteaud, as a diuretic and laxative, and of strychnine to sustain the vitality and excite the nutri- tive functions, will be found to be the most appropriate remedies. Chlorosis, that form of ansemia which is so common at the present time, is usually treated with iron, but the utility of this means of treatment for such a condi- tion remains to be proved. When we see that the cura- bility of chlorosis depends much more upon the regular production of hsemotoblasts than upon the methodical administration of ferruginous preparations ; when we observe that in those cases of chlorosis which are most pronounced the deficiency of iron in the blood is quite insignificant compared with the large quantities which are taken in with the food, and in pharmaceutical preparations ; when we consider that hygienic means — cheerfulness, good air, sunshine, and cold water — are superior to preparations of iron for the treatment of chlorosis, we may be pardoned for having some doubt with respect to the specific virtue which is usually at- tributed to iron. It may happen, in chlorosis, either that the hsematoblasts, after a time, are produced in sufficient quantity, or with a sufficient degree of vital- ity, to accomplish the regeneration of the blood-glob- ules, in which case the disease is quickly cured ; or, on the other hand, that the production of the hsemato- blasts is defective, the preparations of iron exercising no perceptible benefit, in which case the ansemia be- comes pernicious, incurable, and rapidly fatal. Though ELEJIEXTS OF DOSIMETRIC PRACTICE. 125 therapeutics can not interfere directly in the production of the hsematoblasts, it can render good service by its direct influence upon the general vitality, and upon the digestive functions in particular. In chlorosis the vital energy is profoundly depressed. All the functions are deficient in activity, on account of the languor and the sluggishness of the nerve-force. The muscular system does not escape this torpid condition, and gastrointes- tinal inertia is manifested by the customary symptoms. The lesion of the digestive apparatus is the principal obstacle to the rapid cure of chlorosis, for, without per- fect elaboration of the food, without its rapid and com- plete absorrjtion, we can not hope for a general recon- struction of the system, which is indispensable to a proper reorganization of the blood. Herein the ques- tion as to the utility of iron becomes most pertinent. Its absorption is open to doubt ; the larger portion, if not all of it, being recoverable from the faeces. By its astringent action, which is exercised throughout the entire surface of the digestive tract, and propagated by means of the centripetal nerves throughout the entire economy, we can readily explain not only the improve- ment in the working of the digestive apparatus which follows its use, but, in addition, the general tonic effect which follows its prolonged use. In the same manner, it is easily explained that iron has equivalent succe- danea in hydrotherapy, strychnine, gymnastics, change of air, etc. The indication in chlorosis is, therefore, to stimulate to action. In addition to hygienic means, we may use iron, the astringents, and the bitters — strych- nine, quassine, tannic acid, and quinine being preferred. The strychnine may be associated with iron, but the other three must not be so used on account of chemical incompatibilities. The dosimetric arsenal has several ferruginous preparations — the arseniate, phosphate, lactate, valerianate, and salicylate. All of them may be used, either singly or in combination, according to the indications of each case. The arseniate is suitable 126 ELEMENTS OF THERAPEUTICS AND PRACTICE. in most diseases ; of all the salts of iron it is the most readily tolerated, and is least apt to give rise to consti- pation. It is appropriate in the most simple forms of chlorosis. Its combination with arsenic is very advan- tageous. Two or three granules may be given with each meal. The phosphate will be found serviceable in cases in which the nervous functions are much depressed. The lactate is indicated if the stomach is very irritable, with a tendency to gastralgia. The valerianate may be used in those forms of chlorosis which are complicated with neuralgia or other nervous troubles. If a rheu- matic element is present, or there is tendency to rapid decomposition in the stomach, the salicylate may be used. The number of granules to be taken at each dose is the same, whichever salt be employed. As a rule, two of these salts are used in combination, their action being fortified by the use of the arseniate or the hypo- phosphite of strychnine, one or two granules, three times daily. If digestion is difficult, we should employ, in addition, three granules each of pepsin and of diastase with each meal. Such is the fundamental treatment of anaemia. As the symptoms vary, we shall be compelled to complicate the treatment. Palpitations, which occur so often among chlorotic individuals, and which fre- quently destroy the good effect of medication, on ac- count of the moral troubles which have so depressing an action on the sick, should be promptly antagonized with digitaline. Gastralgia, whether it be spontaneous or produced by iron, should be treated with codeine, associated with hyoscyamine, three granules of the for- mer and one of the latter being used, at the same time with the preparations of iron. If the pain is very se- vere, two granules of morphine, with one of sulphate of atropine, may be used every quarter of an hour until the pain ceases, or from three to ten granules of cocaine may be taken in the course of ten minutes. Headache and vertigo may occur, whether from congestion or cerebral ansemia. If due to the former, a granule of ELEMENTS OF DOSIMETRIC PRACTICE. 127 aconitine, given hourly, will relieve the congestion ; if due to the latter, those means should be used which will restore to the brain the necessary blood-supply. Of these, caffeine, two granules every quarter of an hour, may be used ; or bromide of camphor, or benzoate of ammonia, in similar doses ; or two granules of Greg- ory's salt may be given every half-hour. For the more or less periodic neuralgias, which may be present from time to time, five granules of the valerianate of quinine, every half-hour, may be used, until the appearance or the want of appearance of the paroxysm. Irregular forms of neuralgia will be more appropriately treated by guaranine and gelsemine, two granules every quarter of an hour. Amenorrhcea should be met with iodo- form, associated with arseniate of iron, three granules three times daily ; menorrhagia by three granules of ergotine, one to three of sulphate of strychnine, and three granules of tannic acid, every half-hour, or of t- ener, according to the merits of the case. For consti- pation, three to five granules of podophyllin may be given every evening, or three granules of euonymine before each meal. Quassine. Arseniate of strychnine. Pepsin and diastase. Sedlitz Chant eaud. Hypophosphite of strychnine. Salts of iron (arseniate, phosphate, lactate, valerianate, salicylate). Tannic acid. Arseniate or hypophosphite of strychnine. Digitaline. Codeine and hyoscyamine. Hydrobromate of morphine and sulphate of atropine ; cocaine. Aconitine. Gregory's salt, benzoate of am- monia, bromide of camphor. Valerianate or hydrobromate of quinine. Gelsemine and guaranine. Podophylline, euonymine. Iodoform. Ergotine, tannic acid, sulphate of strychnine. ('Anaemia proper Cachectic anaemia Dominant. ( Essential anaemic chloro- sis .... Palpitations . k Gastralgia Cephalalgia | ^stive Variant. ( a gia -j j rre g U i ar Constipation . Amenorrhcea . Menorrhagia . 128 ELEMENTS OF THERAPEUTICS AND PRACTICE. Cerebral Anaemia.— Cerebral anaemia results now from general anaemia, in which the brain participates, and again from a particular ischaemia of the brain, localized in that organ, without the other organs being affected. In both forms the dominant indication is the same — to increase the circulation of blood within the brain — but in the first form the primary cause must also be considered ; otherwise, the results of treatment will be very transitory. That is why the ferruginous preparations, and all other substances which are designed to improve the condition of the blood, should accompany and follow the use of the agents which are particularly indicated for this condition, and which constitute the treatment for the emergency. The active principles of opium, by virtue of their power of increasing the cerebral cir- culation, will satisfy the first indication. Our choice would be Gregory's salt or the hydrochlorate of mor- phine, two granules from two to five times daily, and in case of children a granule of codeine, three to five times daily. If the anaemia is general, we should give two granules of the arseniate of iron three times daily, combined with Gregory's salt. Among the symptoms of cerebral anaemia there are some which call for a particular line of treatment, not only because they are very inconvenient for the patient, but also because they continually threaten his very existence. Thus, we should antagonize vertigo with caffeine or its salts, two granules every half-hour. If the vertigo is very distressing, or is frequently repeated, syncope may be the result, which is not always without danger, and which will be likely to terrify the patient. When the repetition of these attacks of syncope has demon- strated the weakness of the heart and the decided depression of nervous force, we should give one to two granules of hypophosphite of strychnine every hour. Convulsions should be treated with two granules of the bromide of camphor every two hours, or two gran- ELEMENTS OF DOSIMETRIC PRACTICE. 129 ules of the valerianate of quinine every hour. If there is headache, we should give two granules of quassine every half -hour. The nausea which usually accom- panies vertigo may be treated with two granules of codeine every half -hour, or with two granules of quas- sine every hour in case the tongue is foul. Insomnia, which is one of the most distressing elements of this disease, should be treated with three granules of the hydrochlorate of morphine every quarter of an hour, or with the bromide of camphor in the same doses if for any reason it is not desirable to use the morphine. Narceine or croton chloral may be substituted for the other hypnotics should it seem desirable, the doses being the same as were prescribed for morphine. This treatment is almost always crowned with good results, unless the anaemia depends upon incurable organic lesions. The difficulty consists not so much in treating the anaemia as in differentiating that condi- tion from congestion. The symptoms by which these two opposite conditions are manifested are really the same, and it is not by this means that we can estab- lish a differential diagnosis. The general condition of the patient and the state of his vitality, as revealed by his pulse, are better signs than all the others. It is by these means that the physician ought to reach a decis- ion, and that without delay, for the results will be good or bad according as the conclusion in each case shall conform or fail to conform to the facts. A substantial diet, with abstinence from all causes which produce debility, are appropriate in anaemia ; a rigid diet is suitable in hyperaemia. The difference in the condition of the patient as the position of his body is changed is also an excellent means of differential distinction, but the differences are not always sufficiently appreciable, unfortunately, to constitute this a positive element of diagnosis. The physiological groping along, by means of medicaments as a touchstone, will also help the physician in finding the right course. 130 ELEMENTS OF THERAPEUTICS AND PRACTICE. < s | Anaemia . j Arseniate of iron. " \ Gregory's salt. Dominant. / Vertigo . Caffeine. I Convulsions j Valerianate of quinine. ' ( Bromide of camphor. ^ \ Cephalalgia Guaranine. ( Nausea j Codeine. * ( Quassine. PQ W ^VARIANT. ■j Syncope . Hypophosphite of strychnine. o ( Insomnia . Hydrochlorate of morphine. Angina Pectoris. — See Lesions of the Heart. Angina, Pseudo-membranous. — See Diphthe- ritic Maladies, Tinder M. Apoplexy, Cerebral.— See Cerebral Haemorrhage, under Haemorrhage. Apoplexy, Serous,— See Hydrocephalus. Asthma. — Asthma has for its essential cause the abnormal excitability of the vagi, whence a spasmodic condition of the muscles which participate in the act of inspiration results. If the excitability of these nerves is very great, only a slight irritation is neces- sary to provoke a paroxysm of asthma ; if, on the other hand, their excitability is only ordinary, a par- oxysm will be caused only by a very decided irritation. It is very important to understand the causes which are at work in the latter case, for then it will suffice to suppress the determining cause of the paroxysm in order to control the predisposition to this disease, or, in other words, to keep it in a latent condition, which is equivalent to a cure ; and this will facilitate the action of the therapeutic agents upon the nervous lesion, which is at the foundation of the disease. M. Germain See classifies the causes of asthma in the following manner : A. Paroxysms originating from irritation of motor nerves : 1. Impressions received from organic substances in the form of powder. 2. Action of vapors of certain kinds. 3. Influence of the atmosphere. ELEMENTS OF DOSIMETRIC PRACTICE. 131 B. Paroxysms of reflex origin : 1. The stomach and intestines. 2. The uterus or its annexa. 3. The skin and the sensory nerves. C. Paroxysms of central origin : 1. Moral emotions. 2. Medullary lesions. D. Paroxysms of humoral or mixed origin : 1. Alteration of the blood. 2. Poisoning. 3. Constitutional faults. Idiopathic asthma, which is the consequence of a dynamic lesion of the pneumogastric nerves, or of their bulbar center, is not so difficult to cure as is usually supposed. The spasmodic character of the disease re- quires for a dominant hyoscy amine or the analogous alkaloids, atropine and daturine. With a methodical and prolonged plan of treatment, the paroxysms will diminish in frequency and intensity, until finally they will cease altogether. A distinction must be made between the treatment which is appropriate during the paroxysm and that which is appropriate during the intervals. The patient should avoid most carefully at all times all provoking causes which can stimulate the pneumogastric either directly or indirectly. In addition, we should combat the general condition of nervous excitability by the use of two granules of hyoscyamine twice daily, the number being gradually increased if, after a month of systematic treatment, no decided result is apparent. Should the asthma appear in a subject with the her- petic, rheumatic, or arthritic diathesis, the treatment should be of such a character as to modify the diathesis. For the herpetic diathesis we should use hyoscyamine or arsenious acid, six granules daily ; for the arthritic and rheumatismal, four granules of colchicine daily. In all cases we should also give Sedlitz Chanteaud in the morning, and in the evening two to four granules 132 ELEMENTS OF THERAPEUTICS AND PRACTICE. each of aconitine and digitaline. During the paroxysm, whatever its cause may have been, the treatment should be entirely different. The latent excitability of the vagi becomes active and apparent, and results in a loss of equilibrium of nervous force, which is most evident in those muscles which are innervated by the pneumo- gastric, certain other muscles being in a condition of tetanus. Hence arise certain phenomena which are commonly observed in connection with this disease : whenever there is a development of dynamic force in one portion of the organism, there is, of necessity, in- hibition in another, which is more or less closely related to the previous manifestation. To these two lesions we must oppose agents which will serve to ameliorate them, though their respective action may seem antagonistic. We should combat the spasm with one granule of hy- oscyamine, atropine, or daturine, every quarter of an hour, or less frequently, according to the intensity of the spasm. Of the three alkaloids, hyoscyamine is the least active ; daturine produces its effect the most rap- idly, and the effect of atropine is intermediate. The action of the sulphate or the valerianate of atropine is much less intense than that of the alkaloid itself. Pa- ralysis should be combated with the hydroch] orate or the hydrobromate of morphine, either alone or associ- ated with the sulphate or arseniate of strychnine ; three granules of morphine and one of strychnine may be given with each dose of hyoscyamine. Hypodermic injections of five to ten granules (in solution) of the hydrochlorate of morphine, with which one or two granules (in solution) of atropine should be associated, operate with great rapidity, and will produce a sooth- ing effect upon the patient in a very few minutes. Since it is a matter of common observation that the diminution in the intensity of the paroxysm is associ- ated with the secretion of a greater or smaller quantity of viscid mucus, we should endeavor to excite the ac- tivity of this secretion by the use of three granules of ELEMENTS OF DOSIMETRIC PRACTICE. 133 sulphide of calcium every half-hour, or by similar doses of iodoform. These two drugs tend not only to stimu- late the secretion of the bronchial mucous membrane, but also to soothe the nerves which are distributed to the mucous membrane. Such is the ordinary treatment of these paroxysms, and ordinarily it is followed by the best results. It may occur, however, that the physio- logical effects of the drugs which have been prescribed will be apparent before their therapeutic ones, in which case their use must be suspended for the time ; in such cases three granules of bromide of camphor might be used every quarter of an hour, or two granules of lobeline every half-hour. The action of the lobeline is a complicated one, for, by its narcotic action, it has a soothing effect upon respiratory perturbation, while, by its local irritant action, it directs to the stomach the nervous activity which is accumulated in the respiratory apparatus, and thus, in an indirect manner, calms the paroxysmal condition. During the height of the paroxysm the pulse be- comes precipitous, the lungs congested, and there may be a rapid development of temperature, reaching even 40° C. Under such circumstances, digitaline should be given to regulate the pulmonary circulation, and it should be associated with aconitine, one granule of each being given every hour, if the congestion is intense. Whatever be the importance of treatment during the paroxysm, we must not count too much upon its value, unless a continuous plan of treatment is associated with it, which shall aim at destroying the efficient cause of the disease. Unfortunately, in this as in all other chronic diseases which are characterized by acute par- oxysms and long intervals of relief, the patient too often believes that he is cured if he goes for any con- siderable period of time without an attack, and relaxes his course of medication accordingly. The physician should insist, as a condition of treatment which is de- signed to effect a cure, upon a rigorous observance of 134: ELEMENTS OF THERAPEUTICS AND PRACTICE. all his directions for a sufficiently long time — that is, until the evidence is satisfactory that a radical cure had been accomplished. The dread of medicines, with which physicians of the regular school have inspired their patients, is the greatest obstacle in the way of obtaining good results from treatment for their patients. If physicians would see to it that empty medicine-bot- tles were thrown away, instead of accumulating and frightening their patients (on account of the quantity of medicine which has been consumed), the patients themselves would have more perseverance in following treatment than they are wont to show. In the treat- ment of chronic and rebellious diseases, in which there is no irremediable vital lesion, it may often be observed that the failure to effect a cure is due to this very want of perseverance, and in no disease is this statement better illustrated than in asthma. /Dominant. \ Variant. j Excitability of the pneu- 1 mogastric {Rheumatic diathesis I Herpetic diathesis . - Hemorrhoidal, hepatic congestions, etc. . v Other influences / Gastro-intestinal aura S o S Spasm in inspiration Catarrhal secretion . Cardiac perturbations Congested condition Periodicity of the parox- ysms . Hyoscyamine. Colchicine. Sedlitz Chanteaud. Sedlitz Chanteaud. Aconitine. Suppression of the cause. Lobeline. ["Atropine, daturine, mor- phine, arseniate of ] strychnine, bromide of [ camphor. j Sulphide of calcium, iodo- ( form, scillitine. Digitaline. Aconitine. j Hydro bromate of qui- ( nine. Asystolie (or Asystolia). — See Cardiectasis. Athrepsis. — See Pultaceous Stomatitis (under Sto- matitis). Balanitis. — Balanitis is caused by inflammation of the glans penis, or of the preputial mucous membrane, a muco-purulent material being secreted, the fetid char- acter and deleterious action of which depend upon the length of time that it is retained between the glans ELEMENTS OF DOSIMETRIC PRACTICE. 135 and the inner surface of the prepuce. Its principal causes are want of cleanliness of the penis, frequent erections and coitus, and syphilitic or herpetic ulcera- tions. This disease is usually benign in character, but it is less so the greater the difficulty in disposing of the products of secretion. If the glans is ordinarily covered by the prepuce, and the orifice of the latter is small, the superadded inflammatory swelling will almost en- tirely prevent the exit of the smegma and the products of inflammation. The contact of the urine aggravates the condition, and may readily assist in the develop- ment of phimosis, paraphimosis, or even gangrene of the glans. The indications depend, of course, upon the condition or stage of the disease. For the inflammation itself we should use aconitine ; as a curative as well as preventive means to the decomposition of the muco- purulent secretion we should use astringent and anti- septic washes and injections. As the condition is some- times complicated by spasm, we should also use hy- oscyamine. The pruritus, which often accompanies diseased conditions of the glans penis and frequently excites masturbation, may be treated by cicutine and local emollient applications. The quantity of aconitine given must be governed by the intensity of the inflam- mation. One granule every two hours will usually have the desired antiphlogistic effect. For lotions and washes, decoction of mallows or simple warm water may be used ; sulphate of zinc, with or without resor- cin, will furnish the basis for a satisfactory injection material. The following formula is recommended : 9 Aquae 200 grammes. Resorcinse 2 " Zinci sulphatis 1 gramme. Should there be a condition of local spasm, one granule of hyoscyamine may be taken every two hours. For pruritus, one granule of cicutine may be used every two hours, or of tener if necessary. Balanitis of syphi- litic origin should be treated with iodide of mercury 136 ELEMENTS OF THERAPEUTICS AND PRACTICE. internally, and locally by injections of sublimate. Her- petic balanitis may be treated by two granules of the arseniate of soda, and two of veratrine, three to five times daily, and by the topical use of emollients. co J Dominant. Inflammatory element . Aconitine. . Arseniate of soda, veratrine. . Protiodide of mercury. . Cicutine. . Hyoscyamine. . Local use of antiseptics. EH / f Herpes S I I Syplrilis Tuberculous ^Herpetic Aconitine. Aconitine, veratrine, digi- taline. Hydrobromate of quinine. Hydrochlorate of morphine. Gregory's salt, narceine. Bromide of camphor, sul- phate of atropine. j Scillitine, emetic, arseniate ( of antimony. \ Benzoate of ammonia, sul- ( phide of calcium. Colchicine, benzoate of lithia. Iodoform, iron, quassine, strychnine. Iodoform, revulsives. Arseniates of quinine and soda, arsenious acid, vera- trine. 142 ELEMENTS OF THERAPEUTICS AND PRACTICE. Capillary Bronchitis.— Capillary bronchitis is one of the gravest diseases that attacks children. Though this may be considered a catarrhal affection, the pri- mary lesion is superseded by secondary ones which are caused by it. The feeble contractile power of the bronchi becomes the predominant morbid factor, which must be taken into account in treating the disease, for it is the principal cause of its mortality. Therefore, the neurosthenic agents should be used in preference to the anti-catarrhal ; brucine or strychnine will, there- fore, become the dominant medicament, as long as the capillary obstruction lasts, in doses of one granule every hour for children over two years of age. After the permeability of the respiratory tract has been re- stored, we can give two granules of the sulphide of cal- cium every two hours to overcome the catarrhal secre- tion. Helenine will till the same indication, one granule being given every three hours. Though the tempera- ture in this disease is not apt to be very high, never- theless it tends to increase the dyspnoea and the vital prostration. It may be treated with veratrine, the mildly emetic and expectorant powers of which are quite appropriate for diseases of the respiratory ap- paratus in children. One to two granules in solution may be given every hour until vomiting or deferves- cence is accomplished. After having produced a mod- eration of the fever, we should give the hydroferro- cyanate of quinine to overcome the intermittent char- acter of the fever, which is more or less pronounced in all diseases of a catarrhal character. One to three granules may be given every two hours. A dry and harassing cough results from the adhesion of the sputa to the mucous membrane. For this condition expec- torants are indicated, particularly the benzoates of soda and ammonia and scillitine. Two granules may be given every two hours. But, if the spells of coughing are very frequent and fatiguing, several doses of codeine should be given, in quantity one to three granules every ELEMENTS OF DOSIMETRIC PRACTICE. 143 hour, until a calmative effect is produced. The dysp- noea will continue as long as the obstruction in the bronchial tubes exists. In cases in which suffocation seems imminent, an emetic must be given to effect the expulsion of the collections in the tubes. Three gran- ules of emetine in solution may be used for this pur- pose every ten minutes, until an effect is produced. A beneficial result may thus be rapidly produced, but we must not be deceived by it, for it may be only for the moment. The improvement with respect to the dysp- noea may be compensated by the greatest depression of the physical forces— that is, the patient may rapidly get worse ; unless the indication is very urgent, there- fore, we must refrain from using violent emetics, and instead use apomorphine in doses of two granules every two hours. In addition to its incisive properties (in the matter of separating the deposits of mucus), it is also a tonic to the respiratory apparatus, and thus comes to the relief of the dominant. The antimonials (kermes, emetic, and arseniate of antimony) should be held in reserve for the purely catarrhal period. They are too depressing in their action to be used while the pulmonary alveoli are threatened with collapse. Small flying blisters may be of service to stimulate both the local and general vitality, and to overcome pulmonary oedema, which threatens to complicate the situation ; they should not be so large as to confine the field of respiration, nor restrain thoracic dilatation. The effect of vesicants in this disease is dynamic rather than physical, and therefore small ones frequently repeated are preferable to large ones, which can not be renewed very often. The convalescent stage should be watched with great care. Relapses occur very readily, and are the more frequent as the patient is more prostrated. We should not neglect to use all possible hygienic means of precaution in helping the patient through this stage of reparation. Two granules of quassine may be given with each meal to stimulate digestive 141 ELEMENTS OF THERAPEUTICS AND PRACTICE. action, and two granules of the arseniate or sulphate of strychnine, two to four times daily, to increase the vital resistance. JhGQ 1 Dominant. Vaso-motor paralysis Brucine. %&t /Catarrhal secretion . Sulphide of calcium. Fever j Hydroferrocyanate of \ veratrine. » Variant. / Cough . . Benzoates, codeine. Dyspnoea . Apomorphine. og Asphyxia . Emetine, veratrine. \ Convalescence . Quassine, strychnine. quinine, Bronchorrhagia.— See Broncho-pulmonary Hrem- orrhages (under Hcemorrhages). Bubo.— See Syphilis. Cancer of the Stomach. — Though this disease is incurable, the physician should not altogether abandon the patient to his fate. Not only should he use palli- ative means to soothe the pain and prolong the life of the patient, but he should seek for a curative treatment if only by eliminating in succession those medical sub- stances which might by chance be useful. It is not absolutely essential that the treatment of incurable dis- eases should be forced in the expectation of producing positive results, for even negative results have their value, and by the systematic elimination of those means which have been tried and found unsuccessful the proper agent may some day appear, if it exists. Hy- drastine has been recently tried by the author in doses of twelve to fifteen granules daily, divided into three equal parts. The conditions of experimentation have been varied, and in all cases this substance appears to delay the fatal issue. The dose may be increased with- out danger to the patient, and the subject is worthy of further investigation. Arseniate of soda, combined with iodoform by modifying the nutrition, may also be used with advantage. The principal medication must, therefore, be symptomatic in character. The pain of the disease may be relieved by cicutine, the dosage being varied in accordance with the severity of the ELEMENTS OF DOSIMETRIC PRACTICE. 145 case. If the pain is intense, two granules may be given every half-hour ; if less severe, three granules may be given before each meal. The vomiting may be relieved with one granule of valerianate of atropine, combined with three of the hydrobromate of morphine, if the vomiting is the result of irritation ; if, on the other hand, it is due to a catarrhal condition of the stomach, three granules of quassine may be given be- fore each meal with Sedlitz Chanteaud. Difficulty in digestion may be diminished by using three granules of pepsin with each meal. Diarrhoea, resulting from imperfectly digested proteid elements of food, and from the septic products of the ulcerating process, should be treated with the salicylates or iodoform, two granules of each three or four times daily. The anaemia which results from the combined effect of the cancerous dis- ease and dyspepsia may be treated with the salicylate of iron, two or three granules being given with each meal. The hectic fever, which tends greatly to weaken the patient and to shorten his life, may be treated with ten granules of the salicylate of quinine three or four times daily. Dropsy in this disease indicates that the fatal end is near. When it supervenes, we should give sulphate of strychnine, which, though it may not cure it, will at least stimulate the forces of the organism and retard the effusion of serum as the degeneration pro- gresses. The most appropriate form of diet will be the milk-diet ; not only because it will diminish the suf- ferings of the patient, but because it will also have a curative action in those cases which have been wrongly diagnosticated as cancer. After the cancerous tumor has produced stenosis either at the cardiac or the pyloric end of the stomach, it will be useless to insist upon attempting to feed the patient by the stomach. Enemata of peptonized food will sustain the patient better, and will not cause the pain which is produced if food is taken into the stomach. 10 146 ELEMENTS OF THERAPEUTICS AND PRACTICE. s ^ . /Dominant. Cancerous dystrophy . . Hydrastine. f*W| /Pain Cicutine. 0%\ Vomiting . . Morphine, atropine. £3^ I Variant \ Anaemia Salicylate of iron. HO I Diarrhoea Salicylates, iodoform. p E-j I Fever Salicylate of quinine. 5 V Dropsy Sulphate of strychnine. Q Cardiectasis (Asystole, Dilatation of the Heart). — The distention of cavities which are bounded by mus- cular walls always produces a more or less accentuated condition of paresis, which constantly tends to aggra- vation with the correlative exaggeration of this disten- tion. Obstacles, of whatever character, to the pro- pulsion of the blood by the cardiac systole, lead to an accumulation of blood in the heart- cavities, which thus become dilated, and the walls become thinned. The contractile force becomes less energetic at every point, its impulse more feeble, and the evacuation of the cavi- ties more and more incomplete. As long as this diffi- culty is not compensated by hypertrophy, the vicious circle continues, and the functional perturbations in- crease in gravity. Cardiectasis may also arise from primary lesions of the heart-muscle, which give rise to the same train of consequences. If hypertrophy occurs, it delays, but does not obviate, the fatal conse- quences of the failure of mechanical equilibrium. The fundamental lesion in cardiectasis consists in a weakness in the contractile force of the heart. The use of ergotine and sulphate of strychnine, two of the most reliable agents for preserving and increasing the mus- cular force, will, therefore, constitute the dominant. The doses will vary with the pathological effect of the primary lesions. If the perturbations are scarcely per- ceptible to the patient, three granules of each, three to five times daily, will be sufficient ; but, if asystole be- comes imminent, four granules of each must be given every half -hour until a positive result is obtained. (Edema in these cases is due to venous stasis, and con- sequently it is only when the heart regains its energy ELEMENTS OF DOSIMETRIC PRACTICE. 147 that the oedema disappears. For this condition we may- give two granules of the hypophosphite of strychnine three to five times daily, together with two teaspoonfuls of the Sedlitz Chanteaud daily for a diuretic and laxa- tive. Weakness and irregularity of the pulse call for the use of digitaline ; as soon, however, as the physio- logical effect of this drug has been accomplished, we should associate with it the arseniate of strychnine. Vertigo, which results from cerebral ischemia, may be relieved by the use of caffeine or by Gregory's salt, two granules being given every half-hour until the desired effect is obtained. Lipothymia calls for the stimulating action of phosphoric acid, two granules every ten min- utes until relief is obtained. Pulmonary congestion in this disease is sometimes accompanied by rupture of the vessels. This pneumorrhagia should be treated with three granules of ergotine every quarter of an hour, and with one granule of digitaline every half- hour if the pulse is weak and irregular. Congestion will also be benefited by two granules of the sulphate of strychnine every half -hoar or hour. If the cough and dyspnoea do not yield to the dominant, one may give three granules of the hydrobromate of morphine every half-hour. Palpitations are the evidence of the unsuccessful efforts which the heart is making to relieve itself of the excess of its contents. The resulting atony of the cardiac movements may be regulated by two granules each, of arseniate of strychnine and digitaline, two to three times daily. Cardiac cachexia is a symp- tom of grave import, for it shows that it is no longer the heart alone whose energy is depressed, but that the entire organism is compromised by the insufficiency of the pulmonary circulation, which causes difficulty in the passage of the blood, and a condition which may not be easily modified. The general nutrition in these cases is much debilitated, which calls for the use of agents which will modify the blood and the general innervation. The arseniates of iron, strychnine, and 148 ELEMENTS OF THERAPEUTICS AND PRACTICE. antimony may be combined in this attempt to prolong life. If the dilatation is not excessive, life may be pro- longed and asystole delayed by the use of cardiac tonics and a well-regulated hygiene which should prevent any violent disturbance of the equilibrium of the forces, which at such a time is so delicately poised. This end may be obtained by the use of two or three granules of strychnine and of digitaline every evening, and contin- ued for a long time. The digitaline may be replaced from time to time by caffeine or guaranine, three to five granules every evening. The daily use of Sedlitz, physical and moral repose, regularity as to the gastro- intestinal functions, abstinence from coitus and from all stimulants, will be found useful in delaying the ulti- mately fatal issue of cardiectasis. m m < Q Dominant. Variant. Diminution of contrac- tility . / (Edema . Weakness of the pulse Vertigo . Lipothymia Pneumorrhagia Congestion Cough, dyspnoea Palpitations . V Cardiac cachexia \ Ergotine, strychnine. Hypophosphite of strychnine. Digitaline. Caffeine, Gregory's salt. Phosphoric acid. Ergotine. j Sulphate of strychnine, digi- ( taline. Hydrochlorate of morphine. j Arseniate of strychnine, digi- \ taline. \ Arseniates of iron and strych- \ nine. Catalepsy.— This curious disease furnishes one of the most remarkable examples of dynamic affections. Its sudden appearance and disappearance, the profound disturbance which it causes in the most important func- tions, the latter showing nothing abnormal after the attack has passed away, all seem to demonstrate that this disease consists merely in a transposition of forces which have left the brain and accumulated in the spinal cord. It furnishes the clearest confirmation of the the- ory of inhibition and dynamic influence — inhibition on the part of the cerebral functions ; dynamic influence with reference to muscular tonicity. The brain thinks less, the will is abolished, but, as a compensation, the ELEMENTS OF DOSIMETRIC PRACTICE. 149 function which determines stability becomes exagger- ated. Catalepsy, therefore, consists of two principal dynamic lesions — inertia of the brain and spasm of the cord. Treatment must, therefore, be regulated in ac- cordance with this morbid duality, and the pathogene- sis of the condition justifies that form of treatment which associates drugs which have more or less an- tagonistic features as to their physiological action. In this, as in all diseases in which there is a want of vital equilibrium, we must use hyoscyamine and strychnine combined. Each drug directs its action to a particular perturbation, and the disease, thus combated in its two principal manifestations, will yield with more certainty and promptness than by any other method. In the intervals between the attacks we should, therefore, give one granule of each drug three or four times daily. During the attack there is little that can be done ex- cept to seek to re-establish the equilibrium by acting upon the functions which still remain unaffected. One method which is worthy of trial consists in the sub- cutaneous injection of apomorphine, in doses of one hundredth of a grain. Injections of atropine may also be tried. Habitual masturbation, which is one of the most frequent causes of catalepsy, may be treated with three granules of the bromide of camphor morning and evening. AnaBmia and debility are predisposing causes to this condition, and may be treated with two granules each of the arseniate and valerianate of iron at each meal. The nervous irritability, which is especially noticeable among those who suffer with hysteria and other neuropathies, may be treated with three granules of the phosphide or valerianate of zinc three times daily. The element of periodicity, which is often a prominent one in this disease, will call for the use of three to five granules of the valerianate of zinc three times daily. This treatment must be kept up for a long period, as it is evidently impossible to restore the nervous system to its normal condition in any brief period. 150 ELEMENTS OF THERAPEUTICS AND PRACTICE. g /Dominant. Want of nervous equilibrium { H ^?^£ e . arSeniato Put /Masturbation. . . . Bromide of camphor. W *„.»„„•„ ( Arseniate and valerian- ^ Ivariant. Anaemia \ ate of iron. % Instability of the nervous sys- | Phosphide of zinCt \Periodicity .... Valerianate of quinine. o Catarrh, Epidemic (Grippe). — This disease, which was at one time as deadly as the cholera, appears to be due to the development of parasites or miasmatic in- fluences, which are manifested only in connection with certain variations of the atmosphere. The symptoms indicate a toxic condition, and the course of the fever shows that the morbific influence has more or less of an analogy with paludal miasm. The excellent results which have been obtained by quinine confirm this theory, and indicate the alkaloid of cinchona as the true remedy for the dominant. We may use with ad- vantage the hydroferrocyanate of quinine, the anti- periodic action of which has been well proved, and which will also soothe the accompanying irritation of the respiratory passages better than the derivatives of opium. The headache, often intolerable, which accom- panies the invasion of the disease, and which, in con- nection with redness of the conjunctiva, photophobia, and ringing in the ear, shows that there is active con- gestion within the cranium, may be readily controlled by aconitine, which will also moderate the febrile con- dition and the excitement of the circulation. One gran- ule may be given every quarter of an hour, or less fre- quently, as the case may demand. In other cases the most pronounced effects of this disease are manifested in connection with the digestive apparatus, the patient being troubled with nausea, vomiting, diarrhoea, etc. For this variety we should give Sedlitz Chanteaud to produce a prompt elimination of the exciting causes of the disease, and to free the intestine of the contents which are undergoing fer- mentation. The vomiting and diarrhcea may be checked ELEMENTS OF DOSIMETRIC PRACTICE. 151 by the use of two to three grannies of hydrochlorate of morphine every honr, or of brncine in the same quan- tity if the morphine can not be tolerated. The tho- racic variety of this disease presents the form of an acute bronchitis, though the accompanying cough is of a drier character than obtains in simple bronchitis. The sulphide of calcium is indicated as a means of treatment, three granules being required every hour, associated with a like quantity of codeine, until a soothing effect has been obtained. The accompanying broncho-pulmonary congestion demands a granule of digitaline every hour until the cardiac action is regu- lated. The prostration which attends or follows the disease should be met by the arseniate of strychnine. With old and very feeble persons we should remember the difficulty in obtaining complete resolution of the inflammation of the respiratory passage, and anticipate such an accident by the use of hypophosphite of strych- nine. One to two granules of this may be given every two hours until all danger is past. Apomorphine may also be of service at this juncture as a tonic to the lungs, and to facilitate expectoration, two granules being given every two hours. The anorexia, which often retards convalescence after the disease has dis- appeared, may be treated with one granule of quassine and one of arseniate of soda four to six times daily. Whatever the medicament which is imposed by the variant, we should always associate with it the domi- nant until the beginning of convalescence. It is only by this plan that we shall be enabled to obtain positive profit from the symptomatic method of medication. All the morbid elements in this disease must be care- fully recognized and treated, but the paludal element requires especial attention. This is essentially the characteristic of the disease ; therefore, if we omit the use of quinine in our plan of treatment, all the other medicaments may prove futile. In severe and acute cases, in which it is desirable to have an uncomplicated 152 ELEMENTS OF THERAPEUTICS AND PRACTICE. plan of treatment, the accessory indications must be neglected, and all our attention be paid to the funda- mental one. In some cases we will be compelled to give the hydroferrocyanate of quinine every quarter of an hour, perhaps for a long time, and it may be to the exclusion of all other remedies. The great diffi- culty is not so much in recognizing the indications, and the proper remedies for them, as in making a selection of the morbid elements which require especial attention. 2td /Dominant. Miasmatic infection . Hydroferrocyanate of quinine. /Cephalalgia . . Aconitine. Nausea and vomiting Sedlitz Chanteaud, brucine. Diarrhoea ^ Sedlitz Chanteaud, hydrochlo- w o I Variant, ( rate of morphine. Cough . . . Sulphide of calcium, codeine. Bl r^J ; P " lm ° nary Valine. congestion Prostration . . Arseniate of strychnine. \Anorexia . . . Quassine, arseniate of soda. Chancre {Infecting or Hard). — See under Syphilis. Chancre {Simple or Soft).— See under Syphilis. Cholera Morbus. — The value of science is properly understood only at those critical periods when either the individual or the community demands a remedy, effective in its results and rapid in its action, for the plague which threatens its very existence. Then the assistance of medicine and hygiene is earnestly be- sought, and their advice is willingly heeded ; then alone does the state deplore the fact that the public sanitary service is so poorly organized and provided for. Until such a calamity either threatens or actually is present, and the existence and fortune of both gov- erned and governors are in danger, means for the de- velopment and perfection of scientific ends are doled out from the public purse only in the most niggardly manner. Funds enough are always available for monu- ments and theatres, for pomp and display, but to aid learning, to endow schools, to stimulate a love for scien- tific research by honorable prizes and emulation for grand discoveries, not a cent. ELEMENTS OF DOSIMETRIC PRACTICE. 153 When the pestilence or the cholera, leaving the marshy shores of the Ganges, glides across the Indies, stretching one arm toward Turkey and the other toward Egypt, and then reaches Western Europe ; when it penetrates its cities, crowded with marble palaces as well as decaying ruins, making them the centers for its devastating excursions, then kings hide themselves, and the people fly in confusion, like madmen at a conflaga- tion, ready to destroy whatever obstructs their path. Then the academies convene and the doctors discuss. The rulers consult this oracle, and the response is one which excites the derision of the world. These learned men guard against the discovery of a remedy; they hesitate to recommend proper means for the prevention of the plague ; instead, they present us with a microbe, and give it a name which is soon familiar to all. In olden times the people demanded panem et circenses (food and public games) ; now they are satisfied with an empty process of reasoning, or a bon mot carelessly repeated. At such a time one sees the almost impotent condition of science, and then, when controlled by fear, we are promised by the powers that be those reforms which prudence long ago suggested. But this is only the illusion of the moment, for, when the public peril has disappeared, hygiene is again disregarded, thera- peutics is unheeded, and science is more completely ignored than ever. What is the true cause of cholera % * * Dr. Besmer, well known on account of his epidemiological investi- gations, made the following declaration to the Academy of Medicine of Paris at the session of July 29, 1884: "It seems that the discoveries ot clinical medicine and of chemistry have given us nothing that is certain ; we can not yet distinguish during life, nor after death, a case of ordi- nary cholera from a case of Asiatic cholera ; we are still ignorant of the nature of the agent which produces it, its exact method of introduction into the system, the portion of the organism which is first affected, the method and the time in which evolution of the morbid germ occurs in individuals and in objects — in a word, the differences of opinion upon these points are more accentuated than ever." (" Gaz. heb. de Med. et de Chir.," August 1, 1884, p. 517.) 154 ELEMENTS OF THERAPEUTICS AND PRACTICE. The positive notion in regard to the efficient cause or causes of diseases is, without any doubt, the basis of pathogenesis, prophylaxis, and therapeutics. It is for that reason that investigators search so earnestly in cadavers, in excretions, and in etiological factors, for the cause of material lesions and functional disturb- ances. No one doubts at the present time that cholera is a zymotic affection, a disease produced by the intol- erance of the organism for parasites, probably of vege- table origin, which attack it and disturb its functions, whether from the elements which they take away from it, or the toxic elements of secretion or decomposition which they give up to it (on the latter hypothesis they are comparable to the cadaveric ptomaines or alkaloids), or from the irritation which they cause, as foreign bodies, in the living tissues.* This explanation, though hypothetical, is the only one which harmonizes all the facts and circumstances in overwhelming epidemics, such as attend the presence of cholera. Cholera, theo, is due to a microbe which is endemic in India, is propa- gated through great distances, and is transported by * In the lower orders of vegetables, as Blainville showed in 1882, the ternary elements of cellulose exist in greater quantity than the azotized elements. Now, as all varieties of cellulose resist the action of ammonia, and as microbes are not altered by it in their morphological characters, differing in this respect from infusoria, it follows that they should be classified among the vegetables. Besides, acetic acid blanches all animal tissues, but microbes resist its action. Finally, ha3matoxylon colors bac- teria, which would not be the case if they were microzoa. The straight, elongated form which many bacteria present, is also foreign to animal existences. The motion by which they are animated is not an argument against this opinion, for they only execute a motion of translation by one or the other extremity. If microbes are vegetables they can not live without water; dryness ought to destroy them, and moisture ought to favor their development. The medium in which the microbes are found may not be exactly the same as that which their sporules or germs require, which unquestionably is a moist one. The atmosphere does not transport microbes, but it carries and disperses their innumerable germs. The microbes are the agents of contagion ; the sporules of in- fection. ELEMENTS OF DOSIMETRIC PRACTICE. 155 individuals, by objects, or by the atmosphere alone. The transportation of the germs of cholera by the at- mosphere is proved by the influence of all epidemics at a great distance from the foci of infection, by the effects which are x>roduced in all the individuals in the con- taminated localities, by the want of any other expla- nation for certain well-established facts in which the means of contagion can not be discovered, and by the discovery of germs and other microbes which float in the atmosphere. It has been observed that whenever Europe has been visited by an epidemic of cholera, the epidemic has always been preceded by an affection of the digestive tract, which has an entirely different clin- ical physiognomy from that which is usually presented by such troubles ; that whenever the epidemic has be- come established at a given point there is evident, not only in contiguous localities, but in those which are remote, the influence of a morbific agent which produces sporadic cholera, cholerine, and other diseases which are but the shadow of the epidemic itself ; and this in spite of great differences in climate and atmospheric condition. All these diseases have a resemblance, more or less definite, to true cholera. In those localities in which the disease (cholera) appears in all its intensity, though all the inhabitants may not be actually attacked, they all are influenced to a greater or less extent by the disease. Even those who are, to all appearances, in the best of health, show a diminution in the rate of the heart's action. This fact is now explained with more of clearness and reason than formerly, by the presence of microbes in the atmosphere. If, therefore, it is proved that there are germs in suspension in the atmos- phere which circulates around the foci of infection, we must admit that aerial currents transport them from great distances, disseminate them, dilute and attenuate them more and more as the distance from their source increases. From the foregoing it follows that a single microbe may not, necessarily, suffice to produce the 156 ELEMENTS OF THERAPEUTICS AND PRACTICE. disease. The effects of that agency, like those of all other agencies, depend on the one hand upon the energy and number of the elements (microbes), and on the other upon the receptivity of the patient. The question is simply one of dose and of tolerance. In the centers of infection, where the germs are very nu- merous and very active, many individuals are attacked, and the attacks are overwhelming, severe, or mild, ac- cording to the resultant of the two factors. In a circle of territory with a radius of greater or less extent we will find, beyond the cholera zone, one in which chol- erine and sporadic cholera prevail ; beyond this, one in which indigestion and diarrhoea are prevalent ; at a still greater distance, and perhaps at a great altitude, one in which the microbes are relatively infrequent, and cause no noticeable effect upon living organisms. Mi- croscopic analysis of the microbes and germs in suspen- sion in the atmosphere, under ordinary conditions, has as yet failed to explain their differential characteristics. The number of such microbes and germs increases and diminishes with their distance from centers of infection and the conditions of ventilation. The same must be true as regards cholera, and, as a matter of fact, who are the individuals who are the most susceptible to cholera? They are those who dwell where the air is most likely to be infected with cholera-germs. When are the attacks most likely to occur? In the night, when the chilled and condensed air is most abundantly charged with microbes. In what localities do we find the greatest number of cases % In low and damp coun- tries, where ventilation is less active, the air more dense on account of the atmospheric pressure, and, therefore, the germs more abundant. Distance has an influence upon microbes, not only with reference to their number and their dissemination, but also with reference to their quality. Such parasites and their germs, removed from their native center, can not find in the climates of Eu- rope an assured existence. The conditions of their ELEMENTS OF DOSIMETRIC PRACTICE. 157 multiplication must, of necessity, be changed ; hence, the longer the period of time between their birth and their fixation in the suitable medium, the more pre- carious their functions of nutrition and reproduction. Differences of medium, upon organisms so simple and rudimentary, must act rapidly upon their vital energy, modify their malignity, attenuate their virulence, and destroy their pestilential action. It rarely occurs that they can be transported alive, by atmospheric currents, from their home in the Indies to Europe ; but ships are always in readiness as vehicles for their industrious emigration, with their atmosphere below decks abound- ing in moisture and deficient in ventilation. This fur- nishes us with an important hint for the use of pre- ventive and preservative measures. The work of the student of science, on the other hand, is to discover, to recognize, and to explain the causative microbe, and to investigate the conditions of its existence — its nutri- tion and its proliferation. With this end in view, the fluids, the tissues, and the secretions of the body are examined with the microscope, to discover elements which do not normally belong there. If any are found they are at once announced as the source of all the trouble which the disease has caused. In spite of cer- tain obscure conditions, it is quite evident that the comma-bacillus is really the specific cause of cholera. If it is true, as Koch says, that the comma-bacillus dies in acid solutions, but lives in alkaline and neutral ones, this fact can not be insignificant in adopting a curative and counteracting plan of treatment of cholera. On the other hand, this fact would explain how intemperance and f au] ts as to regimen would act in reference to the appearance of cholera. In fact, any irritation whatso- ever will increase the alkaline intestinal secretion and diminish the acid gastric one. Thus it might also be explained why attacks are more frequent at night, for we know that, with herbivores and omnivores, the in- testinal liquids are alkaline during digestion, while, on 158 ELEMENTS OF THERAPEUTICS AND PRACTICE. the contrary, those who are most like the carnivores, whose bile is acid during digestion, and who subsist mainly upon nitrogenous food, are most likely to be exempt from cholera — that is to say, the rich, who are carnivores to a greater extent than the poor, are less apt to be attacked by cholera. Hence it will be proper, during epidemics of cholera, to partake freely of acidu- lated drinks, especially those which contain the mineral acids — sulphuric, nitric, and hydrochloric. Such means are much more available to the poor than any particu- lar form of diet, especially one composed principally of animal food. It will now be proper to see whether there is any sign which will enable us to discover the nature of the disease ; in other words, to ascertain in what part of the body the microbe is located after it has entered it, and what are the primary lesions which it causes. We must first find out whether the microbe infests the entire organism or is limited to the gastro- intestinal canal. According to the theory of Paquet, the parasites, having entered by the respiratory pas- sages as well as by the digestive ones, encompass the entire organism, multiply in all the fluids, attack the nervous centers which preside over the nutrition of the liver and intestines, and the vaso-motor centers of the bulbo-spinal system. Other writers admit only a mul- tiplication in the intestine, and consider that all other symptoms are secondary, and derived from the intesti- nal lesions. The theory of Strauss, that the morbific agent of cholera is in the blood, has never been con- firmed. Thus far the microbes have only been found in the intestinal fluids, and, if the disease continues for some time, in the superficial layers of its inner tunic. Their absence from the blood, the negative or uncertain results which have followed inoculations, would seem to indicate that they could proliferate and be developed only in the fluid which is secreted by the intestinal glands. In those cases which are overwhelming in their effects and rapid in their termination there are no ELEMENTS OF DOSIMETRIC PRACTICE. 159 perceptible lesions ; it is only in cases which have lasted a long time that one finds proliferations, hypertrophies, and evidences of vascular irritation, lesions which are evidently secondary, and evidently caused by the dis- ease and not by the morbigenous agent. It would, therefore, appear that the lesions are primarily dy- namic. The microbe, having been introduced into the intestine, produces, at the ends of the nerves which radiate from the intestine, a modification which de- stroys their vitality, paralyzes their action, and thus disturbs the entire vital equilibrium which is necessary to the perfect performance of the functions. This modi- fication may be due to the irritation caused by contact, to the toxic action of the excretions of the microbe, or to its appropriation of vital energies and nutritive ele- ments. From this primary dynamic depression of the great sympathetic the entire series of other symptoms follows, the order of which is satisfactorily explained by the principles of pathological physiology. Thus the two opinions may be harmonized (concerning a pos- sible intestinal or a neural origin), for the lesion which begins in the intestines is immediately communicated to the entire economy, with the rapidity which charac- terizes neural disturbances. This opinion best explains all the facts ; besides, it is founded upon incontestable principles of experimental physiology. In order to thoroughly understand the pathogenesis of all the cases, we must not forget that every disease depends upon two factors, the agent and the patient. According to the quantity and quality of the morbific cause on the one hand, and the impressionability — that is, the organo- vital conditions of the individual attacked — on the other, we shall have an attack which will be mild, se- vere, or overwhelming; a case of mucous, serous, or asphyctic cholera. With many microbes and great re- sisting power of the nervous system, an individual may remain free from the disease ; with few microbes and feeble resisting power, another may succumb. Physio- 160 ELEMENTS OF THERAPEUTICS AND PRACTICE. logical experimentation, according to Armand Moreau, has thrown mnch light npon this question. He oper- ated by tying the intestine at two points, and then cut the nerves which were distributed in this segment. The next day he found the isolated portion of intestine en- tirely filled with intestinal secretion. On another occa- sion, leaving the nerves untouched, the following day there was no fluid in the intestine ; its walls were de- pressed and almost dry, like those of a fasting animal.* This experiment proves the influence of the nerves upon the intestinal secretions. When their functions are regularly performed, the intestine remains dry ; but when they are paralyzed or destroyed, the intestine quickly becomes filled with enteric transudation. To this experiment may be added the results of every-day observation. We know the depressing effect of certain moral disturbances upon the intestinal secretions, espe- cially the effect of fear. The frightened animal trem- bles, the skin becomes pale and cold, the intestinal secretion increases, there is a serous diarrhoea, and the sphincters relax and allow the urine and f seces to escape. This morbid condition, more or less pronounced, is known by the name of colic, a term which is mainly used to designate its principal localization. Far from being a metaphor, this is the designation of a morbid physical condition which has its seat in the abdomen. All these symptoms have their origin in a depressing moral impression which produces a reflex paralysis of the intestinal vaso-motor nerves. Add to the effect of fear the influence of the microbes, which increases the cause and aggravates the dynamic lesion, the microbes occupying the entire extent of the intestine, and multi- plying in a few hours, with frightful rapidity, when they find conditions which are favorable to their cult- ure ; and there will be little difficulty in understanding how the attack of Asiatic cholera is started and devel- oped. Dartier and Morat have observed, in the course * Budge, "Compendium of Human Physiology,"- p. 210, Paris, 1874. ELEMENTS OF DOSIMETRIC PRACTICE. 1G1 of numerous experiments,* that the intestinal vaso- constriction or paralysis of the great sympathetic coin- cides with the vaso-constriction of the cutaneous and bucco-facial regions. Thus is explained in a satisfactory manner the coincidence and succession of the symp- toms, diarrhoea, algidity, dryness of the tongue, cardiac disturbances, and, as phenomena of dynamic character, the spasms of the muscles animated by the lumbar segment of the cord and then by the upper segments. As all this takes place in connection with the motor- nutrient innervation, we can understand how the related functions may remain intact. The etiological condi- tions of the disease harmonize perfectly with this hy- pothesis. In all the epidemics it has been observed how forcibly fear influences the appearance and the gravity of the attack. All authors agree in recommend- ing calmness and courage as the most efficient prevent- ive means. The venerable Burggraeve, who has already had experience in five epidemics of cholera, concludes, after giving different rules of action, "It is fear, above all things, which must be overcome." We have already seen how the effects of fear, which are explicable only as a temporary paralysis of the sympathetic, resemble cholera in miniature. Colds also predispose greatly to attacks of cholera, and we have already seen that the cutaneous vaso-constriction coincides with the intestinal vaso dilatation. Old people, sick people, and convales- cents, whose nervous force has been lowered, are also very susceptible to diseases like this, and with them it is very apt to be fatal. The same may be said of those who are much emaciated, and those who are badly nourished. The majority of the fulminant cases occur in those who are subjects of relapse. It is natural that the sympathetic, already depressed by one attack, should less readily withstand a second one. It would appear, then, that of the two morbid factors, the agent and the predisposition, the latter is the more to be * See Paquet, " The Preventive Treatment of Cholera," Paris, 1883. 11 162 ELEMENTS OF THERAPEUTICS AND PRACTICE. feared. There need be no fear of exaggeration if we counsel the use of all measures which are capable of preserving the health of mind and body. This would always be the best way to escape the attacks of a pesti- lence. Having thus indicated the primary conditions of the disease, let us now see how it is established. The germs which are found in the epidemic centers in great numbers, either suspended in the atmosphere or deposited in the food which is ingested, penetrate through the mouth, the respiratory apparatus, or the digestive canal. * In the respiratory apparatus, where they do not find a medium favorable for their germina- tion, they remain inert. Those germs which penetrate into the stomach find there an acid medium which de- stroys them. The reaction of the gastric juice, under pathological conditions, may not be acid, however, in which case more or fewer of the microbes would reach the intestines, where they would find a more favorable medium. They would then begin to vegetate, and ex- cite diarrhoea, diminution of the pulse, etc., until they were completely destroyed by surrounding conditions unfavorable to their development ; or at least until the enteric secretion, produced either by intestinal irrita- tion or by depression of a moral character, no longer renders their proliferation easy, on account of the chemical constitution and physical condition of the medium. This enteric secretion in question may also be the result of modification of the regime, of drilling of the surface, etc. In fact, we know to what an extent almost inappreciable differences in the chemical consti- tution of the fluid of Raulin influence the development * It appears to the author that sufficient attention has not been paid to the fact that microbes may enter by the anus. The extreme fre- quency of attacks which occur in infected latrines, the rapidity with which the disease is propagated when it is carried by means of human dejecta, as is observed in the case of armies on the march, lead him to think that this mode of penetration into the economy offers more dangers than its introduction by the superior opening of the digestive canal. ELEMENTS OF DOSIMETRIC PRACTICE. 163 of artificial cultures. As the number of the microbes increases, disease becomes imminent, an attack being made as soon as the resistance of the sympathetic is in- sufficient to hold out against the disturbed equilibrium which is caused by the specific agent of the disease. Some further chemical and pathological considerations will justify to a still greater degree this way of under- standing the pathogenesis of cholera. In comparing this type of microbiosis with other zymotic diseases, we see that there is a complete disparity as to their symp- toms. In variola, typhus, yellow fever, the plague, etc., the disease is constituted by two essential elements, the reaction of the organism to the parasites which have invaded it, and their elimination as foreign bodies. The disease is therefore general, prolonged, and cyclical. In cholera there is nothing of the kind ; all the symp- toms are acute, and are evolved in a short time. There is no reaction preceding elimination, and the disease shows such a degree of gravity, such variable symptoms and progress, that one is compelled to admit that, be- sides the primary cause, the principal element of the disease lies in the nervous system. The microbes, after having caused intestinal transudation, as a result of vaso-motor paralysis, are themselves the means for effecting their own elimination, or rather evacuation. The intestine, having thus been freed from the microbes, the remainder of the morbid evolution is entirely physi- ological. After paralysis has occurred there is neces- sarily a more or less decided tendency toward reaction ; the intestines become irritated and inflamed, the tem- perature becomes elevated, and gives occasion for a new disease, which we might call curative, were we not con- tent with calling it physiological. This disease has nothing specific about it. It is not contagious while it lasts ; neither the blood nor the secretions contain in- oculable material ; the condition is one which predis- poses to a new attack rather than otherwise. Cholera itself, therefore, expends itself entirely in the intestine, 164: ELEMENTS OF THERAPEUTICS AND PRACTICE. while the organism at large intervenes only through the medium of its nervous sensibility. However insensible the intestinal nerves may become to stimulants and to peripheric influences, the cholera will pass away almost unperceived. This is the explanation of the efficiency of opium in certain cases, and it is for the same reason that we must limit ourselves to stimulation of the vital energy, and to diminution of the peripheric sensibility, without seeking in any way to arrest the evacuations, which are the unique but natural means for shortening the attack, by eliminating the cause which produces it. Opium, which is very useful for curing simple forms of diarrhoea, which might quickly become choleraic in character as the composition of the intestinal fluids be- came modified, becomes harmful after the cholera is established, by increasing the time during which the disease-germs are in contact with the organism, and thus supplying new generations of them for the attack. The following conclusions may be advanced as to the relations of the symptoms : 1. Cholera is produced by a microbe, which Koch thinks he has discovered, and which he has called the comma-bacillus. 2. The cholerigenic germ is developed in Europe only in the intestinal fluids. 3. The germ is introduced into the organism through one of the orifices of the intestinal canal. 4. The primordial lesion of cholera is a paralysis of the intestinal nerves. 5. All other symptoms are secondary to this paraly- sis. After these considerations, which are based upon incontestable facts, we are now in position to find a rational plan of defense and attack with reference to this terrible scourge. We shall, therefore, study in a concise manner the practical consequences which must follow to accomplish the preventive, curative, and pre- servative treatment of cholera. ELEMENTS OF DOSIMETRIC PRACTICE. 165 Preventive Means. — It is evident that quarantines and sanitary cordons are useful for the arrest of indi- viduals who have been sojourning in infected places, and have brought with them germs and microbes, the vitality of which depends upon certain conditions which are unknown to us, but which we know exist naturally only in the East Indies. These germs can not long sur- vive in the climate of northern and central Europe. Since these microbes can exist, however, in individuals who are apparently healthy, as well as in the sick, quarantine should continue for a longer time than is usually the case, and all immigrants should be sub- mitted to intestinal disinfection with sulphide of cal- cium and Sedlitz Chanteaud. The dejections of those who are in quarantine should be burned, removed to a great altitude, or mixed with sulphuric acid, so as to disorganize their living elements. A healthy individ- ual, who comes from a center of infection, may be a more decided cause for suspicion and danger than one who is actually suffering from cholera, for the latter, overcome by the disease, can only infect a latrine, a house, or a single place of residence ; the former, on the other hand, being entirely unrestrained in his movements, distributes the choleraic germs wherever he goes and wherever he leaves his dejections, thus creating new centers of epidemic proliferation. While quarantine thus established is useful, it is altogether insufficient, since the germs disseminated by the at- mosphere are easily blown across such barriers. How- ever, as it has been already observed, they become more innocent and impotent the longer they exist, so that a point may be reached when they cease to be so harmful as when transmitted directly by man. The great means of prevention, and the only effective ones, would be to destroy, from the beginning of the epi- demic, all the dejections of all the inhabitants in the region which has been attacked. This end ought not to be so very difficult to attain. 166 ELEMENTS OF THERAPEUTICS AND PRACTICE. Counteracting Means. — These general means ought to be completed by the care which is taken by each individual that he does not furnish in his own person a suitable soil for the culture of the germs of the bacil- lus. In order to attain that end, it will be necessary — 1. To avoid the introduction of germs into his di- gestive tube. 2. To render the conditions which are suitable for the development of the microbe incompatible with the nature of the liquid contained in the intestinal canal. In order to avoid the introduction of germs, one should use the greatest care in avoiding all places for evacuating the bowels which are not thoroughly disin- fected, either by boiling water or by a suitable disin- fecting solution, sulphuric acid being the most reliable of them. The objects which are used for cleansing pur- poses should be changed on each occasion of use, and thoroughly disinfected. Water and instruments for administering enemata may readily become media for the transmission of the disease. No food which has not been recently cooked should be eaten. Water should be boiled ; but, as it is indigestible in this condition, and by aerating it it again becomes dangerous, weak wines should be drunk in preference, or waters from mineral springs or from localities which are known to be free from the cholera infection. Fil- tered water which contains five parts of borax in a thousand may be considered free from danger. Be- tween meals those who have disorders of the intestinal canal, or who must be near the sick, should occasion- ally dissolve in the mouth a pastille of borax or a gran- ule of sulphide of calcium. The studies of Ballesteros lead us to regard the latter as a useful preservative agent ; two granules may be given two to four times daily. The windows should be closed as night comes on, but all of them should remain open during the day. Colds and errors of diet must be avoided ; for, as they excite the intestinal secretion in either a direct or reflex ELEMENTS OF DOSIMETRIC PRACTICE. 167 manner, they render the composition of the contents of the intestinal tube favorable to the development of the microbe. The daily use of Sedlitz Chanteaud may be of service in preventing fermentation in the digestive canal ; but dosimetric physicians are divided in regard to this point, some of them agreeing with the general opinion that it is best to abstain from the use of purgatives while Asiatic cholera is epidemic. It must be remembered, however, that purgation from the use of salines is not analogous to the premonitory diarrhoea of cholera. Esallden stated in the "Union Medicale," in 1849, that he had prescribed, during a recent epidemic of cholera, purgatives and emeto-cathartics by the hun- dred, cholera not being the result in a single case. He even stated that the use of evacuants, by combating dyspeptic and diarrhoeal conditions, would result in saving some individuals from an attack of cholera to which they were predisposed. Fonssagrives,* in com- menting upon this opinion, agreed with its author, and approved of the moderate use of purgatives. Each one must act in this matter according to the best of his judgment ; but it would seem proper that those who are accustomed to the daily use of a rectal enema should continue it, while those who are doing well without it should not change their habits in this respect without good cause. In the same way, those who require, and are in the habit of using, Sedlitz Chanteaud to correct gastric troubles, should not give up its use through any puerile fear. Whatever goes to main- tain health in body and in mind should be contin- ued without hesitation. To advise one to abstain from fear is easy enough, but its practice is difficult. The daily use of strychnine, by acting as a tonic to the nervous system and a stimulant to the mind, should be of great service. The author remembers to have heard Dr. Burggraeve remark that it was his habit to take a few granules of strychnine before proceeding with an * u Traite de Therapeutique appliqnee," tome ii, p. 511. 168 ELEMENTS OF THERAPEUTICS AND PRACTICE, important conference ; and his pupils have been in the habit of saying that, under such influences, his exposi- tion of his doctrine and his refutation of the objections which were made to it were wont to be made with more than usual clearness and earnestness. .Leptan- drine, which is advised by Paquet, and which, in that author's opinion, has the property of exciting the he- patic and intestinal nervous centers, may be associated with strychnine, or be given alternately with it. Curative Means. — If one seeks the most appropriate means, according to classical authorities, for combating this disease in its different phases and according to its different indications, a feeling of fatigue and discourage- ment must follow, for, among all the remedies which are considered appropriate, there is not one which could be recommended with a degree of confidence which would inspire success. It might be supposed that the scien- tific progress which has developed since the occurrence of the last few epidemics of cholera would imply cor- responding progress in the practical application of that knowledge. Unfortunately, the most varied methods of treatment have been tried in cholera-hospitals in the different countries of Europe without a single step of progress on the part of therapeutics, or the least ad- vantage over the ancient methods of treatment. At the Pharo Hospital, in Marseilles, Trastour has had occasion to compare the results obtained by different means, the latter being advised as means which are most rational, and indicated as those which are most efficacious. The methods by the bichloride of mercury, as a germicide, and oxygenated water, produced no result ; the physiological method of treatment with picrotoxine, which produces elevation of the tempera- ture, was equally unsatisfactory, as might have been supposed ; inhalations of oxygen revived the patients for only a moment ; injections of water into, the veins, which was practiced upon two patients, did not prevent them from succumbing in a very few hours. The ex- ELEMENTS OF DOSIMETRIC PRACTICE. 1C9 citant method of treatment with ether and acetate of ammonia appears to have given better results, bnt has not served to lower to any considerable degree the mor- tality in epidemics in which this plan has been fol- lowed. Of two hundred and eighty patients which Trastour received at the hospital in a condition which would indicate that recovery was possible, one hundred and forty-six died. In epidemics which preceded the one from which these statistics are derived, in which some patients were treated and others were not, the mortality was about the same — that is, about fifty per cent. Therefore, since science has taught us nothing new in this matter, let us see whether any advantage can be gained in the way of establishing a rational method of treatment by departing from its principles. From the foregoing observations it must be evident that the principal indications can be reduced to two : 1. To destroy the microbes and prevent the develop- ment of germs, thus annul] ing the cause of the disease. 2. To stimulate nervous vitality by means of all the most energetic excito-motor agents, in order to combat the primary functional lesion, paralysis of the intestinal nerves, from which all other disturbances and symp- toms proceed. To satisfy the first indication, we possess -the sul- phide of calcium, the probable efficiency of which is estimated by the magnificent results which it gives in the other mycoses, and which has the great advan- tage of being readily tolerated. Of what practical advantage is it that agents, such as corrosive subli- mate, sulphate of copper, and carbolic acid, are capa- ble of destroying micro-organisms outside the body if they can not be introduced into the digestive canal in sufficient quantity and in a suitable degree of concen- tration to accomplish the desired result ? Shall we sub- mit the body to a temperature of one hundred and ten degrees, since that temperature is necessary to destroy these germs % The ideal of the investigators should be 170 ELEMENTS OF THERAPEUTICS AND PRACTICE. a parasiticide which will kill the microbes without at- tacking at the same time the integrity of the digestive organs ; and, since sulphide of calcium fills these two conditions, so difficult to unite, it would appear that this is the agent which should be preferred — at least in the present condition of science— as the therapeutic agent in cholera.* The second indication should be filled by means of strychnine and phosphoric acid, which are the most energetic antagonists to paralysis. As soon as we have restored the equilibrium of the intestinal nervous functions, and the microbe has dis- appeared from the enteric mucous membrane, the entire disease will vanish as if by magic, and we will have remaining only an ordinary disease to treat, in which fever or atony will predominate, and the treatment of which will demand no unusual manifestations. If the progress of the disease is not very rapid, we may be able to use certain other medicaments, which would therefore come under the role of the variant. Spasms may be combated by the bromide of camphor, sup- pression of urine by digitaline, suppression of perspira- tion and elevation of the internal temperature by aconi- tine, and intermittence in the symptoms by the valeri- anate or salicylate of quinine. During convalescence the atony of the stomach may be treated by leptandrine or quassine, three granules of each before meals ; the epigastralgia by a well-regulated diet, and by two gran- ules of the tannate of cannabin every half -hour until a soothing effect has been obtained. Before finishing this subject, it is proper to make an observation with respect to the method of administration and fixation of the doses of the drugs which are required, and also to remind the physician that it is necessary to combine internal treatment with external applications. In cases in which the functions are only moderately deranged, the administration of medicaments should follow the * The results which Ballesteros has obtained fully confirm the fore- going statement. ELEMENTS OF DOSIMETRIC PRACTICE. 171 ordinary rules. For the so-called premonitory diar- rhoea, which is nothing less than an attack of cholera in its embryonal stage, we should use morphine, bru- cine, or strychnine, from one to three granules, at in- tervals varying from a quarter of an hour to two hours, according to the severity of the case. With these drugs we may associate sulphide of calcium in suspicious cases. If, on the other hand, the cholera is established, and the intestinal paralysis is beginning to pass away, we should remember that repeated vomiting and fre- quent intestinal evacuations, with the associated abun- dant intestinal transudation, mean that the greater por- tion of the medicines which have been taken are of no benefit, and that, in addition, the absorption of the remainder is very uncertain and irregular. Even if there is no vomiting, substances traverse the intestinal canal with such rapidity that hardly any portion of them can be of much utility. Under these circum- stances we should not give medicaments in the solid condition, but dissolve them in water, or in port or madeira wine, or else in some warm, stimulating infu- sion, being careful to avoid irritating vehicles, which would greatly aggravate the period of reaction. Dur- ing the period of intestinal hypersecretion, the doses should be very large and frequently repeated, if we wish to obtain any result from the use of medicines. The limit of the doses should be subordinated to the rapidity with which the evacuations are repeated ; and as the diarrhoea becomes subdued, and we look for a more nearly normal degree of absorption, the frequency with which they are given should be correspondingly diminished. In the asphyxial period we should have recourse to hypodermic injections of excito-motor alka- loids ; for, if they do not give all the results which we could hope for, they are a]l that is left us for this ex- treme period. It is well to begin using them sooner than is customary, and also in a somewhat different way. Injections consisting of one centigramme of hy- 172 ELEMENTS OF THERAPEUTICS AND PRACTICE. droclilorate of morphine and one half a milligramme of atropine to a gramme of water may be of service in checking the vomiting, which wears out many patients, and completely disturbs the regularity of the treatment which is prescribed for them. Injections of a ten-per- cent solution of hydrate of chloral, used almost simul- taneously at four points — two on the arms and two on the thighs — have sometimes been successful in relieving the cramping pains, and are also perhaps antizymotic. Under the same conditions, and in the same manner, the hydrobromate of quinine may be used in a two-per- cent solution. There may be a particular indication for pilocarpine to re-establish the urinary function, but it must be used with moderation on account of its depressing effects, which would be an obstacle to the establishment of the necessary condition of reaction. The exciting properties of ether may sometimes be used in extreme collapse ; one gramme of it pure should be injected at each attempt. All these means must be regarded as designed only to restore the vitality, that then the alkaloids destined to fill the dominant indica- tion may have time to produce all their effects. Ap- plications of electricity may also be of great service as synergistics in the result which is expected from strych- nine and phosphoric acid. Fumigations, after the method of Guy ton, * and recommended also by Burg- graeve, will contribute to the purification of the air of the sick-room, and increase the volume of oxygen for the patient already troubled as to his respiration, while they will also diffuse the disinfecting fumes of chlorine. Everything which can stimulate the activity of the skin, and provoke a healthful derivative action toward it, should be tried. Of all the means which have been * This method was devised by Guyton de Morveau. The mixture consists of three parts of binoxide of manganese, one of chloride of sodium, and two of dilute sulphuric acid. This disinfectant gave excel- lent results when it was used, in 1809, by Thome Rodriguez Sobral, a distinguished chemist of Coimbra. ELEMENTS OF DOSIMETRIC PEAOTICE. 173 used up to this time, derivatives upon the skin have given the most constant and the most advantageous results. This fact is explained by the antagonism which subsists between the cutaneous circulation and that of the mucous membrane, as was shown by the experiments, already quoted, of Dastres and Morat. The theory is that, if intestinal vaso-dilatation coin- cides with cutaneous vaso-constriction, cutaneous vaso- dilatation will in its turn be accompanied by intestinal vaso-constriction, which is an indispensable factor in the cure of cholera. Consequently, we should not de- spair of success, but persevere in the use of dry rub- bings, rubefacients, stimulants, etc. With regard to the use of the hot blanket, the author hesitates to ex- press an opinion. Though coverings are moistened in boiling water, the patient will be exposed to a chill while they are being adjusted, the consequence of which will be cutaneous vaso-constriction and an ag- gravation of the intestinal vaso-dilatation. Coverings dipped in cold water would be preferable if one were sure of an immediate reaction, but, under the condi- tions of this disease, reaction after such means is so problematical that the risk is not usually warrantable. Sometimes it might be advisable to wrap the patient, in a nude condition, in a dry blanket as warm as the natural temperature of the body. Whenever it might be necessary to uncover him, repeated strokes might be made over the entire body with towels moistened in cold water. / Infection by the comma-bacillus Sulphide of calcium. Dominant, -j Paralysis of intestinal innerva- ( Phosphoric acid, sul- ', tion ( phate of strychnine. Cramps Bromide of camphor. Anuria Digitaline. Fever Aconitine. Intermittence .... Salicylate of quinine. f Codeine. ; Variant. Vomiting J Hypodermic injections & < J of morphine and at- [ ropine. Gastric atony .... Leptandrine, quassine. Epigastralgia .... Tannate of cannabine. 174 ELEMENTS OF THERAPEUTICS AND PRACTICE. Chorea. — Chorea is a neurosis from which one may recover spontaneously in the course of three months, more or less, but which nevertheless may, and not infrequently does, lead to a fatal issue. Its patho- genesis can not be readily explained ; the most reason- able theory is that which attributes it to an original lesion of a rheumatic nature located in the spinal neu- rilemma. The disease affects principally the co-ordina- tion of the motions and the economy of muscular con- tractility. The pharmaco-dynamics of veratrine cor- responds perfectly as dominant with the indications suggested by this pathogenic conception, and trials of it have been made by the author with admirable and rapid results. It should be given in relatively large doses, and it is so well tolerated in such doses that it would seem as if vegetative contractility in choreic patients who received such treatment had been blunted by the excessive excitability from which the muscles are suffering. Two or three granules should be given, therefore, every half- or quarter-hour, day and night, with the greatest regularity, until there is a manifest improve- ment in the condition, or evidence of insurmountable intolerance on the part of the stomach. In the latter case we should not be discouraged, and should add two granules of codeine to each dose of veratrine ; if vomit- ing continues, in spite of this change of method, we should rest for a few hours, and then begin again with doses of one granule, which should be rapidly increased until the dosage originally prescribed is reached. We must not hesitate to keep the patient entirely under the influence of the veratrine for three, five, or eight days, increasing the doses if at the end of three days we have not obtained the desired result. As long as the stomach does not reject the drug, nor the pulse indicate a condition of great depression, we can con- tinue the treatment fearlessly, always seeking to avoid an interruption to the influence of the drug, which ELEMENTS OF DOSIMETRIC PRACTICE. 175 might annul the entire effect. Most patients are not sufficiently careful to prevent such interruptions, espe- cially at night. It must also be remembered that this plan of treat- ment is recommended only for idiopathic or essential chorea. If the chorea is symptomatic, it would be use- less to follow this method. The pains which accompany the ataxia, especially at the beginning of the disease, should be combated by cicutine, two granules every two hours, or by tannate of cannabine, two granules every half-hour. Prolonged lukewarm baths may be used to counteract the hyper- esthesia. The anaesthesia requires no other treatment than the dominant ; suitable local means may be added as they are applicable, if desired. Among such means metallo therapy, xylotherapy, etc., may be used. The cardiac disturbances may result in an ataxic condition as to the heart's movements, in which case the treatment need not of necessity be complicated, or fatigue in the heart-action may be apparent from loss of strength. In the latter case one granule of digi- taline, with two of sulphate of strychnine, should be given four times daily. Digestive troubles, which are complications of ordinary occurrence in this disease, should be treated with one granule of hyoscyamine every two hours if there is vomiting ; by two to four granules of quassine, before each meal, if there is an- orexia ; or by three granules of pepsin with each meal, if there is trouble with the gastric secretions. The anaemia, or chloro-ansemia, which is manifest after the first few days of choreic ataxia, should be treated with two to three granules of the valerianate of iron or of arsenious acid with each meal. Insomnia, which has so great an influence in depressing the strength of the patient, should be combated with the hydrochlorate or the hydrobromate of morphine, associ- ated with croton chloral or the monobromide of camphor. Three granules of each may be used every half -hour. 176 ELEMENTS OF THERAPEUTICS AND PRACTICE. [ Dominant. Want of co-ordination /Pain . Anaesthesia . Hyperesthesia Cardiac perturbations Veratrine. Tannate of cannabine, cicutine. Local measures. Cicutine. j Digitaline. I Stryc k Variant. ( Digestive disturbances Anemia Insomnia Strychnine. ( Hyoscyamine. •j Quassine. ( Pepsin. Valerianate of iron. Arsenious acid. Hydrochlorate of morphine. Bromide of camphor. Croton chloral. Cirrhosis of the Liver.— See Interstitial Hepatitis (under Hepatitis). Colic, Hepatic. — See Biliary Litliiasis (under LitMasis). Congestion, Cerebral. — The therapeutics of cere- bral congestion should always be based upon positive indications, for in diseases of this character, more than in all others, the result depends upon the interpretation of the case. The investigation of the case should be complete, and should apply with more thoroughness and exactness to the patient's past history than to his present condition. While it may be easy to make a diagnosis quickly in a case of this kind, it is not so easy to say under what conditions the hyperemia is pro- duced ; but these are the very conditions which will indicate the proper line of treatment. Active conges- tion of the brain may occur, whether from the sup- pression of a periodical flow (as in connection with haemorrhoids or menstruation), or from the accumula- tion of blood in the brain in consequence of a sudden diminution of the capacity of the general circulation (as by means of ligatures, compression of the vessels, etc.). There is, then, a collateral hyperemia of physi- cal origin, and which must be treated on hydraulic principles — that is, by removing as much blood as will be necessary to restore the equilibrium of the vascular pressure. To accomplish this end we may use general or local bleeding ; we may obtain serous discharges by ELEMENTS OF DOSIMETRIC PRACTICE. 177 means of pilocarpine, which will at the same time in- crease the salivary, sudoral, and renal discharges, or we may use saline purgatives. But, even in these cases, we have something besides a physical accumula- tion of sanguineous fluid to deal with. This accumula- tion might be again distributed equably in all the ves- sels, or be carried to some other organ than the brain. Therefore, the existing condition is principally a certain want of vital equilibrium — a want of resisting power in the cerebral vessels — which demands the ad- ministration of strychnine and of ergo tine, in order to give to the dilated vessels the necessary tonicity to enable them to oppose a new hypersemia, which will return, after the abstraction of blood by operation, with returning plethora. Hypersemia may also originate in the brain itself, in consequence of increased irritability in that organ. Congestions produced by the presence of some morbid product, or by the want of cerebral rest (as in vigils, excessive intellectual labor, etc.), are in- stances of this mode of causation. In these cases the congestion is the first phase of an approaching en- cephalitis. Aconitine and digitaline, one granule of each being given every half -hour until an effect is pro- duced upon the circulation, are indicated, and have a rapid and certain action. Revulsives must be avoided, the stimulation to the brain which follows their use being just what we should aim to obviate. Complete rest to the nervous system is an end which must be assiduously sought. The hypersemia may also be reflex in character — that is to say, the impression upon the brain of a cause which is more or less remote. An example of this might be noted in the bad re- sults which sometimes follow the use of revulsives ; it may be added, however, that this means of treatment is not always contra-indicated in this form of cerebral congestion. Reflex hypersemia, in most cases, is at- tributable to the stomach ; Sedlitz Chanteaud and the other evacuants are therefore appropriate. In all cases 12 178 ELEMENTS OF THERAPEUTICS AND PRACTICE. of active congestion we can use cocaine with great ad- vantage, its anaemic effects extending to the brain, especially if it is administered hypodermically. Three granules of it may be used every quarter of an hour. Passive congestion may be caused by interference with the return of the blood to the heart, whether by an immediate obstacle, which causes an accumulation of the blood in the head, such as a tumor of the neck, which might compress the jugu]ar veins, or by remote obstacles, which act in an indirect manner — for exam- ple, cardiac or pulmonary lesions. In the first condi- tion the application of leeches to the nasal fossse, the mastoid region, or the neck, should first be made, to prevent accumulation of the blood by withdrawing a portion of it. As soon as depletion has been obtained to a sufficient degree, strychnine must be used to pre- vent an immediate return of the same phenomena. In the second case means must be used which will restore the equilibrium in the circulation, and among such means digitaline, caffeine, strychnine, and Sedlitz Chan- teaud will be found especially serviceable. Since con- gestions, whether active or passive, do not always have the same symptomatic characters, we must sometimes fill, as a variant, indications which are peculiar to a given case. Headache in connection with active congestion may be successfully treated with aconitine, and in pas- sive congestion with the citrate of caffeine. One gran- ule may be used in each case every half -hour. Yertigo, which is a means of terror to patients, and may in this way aggravate the congestion, will disappear under the use of two granules of the valerianate of caffeine every half-hour. Constipation will yield to the continued use of Sed- litz Chanteaud or podophyllin, or in very rebellious cases to the combination of these purgatives with strychnine or euonymine. Of the strychnine, two granules may be given with each dose, or five of the euonymine. Delirium, which depends almost always ELEMENTS OF DOSIMETRIC PRACTICE. 179 upon localized congestion in the gray matter, should be combated, at its first appearance, with aconitine, associated with the bromide of camphor. Three gran- ules of camphor and one of aconitine may be used as often as indications warrant. In the comatose or apo- plectic condition it is not essential to give anything in a fluid form to the patient, not only because it is doubt- ful whether the stomach retains its power of absorp- tion, but especially because there is risk that fluids may enter the respiratory passages on account of the abolition of the movements of deglutition, and thus increase the difficulties of respiration and accelerate asphyxia and death. In the apoplectic form all medi- cation should be hypodermatic. If there is indigestion, injections of five to ten granules of apomorphine will excite vomiting ; if there is evidence that a haemorrhage has taken place, we must use injections of ergotine ; if the temperature increases, and the pulse becomes more frequent and harder, we must not hesitate, as a last resort, to use injections of aconitine.* The disturbance which extends to all the vital acts from the cerebral trouble necessitates the greatest care with respect to the alimentation of the patient ; for, while indigestion on the one hand may renew the congestion, exaggerated or prolonged abstinence may lead to the same accident, on account of the excess of impressionability and vas- cular relaxation which accompany organic debility. * The hypodermic syringe usually contains twenty drops of liquid. It will dissolve twenty granules of apomorphine, of which five drops may be injected every ten minutes until vomiting is produced. The same quantity of water may be used to dissolve ten granules of ergo- tine, which is a proper quantity for each injection, and may be repeated every half-hour until the patient recovers consciousness. Four granules of aconitine may be dissolved in the same quantity of water, five drops to be injected at a time, and repeated every hour until the effect is noticeable upon the pulse and temperature. In passive congestions, due to asystole and dangerous to life, injec- tions of fifteen drops of liquor ammonia in fifteen drops of water may be made into the median cephalic vein. 180 ELEMENTS OF THERAPEUTICS AND PRACTICE. Dominant. Variant. r Collateral Active congestion -j irritative I Reflex . f Direct ^Passive congestion -j [indirect . (Cephalalgia . Vertigo Coprostasis . Delirium Coma . j Depletions of blood and \ serum, strychnine. Aconitine, digitaline, cocaine. Revulsives, derivatives. C Leeches in the nasal < fossae or around the ( ears. {Digitaline, strychnine, caffeine, Sedlitz Chan- teaud. Aconitine, citrate of caffeine. Valerianate of caffeine. Sedlitz Chanteaud, podophyllin. Bromide of camphor, aconitine. Flagellations. Intravenous injections of dilute am- Congestion of the Liver. — Few of the organs of the body are so susceptible to hyperemia as the liver. Compelled, as it is, to experience all the disturbances which occur to the circulatory system, on account of its peculiar anatomical disposition in the course of the blood- current, it is also the seat of active changes, and the point of convergence of all the media by which in- testinal absorption is accomplished. It is not an aston- ishing fact, therefore, that the quantity of blood which reaches it varies each moment, and is influenced by all the conditions which have a bearing upon the status of the general circulation. These changes, which were re- ferred to, are diminished in a favorable manner owing to the extensive ramification of the vessels, both the aiferents and the efferents, within the structure of the liver. Hepatic hyperemia may, therefore, go beyond certain limits, or continue for such a period of time as to be considered a morbid condition. But, even with this restriction, it is very often ob- served that there are well-defined congestions of the liver. Congestion of this organ depends essentially upon paralysis of the pneumogastric ; and this fact has been experimentally verified by Yulpian, who cut this nerve, and found, by measuring the biliary secretion, that it could be increased only as the volume of blood was in- creased to a corresponding degree. Upon this experi- ELEMENTS OF DOSIMETRIC PRACTICE. 181 mental fact, of the accuracy of which there can be no doubt, rests the dominant in the dosimetric plan of treatment of congestion of the liver. It consists in the use of that agent which produces or provokes nervous force to the most decided degree, and which is designed to take the place of the force which should be transmitted by the vagus ; that agent is strychnine. In order to facilitate the practical appli- cation of the dosimetric treatment we must consider congestion as mechanical, active, and passive ; really admitting, however, that there is no essential difference between the three forms, since all depend upon the same primary cause, insufficiency of nerve-force. They may appear to differ on account of the different ways in which they are established, the rapidity with which they are developed, and the subjective symptomatology which each one presents ; fundamentally, they are one and the same thing. Mechanical congestion, which is caused by obstacles to the circulation, either without or within the liver, is also due to the want of resistance on the part of the walls of the blood-vessels to the intra- vascular pressure. The treatment should consist (1) in destroying or neutralizing the obstacle ; (2) in increas- ing the resisting power of the vessels. Both these in- dications are filled, if such a thing is possible, by the use of strychnine and digitaline. All indirect means which would diminish the intravascular pressure would antagonize, for the moment, the congestion, but could not be considered as curative agents of this disease. Purgatives will bring a certain degree of comfort to the patient, but that is their only effect. The same might be said in regard to bleeding, whether from leeches or cups ; but the slight advantage which might result is more than compensated by the great risk which attends the use of such means. There are cases, how- ever, in which the congestion must be relieved by what- ever means, even though the result be of but short du- ration. 182 ELEMENTS OF THERAPEUTICS AND PRACTICE. For example, in cases in which dyspnoea, produced by great enlargement of the liver, is so distressing as to demand immediate relief, we must not hesitate to use purgatives, and especially those which have the prop- erty of exciting the secretions of the liver, as well as producing free serous depletion. We should use, as such means, podophyllin or jalapine, associated with the dehydrated Sedlitz, but without discontinuing the strychnine, which, in addition to its role of dominant, has also the advantage of fixing and rendering more constant the serous ischsemia, which is effected by the current of fluids diverted to the surface of the intes- tines. As to dosage, three or four doses, consisting of five granules each, of podophyllin or jalapine, with a solution of Sedlitz Chanteaud, will cause copious evacu- ations, containing an abundance of bile. In cases in which the principal morbid element takes the form of ascites, which we desire to treat with diuretics, we may use caffeine, colchicine, or asparagine, associated with digitaline and strychnine. Two granules of each may be given every three hours. Active congestion has sev- eral causes ; their suppression usually suffices to cure the patient. Its etiology should therefore be very care- fully studied. If the congestion is due to intemperance or the use of irritating food, a well-regulated diet and the use of sulphate of strychnine with each meal will rapidly overcome the hyperemia. In tropical regions, where the continuous heat alone seems to weaken the force of the hepatic circulation, we should prescribe two granules of aconitine morning and evening, or oftener if the case requires it. Sup- pression of perspiration is also a frequent cause of con- gestion of the liver. The nitrate of pilocarpine, by in- creasing the contractile force of muscular fibers and producing diaphoresis, will be of great service in such cases. The dose should be three granules every ten minutes, by the mouth or hypodermically. The con- gestion which accompanies or follows malarial fever ELEMENTS OF DOSIMETRIC PRACTICE. 183 may be effectively treated by the arseniate of quinine, combined with the arseniate of strychnine, two granules of each being given three or four times daily. Simple congestion, which may accompany syphilis, is not of frequent occurrence from such a cause. If syphilis be the cause, calomel is indicated, the doses being graduated in accordance with the severity and chronicity of the disease, and in accordance with the rules of dosimetric therapeutics. There are not usually any alarming symptoms in connection with the estab- lishment of active congestion. It may be accompanied with some elevation of temperature, however, and as this may be the first indication of an imminent hepa- titis, we should use one granule of aconitine every hour or half -hour until the temperature has declined to the normal again. The pain in the hypochondriac region is seldom severe ; if it should become annoying, and evidences of inflammation should be present, codeine may be administered. Anorexia will readily yield to treatment with quas- sine, which also seems to excite the flow of the bile. Tenesmus may be treated by the purgatives which have already been referred to, and by one-granule doses of hyoscyamine, repeated as often as necessary. Icterus will promptly disappear after treatment with arseniate of soda, six to ten granules of which may be given daily. By this means the digestive functions will also be benefited. For passive congestion, whatever its pecul- iarity, the liberal use of strychnine can not be dispensed with. The indication for this drug is so manifest that even Jaccoud appears to advocate it.* In all cases in which stasis occurs, strychnine must be used freely, its * " It is very probable that the action of the muscular fibers iu the intestines and spleen, nnd the contractility of the vena porta, the hepatic artery, and veins, are necessary to the regular circulation of the organ, and that derangement of these motions may lead to stases." — Jaccoud, 11 Pathologie interne," 2d edition, tome ii, p. 395. 184: ELEMENTS OF THERAPEUTICS AND PRACTICE, effect being aided by hydrotherapy, especially in the form of cold douches. The dominant treatment must be re-enforced by that of the variant, according to the etiological indications. The stases which result from a suppression of the discharge to which the system had become accustomed, or which were indispensable for the performance of its various functions, can be readily combated by aconitine and ergotine, the first having the effect of a bloodletting, the second acting upon muscular contractility, and thus relieving the abnormal pressure in the hepatic canals. One granule of aconi- tine and three of ergotine may be used every two hours. Habitual constipation may be both a cause and an effect of congestion of the liver ; whichever its character may be, it is well to treat it with three granules of podo- phyllin and two of hyoscyamine, night and morning, together with a sufficient quantity of Sedlitz Chan- teaud. Sedentary habits of life, acting somewhat like paralysis, by requiring very little muscular activity, are also a frequent cause of congestion of the liver. The best cure for this condition, when it arises from such a cause, is an active life, exercise in walking and riding, sponge baths, and a spare diet. From the foregoing observations it will be evident that the treatment of this condition is not so simple as the masters in classical therapeutics have described it. The alkalies which are advised by them in almost all cases can only be of assistance by rendering the blood less dense, and thus facilitating its progress through the vessels. This advantage is counterbalanced by the inevitable tendency of the alkalies to destroy a great number of the red corpuscles, to increase or to produce ansemia, which is developed by the nervous debility which gives rise to passive congestion, and thus to in- close the disease in a vicious circle, from which there is no relief but the adoption of a different line of treat- ment. The diseases which the allopathic practice pro- duces, and the paternity of which it ingenuously ad- ELEMENTS OF DOSIMETRIC PRACTICE. 185 mits, by giving them sonorous and elegant names, give us a proof that forces which are out of equilibrium are not to be overcome or restored by the application of material influences. Anaemia from the use of alkalies is an artificial disease which is produced by allopathy, a hybrid product of science and blindness. CONGESTION OF THE LIVER. Dominant. Variant. Dominant. Variant, 1st. Mechanical. Want of heart-force for organic disturbances .... f" Dyspnoea owing to excessive size J of the liver .... Ascites 2d. Active. Paralysis of the muscular fibers of the vessels, of those of the capsule of Glisson, and of the abdominal muscles . > Fever .... Hepatic pain Anorexia . symptomatic. J Tenesmus . Constipation Variant, causal. Dominant. Variant, causal. Icterus > Irritating food . Elevated temperature Suppression of perspiration I Malarial infection I Syphilitic infection 3d. Passive. ( Paralysis of the muscles which ■< can influence the circulation ( of the liver .... ' Suppression of customary dis- charges Constipation t Sedentary life j Digitaline, sulphate of } strychnine. j Podophyllin, jalapine, j Sedlitz Chanteaud. ] Asparagine, caffeine, I colchicine. Sulphate of strychnine. Aconitine. Codeine. Quassine. Hyoscyamine. Sedlitz Chanteaud. Arseniate of soda. Diet. Aconitine. Nitrate of pilocarpine. Arseniate of quinine. Calomel. / Sulphate of strychnine. f Hydrotherapy. Aconitine. Podophyllin. Sedlitz. Exercise. Congestion and CEdenia of the Lungs. — Con- gestion of the lungs may be either active or passive. The first, or fluxion, may be irritative, when the agent which produces it acts upon the pulmonary tissue itself ; reflex, when it acts upon a distant point, whence the irritation is transmitted to the lung ; the result of want of equilibrium as to pressure, when the vessels are de- ficient as to the degree of external pressure which regu- 186 ELEMENTS OF THERAPEUTICS AND PRACTICE. lates their capacity ; the result of want of equilibrium in the circulation, when the intra-vascular pressure is increased on account of obstacles which are introduced into the circulation. Aconitine is the remedy which should be preferred, being administered with more or less constancy, accord- ing to the degree of the fluxion. One or two granules may be given every half-hour, or less frequently. Passive congestion results from the retardation of the blood in the pulmonary vessels. The stasis in this case is due either to an obstruction in the current or to weakness of the heart's systole. Two granules of digi- taline may be prescribed, two to four times daily. This will increase the energy of the heart, and make its movements more regular and effective. (Edema is due to the transudation of serum through the vessels, in consequence either of changes of pressure or of altera- tion in the constituents of the blood. The first of these causes proceeds from pulmonary lesions, the second from general diseases. Aside from the particular treat- ment of the original lesions, we may use five granules of podophyllin two or three times daily, with a tea- spoonful of Sedlitz Chanteaud for each dose of the podophyllin. Purgative and diuretic medication may be used alternately. Five granules of caffeine, given two or three times daily, will fill the latter indication, the object being to obtain not a violent but a mild ac- tion, which can be continued a long time without excit- ing intolerance. In all these cases there is a common and principal vital lesion — vaso-motor paralysis. However much the congestion may be due to irrita- tion or to stasis, to whatever degree the oedema may already exist, the vessels dilate because the vasocon- strictor nerves do not oppose sufficient resistance to the tendency to dilate. The true dominant indication is, therefore, strychnine, that reliable vital excitant and most faithful regulator of all the substances which act upon the organism. For the active congestions prefer- ELEMENTS OF DOSIMETRIC PRACTICE. 187 ence should be given to the arseniate or the sulphate of strychnine, two granules of each every two hours ; for the passive congestions two granules of the hypophos- phite, four or five times daily, will be appropriate. Pain is sometimes present, either before or during the period of congestion, and should be met with two gran- ules of the hydrobromate of morphine every quarter of an hour. Haemorrhage, which will often, apparently, abort the congestion, is almost always a symptom which is followed by bad results, even among those who are exempt from all traces of tuberculosis. It should al- ways be treated with ergo tine, three granules of which may be given every quarter of an hour. Dyspnoea calls for digitaline, to aid the heart in relieving itself of an excessive supply of blood ; one granule may be given every half-hour. Cough, which causes afflux of the blood and exaggerates the irritation, may be soothed by two granules of codeine every quarter of an hour. If a febrile movement should manifest itself, we may combine aconitine and digitaline, one granule of each every half -hour, repeating until the normal temperature is again reached. CONGESTION AND OEDEMA OF THE LUNGS. Active congestion Passive congestion (Edema Dominant, Irritative . Reflex From want of equilibrium in pressure From want of equilibrium in the circulation . From mechanical obstruc tions in the circulation From cardiac weakness j From local diseases . ( From general diseases Variant, Pain in the side Haemorrhage Dyspnoea . Cough Fever . Hyperemia . Aconitine. Atony Digitaline. Transudation ( ffl* of serum } Sedntz . Hydrobromate of morphine. Ergotine. Digitaline. Codeine. Aconitine. 188 ELEMENTS OF THERAPEUTICS AND PRACTICE. Congestion of the Uterus. — Active congestion or fluxion of the uterus frequently occurs at the period of puberty, in conditions of plethora, and with very irrita- ble women. It may be caused by prolonged continence, by excessive sexual indulgence, by masturbation, by emmenagogues, by suppression of the menses, and by colds. It almost always comes on suddenly, and is an- nounced by a feeling of heat and weight in the pelvis, the perinseum, and the sexual organs. It is sometimes accompanied by spasms or by uterine colic, due to con- tractions which have been excited by the excess of blood. The patient remains apyretic, and after a few days of rest and careful diet all the symptoms will as a rule disappear. If these congestions are neglected, an exaggerated condition is favored, and sooner or later there may be an acute or chronic metritis which can be attributed to no other cause. Uterine congestion depends, on the one hand, upon an accumulation of blood in the organ ; on the other, upon a too distensible condition of the walls of the uterine vessels. Aconitine and ergotine are the agents which will restore the uterus to a normal condition ; one granule of aconitine and two to four of ergotine being given every two hours. At other times the condition seems to be caused by a spasmodic condition, which is op- posed to the free passage of the blood. This is what occurs in congestions which follow violent disturbances of a moral character. One granule of hyoscyamine every two hours will quickly restore the physiological equilibrium. Uterine colic, which is sometimes extremely violent, has the same cause, and calls for similar though more active treatment, one granule of hyoscyamine or of valerianate of atropine being required every half -hour until an effect is produced. ELEMENTS OF DOSIMETRIC PRACTICE. 189 Together with the uterine congestion there may be a similar condition of the bladder, and the frequent de- sires to micturate which are symptomatic of it may be relieved by two or three granules of the bromide of camphor every hour. After the congestion has disap- peared we should give for a long time, in gradually de- creasing doses, ergotine or sulphate of strychnine, to give tone to the organ and ward off a repetition of the hyperemia — two granules may be given three to five times daily. CONGESTION OF THE UTERUS. r\^,^r . ™, ( Hyperemia Aconitine. Dominant, -j M ^ cular atony Ergotine. I Spasms Hyoscyamine. Variant. < Colic Valerianate of atropine. ( Frequent micturition . . . Bromide of camphor. Constipation, — This is a symptom which occurs in several morbid conditions, and indicates different disturbances in the physiological condition of the in- testines according as it is caused by changes in their contents, or in the activity of their blood circulation, their innervation, their contractility, or in the secre- tions of the glands which open upon their inner surface. The hygienic regimen of an individual, and espe- cially the matter of diet, has a great bearing upon con- stipation in its various forms. A difference in the water that one drinks, a diminution in exercise, a moral impression, a change in the hygrometric condi- tion of the atmosphere — any of these is sufficient to dis- turb the regularity of the intestinal function. Constipation is of short duration if its causes are also transient. A discussion of the necessary plan of treatment for accidental constipation is not required, for the simple removal of its cause or the use of a small quantity of Sedlitz Chanteaud will relieve the difficulty. But, if the causes recur daily, and the constipation con- tinues a long time, we can not expect to get rid of the difficulty so easily. In such cases it becomes necessary to search carefully for the physiological element whose 190 ELEMENTS OF THERAPEUTICS AND PRACTICE. activity is perverted, that is, for tlie predominant morbid element, in order to obtain safe and durable results. The act of defecation depends upon different factors, the most essential of which are the presence of the fecal mass, an impressionable condition of the intes- tines, an impression transmitted to nervous centers, and the provocation of expulsive movements. In ad- dition it is necessary that the intestinal canal be not obstructed, and that it should be lubricated by the secretions of mucus and bile, so that the mass may be projected by the contractions of the intestines which are exerted upon it. The muscular fibers of the intes- tines are arranged in two layers, one of which is circular and the other longitudinal, the two layers acting forci- bly together in the peristaltic movements of the intes- tines. The circular fibers compress the contents of the intestinal tube and thus force them onward, but, if this constriction is exaggerated or is exerted beyond the usual point, spasm will result, the dominant indication for which will be hyoscyamine, daturine, or atropine, the regulating properties of which in certain forms of constipation have long been known. When the spasm ends, the longitudinal fibers again become predominant, and the physiological equilibrium, without which there can be no health, is again restored. One or two gran- ules of the before-mentioned alkaloids may be given twice daily for several weeks. After regularity of de- fecation has been established, it is necessary to con- tinue this line of treatment for some time, though in diminishing doses, to prevent a recurrence. Intestinal paralysis, on the other hand (as a cause of constipa- tion), demands the sulphate or the hypophosphite of strychnine, in doses of two or three granules, three times daily. In other cases, the main cause of the coprostasis is to be found in the circulation. There is, perhaps, a chronic hyperemia, which by its influence upon contractility, upon the secretions, or upon the resorption of the intestinal fluids, modifies in different ELEMENTS OF DOSIMETRIC PRACTICE. 191 ways the movement or the composition of the fecal mass. There may be various causes for this hyperemia. It may be due to a want of physical exercise, to irritat- ing elements, or to compression of the abdominal organs, etc. The dominant treatment will consist in the use of two granules of aconitine two or three times daily, and in the removal, at least so far as possible, of the excit- ing causes. The fecal mass may also be retained in the intestine on account of insufficient lubrication. A diminution in the quantity of bile and intestinal mucus secreted always produces coprostasis. To increase the flow of bile we use cholagogues, among which podo- phyllin is especially serviceable. The action of podo- phyllin, as used by dosimetrists, is always mild, and patients are never annoyed by the griping pains which many practitioners ascribe to it, as an inevitable con- comitant. The difference in effect may depend upon the purity or impurity of the drug. As a regulator it may be given in doses of three to five granules every evening ; as a purgative, in doses of three granules every half -hour, until three or four doses have been given. The full effect of this medicine may not be experienced for twelve to twenty-four hours. A more rapid and profound result may be obtained by combining with it small doses of Sedlitz Chanteaud. Sedlitz Chanteaud is of itself an excellent laxative, which may be used every day without causing either pain or exhaustion. As its taste is slightly disagree- able, it is well to combine with it an equal weight of sugar. For those persons who are subject to constipa- tion on account of a want of exercise, or on account of the water which they drink, or on account of improper alimentation, the Sedlitz will be the best remedy. A suitable dose is a teaspoonful with a teaspoonful of sugar, in half a glass of water, night and morning. A few swallows of water may be taken after this draught, which may be taken with relish and profit for a long time. 192 ELEMENTS OF THERAPEUTICS AND PRACTICE. An imitation of this salt is on the market, but it is nauseating to the taste on account of the impurities which it contains. If one is to use this salt systematic- ally, it is better to buy it in the original bottles, and thus be sure of obtaining the genuine. When con- stipation is complicated with other troubles, the Sedlitz may be combined with agents which are suitable for the complications ; thus we may avoid increasing the doses of the Sedlitz. The deficiency in the supply of bile may be corrected by the use of three granules of colchicine every evening, or by ten granules of euony- mine, or by ten granules of iridine. The deficiency of mucus, which is indicated by hardness of the faeces, and their division into scybalce, calls for two or three granules of veratrine half an hour before each meal. Jalapine, elaterine, and hydrastine are excito-motors of the muscular coats, and excite the secretion of bile. They may be used as substitutes for podophyllin, iri- dine, or colocynthine, in doses of three to ten granules, from one to three times daily. Those agents which excite the secretions should be given in such a manner as not to exhaust the organs upon which they are to act, nor to make them a necessity for those organs. The doses should be graduated in accordance with their effects, the objects being that the system should suffer neither from excess nor from deficiency in the use of these drugs. Skill on the part of the clinician consists in requiring only what is necessary, and in not termi- nating a course of medication too early or too abruptly. In the treatment of chronic diseases, since the effect of medication is not so evident as in acute ones, we must rely upon time and perseverance in place of the activity and energy by which the treatment of acute diseases is characterized. It is also worthy of note that it is more difficult to retain results in chronic diseases than it is to acquire them, and this difficulty is mainly due to a want of patience on the part of the sick person, or of perseverance on the part of the physician, both trusting ELEMENTS OF DOSIMETRIC PRACTICE. 193 too much to fortune, which rewards tenacity of purpose rather than audacity. After the fecal mass has reached the large intestine, its presence excites contractions in different groups of muscular fibers which concur in the act of defecation. If the mucous membrane is de- ficient in sensitiveness, no impression is communicated to the nervous centers, and the faeces accumulate with- out a consciousness on the part of the patient that they should be evacuated. Inertia of the rectum leads to the same result. Palliative means of treatment for this condition consist in the use of rectal enemata of cold water, and removal of the scybalous masses with the finger. Curative means are furnished by the hypo- phosphite of strychnine and phosphoric acid, two gran- ules of each three or four times daily, or by electricity. In cases of inertia, Hve granules of bryonine or of colocynthine may be given two or three times daily. If the diet is composed of such food as leaves little residue after digestion, the evacuations will be less fre- quent and less abundant. In such cases there is no real constipation, for there is no retention of material. The remedy consists in giving a different kind of food. In no case is it well to leave the intestinal secretions in the digestive canal for a very long time, because, aside from other inconveniences, it is indispensable to health to keep the passages for elimination and absorption free and unobstructed. This end may be accomplished by using Sedlitz Chanteaud every other day. Copro- stasis which is caused by mechanical obstacles to the passage of the fecal mass will be considered under the head of intestinal occlusion. Whatever the pathogenic cause of constipation, there are certain symptoms which frequently accompany it, and may call for special treat- ment. The variant requires active means in this as in all cases, while the dominant requires means which can be used for a long time without danger ; it may be necessary to vary the dosage, or even to substitute its succedanea, but the indication continues constant. 13 194 ELEMENTS OF THERAPEUTICS AND PRACTICE. Headache, which is present in some cases whenever there is the least irregularity in the intestinal func- tions, may be treated with two granules of guaranine every half -hour, or by one granule of aconitine, if there are signs of cerebral congestion, every half -hour, or less frequently, according to circumstances. Two granules of caffeine may be given every quarter of an hour for the vertigo. Want of appetite and gastric catarrh, which frequently occur in connection with habitual constipation, may be treated with two granules of quas- sine every three hours, or four granules of col ocyn thine night and morning. Lumbar pains, which are indica- tive of congestion of a particular character, may be treated by one granule of aconitine every two hours. Eructations, which occur when there is intestinal pa- resis, will quickly be controlled by three granules of brucine or two of sulphate of strychnine three to four times daily. Colic may be soothed with one granule of hyoscyamine every half-hour, or two of gelsemine every quarter of an hour. Spasm Paralysis Hyperemia . Deficient secretion /Dominant. atropine, of mucus of bile Anaesthesia Torpor Mechanical obstacles 1 Headache Vertigo . Want of appetite . Lumbar pains Eructations . Colic j Hyoscyamine, \ daturine. ] Sulphate and hypophos- \ phite of strychnine. Aconitine. Podophyllin. Veratrine. Rectal enemata.bryonine, colocynthine. Proper diet, Sedlitz Chan- teaud. j (Under Intestinal Occlu- ( sion.) Guaranine, aconitine. Citrate of caffeine. Quassine, jalapine. Aconitine. Brucine, strychnine. Gelsemine. Coryza. — See Rhinitis. Croup,— See Diphtheria. Cystitis. — Inflammation of the bladder may arise from different causes. At one time it may be caused by cold or by traumatism, including in the latter term ELEMENTS OF DOSIMETRIC PRACTICE. 195 difficult parturition and maladroit catheterization ; at another by the extension of an inflammation in neigh- boring or contiguous organs ; at another by direct irri- tation of the mucous membrane from contact with a foreign body, or with urine which contains an irritating substance which has been eliminated by the kidneys, or is due to decomposition of the urine itself. In the greater number of cases of acute cystitis a cure results from the suppression of their cause ; but the disease not infrequently becomes chronic, and the effect per- sists after the cause has disappeared. In the treatment of simple acute catarrhal cystitis aconitine should be the dominant. As long as the symptoms indicate in- flammation of the vesical mucous membrane, whether there be an accompanying febrile condition or not, we should use aconitine at longer or shorter intervals, ac- cording to the severity of the inflammation. One gran- ule may be given every quarter of an hour, every hour, or every two hours, until the desired result is obtained. The temperature in some cases reaches 40° C. If there are decided intermissions, either in the fever or in the other symptoms, twenty granules of hydrobromate of quinine may be given every two hours. Acute cystitis is always accompanied by pain, which is more or less severe in character. At times it is localized in the hypogastrium, at others it radiates to the perinseum, the testicles, etc. If much suffering is experienced, two granules of cicutine may be given every hour until the pain is relieved. Tenesmus, which is sometimes unendurable, may be treated with one granule of hyos- cyamine every half -hour until micturition becomes less frequent, or until the physiological effect is produced. Hyperesthesia of the mucous membrane, which causes the urine to produce a scalding sensation and compels one to empty the bladder frequently, may be relieved with three granules of the monobromide of camphor every half -hour. Sedlitz Chanteaud should be taken freely, not only 196 ELEMENTS OF THERAPEUTICS AND PRACTICE. for the purpose of keeping the bowels freely open, but also to alkalinize the urine. If the sphincter is con- tracted to such a degree as to prevent free discharge of the urine, retention may result, which in some cases will require surgical attention. These means should never be employed except in cases of great urgency, and only after the use of such alkaloids as hyoscya- mine, daturine, and atropine, which will tend to dilate the sphincters. Retention, by exaggerating the dilata- tion of the bladder, may produce paralysis of its mus- cular coats, in which case the administration of the sulphate of strychnine will be required to restore vital- ity to the contractile elements. One granule may be given every half -hour, and hyoscyamine may be com- bined with it if the circular fibers show an exaggerated tonicity. Chronic cystitis is singularly rebellious to all means of treatment, hence the necessity is apparent of treating the inflammation in its early stages, modifying the character of the urine, and manifesting such energy as will cause a disappearance of the given lesions. The increase in the secretion of mucus by the bladder should be treated with two to four granules of arbutine four times daily, and five granules of the benzoate of soda four times daily. The use of revulsives, especially those of a caustic character, is not always attended with good results. If there is suppuration, two granules each of iodoform and arseniate of soda may be given three or four times daily, and the bladder may also be washed out either with simple warm water or weak so- lutions of nitrate of silver, tannin, etc. A catheter which will admit of a double current must be used, and the injection must be made with great care, to avoid dilating the bladder. If the products of ammoniacal decomposition of the urine are being absorbed through a more or less ulcerated mucous membrane, Sedlitz Chanteaud or some other saline laxative must be given, and means must be taken for prompt removal of the ammoniacal urine and careful cleansing of the bladder. ELEMENTS OF DOSIMETRIC PRACTICE. 197 Septicaemia resulting from decomposition of diseased tissues will also require the use of the same surgical means as the foregoing, while internally two granules of salicylate of quinine and salicylate of ammonia may be given every hour. Cantharidal cystitis, which- re- sults from the prolonged application of cantharidal vesicants, may be relieved by hyoscyamine and the bromide of camphor. Cystitis of rheumatic origin should be treated with colchicine. The paralytic form of cystitis, occurring in the aged, should be treated with three granules each of quassine and hypophosphite of strychnine at each meal. Alkaline and sulphurous mineral waters may be useful in all cases of chronic cystitis. Careful diet, frequent evacuation of the blad- der, and abstinence from alcoholic drinks and from irritating food are prescriptions which the physician should never fail to give, and the patient to follow in all cases of this disease. m Dominant. / Acute cystitis j Inflammatory ele- \ ment . / Fever . Periodicity . Radiating pains . Tenesmus Hyperesthesia Constipation . > Paralysis Rheumatic element Cantharidal elimi- nation Catarrhal secretion Purulent discharge Ammoniaemia Chronic cystitis { Septicaemia Paralysis Aconitine. Aconitine. Hydrobromate of quinine. Cicutine. Hyoscyamine. Bromide of camphor. Sedlitz Chanteaud. Hypophosphite of strych- nine. Colchicine. Hyoscyamine. Arbutine, benzoates. Iodoform,arseniate of soda. Saline purgatives. Salicylates of quinine and of ammonia. Quassine, hypophosphite of strychnine. Hydrotherapy. Cysts (Hydatid, of the Liver).— From the eggs of Tcenia ecMnococcus are produced cysticerci, which find a lodgment in different organs, but especially in the liver, where they multiply and form cysts which sometimes reach an enormous size. These cysts give 198 ELEMENTS OF THERAPEUTICS AND PRACTICE. rise to various troubles, and frequently cause death, either by opening into important organs, by causing purulent infection, or as a result of the haematopoietic disorders which are inseparable from disturbances in the functions of the liver. As a means of prophylaxis, one should not drink river- water, nor water which is likely to have flowed over or drained through fields in which animals which are subject to taenia have been kept. Boiled water is free from all danger of produc- ing this condition. Surgical treatment is almost always required, whether one operates by aspiration, by means of large openings, with injections of a one-per-cent so- lution of hydrate of chloral, or by electrolysis. But, whatever procedure be adopted, medical treatment should be tried to accomplish, if possible, the absorp- tion of the contents of the cyst, which is considered a lesser evil than the long period of suppuration which will follow either of the operations suggested. In the first place, iodoform should be given in doses of four to eight granules three times daily. , If the result of this treatment proves unsatisfactory, we should operate, opening the cyst with a large trocar, and completely evacuating it. Frequent injections should subsequent- ly be made, and a drainage-tube should be left in the wound. Surgical treatment should be attended with antiseptic precautions, and subsequent treatment should be tonic and antipyogenic, two granules each of iodo- form and of arseniate of soda being given three or four times daily, and two or three granules of arseniate of strychnine with each meal. Should fever follow the operation, one granule each of aconitine and arseniate of quinine should be given every half-hour until the fever abates. For other indications as to treatment, any of the classical works on therapeutics may be con- sulted. Delirium Tremens.— Life is, without doubt, the result of the struggle between stimulant agencies — either from without, and received by the peripheral ELEMENTS OF DOSIMETRIC PRACTICE. 199 ends of the nerves, or from within, and received by the nervous centers and the splanchnic radiations ; and, on the other hand, individual impressionability, which re- sults from the impressionability peculiar to each ana^ tomical element. Life depends, therefore, upon the external and internal media appertaining to the indi- vidual, and upon his somatic constitution, which is animated ab ovo by a special force which is called vital force. Differences in life will result, therefore, per- haps from modifications in its media, perhaps from changes in impressionability, perhaps from both these causes combined. Gradual intoxications have only the effect of modifying the material constitution of the in- dividual by causing assimilation of substances foreign to its normal composition ; they also change the consti- tution of the blood, that internal medium, the troubles of which have much more importance than bad exter- nal conditions. They thus give origin to impressiona- bility of a new character, for the elements, being com- pelled to live in a modified medium, end by adapting themselves to that medium, in which their reactions are different from what they were originally. For a long time this adaptation will preserve the vital equi- librium, with all the appearances of health ; but, if the new stimulant to which the system has become habitu- ated suddenly fails, the entire equilibrium will be de- stroyed, because the adaptations are slow and progres- sive, and the vital acts can not be accomplished with the regularity and perfection which is observed in the case of individuals who are in a normal physiological condition. In a word, the organism accustomed to the exceptional finds itself in the presence of the regular, and in unusual conditions which disturb it profoundly. Such is the course of events in connection with alcohol- ism. Not only does the alcohol modify the tissues physically and chemically, it also modifies the blood- current, and mingles with the secretions, thus acting in a double manner upon impressionability. In fact, the 200 ELEMENTS OF THERAPEUTICS AND PRACTICE. sensibility, contractility, and irritability of alcohol- users are no longer the same as before their excesses began, and for that reason physiology, pathology, and therapeutics, as applied to such cases, are entirely dif- ferent from their application to sober and temperate people. In other respects the lesions which one finds in alcoholics are the same as those which are observed in pathological states due to other cause, and having the same anatomical situation. The treatment will therefore be the treatment which is proper for such lesions, aside from the removal of the cause. But it is not the same for functional lesions, the most of which are peculiar to alcoholism, and demand peculiar treat- ment. The functional perturbations arise from changes in the physiological condition, as has been already ex- plained, and neither require a long time nor are diffi- cult to cure, if one understands the treatment which should be adopted. It must be clearly understood that the least change in this artificial physiological con- dition necessitates decided disturbance of equilibrium, and may even be the cause of death, without the mani- festation of sufficient cause, from such a source, to ex- plain it. Sufficient cause for a sudden and unexpected attack of delirium tremens may be found in an increase in the elimination or a decrease in the dose of alcohol, in an exaggeration with respect to its combustion, an exaltation in the impressionability of the individual — in fact, in a cause which might, under ordinary circum- stances, seem insignificant. The duration of such an attack will depend upon the manner in which it is treated, and the different causative elements. All the causes which lead to want of equilibrium in such cases may, however, be reduced to two : diminution or increase of the habitual stimulant relatively to the impressiona- bility of the patient. These two modes of pathogenesis must be held in mind in arranging a plan of treatment, and one must be carefully distinguished from the other, the more because the problem of treatment is almost ELEMENTS OF DOSIMETRIC PRACTICE. 201 always complicated. We should therefore consult the impressionability of the patient, incite it when de- pressed, or soothe it when exalted. Whatever be the customary dose of the stimulant, we must suppress it, for it is preferable to seek to restore the equilibrium by acting upon the vitality. If the absence of the stimu- lant causes disorder in the functions, we must use incit- ants ; if, on the other hand, the trouble is due to exces- sive use of the stimulant, we must restore calmness, either by inciting antagonistic functions or by weaken- ing synergical functions. Life being a struggle, a con- flict, the resultant of opposed and antagonistic forces, there are in all diseases two means of restoring the equilibrium of health : one, a direct method, consisting in an attempt to correct the disturbed functions imme- diately ; the other, an indirect one, by acting upon the functions which moderate or regulate the first. The form of treatment which is most in vogue for deli- rium tremens is that which was suggested by Jac- coud, and consists in the use of alcohol. If the attack is produced by the want of the habitual stimulant, or of any other stimulant which, with the habitual one, will establish the functional equi- librium, the results of this treatment are prompt and admirable. But if the quantity of the stimulant consumed is in excess, or, the dose of the stimulant remaining the same, the impressionability is exalted, alcohol as a means of treatment will do harm, and we should use in preference such calmatives as digitaline, aconitine, hyoscyamine, morphine, chloral, etc. But alcohol, even in cases in which good results may be expected, on account of its previous disuse as a stimu- lant, is a bad remedy, because it tends to perpetuate chronic alcoholism, and may cause the repetition of acute paroxysms. Besides, it has the great disadvan- tage of being opposed to reformatory steps on the part of the patient, for, if alcohol serves to cure alcoholism, it ought to be still more useful as a means of prevent- 202 ELEMENTS OF THERAPEUTICS AND PRACTICE. ing it. With such treatment the patient has no oppor- tunity to cure himself of his bad habits, and be enabled to live without using alcohol. JSfo thing can equal strychnine in the treatment of this condition. Aside from the fact that it is superior to alcohol as an incit- ant, it also gives better results. It was first recom- mended by Falck Wunderlich and then by Luton. Recently it has been used with considerable audacity by Lardier, who seems to have borrowed his method of administration from the dosimetric system. He has obtained the best results without running any risk. The doses should be very large, and should be repeated at short intervals. Three to five granules at a dose may be given every half -hour or hour until an effect is pro- duced upon the insomnia and the condition of the pupils. Strychnine is not suitable for all cases, how- ever, and should not be administered alone. Often, in place of cerebral asthenia, one meets with a hyper- sthenic condition in delirium tremens, or these two conditions may co- exist in different parts of the nerv- ous system — a condition which requires the use of hyoscy amine until the physiological effect is indicated by the condition of the pupils and pulse. The follow- ing case demonstrates the fact that we must not use the same remedy for all cases, nor even for all phases of the disease in the same individual : F was sud- denly stricken in the street with apoplexy, and was borne to his house in an unconscious condition. He revived after a short time, but was excessively agitated, delirious, and wakeful ; his countenance was red, his pupils were dilated, his pulse full. Three granules of arseniate of strychnine hourly were prescribed until he should become quiet or go to sleep. The next day he was much more tranquil ; he had slept well, and his pupils were normal in appearance, but his delirium, though less intense, continued. The strychnine was persisted in on account of the previous good results. His next night was a bad one, and on the following ELEMENTS OF DOSIMETRIC PRACTICE. 203 morning his delirium was more intense, and had changed its character ; the pupils were excessively con- tracted, the pulse was hard, and the countenance pale. Under these circumstances, hyoscyamine was substi- tuted for the strychnine. One granule every three hours restored the patient in twenty-four hours, excepting a general weakness, which lasted a long time, and which was due to the want of alcohol, from which the patient abstained as long as he was confined to his bed. He was thus under the best conditions for recovery, for abstinence for a month is sufficient for one of good will- power to overcome a habit which is as blameworthy as it is harmful. gg/Do— \*ssst of the O !=! I / Want of stimulant . . . Strychnine. Increase of impressionability . Hyoscyamine. Sthenic condition of the circula- ) -n- -, i- „„ •■• „ , • - Digitalme, aconitine. 3« Variant. / Insomnia from want of stimu- / "Mornhine lant < Insomnia from excess of stimu- ) lant or increase of impression- V Codeine, narceine. ability ) Dermatoses. — The study of diseases of the skin ought to be placed upon new foundations. All the classifications which have thus far been presented have the fault of overlooking the vital nature of the different lesions, and attributing importance only to organic lesions, those which are apparent and su- perficial. This fault is especially perceptible in its application to the subject of treatment. The Vienna school goes even further, and pretends to isolate the affected portion from the rest of the organism, but the facts do not cease to protest against this localism. The result of these artificial classifications, which attach to themselves scarcely any of the important elements of the diseases, is to reduce the therapeutics of this de- partment to a chaos of empirical formulas and remedies, to apply to the same lesions different preparations, the pharmacodynamics of which often differs, and is some- 204: ELEMENTS OF THERAPEUTICS AND PRACTICE. times antagonistic, and to prescribe almost always the same treatment for all diseases. Cutaneous diseases ought to be divided into two great classes, leaving aside those in which the eruption is only a secondary symptom of a general disease — for example, the eruptive fevers, purpura, etc. The first group includes diseases which consist in the irritation of the cutaneous tissues pro- duced by the presence of parasites, as in scabies, favus, etc. The second should include those which proceed from a lesion of the vitality — that is, from a fault in the innervation, whether of excess or perversion. These functional troubles lead to disorders of nutrition and circulation, which in their turn cause organic difficul- ties, which are manifested externally by the different dermatoses. Modifications of the secretions, which are the essential features of the diatheses, cause dynamic troubles in the nervous expansions, which are trans- formed into lesions which are localized in the regions where a supplementary cause of irritation exists, or some difference in vitality limited to a small number of nerve filaments. The dominant in the dermatoses should vary, therefore, with the dynamic cause which produces it. If the irritation is caused by parasites, we must eliminate the cause with sulphide of calcium and the most appropriate local treatment ; if the trouble arises from a want of innervation, we must give strych- nine and phosphoric acid ; if, on the other hand, the irritation reveals an exaggeration of the phenomena of nutrition, we should give aconitine or vera trine. For the diathetic dermatoses, the treatment which is fun- damental for each diathesis is proper — that is, mercury for syphilitic, the arseniates for the herpetic, colchicine for the arthritic, iodoform or sulphide of calcium for the scrofulous. In the treatment of diseases of the skin, we should be less influenced by the outward form of the lesions than by the principal morbid element which characterizes them. In eczema, in many cases of acne, in herpes, sycosis, etc., that which excites at- ELEMENTS OF DOSIMETRIC PRACTICE. 205 tention is the congested condition, the phlogosis of the skin. Eight to twelve granules of veratrine daily will be found effective in these cases, because by its de- pressant action it destroys the principal morbid ele- ment of the disease. In the active forms of hyperemia, like erythema, etc., aconitine will prove effective on account of its ansemiating properties. Two granules may be given for this purpose three or four times daily. Pemphigus, rupia, and ecthyma, which are the outward evidences of great vital depression, call for the use of the arseniate of iron and the hypophosphite of strych- nine. Two granules of each may be given four times daily. Those affections which are characterized by dryness of the skin, especially the squamous affections like psoriasis, icthyosis, etc., indicate defective nutri- tion in the epithelial tissue, which may be corrected by the arseniates, and especially by arsenious acid, six to ten granules of which may be given daily. Those diseases which are accompanied by pruritus or neuralgia, like zona and prurigo, should be treated by calmative agents to the nervous system, especially by cicutine, two gran- ules of which may be given four or five times daily. The method of treatment will be governed by the time that the disease has lasted, or, in other w^ords, by the degree of resistance which is opposed to the remedies used. Thus, an exudative eczema which has lasted only a few days can be cut short by active treatment with veratrine, one granule of which should be given every quarter of an hour, while the dry forms of eczema will be controlled by sulphide of calcium, one granule being required every half-hour. The activity with which medication is carried out has a decided bearing upon the duration of a disease of this kind. Timid treatment serves only to prolong the disease indefinite- ly, and compels the physician to be constantly chang- ing his remedies w T ith no advantage to any one. A re- cently observed case has convinced the author of the necessity of observing these principles, which are the 206 ELEMENTS OF THERAPEUTICS AND PRACTICE. exact principles of dosimetry. The case was that of a child fourteen months old, who was suffering with eczema of the face, for which six granules of sulphide of calcium daily had been ordered. At the end of three weeks there had only been slight improvement. At that time the child was attacked with croup, for which one granule of sulphide of calcium was ordered hourly, this being continued for two days. At the end of that period the eczema had entirely disappeared. Thus two days of active treatment produced more effect than the previous three weeks of insufficient dosage. It is neces- sary to avoid gastric intolerance, and all other bad re- sults which would compel us to interrupt the treat- ment ; but we should not hesitate to give doses which are sufficiently large, because in this way much time will be gained, and many complications and annoy- ances may be avoided. The local treatment should amount to very little. It may consist of simple baths, to assist in removing the exudate ; of pure vaseline, to prevent contact with the air and the deposit of sub- stances which are suspended in the air ; of starch, on account of its absorbing and refreshing qualities ; of vaseline and calomel, or precipitated sulphur (ten per cent), for parasites which are accessible by external means. The use of irritating substances must be rigidly avoided, at least in those forms in which they produce active irritation. f Parasites I Herpetic diathesis 'Dominant. \ Syphilis . Arthritic diathesis Scrofula Hyperaemia . Phlogosis Atony . Anaemia \ Variant. ( Pains Pruritus Epithelial hyperpl \ Ulcerations . Sulphide of calcium. Arseniate of soda. Biniodide of mercury. Colchicine. Iodoform. Aconitine. Veratrine. Strychnine. Arseniate of iron. Cicutine, morphine. Gelsemine, hydrobromate of cicutine. Arsenious acid. Hypophosphite of strychnine. Phosphoric acid. ELEMENTS OF DOSIMETRIC PRACTICE. 207 Diabetes. — More than fifty theories have been ad- vanced to explain the pathogenesis of diabetes, which is equivalent to saying that there are at least fifty causes for it. This superfluity of hypotheses also indi- cates our ignorance as to the exact nature of glycosuria, and the mechanism by which one passes from health to diabetes. The theories which are based upon experi- mental physiology and pathology are not relevant to the question, for it is impossible to compare artificial glycosuria with diabetes, just as one can draw no con- clusions from albuminuria in respect to Bright' s disease. In every case glycosuria is unquestionably a constitu- tional disease, characterized essentially by a grave dis- turbance of the nutritive functions which will not lend themselves for the assimilation of glucose, or else trans- form into glucose the principal elements of the organ- ism. The nervous system, which presides over acts of nutrition, preponderates among the agents which inter- vene to produce diabetes, and the efforts of therapeu- tics should converge mainly in the direction of trophic innervation. Want of equilibrium in the nutritive functions should be corrected in three ways : (1) by furnishing to the blood all the materials capable of im- proving its constitution ; (2) by exciting, through the influence of the nervous system, the functions of assimi- lation ; (3) by stimulating the digestive functions to activity, in such manner as to furnish for assimilation an abundance of well-elaborated material. The first indication should be filled with the arseniates of soda, potassium, and iron, two or three granules of each being given three times daily ; the second, with the arseniate of strychnine and phosphoric acid, two gran- ules being given three times daily ; and the third, by quassine and pepsin, two to three granules with each meal. Saccharine and starchy articles of food should be abstained from as far as possible, so as to avoid aggravating the kidneys by the frequent passage of a thickened and abnormal urine. But to completely 208 ELEMENTS OF THERAPEUTICS AND PRACTICE. abandon starchy foods in order that by this means the patient may excrete less sugar, to run the risk of gravely disturbing the digestive functions and thus rapidly weaken the patient, a thing which is to be stu- diously avoided in all chronic diseases, but especially in those which quickly affect the nutrition, appears to the author to be a serious mistake, a confounding of glycosuria with diabetes, and a vain attempt to cure a disease by diminishing the intensity of a single one of its symptoms. It is like attempting to cure a cirrhosis of the liver by diminishing the quantity of fluids in- gested, and thus expecting to relieve the ascites. It is believed that many cases of diabetes get well spontane- ously, and also that the facility and frequency with which we discoyer glycosuria by examination of the urine have had the singular result of diminishing the gravity of the prognosis, and of attributing to hygienic treatment an efficiency which it does not really possess. In the days when diabetes was recognized only at a peri- od in which the condition was a very bad one, recoveries never occurred ; now, when one finds it in individuals who present every appearance of health, the disease is considered curable, and this fortunate result is attrib- uted to the suspension of glycogenic substances. When the patient can no longer endure the rigid diet which is imposed upon him, an infraction of it does not seem to do him any harm. The glycosuria increases, it is true, in proportion to the quantity of sugar ingested, but the disease itself is not intensified thereby. Followers of the doctrines of Bouchardat ought for the same reasons to seek to cure diabetes by devoting their attention only to the relief of the polyuria, and to accomplish this they need only abolish water from the regimen. The patient would pass a much smaller quantity of urine, but the deprivation of fluids would only increase his sufferings. The variant in diabetes is unfortunately very limited. The complications are especially sec- ondary diseases which appear during the period of ELEMENTS OF DOSIMETRIC PRACTICE. 209 gravity, and consequently yield with difficulty to a symptomatic treatment. The polydipsia may be re- lieved by codeine, three to five granules being given between meals. The polyuria is correlative with the polydipsia ; the less the patient drinks the less he urinates, and the less also he suffers from the erup- tions which ordinarily involve the external genital organs in this disease. The polyphagia may be satis- fied as far as the digestive powers of the patient will permit. If the appetite is exceedingly voracious, we should use one to two granules of hyoscyamine two hours before each meal. Vomiting and diarrhoea should be treated, aside from precautions as to diet, by the hydrochlorate of morphine and brucine, two to three granules being given every three hours. For the constipation three to five granules of podophyllin should be given before retiring. Impotence rarely dis- appears until a favorable modification of the disease takes place. This is one of the symptoms for which the patient insists upon relief more earnestly than for any other, and should be treated with neurosthenics, espe- cially with the arseniate of strychnine, two or three granules being given three times daily. The cutaneous eruptions, furuncles, erysipelas, anthrax, etc., should be treated with two granules of sulphide of calcium every two hours, and during suppuration, by two granules each of iodoform and arseniate of sodium, three or four times daily. The visceral inflammations, the most frequent of which are bronchitis and pneu- monia, are always of grave significance, because they are frequently terminated by gangrene. The use of tonics should be insisted upon, especially the hypophos- phite of strychnine, and the antiseptics, the salicylates of ammonia and quinine, and iodoform — two granules of each may be given every hour. We should make care- ful inquiry with respect to the diatheses which have been able to beget this disease, for by recognizing them important therapeutic results may be obtained. The 14 210 ELEMENTS OF THERAPEUTICS AND PRACTICE. general diseases which most frequently give rise to glycosuria are syphilis, malaria, and arthritis. For the syphilitic infection we should give five to fifteen granules of the protiodide of mercury daily, watching their effects in order to avoid mercurial salivation, which would be most undesirable. Malarial poisoning should be treated with the arseniate and salicylate of quinine, and arsenious acid — five to ten granules of the first with two of the second being given two or three times daily. The arthritic diathesis, which is one of the most common of the predisposing causes, calls for colchicine and the arseniate of soda, two granules of each being given two or three times daily. f Impairment of nutrition ('Dominant. \ Depression of the nerv- ous system Dyspepsia . Glycosuria . Polyuria Polydipsia . Polyphagia . Constipation Diarrhoea Vomiting K Variant. ( Impotence . Visceral inflammations Gangrene Arthritic diathesis Malarial poisoning \Syphilis Arseniates of sodium, potassi- um, and iron. Arseniate of strychnine, phos- phoric acid. Quassine, pepsin. Benzoate and salicylate of am- monia. Codeine. Hyoscyamine. Podophyllin. Hydrochlorate of morphine. Arseniate of strychnine. Sulphide of calcium. Salicylates, iodoform. Colchicine, arseniate of sodium. Arseniate and salicylate of qui- nine. Protiodide of mercury. Diarrhoea. — This symptom, while it may be studied in all the diseases in which it is present, yet deserves particular attention, especially in relation to its causes. One of the most frequent causes is the imperfect elab- oration of the food, whether on account of excess as to its quantity or quality, or the accentuated influence of dyspeptic conditions. Want of food may also cause diarrhoea. Diarrhoea a crapula is cured by abstinence; diar- ELEMENTS OF DOSIMETRIC PRACTICE. 211 rhcea in consequence of dyspepsia calls for appropriate treatment, the basis of which should be pepsin, two or three granules four times daily. Sedlitz Chanteaud in small doses will regulate the intestinal functions, and cause the evacuation of any undigested material which the intestines may contain. In other cases the diarrhoea is due to an excess of bile. Sedlitz Chanteaud, or mild cholagogues, by exciting the liver to disgorgement, will diminish the flow of bile, and thus destroy the efficient cause of the diarrhoea. In such cases we should give two granules of hydras tine three or four times daily, or euonymine in similar quantities. One of the most com- mon causes of diarrhoea is vaso-motor paralysis, and the latter gives rise to this symptom in many diseases. A chill, a moral emotion, may be enough to excite it. This theory as to pathogenesis is confirmed by experi- mental physiology. If the nerves which are distributed to a limited portion of the intestine are cut, in a few hours this isolated portion will be filled with serum. Many varieties of congestion and inflammation have the same origin. In cases of simple paralysis of the nerves, one should give three granules of brucine every two hours, or two granules of the sulphate of strych- nine every two hours. Should the inflammatory ele- ment complicate the vaso-motor trouble, it would be proper to add a granule of aconitine every two hours. Three granules of morphine every two hours, or two of narceine every hour, will also be of service, if there is pain in connection with the diarrhoea. The diarrhoea! flow will be checked much more quickly if these two varieties of agents are combined. The passive conges- tions which are caused by interference with the portal circulation can be treated with less certainty of a cure on account of the permanence of the cause. The means which may be used with more confidence than any others are Sedlitz Chanteaud, to relieve the engorged mucous membrane, by exciting a serous discharge ; strychnine, to increase the vaso-motor tonicity ; and re- 212 ELEMENTS OF THERAPEUTICS AND PRACTICE. vulsives, which, may be frequently repeated. The latter means have frequently given excellent results, both in cases of this kind and also in cases of chronic diar- rhoea ; they may be applied over different portions of the abdomen. Vesicants and the actual cautery, in points or in transcurrent lines, will prove very valuable in many cases which have resisted other forms of medi- cation. These methods must be used with care and persistence, however, in order to obtain the desired results. The intestinal mucous membrane, which is also a very active organ of elimination, often suffers because this function is exaggerated or perverted, by reason of the nature of the substances which it is com- pelled to excrete. It is in this way that miasmatic infection produces diarrhoea, which can be effectively checked only by the use of sulphate of quinine, two granules of which may be given three or four times daily. The elimination of animal matter which has undergone decomposition and then absorption also takes place by way of the intestinal mucous membrane. For such a case one should prescribe three granules of the salicylate of quinine every two hours, for its anti- septic effects. The deterioration of the constituents of the blood, which gives rise to the various diatheses, is also the source of a similar elimination, which, by irri- tating the mucous membrane, also excites diarrhoea. The arthritic and the herpetic diatheses are the ones which most frequently give rise to this condition. In the herpetic diathesis we should give two granules of the arseniate of strychnine four times daily, and in the arthritic a similar quantity of the benzoate of soda. In all cases we should also give Sedlitz Chan- teaud, which, by facilitating the intestinal and renal elimination, will aid in restoring the secretions to their normal condition. Excessive peristaltic motion may also cause diarrhoea, by the hasty manner in which its contents are propelled through the intestine. For such cases one granule of hyoscy amine or sulphate of atro- ELEMENTS OF DOSIMETRIC PRACTICE. 213 pine, every three hours, may produce a cure after other means have failed, by regulating the contractile power. Diarrhoea may also be excited by the presence of para- sites. Such appears to be the origin of the form of diarrhoea which is prevalent in Cochin China. It is also sometimes seen as an apyretic disease among chil- dren, which fails to respond to ordinary treatment, but yields to santonine, five granules of which may be used three or four times daily. Diarrhoea in children, when it assumes the violent form known as cholera infantum, calls for energetic and immediate treatment, provided that the vital forces are not entirely prostrated, for in such a case all treatment would be useless. We need not hesitate to administer morphine to children, if the dosimetric system of treatment be followed. One half or one third of a granule may be given every two or three hours, until the therapeutic or physiological effect is obtained. After this effect has been produced, and in case the child becomes sleepy before the diarrhoea has been checked, we must seek to dissipate the nar- cotic effect by giving a granule of brucine or of tannic acid every three hours. The diarrhoea of nursing chil- dren is almost always dependent upon improper ali- mentation. Hygienic methods are the best, both for preventing the disease and its recurrence ; but any in- testinal derangement whatever in children of such a tender age must be checked at the beginning, for a dis- order which is apparently not severe may quickly lead to a fatal termination. The regular school of practice has an arsenal with a variety of instruments for the treatment of diarrhoea ; but the quantity of its arms is far from compensatory for their quality. Most of its successes are only apparent. The subnitrate of bis- muth, the pulverized preparations of lime, the absorb- ents in general, are limited to an absorbent action upon liquid exudations, which remain, on account of this change in the consistency, at the entrance of the large intestine. If the treatment be interrupted, supposing 214 ELEMENTS OF THERAPEUTICS AND PRACTICE. that a cure has not taken place spontaneously, the diarrhoea will reappear, because, in reality, it has never been cured. Remedies which do not act upon the vital- ity are always uncertain ones. Almost the same state- ments may be made concerning astringents. They act in two ways : chemically, by coagulating the albumen of the intestinal contents, which are thus made less fluid in consistency, and are more easily retained; vitally, by causing contraction of the tissues, the impression being communicated to the nervous centers, from which it is sent away transformed into an increase of tonicity. Unfortunately, tannic acid and substances which con- tain it can not be used for very long periods, because they modify the composition of the tissues and the se- cretions. The perchloride of iron has given the author excellent results in diarrhoea, and in cases, too, in which other remedies had been tried in vain, like tannin ; however, it should be used only in acute affections, for its prolonged use might do harm. The anexosmotics are of greater utility ; but we should give up the com- plex preparations of these substances which are on the market, as they contain inconstant quantities of the active substance, and include, in addition, other sub- stances which have an opposite action, or an action which offers some inconveniences. Thus, diascordium (of the Parisian Codex) not only varies on account of the uncertain composition of the opium which it con- tains, but also by the chemical combinations which the tannin of several of its component parts forms with its alkaloids. Laudanum, which includes such variable proportions of morphine, is measured by drops, the weight of which is also very uncertain. It is therefore not astonishing that so much fear is manifested in ad- ministering these drugs to young children, who are very sensitive, it is true, to the action of certain drugs, but who are governed, nevertheless, by the ordinary rules of vitality. Poisonous effects among them are attributed to differences in the doses of the active prin- ELEMENTS OF DOSIMETRIC PRACTICE. 215 ciple— differences which are perceptible to a less degree in large quantities of the remedy than in small ones. While the activity of morphine may be greater than of opium, it is far less dangerous to use such a substance, which is always identical and may always be measured with exactness, than another which varies constantly in its activity, and always leaves us uncertain whether we have given too much or not enough, for it is only by chance that we give just the necessary quantity of it. DIARRHCEA. From excess or bad quality j Food . . Pepsin. of substances ( Biliary matters Sedlitz Chanteaud. -T7- . , -. i I Nervous . . Brucine, strychnine. Vaso-motor troubles . . j Inflammatorv Aconitine, codeine. ( Sedlitz. From passive congestion . . . . -j Brucine. ( Revulsives. uti^v, +t,« i««*4-«««« f Miasmatic . . . Sulphate of quinine. ° <2i * mt ^ T J Decomposed . . Salicylate of quinine. asi&ssti-l r petic A -- teof strych ", ( Arthritic Benzoate of soda. J From exaggerated contractility . . . Ilyoscyamine. From parasites Santonine. Diphtheria (Diplitheritic Diseases, Croup, Pseudo- membranous Angina). — Diphtheria may arise in two ways : there may be a general infection of the organ- ism by the micrococcus of diphtheria, with subsequent localizations ; or the infection may be local primarily, two conditions presenting themselves — by the first, the disease remains more or less localized, the microbes failing to infect the entire organism, owing to the ab- sence of receptivity on the part of the organism ; by the second, receptivity exists or is subsequently estab- lished, and the local disease becomes general. The primary general infection is always the most dangerous, because the vitality of the entire economy is attacked ; the purely local infection may be consid- ered benign, because it gives us time to put the organ- ism in a state of defense against its general diffusion. In both cases the dominant consists in the modification 216 ELEMENTS OF THERAPEUTICS AND PRACTICE. of the organism in such a way that it shall be an un- suitable medium for the cultivation of micrococci. The general treatment is the most important, and for that reason we should not hesitate to administer the sul- phide of calcium upon the least suspicion of the inva- sion of the system by diphtheria. The excellence of the results will depend especially upon the opportune- ness and the energy of the treatment. Opportuneness will consist in attacking the disease as soon as it ap- pears ; energy will consist in the regular administra- tion of the proper doses until a result has been obtained. One granule of the sulphide of calcium every quarter of an hour, for infants ; or two at a dose for young children, given with regularity and perseverance until a positive result is obtained. This is the only way to neutralize the infection after it has been accomplished, or is about to be accomplished. When the patient begins to exhale sulphureted hydrogen, the medicine may be given once an hour for several hours ; after which, the symptoms of sulphuric saturation having diminished, the former dosage may be resumed. In giving this medicine to children the granules may be powdered, and then placed on the child's tongue with the fingers, or with the end of a spoon. Sometimes a little sugar or a little milk must also be given. Whatever be the method of adminis- tration, it will not usually be found difficult to give this drug to children. In doses of one granule every quarter of an hour it is very well tolerated for two or three days. The child may take nourishment, and may sleep, without interrupting the regularity of the treatment. But we should not fear to awaken him if necessary, for success depends upon regularity in the treatment. Whether diphtheria be localized in the pharynx, upon the mucous membrane of the bladder, or upon any portion of the tegumentary surface, the fundamental treatment should always be the same — the sulphide of calcium. It will sometimes happen ELEMENTS OF DOSIMETRIC PRACTICE. 217 that the infection may be so pronounced, or that medi- cal intervention may occur so late, that it will not be possible to save the patient. This is no reason for casting reproach npon the method of treatment, for no better result would have been attained by any other. We are indebted to Dr. Fontaine for the introduction of this excellent microbicide into dosimetric therapeu- tics. The clinical results of this treatment which have been obtained in all countries constantly tend to estab- lish the renown which the future has in store for him. False membranes being a center for diphtheritic mi- crobes, it is most important that they should be removed and destroyed, especially when the infection is no longer localized. Topical applications are of especial value for this purpose, and two are recommended, the properties of which are well established by the results of experi- ence. They are pure lemon-juice and a five-per-cent so- lution of lactic acid, and they are the only ones which it is proper to use. Repeated applications with these substances should be made at short intervals, by means of a forceps or a small sponge attached to a long rod. In croup and pseudo-membranous angina it is some- times necessary to give an emetic, in order to displace and expel the obstructing false membranes. Sulphide of calcium will tend to break them up, and the topical applications to dissolve them ; but, aside from this action, especially in croup, it is absolutely necessary in certain cases to excite vomiting in order to effect the complete expulsion of the membranes. This is only an exceptional means of treatment, however, and it would be bad practice to use it generally. In order that the emetics may have good effect the mem- branes must be partly detached from the tissues which they cover, otherwise the vomiting must be repeated, at the cost of great fatigue to the patient. If the emetic fails to produce vomiting the effect is even worse, for in that case, being absorbed, it tends to aggravate the collapse into which the patient has fallen. For an 218 ELEMENTS OF THERAPEUTICS AND PRACTICE. emetic, three granules of emetine, dissolved in a tea- spoonful of warm water, may be given every five min- utes until the desired result is obtained. To assist in producing the effect the palate may be tickled, or we may give, in addition, one granule of emetic, also at intervals of five minutes. These means should be used with great caution, and only in those cases in which their use is clearly indicated. Spasm of the muscles of the glottis is sometimes the principal cause of the dyspnoea. In such cases we should give half a granule or a granule of hyoscy amine every half-hour, regulating its administration by the state of the pupils — that is to say, suspending it when the iris is well dilated. Paralysis of the muscles of the glottis calls for one granule of brucine every hour, in the less acute cases, or every quarter of an hour, if a very prompt effect is desired. Adynamia, which may be so quickly established, especially if emetics have been injudiciously used, may be treated with one gran- ule of brucine every two hours. For children over three years of age arseniate of strychnine may be substituted for the brucine. When asphyxia is imminent, as a last resort for improving the respiration, tracheotomy must be performed. The result is always doubtful, but it may bring relief. The paralyses which follow the dis- ease may be treated with two to six granules of the hypophosphite of strychnine daily, according to the age of the child. The fever may be almost neglected, as an element of secondary importance in this disease. It is usually neither very high nor of sufficiently long duration to greatly enfeeble the patient. It is better to concentrate one's entire attention upon the infective element of the disease ; besides, a defervescent action accompanies the effect of the parasiticide. Should the temperature reach 40° C, we may give three granules of veratrine every half -hour, if we wish to obtain an emetic effect, or one granule if we seek only the anti- thermic effect. Two granules of the hydroferrocyanate ELEMENTS OF DOSIMETRIC PRACTICE. 219 of quinine may be given every half -hour, if the febrile movement should proceed by intermittent paroxysms. [^H^^SLc.is : | Sulphide of ca,ciu m . i Topical solvents. ( Obstruction by membranes . < Emetic. ( Emetine. Spasm of the glottic muscles Hyoscyamine. Paralysis of the glottic mus- ) Brucine> Adynamia .... Arseniate of strychnine. Imminent asphyxia . . Tracheotomy. Fever ■! ^ on tinued • Veratrine. * 1 Intermittent j Hydroferrocyanate of qui- Subsequent paralyses . . \ Hypophosphite of strycli- \ Variant. nine. Disease, Addison's. — Jaccoud announces the path- ogenesis of Addison's disease in the following manner : "Pathological anatomy and pathogenic interpretation make it evident that the clinical phenomena of Addi- son's disease take their point of departure from an abnormal excitation of the abdominal sympathetic plexuses, the semilunar ganglia, and the trophic nerves which originate there. This excitation is the result of a morbid process which is anatomically appreciable, which may involve the suprarenal capsules, under the form of a sclerosis or a caseous inflammation ; or the semilunar ganglia under the form of sclerosis, an essen- tially irritative process. According to its initial center we have, as a result of the excitation, which acts by radiation and by reflex action, gastric, hypochondriac, intestinal, or lumbar pains, vomiting, nausea (the gas- tric, hepatic, or mesenteric plexuses being involved), palpitations, and syncope (from the involvement of the semilunar and thoracic ganglia) ; and, since the sympa- thetic draws its activity from the cerebro-spinal center, incessant calls of this character, to keep up the abnor- mal state of excitation, break down the central appa- ratus, and diminish the activity of the functions which are dependent upon it. From this results the profound asthenia, which is inevitably fatal, notwithstanding the 220 ELEMENTS OF THERAPEUTICS AND PRACTICE. absence of any notable emaciation. With regard to the dark color of the skin in this, disease — the melanodermia, as it is appropriately called — it shonld not be attributed to an alteration of the pigment in the blood ; it is due rather to a hypergenesis, to a pigmentary change which is caused by excitation of the trophic nerves. The indication for the dominant is, therefore, to at- tack the principal dynamic lesion — i. e., the nervous excitation — and the most important material lesion, which consists in the trophic modifications of the supra- renal capsules, the nervous ganglia, and the nerves themselves, which have undergone degeneration. With one granule of hyoscyamine every three hours, com- bined with three of iodoform, this double indication may be filled. The asthenia which results from this constant excitation is the manifestation of the want of equilib- rium in the vital motion. In order to supplement the deficient vitality of the cerebro-spinal system, we should give two granules of the arseniate of strychnine or of phosphoric acid every two hours. The lipothymia and syncopes, which are the result of nervous asystole, or of fatty degeneration, call for caffeine or guaranine, dy- namophoric substances, which act as a tonic without producing excitement. Three granules may be used every quarter of an hour until an effect is produced. If the nausea and vomiting do not yield to the action of the dominant, quassine may be given in two-granule doses every half-hour. Epigastralgia and lumbo-ab- dominal pains may be assuaged by the hydrobromate of cicutine, the tannate of cannabine, or croton chloral, three granules to be given every quarter of an hour until a sedative effect is obtained. The melanodermia, by which the skin, however white it may be naturally, is colored as dark as that of a mulatto, may be treated with arsenious acid, care being taken that the pigment- ary hypergenesis be not increased by the efforts to di- minish it. Two granules of it may be given three to five times daily. ELEMENTS OF DOSIMETRIC PRACTICE. 221 Dominant. Variant. Excitation of the abdom- inal sympathetic plex uses Asthenia . Lipothymia Vomiting . Epigastralgia Lumbo-abdominal pains Melanodermia . Hyoscyamine, iodoform. Arseniate of strychnine. Caffeine, guaranine. Quassine. I Hydrobromate of cicutine. Arsenious acid. Diseases, Tuberculous. — Little can be said in re- gard to the means of combating this class of diseases. Their pathogenesis is still uncertain, notwithstanding the discovery of Koch's bacillus. It is difficult to be- lieve that in hereditary phthisis, for example, the germ is preserved in a lethargic condition for fifteen, twenty, thirty, or more years, being perfectly tolerated by the organism until certain particular conditions suddenly excite it to fatal activity. It is easy enough to believe that the bacillus is capable of producing tuberculosis, and to admit that local forms of tuberculosis have no other origin ; but, with respect to pulmonary phthisis, it would appear that there must be a precedent disease of the lungs in order that the bacillus might develop — an atonic condition of the pneumogastric nerve, which should constitute more than a simple predisposition, and should become a true hyposthenic neurosis. At least such would seem to be the condition in the ma- jority of cases. The constitutional weakness, greatest in the organs of least resistance, produces a diminution in the energy of the trophic functions. Then the first period of phthisis is established — the period of pulmo- nary adynamia. It may be that, at this time, the bacilli, finding a soil which is suitable for their germination, attack the respiratory organs, and become the principal cause of different symptoms, aiding in hastening the progress of the disease. It is not an agreeable thing to admit, however, that the bacilli find material for their nourishment and development in the lungs, the vitality of which is unimpaired. For this reason pre- disposition should receive the first place among the efficient causes, infection from bacilli being placed sec- 222 ELEMENTS OF THERAPEUTICS AND PRACTICE. ond. The dominant should, therefore, consist in the use of the most powerful neurosthenic agents, both of a hygienic and a pharmaceutical character. Under the first of these heads may be mentioned superali- mentation, a cold, dry climate, gymnastics, hydrother- apy, etc. ; among the second, the arseniate of strych- nine and phosphoric acid, or arsenious acid and the hypophosphite of strychnine. By alternating the two latter combinations, we may avoid the inconveniences which attend the too prolonged use of the same medica- ments, for it must be realized that this treatment should be followed up with perseverance and without inter- ruption. There is no middle ground, the disease will not capitulate ; either it must die or it will kill the patient. The doses should be gradually increased, two granules of each substance being given at first three times daily, and this quantity being increased according to the indications, without any fear of an accumulation, which is never seen, in fact, not even if doses which are apparently exaggerated are administered. This treatment may be continued indefinitely; in fact, its principal advantage consists in so doing. It is entirely useless to experiment with any form of treatment or alimentation, however much hope it may give us, if it can only be followed out during a more or less limited period. The advantage which may be gained from it is ephemeral, and is compensated inversely by the loss of ground which follows these attempts and leaves the patient in a worse state than before. This has been the history of all those specifics which have been praised immeasurably, and have gone out of fashion again almost as soon as they came in. The same is true of cod-liver oil and other indigestible or nauseat- ing foods which are badly tolerated. The treatment of the hyposthenic condition should be continued uninterruptedly for years, until the patient has entirely recovered his health. It would ELEMENTS OF DOSIMETRIC PRACTICE. 223 also seem advisable to proscribe and severely condemn all the forms of depressing, defervescent, contrastimu- lant treatment, etc., which may modify some of the symptoms for the time, but can never be of any real advantage to the patient. The fever and the element of infection, in spite of their pathological importance, should be treated in a very different manner from that which has been advised in other diseases. Suppose that all the bacilli have been destroyed. Shall we have gained anything by this means % No, for the predispo- sition remains the same, and a second invasion would be more easily made than the first. The principal in- dication is to overcome pulmonary atony. This point having been gained, the bacilli will die, finding no longer a suitable soil, and new bacilli will no longer be able to establish their colonies. Therefore defer- vescents and bacillicides are to be objected to as harmful unless it be at the beginning of the dis- ease, when the local adynamia can still be easily modi- fied, and the paroxysms of fever are not yet continu- ous. We should therefore prescribe at the beginning of the disease two granules of aconitine and two of digitaline, three or four times daily, to moderate the fever ; as a parasiticide we should give two granules of the sulphide of calcium every hour, if this quantity does not disturb the patient' s stomach nor interfere with his sleep. Impairment of nutrition must be carefully treated with those forms of medicinal food which are best tolerated. The phosphates of lime and of iron, the phosphide of zinc, the arseniates and hypophosphites of lime and soda, separately or in combination, will satisfy this requirement. Paroxysms of intermittent fever should be combated with small doses of the hydroferrocyanate or the salicylate of quinine, three granules at a dose being given three or four times daily. Profuse sweating, which annoys and weakens so many patients, may be profitably treated with atropine or one of its salts (the sulphate or the valerianate). Two 224 ELEMENTS OF THERAPEUTICS AND PRACTICE. granules might be given when one retires, and the dose might be repeated when one became conscious that a sweat was coming on. The choice of the salts of atro- pine must be changed from time to time, to prevent habituation, or agaricine might be substituted for atropine, five to ten granules being given two or three times every night. The diarrhoea which results from the condition of the digestive passages may be relieved by the use of two granules of quassine and two of pep- sin with each meal. If the diarrhoea is due to intes- tinal ulcerations, it will be relieved with difficulty. Two granules of the hydrochlorates of morphine and of cotoine may be tried every hour, or every two hours, ac- cording to the resistance of the symptoms and the other conditions of the patient. For the haemorrhages or hsemoptyses, five granules of ergotine may be given every quarter of an hour until a haemostatic effect is produced. Three granules of veratrine dissolved in a teaspoonf ul of water, and given every ten minutes, may serve the same end, the dose being repeated until a haemostatic or a contrastimulant effect is obtained. This drug (veratrine) is only suitable, however, for patients who are still strong, for florid phthisical subjects, and for those who resist other means of treatment. It may be added that iodoform is an excellent remedy for this disease, if it can be tolerated. It may be given in doses of three granules every two hours. Its function is to disinfect the expired air and to quiet the cough. Helenine may be found useful as an expectorant, two to five granules being given three to fiYQ times daily. For the fatiguing cough, the neuralgias, and the in- somnia, the salts of morphine, cicutine, and cannabine may be given. The pains which accompany the disease may be treated with one granule of hyoscyamus every three hours, while the vomiting may be checked by combining the hyoscyamine with strychnine. Little more need be said in respect to this disease, which is the least satisfactory of all diseases as to its treatment ELEMENTS OF DOSIMETRIC PRACTICE. 225 — whether in practice or in theory. This feeling of repugnance is justified by the unhappy result which almost invariably occurs, though it is still the physi- cian's duty to struggle with it to the end, without giv- ing way to despair. Cases of positive cure which have occurred in all stages of phthisis demand perseverance in treatment, and justify the hope of a satisfactory re- sult. It is for these reasons that we should prevent, as far as possible, the severe consequences which almost always follow pulmonary inflammations of greater or less extent, and not limit ourselves to fighting with the existing disease. These morbid intercurrences should be met and cut short on account of the great impor- tance which they have in respect to the development of the disease. I Dominant. Variant. Impaired nutrition . Pulmonary adynamia f Bacillar infection Haemorrhages . Nocturnal sweating . Diarrhoea . Fever Cough Neuralgia j Arsenious acid. "I Phosphates. iArseniate of strychnine. Phosphoric acid. Hypophosphite of strychnine. j Sulphide of calcium. \ Iodoform. \ Ergotine. 1 Veratrine. j Atropine. ( Agaricine. ( Pepsin. -j Agaricine. ( Cotoine. ( Digitaline, aconitine. ■< Salicylate and hydroferrocyanatt ( of quinine. Iodoform, morphine, helenine. j Tannate of cannabine. ( Hyoscyamine, Gregory's salt. Dysentery. — Science has not yet found out the real cause of dysentery. With some individuals it is sim- ply an inflammatory affection ; with others it is the result of parasitic infection, and is due to particular forms of bacteria. The progress of the disease, its con- tagiousness, the constancy of certain accordant causes in all cases, tend to confirm the second theory. Dys- entery appears to be localized primarily in the colon, whence it extends to the small intestine, the liver, the 15 228 ELEMENTS OF THERAPEUTICS AND PRACTICE. lungs, etc., gradually involving the entire organism, which is apparently suffering from a slow and pro- gressive intoxication. The dominant should, therefore, be chosen from the parasiticides. But, considering the results of treatment with the standard remedies in classical practice — that is, such remedies as ipecac and calomel — it would appear that the best means of anti- parasitic treatment is furnished by the organism itself in the shape of the bile. In fact, at the very beginning of the disease, as soon as the bile comes in contact with the surface of the colon, the disease is usually checked, and a cure is announced by the presence of the bile in the intestinal evacuations. Cholagogues should there* fore occupy a predominant position in the list of reme- dies. The excellence of the results which have been obtained by ipecac, as well in temperate as in tropical climates — the drug itself, and the method of its use in this disease, having been brought to us from tropical climates — should induce us to use it by means of its alkaloid emetine as the principal means of treatment. It must be conceded that it has a specific action, the exact method of which is not known, though it evidently operates particularly upon the liver and the nerves, which are distributed in the abdominal viscera. As to the frequency of dosage which is required, the toler- ance of the stomach must be consulted. If there is a tendency to vomit, we should administer one granule every two hours, and, if there is still nausea, we should combine with each dose two granules of codeine. If the stomach will allow it, we should give two granules of emetine every hour until there is a manifest remis- sion of the symptoms. The spasmodic element, which almost always accompanies the pathogenic element, requires the combination of hyoscyamine with eme- tine, and thus the therapeutic effect of the latter will be more rapidly obtained. If the emetine can not be borne at all, five granules of calomel may be given every hour. Cotoine may also be tried, but with these ELEMENTS OF DOSIMETRIC PRACTICE. 227 three remedies the dominant indication can usually be satisfied. It must not be forgotten that the case is always sufficiently urgent to institute an active and systematic treatment, whatever be the apparent or real benignity of the disease at its beginning. There is no question but that the stages of dysentery succeed each other regularly, and that one comes in contact with the last only in those cases in which the first have not been treated according to proper rules. But, while the dis- ease is readily curable in its early periods, it is very rebellious in the later ones, because the means which are intended to overcome the morbid principle can not accomplish it, because the lesions have extended greatly, have gained in significance, have multiplied, and because there are secondary complications which have their seat in the parts which are most subject to vital depression, which lead to adynamia, to gangrene, and to death. When the disease begins we may treat the acholia with Sedlitz Chanteaud, but not with such persistence as to increase the debility of the patient. If there is high fever, and it is usually of a remittent or an intermittent type, it may be moderated by the use of aconitine, while the hydroferrocyanate of qui- nine may be used to arrest the periodic character of the paroxysms. The aconitine may be given in doses of one granule every hour or every half -hour, according to the temperature ; the quinine in three-granule doses every hour during the remissions, the use of the aconi- tine being resumed when the temperature again be- comes elevated. The vomiting, which, as has been observed, may compel a modification of the treatment, and is also the cause of the great physical prostration which is experienced by sufferers with dysentery, may be treated with codeine, Sedlitz Chanteaud having first been given. The codeine should be given in doses of two granules every quarter of an hour, and, besides checking the vomiting, it will also soothe the abdominal pain, which is sometimes almost unbearable if narcotics 228 ELEMENTS OF THERAPEUTICS AND PRACTICE. are omitted. The adynamia, which is sometimes mani- fested from the very beginning of the disease, may be an- ticipated or relieved, if it has actually occurred, by one or two granules of sulphate of strychnine given every two hours. Tenesmus, which is a great source of suffer- ing, and which quickly reduces the vital forces, may be treated with one granule of hyoscy amine every half -hour until relief is obtained. Should the physiological ef- fects of hyoscyamine or its congeners, atropine or datu- rine, be manifested before the therapeutic effects, its administration must be interrupted, but not abandoned, two granules of gelsemine being substituted for the time every half-hour. The rectal haemorrhages, which do not proceed from exudations, but from ulcerated vessels, often constitute an annoying element in the disease, because they increase the weakness which is already sufficiently pronounced from other causes. These haemorrhages should be treated by means of three granules of ergotine every hour, without sus- pending the other medicaments. Ataxia and delirium call for the use of the bromide of camphor, the sedative and antispasmodic properties of which will aid the dominant treatment. Two or three granules may be given every two hours or oftener, as the case demands. In some cases pains, which resemble those of rheu- matism, are present, and should be treated by the bro- mide of camphor, for they are almost always the result of spasmodic contractions ; at other times the pains are actually rheumatic, and therefore demand the use of colchicine, the cholagogue properties of which are thus added to the treatment of the dominant. One granule may be given every two hours. The suppura- tion in the cellular tissue which surrounds the colon or the rectum is a dangerous consequence of ulcera- tions in the mucous membrane, and should be treated persistently with iodoform and arseniate of soda. Two granules of each may be given three or four times daily. The paralysis of the sphincter ani and the permanent ELEMENTS OF DOSIMETRIC PRACTICE. 229 prolapse of the rectum should be treated with excito- motor agents for a long time. The hypophosphite of strychnine is to be preferred, six to eight granules being given daily. The icterus which attends the first stages of the disease calls for no particular or immedi- ate treatment. Should it persist after the dysentery has been controlled, colchicine combined with the ar- seniate of quinine may be used, two granules of each being given three or four times daily. Dysentery often appears in such a manner that the clinician is com- pelled to regard it as a manifestation of malarial infec- tion. In such cases nothing can control it more effect- ually than ten granules of the salicylate of quinine every three hours. Gangrene, whether manifested in the rectum or in remote organs, should be treated with disinfectant rem- edies locally (for example, injections of a bora ted solu- tion of chloral, Hebert's formula for which is the fol- lowing : Chloral hydrate 10 grammes. Borax 5 " Aquse 250 " Sig. : Dissolve a tablespoonful to a glass of water), while internally two granules of salicylate of ammonia may be given every hour. Chronic dysentery may be regarded as a simple catarrhal inflammation. Treat- ment should be directed to the inflammation of the mucous membrane, and two granules of aconitine and two of the arseniate of soda may be given three times daily. If there is tenesmus, we should give as a variant one granule of hyoscy amine and one of emetine every two or three hours. The diet should be tonic but not stimulating, and may include rare meats, milk, and albuminous fluids. The patients should not be debili- tated by depletive means, such as leeches, etc. Dysen- tery may be regarded as the cholera of the large intes- tine ; a very slight weakening of the physical forces may prove an insurmountable obstacle to a cure: 230 ELEMENTS OF THERAPEUTICS AND PRACTICE. Dominant. Parasitic element . / Acholia .... Fever .... Vomiting Pain .... Adynamia Tenesmus Haemorrhage . Ataxia .... Delirium Rheumatoid pain . Perityphlitis . Periproctitis . Paralysis of the sphincter ani .... Icterus .... Malaria .... Gangrene \ Chronic stage Variant. ( Emetine. Sedlitz, calomel, j Aconitine. I Hydroferrocyanate of quinine. j- Codeine. Sulphate of strychnine. Hyoscyamine, gelsemine. Ergotine. Bromide of camphor. Colchicine. I Iodoform, arseniate of soda. (• Hypophosphite of strychnine. Colchicine, arseniate of strych- nine. Salicylate of quinine. ( Salicylate of ammonia. ( Antiseptic injections. \ Aconitine, arseniate of soda. ( Emetine, hyoscyamine. Dysmenorrhea. — Difficulty in the expulsion of the menstrual products may arise from various causes, which must be carefully studied and understood in order to establish a rational and efficacious plan of treatment. The obstacle may be either dynamic or organic. In the first condition there is a spasm of the neck of the uterus, analogous to the spasmodic contrac- tion of the neck of the bladder* In the second condi- tion there is equal difficulty in disposing of the men- strual fluid, but the cause is different. At one time it may be due to an obstruction in the cervical canal, con- sisting of mucus, etc. ; at another, the obstruction may consist of a tumor of different characters ; at another, in the presence of coagula or the debris of mucous membrane which have not been discharged. Spasmodic dysmenorrhcea is the form which yields most readily to treatment. One granule of atropine or daturine given every half -hour during the paroxysms of pain will allay them, and permit the free passage of the catamenial flow. In the intermenstrual periods one granule of the sulphate of atropine and one of the sulphate of strych- nine may be given three times daily. If the obstacle is ELEMENTS OF DOSIMETRIC PRACTICE. 231 due to congestion or inflammation of the mucous mem- brane, its engorged condition producing a stricture of the canal, we should use, during the intermenstrual period, two granules of aconitine three times daily. If the canals concerned in menstruation are normal in caliber, and the difficulty arises from the quality of the secretions, we should give ergotine to assist the uterus in expelling the body which it contains, and hyoscya- mine to overcome the cervical spasm, which almost al- ways accompanies the exaggerated irritability of the body of the uterus after that organ has vainly attempt- ed to empty its cavity. Stricture, whether cicatricial, congenital, or organic, should be treated by gradual dilatation. For endometritis, with its abnormal dis- charges, we should use for a long period iodoform, arseniate of iron, hydrotherapeutics, revulsives, etc. The same treatment applies for membranous dysmenor- rhea. Uterine colic, which is sometimes excessively painful, should be treated with one granule of hyos- cyamine every quarter of an hour, or two granules of tannate of cannabine every quarter of an hour. Dys- menorrhea, which is caused by the presence of foreign bodies in the uterus, by polypi, or other tumors, must be treated by surgical means, with reference to its cause. During the menstrual crisis we should help the general condition (indirectly) by giving strychnine, which will strengthen the contractile force of the body of the uterus, and hyoscyamine, which will facilitate the dila- tation of the neck. This will not cure the disease nor destroy its cause, but it will make the expulsive action of the uterus as effective as possible. C Spasmodic dysraenorrhoea . 'Dominant J Congestive dysmenorrhcea . 1 l x ' 1 Inflammatory dysmenorrhcea [ Atonic dysmenorrhcea l Stricture of the cervix Variant. Daturine. j- Aconitine. Ergotine. Gradual dilatation. ( Iodoform, arseniate of ( iron. j Colic Tannate of cannabine. [ Foreign bodies and tumors . Surgical means. Endometritis 232 ELEMENTS OF THERAPEUTICS AND PRACTICE. Dyspepsia, — Dyspepsia is a disturbance of one or of several of the functional acts which contribute to effect normal digestion. This complex digestive func- tion is subject to different causes, which require a hy- gienic and pharmaceutical treatment, varying accord- ing to the case. With some, all that is required in the way of treatment is a slight modification in the way of diet, or perhaps only a greater degree of care in mastication ; with others, there must be the com- bined influence of several different means, hydrothera- py, electricity, nervines, eupeptics, etc., in order to effect a cure. The physical, chemical, and mechanical acts which are necessary for the transformation of food into absorbable material begin in the buccal cavity, are continued in the stomach, and are terminated in the in- testine ; and, as dyspepsia may be established in any one of these cavities, therapeutics must consider buccal, stomachal, and intestinal forms of dyspepsia. Buccal dyspepsia is caused by imperfect mastication, by loss of the teeth, or by a diminution in the ptyalin or dia- stase which is secreted by the salivary glands, and the object of which is to convert starchy matters into glu- cose. Mastication should therefore continue for a cer- tain length of time, especially if the teeth are absent or imperfect, not only that the mechanical division of the food may be properly accomplished, but also that the starchy matters may be impregnated with saliva, and be transformed (to a greater or less degree) into dextrine and then into glucose. Diastase is especially useful, therefore, in buccal dyspepsia, to supplement the nat- ural ptyalin. Having been artificially supplied to the stomach, it digests the starches which it finds there, which without this ferment would remain in the stom- ach like foreign bodies, unaffected by the gastric fluids. Three granules of it may be used with each meal in which starchy substances form a portion. Diastase is not a true medicament for conditions like this, for it does not produce any curative dynamic modification. ELEMENTS OF DOSIMETRIC PRACTICE. 233 Its role is limited to the production of an artificial digestion. To increase the salivary secretion we should use the nitrate of pilocarpine, which excites both the internal and external glands of the tegument to action. Three granules of it should be used two hours before each meal. The gastric form of dyspepsia is due to lesions affecting contractility, secretion, or innervation. The muscular tunic of the stomach may be so affected that its peristaltic movements become very weak. The result of this will be that the food in the stomach is not sufficiently impregnated with gastric juice, and that chymification takes place too slowly. Then the stomach is gradually dilated by the gases which are generated in it, its atonic condition becoming more and more pronounced. Such is the pathogenesis of flatu- lent dyspepsia and of gastric dilatation in its simplest form. The effective agents in the treatment of this form of dyspepsia are those which will restore to the organ the energy of contractility which it lacks. Such are the sulphate of strychnine, of which one to three granules may be given before meals ; euonymine or elaterine, five granules at a dose ; brucine, two to three granules ; hydrotherapy, electricity, massage, etc. In- directly we may attain the same result by diminishing the work of the stomach by a proper selection of food, by reducing the quantity which is taken, and by giving preference to those which are fluid or semi- solid, which offer less resistance to the functional action of the stomach. It is also desirable that plenty of time should be allowed for the meals, and both pepsin and diastase administered with the meals, that digestion may be accomplished as rapidly as possible. The regimen should be adapted to the capabilities of the stomach, but at the same time the strength of the system at large must not be interfered with. Upon this theory is es- tablished the method of washing out the stomach with Fancher's tube, and artificial feeding by the same means, which has given excellent results in cases of 234: ELEMENTS OF THERAPEUTICS AND PRACTICE. gastric dilatation. In other cases the contractile power of the stomach is exaggerated, and as a result the patient suffers from vomiting and eructations. This frequently occurs during the first months of preg- nancy. The so-called uncontrollable vomiting will almost always yield to the influence of two gran- ules of hyoscyamine combined with one of sulphate of strychnine, which, by restoring the physiological equilibrium, will readily dissipate the spasmodic con- dition which is the cause of the vomiting. The stom- ach has two varieties of glands. In one of them is secreted the gastric juice, which contains the pepsin which is indispensable for the conversion of nitro- genized substances into peptone ; the others secrete mucus, and by their situation seem to be intended to facilitate the passage of the bolus of food through the pylorus. The quantity of pepsin which is con- tained in the gastric juice may be too small to effect a prompt peptonization of the proteids with which it comes in contact, which consequently remain in the stomach and undergo decomposition, the exist- ence of which is announced by the liberation of offen- sive gases, and by diarrhceal discharges which contain undigested food. For this form of dyspepsia, which has the name of putrid dyspepsia, two or three gran- ules of pepsin may be given with each meal, and two drops of hydrochloric acid in a glass of water after meals. The treatment may be completed by the use of peptones, of meat powder, of food in general which is not highly nitrogenous, of milk, and, as antiferments, three granules of salicylate of quinine and two of iodo- form. If the passage of imperfectly digested food through the alimentary canal causes colic, three gran- ules of codeine may be administered after each meal, or three of cocaine with each meal, the dynamophoric and antidyspeptic properties of this drug being very valuable. The vomiting is due to indigestion, and the principal remedy is still pepsin. If the slow effects of ELEMENTS OF DOSIMETRIC PRACTICE. 235 this substance can not be waited for, sulphate of atro- pine may be substituted, one granule being used every half-hour until the proper effect is produced. Hyos- cyamine and atropine tend to destroy the appetite and to increase the lingual catarrh ; but these are transient effects, and, after they have disappeared, they leave the patient in a better condition than he was before the use of the mydriatic alkaloids. If the quantity of pepsin in the gastric juice is excessive, symptoms of acid dyspepsia are apparent. This excess may be remedied by the use of two granules of the ar- seniate of soda and two of the salicylate of soda with each meal, and alkaline mineral waters. Pyro- sis may be treated by the same means, and cardi- algia by three granules of cicutine after each meal. The treatment of acid dyspepsia may be completed by proper exercise, including stimulation of the sweat- glands, three granules of the carbonate of lithia three times daily, and abstinence from all stimulants. An exaggerated secretion from the mucous glands of the stomach causes pituitary dyspepsia. It should be treated with the bitters, especially quassine, in doses of two to live granules three times daily, and two to three granules of brucine. A proper dietetic regi- men should also be determined upon, and rigor- ously carried out. Condiments and alcoholic liquors should be avoided, and either a diet of milk or the grape-cure will be found to be serviceable. Disturb- ances in the gastric innervation will give rise to gastro- dynia, which is the characteristic feature of gastralgic dyspepsia. In its treatment, three granules of the tan- nate of cannabine or of the hydrobromate of morphine may be used, combined with one granule of hyoscya- mine or three of codeine, and repeated as often as the pain requires. Under the head of those classes of dys- pepsia may also be placed diminution of the appetite, or anorexia ; excess of the same, or boulimia ; and per- version, or heterophagia. Anorexia requires different 236 ELEMENTS OF THERAPEUTICS AND PRACTICE. treatment, according to its cause. Generally the appe- tite may be excited by the nse of two grannies of quas- sine or two of piperine before eating. Two or three grannies of veratrine, three times daily, will almost always have a similar effect. Bonlimia may be relieved by one grannie of atropine every three hours, or three granules of morphine every half -hour until the vora- cious character of the appetite is overcome. Hetero- phagia, which is also known as pica or malacia, requires a severe hygienic regimen and the use of one granule of hyoscyamine, combined with one of strychnine, two hours before eating. Such are the means for treating these well-defined forms of dyspepsia. Unfortunately, they rarely appear singly, and the symptoms which are associated with them result in the manifestation of very complex conditions. It is therefore necessary to combine different agents in treating them, and to select the most important among the phenomena for succes- sive treatment, in the order of their gravity and their affiliation. Sedlitz Chanteaud should form an essential portion of the treatment of almost all forms of dyspep- sia. It is indispensable for relieving the alimentary canal of portions of undigested food, which would be- come sources of renewed trouble if allowed to remain. It also acts by virtue of its alkaline properties, and enables one to dispense with the alkaline mineral wa- ters. The hygienic and alimentary regimen, regulated in accordance with the agencies which have brought about the dyspepsia, is also deserving of careful con- sideration. Indications of this kind occupy almost the entire attention of the most celebrated physicians of the official school. Experience taught them that Galen- ic preparations were harmful, not only because they annoyed the patient, but because of the difficulty which the stomach experienced in digesting insoluble and irritating substances. Such substances almost always exaggerated the disease ; or, if they did not, they were taken with a sense of horror by the patient, who was ELEMENTS OF DOSIMETRIC PRACTICE. 237 also compelled to persevere in their use for a long time. Such treatment bears no resemblance to that which consists in the use of alkaloids. Under this system the granules are taken with the greatest facility, and with- out the slightest repugnance. They are readily dis- solved when they come in contact with the mucous membrane, and are absorbed in a few minutes without effort and without fatigue. The triumph of dosimetry in chronic diseases is never so manifest as in diseases of the alimentary canal. Intestinal dyspepsia might also be considered, but the indications which pertain to it are almost always those of gastric dyspepsia. Pepsin and diastase in combination should be pre- scribed for it, and the biliary secretion should be stimu- lated by the use of cholagogues, which have a tonic action upon the intestine — such as jalapine, colo- cynthine, elaterine, and iridine — three or four gran- ules being given with each meal. DYSPEPSIA. 1st. Buccal. Mechanical troubles Prolonged medication. Deficiency of ptyalin .... Diastase, nitrate of pilocarpine. 2d. Stomachal. Lesions of Contractility. Flatulent dyspepsia . \ W^ of strychnine. J L r ( yuassine. uonymine, electricity. Spasm . . -j E^tifns ! '. \ \ H y°scyamine, strychnine. Lesions of Secretion. -n;™;~ +• * • , Apepsia . . Pepsin, hydrochloric acid. Diminution of pepsin j ^eructations Iodoform; salicylate of quinine. (Flatulent dyspepsia . 1^0^^ Atonv •) * C^uassme. 7 ' •(Dilatation. . . i ^"W hydrotherapy, Putrid dyspepsia . j™f; Increase of pepsin . i J rosis (Acid dyspepsia.) ( Cardialgia . Increase in the secretion of mucus . (Pituitary dyspepsia.) [• Quassine, brucine. Vomiting Codeine. Sulphate of atropine. Arseniate of soda, carbonate of lithia. Cicutine, cocaine. 238 ELEMENTS OF THERAPEUTICS AND PRACTICE. Lesions of Innervation. Pain (gastralgic dyspepsia) . . ■ \Xot?Zn, ^ ^^ Anorexia Quassine, piperine, veratrine. -r, ,. . ( Atropine, hydrochlorate of Boulimia \ morphine. Heterophagia Strychnine, hyoscyamine. 3d. Intestinal. Deficiency of pancreatin .... Diastase, pepsin. Deficiency of bile Iridine, colocynthine, eiaterine. Intestinal atony Jalapine, brucine. Emphysema, Pulmonary, — After emphysema has been established, whatever be its cause, it will be im- possible to cure it entirely. It belongs to that class of irreparable lesions for which treatment can only ameli- orate this or that symptom. But, as such lesions are generally progressive, we should aim at a plan of treat- ment which will prevent or retard development, as far as possible, and delay the time when the condition will be incompatible with life. If we can not hope that the alveoli, after their forcible dilatation, will recover the resisting power which they have lost, we can at least increase the resisting power of those which are still un- injured. Notwithstanding the incurability of the dis- ease, there is still a dominant indication, which is to fortify the resisting power of the pulmonary tissue. This will be accomplished by the use of the hypophos- phite of strychnine during the entire duration of the disease ; two granules should be given three to five times daily. The variant should endeavor to remedy the venous stasis, by increasing the cardiac contractility by the use of three granules of caffeine every two hours ; to this two granules of the arseniate of strychnine may be added every hour when the circulatory disturbances make the condition one of danger. Dyspnoea is the fatal consequence of emphysema ; suffocation may be temporarily relieved by the use of revulsives. Palpita- tions, which are the expression of cardiac troubles re- sulting from interference in the regular course of the blood-current, demand digitaline in order that the ac- ELEMENTS OF DOSIMETRIC PRACTICE. 239 tion of the heart may be more regular and vigorous ; two granules may be given two or three times daily. The catarrh, which is the result of stasis and subse- quent paralysis, may be relieved for a time with large doses of ergotine ; three to five granules may be given every hour. The cough should be effectively treated, not only because it is a source of great discomfort to the patient, but also on account of the bad effect which it has upon the progress of the emphysema ; all mus- cular effort tending to make this condition rapidly worse. For this purpose the most useful agent will be morphine, either the hydrochlorate, the hydrobromate, or the hydriodate being used ; and this will not only greatly diminish the number of attacks of cough, but by its tonic action upon the cardio-pulmonary functions will assist the other medicaments in arresting the de- velopment of the emphysema. ^ . /Dominant. Atony of the pulmonary tissue . . Strychnine. W^j i /Venous stasis Caffeine. Ph £3 \ I Dyspnoea Apomorphine. r| an Variant. ( Palpitations Digitaline. " ' Catarrh Ergotine. I Cough Morphine. Encephalitis, Acute.— Acute encephalitis is al- most always consecutive to inflammatory lesions of organs which bear more or less intimate relations with the brain. The most frequent of such lesions is otitis, especially if the otorrhceal discharge does not find a ready exit externally. Acute encephalitis should be thoroughly treated with aconitine, and with the greater activity as its use is begun near the starting-point of the disease, and as the general symptoms are the more acute. The congestions which are established around the inflammatory center, which are the cause of the extension of the disease, and give rise to many symp- toms, should be perseveringly treated, if we desire to prevent that aggravation of the disease which occurs in the majority of cases. The frequent repetition of these hypersemic conditions may be prevented, as far 240 ELEMENTS OF THERAPEUTICS AND PRACTICE. as is possible, by the combination of cocaine with aconi- tine, two granules of each being given three or fonr times daily. The cephalalgia, when it is simply con- gestive, will disappear nnder the use of two granules of caffeine every half -hour, but if it is associated with suppurative inflammation we should use codeine, nar- ceine, or the tannate of cannabine in two-granule doses every half -hour until relief is obtained. The vertigo may be due to a variety of causes, but is most fre- quently associated with disorders of the circulation and with intracranial pressure. This symptom will almost always yield to the valerianate of atropine in doses of one granule every two hours. Disorders of vision and hearing, convulsions and contractures, will be relieved, if they are susceptible of relief, by one granule of hyoscyamine every half-hour. Delirium may result from disorganization of the nervous tissue, or from irregularities in the circulation of the blood. If from the latter of these two causes, we should give one granule of digitaline and one of aconitine every two hours. Different forms of paralysis attend this condition, some of which are curable, while others are not. But, as the curable can be differentiated from the non-cura- ble only by the fact of their disappearance, we should persevere in efforts to facilitate the return of motion. Two or three granules of brucine may be given three or four times daily, to fulfill this indication. The fever, which is the measure of the severity of this condition, should always be treated with defervescents until the desired result is obtained. Such agents should consist of a combination of veratrine, aconitine, digitaline, and the hydrobromate of quinine, in doses which are re- peated with sufficient frequency to control the hyper- thermia. Constipation, which is very common in en- cephalitis, may be modified by the regular use of three to five granules of podophyllin every night, with Sedlitz Chanteaud in the morning if necessary. Retention of ELEMENTS OF DOSIMETRIC PRACTICE. 241 urine, which is almost always due to spasm of the vesical sphincter, may be relieved by one granule of daturine every two hours. In almost all cases strych- nine must be combined with it to overcome the spas- modic condition, two granules of the sulphate being given with each dose of daturine. Vomiting may be relieved by a combination of two or three granules of codeine with an equal quantity of quassine every half- hour. If these means should prove inefficient, we may use two granules of the hydrobromate of morphine every quarter of an hour. In the remissions of the disease, which suggest a return to health, the cerebral functions must not be stimulated, and irritability of the nervous system may be quieted by the use of two to four granules each of digitaline and aconitine every evening. Improvements of this character must not de- ceive us and encourage inactivity as to treatment, but rather should they stimulate us to interference, with more hope that a useful purpose will be accomplished. GO I Dominant. Inflammatory element . Congestion Cephalalgia . Vertigo .... Troubles of sight and hearing Contractions . Convulsions . Delirium. Paralyses \ Variant. / Fever Constipation . Retention of urine ^Vomiting Aconitine. Cocaine. Caffeine. Valerianate of atropine. Hyoscyamine. Aconitine, digitaline. Brucine. Veratrine, aconitine, digi- taline, hydrobromate of quinine. Podophyllin. Daturine. Codeine, quassine. Encephalitis, Chronic (Sclerosis of the Encepli- alon). — When sclerosis begins to show appreciable symptoms, the lesions have already reached such an advanced stage that a cure can not be expected by any course of treatment. Only a decided modification of the nutrition of the nervous centers could effect a re- generation of the compromised tissues, or prevent the neoplastic process from continuing to develop. If 16* 242 ELEMENTS OF THERAPEUTICS AND PRACTICE. syphilis has taken possession of the organism, we can accomplish much by an active course of antisyphilitic treatment ; but in other cases we shall do well if even slight results are obtained with a combination of iodo- form and phosphide of zinc. Four granules of each may be used three or four times daily. The fever and perisclerotic congestions may be checked by the use of one granule of aconitine every half-hour, in acute cases ; in chronic ones, by two granules, two to four times daily. Abolition of functions, which results from the destruction of organs which should execute or direct certain functions, is irreparable. Cephalalgia, which is almost always caused by congestion, will yield to aconitine, which is also the best remedy for periph- eral neuralgias in general. In some cases gelsemine will be more suitable than aconitine, especially if the case present decided evidences of depression ; two gran- ules may be given every half-hour. For vertigo, two granules of caffeine should be given every half -hour, or guaranine in similar doses, or valerianate of atropine in one-granule doses every hour. The paralyses which result from want of equilibrium in the innervation may be overcome by the prolonged use of sulphate of strych- nine, two granules being given every two hours. Those forms which result from the destruction of gray matter, owing to the proliferation of the neuroglia, are com- pletely incurable, the progress of the disease being marked by successive congestions, followed by inflam- mation with proliferation. The plan of treatment should be directed mainly against hyperemia, if we desire to prevent, or at least to retard, the progress of the lesions. °3 /r>mi/rTMATtfT J Modification in the nntri- j Iodoform, salts of mercury, tion of the nerve-tissue \ Phosphide of zinc. Fever . ) Congestion Abolition of function Variant. (Cephalalgia . Neuralgia Vertigo . i Paralysis . Aconitine. Incurable. Aconitine. Gelsemine. Caffeine. Sulphate of strychnine. ELEMENTS OF DOSIMETRIC PRACTICE. 213 Endocarditis. — See Pericarditis. Enteritis. — Enteric fluxion may be produced by the most varied causes, and none of them should be overlooked if therapeutic intervention is to be really effective. Enteritis may arise from direct irritation, as is the case when imperfectly digested food is con- verted into a foreign body within the intestines, and inflammatory reaction of the intestinal mucous mem- brane is the result. Dyspepsia, therefore, is frequently the cause of enteritis. In such a case pepsin would be indicated to facilitate digestion, and Sedlitz Chanteaud to secure regular evacuations of the bowels. Of the pepsin, two or three granules may be given with each meal. If constipation exists, the prolonged contact of fecal matter with the intestine, together with the irri- tation which is caused by its decomposition, may result in inflammation. The daily use of Sedlitz Chanteaud, and of three to Hive granules of podophyllin at night, will be sufficient to relieve most of the cases. The presence of worms and other foreign bodies in the intestine has the same pathogenic action, and calls for the same treatment. Irritative fluxion, whether direct or reflex, if it is repeated and intense, almost always demands the use of aconitine, one or two granules being given three or four times daily. Reflex irrita- tion may be caused in different ways, the most fre- quent of which are associated with the action of cold, extensive lesions of the skin, and strong moral emo- tions. In the first case, it is necessary to excite to action the secretory functions of the skin by means of aconitine, which acts not only as a preventive of con- gestion, but also as a diaphoretic ; one granule may be given every half-hour or every two hours, according to circumstances. In the second case, since the condition is one of nerve paralysis rather than of vascular irrita- tion, the hydrochlorate of morphine is preferable, and two granules of it may be given every hour. The sup- pression or diminution of a hsemorrhoidal flux may 244 ELEMENTS OF THERAPEUTICS AND PRACTICE. also excite intestinal congestion by a compensatory action. If haemorrhoids are present, we may use two grannies of aconitine and two of ergotine three or four times daily ; while for dysmenorrhea, one granule of veratrine and one of hyoscyamine may be given every two hours. The stasis which is caused by hepatic or cardio-pulmonary lesions requires that the nervous system be relieved of its excess of blood. The use of leeches may be of service, but in general it will suffice to administer a heart tonic, and to produce sufficient purgation to diminish the intestinal congestion. To accomplish this purpose, two granules of digitaline may be given two or three times daily, and ^ve of podophyllin every hour, until four doses have been given. In other cases the enteritis is the result of gen- eral infection of the organism. If it is due to malaria, which is indicated by a more or less pronounced peri- odicity of the intestinal disturbances, five granules of the sulphate of quinine may be given every hour. If the cause is typhoid or variolous intoxication, the sul- phide of calcium, or the salicylates of soda, quinine, or iron, may be given in doses of two granules every two hours. The dyscrasias may also give rise to exces- sive intestinal secretion with or without diarrhoea, as is seen in the case of Bright' s disease, cancer, etc. The best agents for such conditions are cotoine, in three to five granule doses four to six times daily, and diuretics to divert the discharges into other channels. Impor- tant symptoms which can not be neglected are pains of a colicky character, which should be treated with the hydrobromate or the hydrochlorate of morphine, in two-granule doses every quarter of an hour. They may be used alone or in connection with one granule of hyoscyamine every half -hour, if there are excessive contractile efforts. Mucous diarrhoea should be treated with morphine and brucine, two granules of each being given every hour. Digestive troubles demand the use of quassine and pepsin, two or three granules of each ELEMENTS OF DOSIMETRIC PRACTICE, 245 to be given with each meal. Fever should be treated with one granule of aconitine every quarter of an hour, or less frequently if the fever is not severe ; and this treatment should be adopted before that which is de- signed to check the catarrhal discharges. Icterus, which is frequently present when the upper portion of the intestine is involved, may be treated with Sed- litz, to which two granules of calomel every hour may be added. The foregoing are the most common symptoms in catarrhal enteritis. If the disease is of the choleriform variety, or cholera nostras, the same treatment which was prescribed for epidemic cholera (see under Cholera Morbus) should be followed, for the disease has the same clinical physiognomy, and differs from the epi- demic form only by its slight mortality rate, and the infrequency of the cases at a given period. The most frequent symptoms of this variety are vomiting and serous diarrhoea, which may be treated with one to three granules of hydrochlorate of morphine and of sulphate of strychnine, every quarter of an hour, dis- solved in a stimulant infusion. Hypothermia may be effectively treated with two granules of phosphoric acid every half-hour. Painful cramps may be relieved by one to three granules of the bromide of camphor every quarter of an hour, or one granule of hyoscya- mine every half -hour. Adynamia requires heavy wines, should the vomiting continue, together with one gran- ule of the sulphate or the hypophosphite of strychnine every hour. In the chronic form of this disease the symptoms are quite different. Those which require particular attention are constipation, tenesmus, and lientery. The first should be treated with two or three granules of veratrine three or four times daily ; the second, with one granule of atropine every two or three hours ; and the third, with a diet of milk, meat pow- der, peptones, etc., together with pepsin and diastase to assist the digestion. 216 ELEMENTS OF THERAPEUTICS AND PRACTICE, ENTERITIS. f Direct irrita- tion . Reflex irrita- tion Compensatory fluxion Stasis Infection ^Dyscrasias Catarrhal T Dyspepsia . •I Coprostaxis I Foreign bodies . ( From cold •< Cutaneous lesions ( Moral emotions j Haemorrhoids . ( Dysmenorrhcea . I Of hepatic origin < Of cardio-pulmonary ( origin . ( Malaria 1 Typhoid . ( Variola \ Bright's disease ( Cancer " Colic . Mucous diarrhoea Apepsia . Fever V Icterus Sedlitz Chanteaud, pepsin. Sedlitz Chanteaud, podophyl- lin. Podophyllin, aconitine. Aconitine. Nitrate of pilocarpine. Hydrochlorate of morphine. Aconitine. Veratrine. Podophyllin. r Podophyllin, digitaline. Sulphate of quinine. Sulphide of calcium. Salicylates. Cotoine. Diuretics, j Hydrobromate of morphine. { Hyoscyamine. j Hydrochlorate of morphine. ( Brucine. Quassine, pepsin. Aconitine. Sedlitz Chanteaud, calomel. Epilepsy. — It is not yet known with positiveness in what way epilepsy is originated. While it may be said that cerebral anaemia is the primordial lesion, this does not suffice to give us a clear knowledge as to its pathogenetic process. In cerebral anaemia, which is caused, for example, by lesions of the aortic orifice, we seldom observe disturbances like those which charac- terize the morbus sacer. There must therefore be something besides cerebral anaemia which acts as the cause of this neurosis. Epilepsy has been the subject of patient investigations, and the occasion for the most varied forms of treatment. At the present time, most of the drugs which were formerly employed have been discarded, the treatment being limited to large doses of the bromide of potassium. Medication with this drug furnishes results which are apparently favorable ; but, if the case of the patient who has undergone such treat- ment is followed for some time, it will be seen that im- provement is almost always temporary, and is likely to be counterbalanced by psychical lesions of an impor- tant character. In the author's opinion, the use of the ELEMENTS OF DOSIMETRIC PRACTICE. 247 bromides in large quantities should be reserved for cases which are rebellious to every other form of treat- ment, and in which the repeated attacks of the disease, and the psychical troubles which are peculiar to it, render life unendurable. Before using the bromides, we should try other agents which are less harmful, and in many cases are quite as beneficial. We should first distinguish idiopathic from symptomatic epilepsy. The latter may or may not be curable, according as the con- dition of which it is a symptom is or is not curable. Reference is now made to the former variety in detail- ing a plan for treatment. Cerebral ansemia should be treated with atropine, the doses being regulated by the tolerance of the patient, and care being always taken not to exceed the physiological effect. Twice a day, one to three granules of atropine may be given, whether the attacks occur regularly or not. If they occur peri- odically, or are announced by unequivocal prodromal symptoms, the treatment should be of a still more act- ive character ; and, as the time for an attack approach- es, one granule should be given every half -hour, until the throat is dry and the pupils are dilated. The sus- ceptibility of the nervous centers should be controlled by hydrotherapy and gymnastics, so regulated that they will not be harmful instead of useful. Certain diatheses have a decided influence upon the production of the disease. We should therefore insist upon anti- diabetic treatment, if we desire to obtain certain and durable results. The arthritic diathesis calls for the use of two granules of colchicine two or three times daily, and two granules of the salicylates of soda and lithia three times daily. In cases which are associated with syphilis, three granules of iodoform should be given three times daily, or six to twelve granules of the iodide of mercury daily. Scrofula demands two granules of iodoform and two of the arseniate of iron three times daily ; and chlorosis three gran- ules of the valerianate of iron three times daily, or 248 ELEMENTS OF THERAPEUTICS AND PRACTICE. six to nine granules of the arseniate of manganese daily, together with two granules of the hypophos- phite of strychnine, three times daily. The readi- ness with which attacks are sometimes excited by causes which are apparently insignificant shows that there is an exaggerated condition of irritability, both central and peripheral. This condition may be relieved by the use of two to four granules of the bromide of camphor three times daily, and the number of doses may be increased if the sensibility of the patient indi- cates that an attack is approaching. Mobility of the nervous system may be relieved by two or three gran- ules of the valerianate or the phosphide of zinc three times daily. For the excitability of the medulla ob- longata, which is sometimes the principal cause of epi- lepsy, but of the nature of which we are ignorant, we should give for a long period one granule of aconitine and one of cicutine three times daily. The cardiac troubles, which influence the circulation deleteriously, and by that means the functional activity of the nerv- ous system, may be treated with two granules of digi- taline and live of caffeine two or three times daily. Nocturnal attacks may be controlled by giving, each night before retiring, five granules of croton chloral every quarter of an hour until a hypnotic effect is pro- duced. The sirup of the hydrate of chloral will produce the same result ; but its effect upon the digestive organs is bad. In rebellious cases of epilepsy we may use ni- trate of silver, though its efficiency is doubtful, or the bromide of potassium,which will control the attacks more or less completely as long as its sedative action lasts. EPILEPSY. g /Pathogenic Cerebral anemia . | Atropine, hydrotherapy, gymnas- S J /a ,+!.,**« AUM«*A. i Colchicine, salicylates of soda and „, , Arthritic diathesis . -j of lithia> 5 / Syphilis . . . Iodoform, iodide of mercury. \ Etiologic i Scrof ulosis . . Iodoform, arseniate of iron. i Valerianate of iron, arseniate of manganese, hypophosphite of strychnine. ELEMENTS OF DOSIMETRIC PRACTICE. 249 /Exaggerated central and peripheral ) Bromide f hoi , irritability ) * . Mobility of the nervous system . j V ^ nate and P hos P hide of | J Excitability of the medulla oblon- ) Aconi t ine and cicutme> gata ) Cardiac troubles .... Digitaline and caffeine. Nocturnal attacks. . . . j ^°^J^° Y ^ ™ ^^ ° f Rebellious cases . . . . | ^t^ of silver, bromide of po- Epistaxis. — The predisposing and determining causes of nasal haemorrhages are those which pertain to all haemorrhages. Among the most frequent of the former are youth, the lymphatic and sanguineous temperaments, degeneration of the vascular tunics, stimulating food, insolation, etc. Among the latter are traumatism, active and passive congestions of the cranium, sneezing, foreign bodies, etc. Under whatever form the haemorrhage may be produced, it is evident that the principal lesion consists in the want of resisting power on the part of the vascular walls. The dominant vital indication will consist, therefore, in increasing their tonicity by restoring the contractility of their muscular elements. The most useful medicaments in the majority of cases will be three granules of ergotine every quarter of an hour, or one granule of sulphate of strychnine every quarter of an hour. When the haemorrhage is caused by active congestion, we should meet it with aconitine, as well during the crisis as in the intervals, one granule being given every half-hour until the symptoms disappear. Two granules twice daily will prevent the recurrence of the flow, especially if digitaline be combined with it. Epistaxis from passive congestion should be treated with revulsives, derivatives, and the sulphate of strych- nine, combined with digitaline, to facilitate the venous circulation. Two granules of each may be given three times daily. In the cases in which the dyscrasias are complicated by haemorrhages, two granules of the ar- seniate or the phosphate of iron may be given every 250 ELEMENTS OF THERAPEUTICS AND PRACTICE. two hours during the attacks ; two granules three times daily in the intervals. The adynamic forms of disease are often accompanied by nasal haemorrhage. We should give, in such cases, two granules of ergotine, or of sulphate of strychnine and phosphoric acid, every hour until the desired effect is obtained. Malarial poi- soning may have for one series of phenomena epistaxis, which is more or less periodic in character. Twenty granules of the sulphate of quinine, with three of the arseniate of strychnine, three times daily, will cause the disappearance of this symptom, which in some cases may excite alarm on account of its resistance to all the haemostatics. The haemorrhage appears periodically in some cases in which malarial poisoning is not a com- plicating element. It is so in those cases in which it is excited by alcoholic liquors, by irritating food, etc. Aside from the removal of the cause, which does not always suffice, as the organism, in such cases, seems to have acquired a habit of congestion, it is indispensable that the arseniate or the hydroferrocyanate of quinine be given in two-granule doses three times daily. The anaemia which results from severe or frequently re- peated haemorrhages from the nose, and which pre- disposes the patient to additional haemorrhages, may be cured by the use of two granules of quassine and three of the salts of iron three times daily. Syncope, in debilitated persons, or in those with whom the loss of blood has been considerable, should be treated at once with phosphoric acid, hypophosphite of strych- nine, and caffeine, one granule of each being given every quarter of an hour. If the condition of the pa- tient is such that the rapid absorption of medicinal substances can not be anticipated, a gramme of ether should be injected into the cellular tissue, and this will quickly revive the patient. Internal treatment should be supplanted in such cases by the use of suitable local haemostatics. The most efficient means of this charac- ter are a three- or six-per-cent solution of perchloride ELEMENTS OF DOSIMETRIC PRACTICE. 251 of iron, which may be injected into the nostrils, a ten- per-cent solution of cocaine, or, as a last resort, the plugging of the anterior and posterior nasal fossae. In simple cases of haemorrhage, such, for example, as may constitute a natural therapeutic agent, cold will suffice, if a haemostatic is required, applied to those regions which are most sensitive — for example, the testicles, sides, chest — or compresses saturated with ether may be applied to the frontal region. /Dominant. . Vascular atony ' Active congestion Passive congestion Causal . . ( Dyscrasias tf ] /Periodicity ^f> | f Anaemia Ergotine. Aconitine. Strychnine, digitaline. Arseniate of iron, ynamia . . Sulphate of strychnine. Malarial poisoning Sulphate of quinine. E" 1 \ g | | Adynamia ^ Ipt Hydrof errocyanate of quinine. Quassine, iron. j Phosphoric acid, hypophos- \ phite of strychnine "caffeine. Local haemostatics. ^Symptomatic gyncope 1 llhinorrhagia Erysipelas. — Pathologists are not in accord as to the primary cause of erysipelas. While some consider it a specific disease, others recognize in it only the char- acters of a simple inflammation of the skin. Such is the influence which is exercised by preconceived no- tions that the simplest facts are differently interpreted by different authors. Jaccoud, for example, considers erysipelas as a cyclical disease — that is to say, a series of phenomena with a definite duration, the phenomena succeeding each other in a regular order, and disap- pearing in obedience to the action of remedies. Hebra, on the contrary, denies that there is any regular order in the succession of these phenomena, and that their duration can either be determined or foreseen. This variability in the phenomena is so little influenced by treatment that Hebra is persuaded that the result will always be the same, whatever form of treatment is fol- lowed. According to the same author, most of the patients recover, some of them die, but the relative mortality remains constant from year to year. Let us see if it is possible to harmonize these two opposing 252 ELEMENTS OF THERAPEUTICS AND PRACTICE. views. Dosimetry can not admit, however, that the same disease can be cyclical and non-cyclical at the same time. It has been said of dosimetry that it is a system of medicine which is limited to symptoms, but that is the case only when the poverty of science pre- vents it from being anything else. Always, on the contrary, when the fundamental cause is known, dosimetry procures the most active weapons for fighting it. That is the reason why it never loses from view the principle of the dominant, which has so important a bearing upon all questions of pathogenesis. From a knowledge of such questions therapeutic results proceed, and these should be the object and aim of all physicians who desire to cure or to relieve their patients. Every cyclical disease pre- supposes a morbid principle which undergoes a certain evolution, and, in so far as this evolution is incomplete, the disease has not terminated. This morbid agent is, then, a substance which lives in our organism. For- tunately, we know that these agents may die before they have completed their natural evolution ; further- more, we know what agents will destroy them, and in this fight we possess weapons of precision to use against the infinitely small, but likewise the infinitely numer- ous. This theory of specificity reckons among its most distinguished defenders Wells, Yelpeau, Bouillaud, Trousseau, Gosselin, Jaccoud. Even before the micro- scope had demonstrated the enemy, its presence was sus- pected, and since then the question of the existence of the parasite has been settled by the labors of Hueter, Orth, Cohn, Bouchard, and, quite recently, Dupeyrat and Fehleisen. The opposite theory will not yet admit that it is defeated, and, while it does not deny the exist- ence of parasites in the blood and other fluids of ery- sipelatous patients, it attributes their existence to ; morbid modifications in the organic liquids, which ' enable the parasites to live. The cultures recently made by Fehleisen with micrococci (bacterium jpunc- ELEMENTS OF DOSIMETRIC PRACTICE. 253 turn) found in the lymphatics of that portion of the skin which has been invaded by erysipelas, and the re- production of the disease with all its characteristics in a woman by inoculation with these culture fluids, have dis- sipated the last doubts of the few remaining partisans of the humoral and inflammatory doctrine. But, if it is demonstrated that erysipelas is a parasitic or a microbi- otic disease, how does it happen that so careful an ob- server as Hebra has failed to recognize the fact that the disease is of a cyclical character % How can its contagi- ous character, its eruptive phenomena, its reproduction by inoculation, be harmonized with the inconstancy of its duration \ The solution of this question is furnished by the study of the disease. Its progress is essentially the same as that which exists, or is believed to exist, in connection with furuncles, which are propagated and multiply by a kind of auto-inoculation. Parasitic in- fection is therefore local, that is, limited to a certain zone of the skin. For, by studying the morbid process upon that zone exclusively, it is observed that the disease always evolves in the same way, and that its duration is constant in all cases. It is really, then, a cyclical disease. But, as it almost always extends and is propagated per contagium, as Hebra says, it happens that it varies in its ensemble, according to the nature of the tissues attacked and its extension, which gains from step to step. In other words, the disease is com- posed of a variable series of local invasions, each one of which is subject to the same invariable rule of mor- bid phenomena. The cyclical character of erysipelas explains the want of success which has attended its treatment with the means which have hitherto been used, Jaccoud even declares that the power of the physician is limited to converting into a serious form this disease, which is usually of a benign form. Hebra, after having obtained the same result from treatment of different kinds, concludes in favor of the expectant method. Louis shows by statistics, which are as exten- 254 ELEMENTS OF THERAPEUTICS AND PRACTICE. sive as they are exact, that the most active form of treatment can boast of shortening the disease by only three quarters of a day when compared with other methods. This result is not surprising, for, aside from the fact that the treatment is almost always exclusively symptomatic and most frequently local, allopathic means of medication are almost always perturbing, and very rarely effective. The treatment should be both fundamental and symptomatic ; in other words, both the dominant and the variant should be enforced. Since erysipelas is due to the proliferation of the bacterium punctum, we should oppose this morbid agent during the entire course of the disease by the most efficient parasiticides. As a rule, the alkaloids are parasiticides, which accounts for the results ob- tained in eruptive fevers by the administration of def er- vescents — aconitine, veratrine, digitaline, and strych- nine. The most efficient agent in all diseases of this kind is sulphide of calcium, and its use should not be neglected as soon as the disease appears. Its action may be increased, if necessary, by the use of salicylic acid and the salicylate of quinine. The sooner one has recourse to the dominant, the greater will be the profit which is derived from it. It is all important to establish the diagnosis as soon as possible, and thus prevent the extension of the disease by the dissemination of its germs. During an epidemic the diagnosis is easily made in consequence of the painful engorgement of the glands in the vicinity of the region in which the exanthema is first apparent. Sulphide of calcium should be given every quarter of an hour or every hour, or in two-granule doses every two hours, according as one designs to accomplish the checking or the attenuation of the disease. The period of invasion is sometimes announced by such violent chills that they seem like the precursors of pneumonia. In this stage of febrile movement we should give phos- phoric acid and the sulphate or the arseniate of strych- ELEMENTS OF DOSIMETRIC PRACTICE. 255 nine. The valerianate or the arseniate of caffeine will relieve cephalalgia. Nausea and vomiting, which in- dicate that the parasite has established itself upon the gastro-intestinal mucous membrane, require evacu- ants, of which Sedlitz Chanteaud, emetic, or emetine will be found efficient. For children emetine should be preferred, two or three granules being dissolved in a little water, and the dose being repeated at inter- vals of ten minutes until vomiting is produced. In the period of eruption, when by the sensitiveness of the organism the foreign bodies which irritate it are expelled from the tissues, all the phenomena are still due to the presence of the parasite. The dominant is always indicated therefore, and the variant must be chosen in accordance with other indications which, though secondary, should engage our attention. The fever, which is almost always elevated, might, perhaps, be of service, if we had not always other weapons for the essential cause of the disease ; but, as there are other means at our disposal, we should modify the fever so as to economize the forces of the body to the greatest pos- sible extent. The means which may be used to over- come the disease by assisting the dominant, when the febrile elevation interferes with its action, are veratrine, when the digestive passages are obstructed or the phlogosis of the skin is excessive ; digitaline, when there is delirium in consequence of an irregular distri- bution of the blood ; aconitine, when the fever exceeds 39°; the arseniate or the salicylate of quinine, when the type of the fever is intermittent or remittent. Delirium from cerebral anaemia, when the fever is very high, will yield to the use of generous wine and arseniate of strych- nine ; albuminuria, which is almost always transient, calls for means which will facilitate diuresis without un- duly stimulating the renal function. Such means may be supplied with a few granules of colchicine or of digi- taline. After the parasites have been destroyed, means should be employed to excite elimination of the morbid 256 ELEMENTS OF THERAPEUTICS AND PRACTICE. products which they have left behind them, and, as bacteria prefer the protective tissue, it is in these tissues especially that elimination should be stimu- lated. Diaphoretics, and among them the nitrate of pilocarpine, may be used with advantage ; but as a rule the action of the sulphide of calcium upon the skin will be sufficient both to kill and to eliminate the para- site. When the digestive organs are in such a condi- tion that reparation by means of food is too slow, the appetite may be revived and the strength increased by quassine, arseniate of iron, and sulphate of strychnine. Local or external means of treatment should be limited to the use of weak local disinfectants ; for example, of lycopodium, salicylated starch, or camphor. External applications of cotton wool will also be of service in preventing contact with the atmosphere and dispersion of the germs. Constant applications of cold water will also soothe the patient and reduce the local as well as the general temperature ; they will in addition assist in destroying the microbes. Though such applications may sometimes be useless, they are at least, according to Hebra, always free from danger. The means which have been devised for preventing the entrance of the microbes into the body may sometimes be injurious. In the attempt to derive much benefit from such means, we might unintentionally destroy the lymphatic vessels, by which the elements of the disease are disseminated. ( Dominant. . -f Inf action by the baote ( 1st period : Invasion, 2d period : Eruption. 3d period : \ Destruction. num punctura Chills . Cephalalgia . Nausea and vomiting 'Fever . Delirium Albuminuria ; Gastric disturbance Elimination of morbid products Restoration of strength and relief of gastric •< Arseniate of atony ( Salicylate of quinine. I Sulphide of calcium. ] Phosphoric acid, sulphate ( of strychnine. Valerianate or arseniate of caffeine. Emetine, emetic. Veratrine, digitaline. Arseniate of strychnine, wine. Colchicine. Sedlitz Chanteaud. Sedlitz Chanteaud. Nitrate of pilocarpine. ( Quassine. ( Sulphate of strychnine. ELEMENTS OF DOSIMETRIC PRACTICE. 257 Fever, Intermittent. — See Paludal Infection (un- der Infection). Fever, Puerperal. — Under this title will be con- sidered the infectious and contagious parasitic disease which occurs during the puerperal condition, and is known under the different names of puerperal metritis, puerperal metro-peritonitis, puerperal typhus, puerpe- ral poisoning. The characteristic feature of this dis- ease is an infectious element, which has not yet been thoroughly investigated, which is believed by many to be a ferment, and which bears the name of lochine. The inflammatory element, which is often regarded as the most important one, is often present as a predispo- sition to or a complication of the disease, but of itself it is not sufficient to produce the condition which is known in practice under the name of puerperal fever ; on the contrary, we sometimes see the infectious ele- ment appear by itself, without any evidence of inflam- mation on the part of the uterus. In a word, there is a puerperal metro-peritonitis of an infectious charac- ter, but there may also be puerperal infection without metro-peritonitis. It is the predisposition to puerperal infection caused by metritis, and the frequency with which inflammatory lesions are produced by the lochial virus, which has influenced many writers to believe in the identity of the two conditions. But, if the differ- ences of opinion of the pathologists in respect to the pathogenesis of this disease are to be regretted, their agreement in respect to prognosis is equally so. In fact, as Pajot says, "if they differ in regard to its pathogeny, they agree in regard to its fatal character," which demonstrates the absolute impotence of the official method of practice, and the uselessness of all forms of treatment which have been recommended by the different schools. Pajot has even added: "The only treatment for puerperal fever consists, on the part of women, in not having it, and, on the part of physi- cians, in not communicating it." Still one sees popular 17 25S ELEMENTS OF THERAPEUTICS AND PRACTICE. physicians prescribing remedies in which they have faith every day, but the inefficiency of which is sadly demonstrated by results, at least to those who are not blinded by routine action. The sulphate of quinine is the remedy which is always prescribed for puerperal fever. The patients die one after another, but the tra- ditional treatment continues, notwithstanding these consequences. Why should we change, for magister dixit f Official science has yet to find any other reason for its practice in this matter. Since death is certain, whether large doses of quinine are or are not given, why should the quinine be insisted upon ? If some other agent were employed, however unlikely success from its use might seem, there would at least have been the merit of attempting to save one' s patients ; but to continue in the use of a drug which constantly gives negative results is not justifiable. The one who con- demns quinine as useless, and with high authority, is Pajot himself, the specialist in diseases of this charac- ter. Ten years ago he wrote: "I gave sulphate of quinine in large doses so often during the lifetime of the lamented Dr. Beau that no illusion concerning this drug could be experienced by me. Marvelous as is its action in other conditions, it is perfectly useless in the one which we are discussing." (Letter to Dr. Yerrier, in the " Gazette Obstetricale," concerning the treat- ment of puerperal fever.) The dosimetric system is more fortunate. Its plan of medication varies in ac- cordance with the symptomatic phenomena, but its object is always to attack the cause of the disease by interpreting in a logical manner its true nature. It does not always succeed, perhaps because the infection is already so pronounced that it quickly annihilates the vital forces, in the absence of which there can be no curative action ; perhaps because its intervention is required when the anatomo-pathological lesions can not be relieved — a condition which is soon reached in puerperal fever. Notwithstanding all adverse condi- ELEMENTS OF DOSIMETRIC PRACTICE. 259 tions, cures by this method are not infrequent, and desperate cases are recorded in its journals which are readily cured by alkaloid o therapy. It will be proper to describe the method for the prevention of puerperal accidents, which is useful at all times, but is indispen- sable during epidemics. Accouchement signifies a trau- matism of considerable moment, together with general prostration, which is the result of muscular action and moral impression which the patient can not avoid. The wounded surface is supplied with important veins, which, having been torn, are exposed to the contact of air and the decomposing liquids which form the lochia. It is therefore easy to understand the condition which may be present in the venous system from the intro- duction of air and the absorption of septic products, which include miasms, bacteria, parasites — in a word, agents which result in puerperal infection, and which are developed with marvelous rapidity. The indication in such cases is therefore to contract the traumatic sur- face to its narrowest limits, rapidly inducing uterine involution by means of ergotine ; to restore by strych- nine to the muscular and nervous systems the force which was expended during labor ; and to relieve the uterine mucous membrane of congestion, so as to avoid inflammation, by means of aconitine and the hydro- ferrocyanate of quinine. Ergotine should be given in two-granule doses every hour as soon as possible after labor is finished, and continued until the uterus has resumed its normal volume. After this involution has been obtained, we should give one granule of aconitine, one of strychnine, and two of quinine every three or four hours, until the fever which attends the establish- ment of lactation has disappeared. With regard to the curative treatment of puerperal infection, it should be observed that hyperthermia is the most notable characteristic of the disease. The fever may rise to 42° C, or higher, appearing in exacerbations, which occur once or twice daily. We have seen that the antiperi- 260 ELEMENTS OF THERAPEUTICS AND PRACTICE. odic action of quinine can not be trusted for this con- dition, whatever be its dosage. Something besides periodicity must be opposed in this fever, namely, the infectious element ; and this must be met with the sali- cylates or the sulphide of calcium, and local antiseptic applications. Hyperthermia demands very active def- ervescent treatment. The dominant may be satisfied, therefore, with two granules of the salicylate of quinine and one of aconitine every half -hour. This treatment is generally instituted by the author in his practice at the beginning of the disease, and the results have al- ways been very favorable, if the attendant realizes the importance of regularity in the administration of the medicine. After the disease has passed its first phase, we may add to the treatment two granules of the sul- phide of calcium every quarter of an hour, and dimin- ish or double the quantity of aconitine according to the requirements. The thermometer should be the sole guide for the continuance, diminution, or increase of the dosage. The local treatment must not be neglect- ed, and uterine or vaginal injections must be system- atically made with a 2|-per-cent solution of salicylic acid. Uterine injections of chloride- of -zinc solution, 1:1,000, may also be serviceable. When the invasion of the disease is announced by chills, we should give one granule of phosphoric acid and one of the arseni- ate of strychnine every half-hour until a reaction oc- curs. It is also worthy of notice that the better the innervation of the system during the period of con- centration of the virulent influences, the better will be the condition of the organism to endure reac- tion. Abdominal pain is sometimes intense, espe- cially if the peritonseum is implicated ; it should be treated with the hydrochlorate of morphine. Two granules may be given every half-hour, and it will both relieve the vomiting and check the diarrhoea, which may be accompanying conditions. Insomnia, which is often rebellious and of grave import, may be treated by ELEMENTS OF DOSIMETRIC PRACTICE. 261 similar means. The delirium and cephalalgia may re- quire caffeine in two-granule doses every half-hour, in addition to the aconitine, which will relieve them if it produces its complete effect. If abscesses are formed, indicating purulent absorption, there will be little hope of saving the patient. Nevertheless, it will still be worth while to try the effect of salicylate of ammonia, with iodoform and arseniate of quinine ; one granule of each may be given every half -hour. Prostration, which is almost always considerable, even when the disease has not been of long duration, should be treated with one granule of the sulphate of strychnine every hour. Suppression of the lochia calls for veratrine and aconi- tine, and retention of the urine for one granule of digi- taline and one of hyoscyamine every two hours. This plan of treatment may be followed with all confidence, persistence and regularity by night and by day being essential, and also regulation of the dosage both as to quantity and frequency, according to the urgency of the indications and the effects which are produced. Extreme cleanliness, ample ventilation, a tonic regimen regulated by the digestive ability of the patient, and absolute exclusion of all moral influences of a de- pressing character are the hygienic precautions which should be prescribed and rigorously observed. Cases of simple metritis and metro-peritonitis should be treat- ed as if they were infectious, for the reason that it is not easy to distinguish their true character at the be- ginning, and because it is in this first stage that they may be checked, and that our means of action will have the greatest effect. PUERPERAL FEVER. Preventive Treatment. Slow involution Ergotine. Fatigue Strychnine. Hyperemia j Aconitine, hydroferrocyanate of ^ ° ' * ( quinine. 262 ELEMENTS OF THERAPEUTICS AND PRACTICE. Curative Treatment. (Hyperthermia . . . Aconitine. Dominant. / Febrile intermittence ' \ Infectious element . I Local infection /Chills Abdominal pain Insomnia . Vomiting Diarrhoea . Variant. Purulent infection . Adynamia Suppression of the lochia Retention of urine . Salicylate of quinine. Antiseptic injections. j Phosphoric acid, arseniate of \ strychnine. I Hydrochlorate of morphine, co- j deine. j Salicylate of ammonia, iodoform, \ arseniate of quinine. ] Sulphate of strychnine, generous \ wine. Veratrine. Digitaline, hyoscyamine. Fever, Traumatic, and Other Accidents ac- companying Traumatisms. — No one, at the present time, is able to tell exactly what traumatic fever is ; after operations and injuries a train of local and general symptoms is observed, with varying degrees of severity, from simple epitraumatic fever to purulent infection and septicaemia, of the nature of which we are ignorant, and the varieties of which are not well defined. These accidents do not depend essentially upon traumatism — that is, traumatism alone is not sufficient to produce them, for we often see traumatisms follow the custom- ary course to complete cicatrization, without any evi- dence that the general condition is affected. The influ- ence of curative agents and of the hygienic conditions of the wound upon the appearance and progress of dis- turbances of the general condition shows also that fever is not provoked by simple lesions of structure. The most reasonable theory is that fever is produced by the absorption of decomposed matter in the form of certain ptomaines, which are developed at the sur- face of injured tissues, and which, by modifying the condition of the blood, influence the innervation of the nutritive system to such an extent as to deter- mine febrile reaction. According to the malignity and the quantity of these products, as well as the facility with which they are absorbed — in a word, ELEMENTS OF DOSIMETRIC PRACTICE. 263 according to the dose of these deleterious matters which is introduced into the blood, and the impres- sionability of the patient — will result the intensity of the traumatic fever and the development of its vari- ous forms. The indication is, therefore, to prevent the decomposition of the liquids which bathe the wound by perfect cleanliness, the application of unirritating disinfectants, and prevention of the entrance of mi- crobes from without ; in the second place, by relieving the nervous and circulatory systems of congestion, so as to prevent reaction from the irritation which has been caused by the absorption of toxic matter. This will be accomplished with aconitine and veratrine joined with tonics, such as strychnine and the hydroferrocya- nate of quinine. Treatment may be preventive or cura- tive. If preventive, it should begin, if possible, a few days before the reception of the traumatism, and con- sist in the administration of two granules of aconitine and two of veratrine three times daily. After the op- eration has been performed, we may give two granules of the arseniate of strychnine and two of the arseniate or the hydroferrocyanate of quinine three times daily to stimulate the nervous system, repair the losses which have been sustained, and develop impressions which should be strengthened by the modifications which are effected in the secretions. This treatment has given surprising results whenever it has been em- ployed. The traumatic fever becomes a matter of no consequence, and cicatrization takes place with remark- able rapidity. The absence of fever enables us to feed the patient liberally, a condition which is very impor- tant for the attainment of good results from operations. If this preventive treatment can not be adopted, or proves ineffective, we must endeavor to check energetic- ally the fever which is developed. We should make use of the same means as in the previous condition, but they should be used with greater activity. One granule of aconitine and one of veratrine may be given every 26i ELEMENTS OF THERAPEUTICS AND PRACTICE. half -hour until the mercury indicates 38° C. As soon as there is a remission, three granules of the hydroferrocy- anate of quinine with one of the arseniate of strychnine may be given every two hours. Purulent infection calls for the same treatment, defervescents being added — for example, one granule of the salicylate and one of the arseniate of quinine being given every half-hour. In cases of septicaemia the salicylate of ammonia may be added, the antiseptic action of which has often been demonstrated by the author. Two granules may be given every hour. The vitality of wounds will be modified by dosimetric agents as surely as by external means — the inflammatory condition by one granule of aconitine every two hours ; the atony by two granules of phosphoric acid four times daily, and strychnine in similar doses ; the pain by two granules of morphine or gelsemine every quarter of an hour until relief is ob- tained. Somnolence after wounds have been received will indicate the use of two granules of the arseniate of caffeine every two hours ; want of appetite should be met by properly selected diet, and by two or three granules of quassine before eating ; constipation, which is of such common occurrence on account of the en- forced rest in bed, will be relieved by the daily use of Sedlitz Chanteaud. Suppuration of a non-laudable character, which in- dicates retarded cicatrization and is an attendant of weak constitutions and lymphatic temperaments, re- quires two granules of iodoform and two of the arseni- ate of iron three to six times daily. Aconitine, veratrine, arseniate of strychnine, hydroferro- cyanate of quinine. Quassine. Sedlitz Chanteaud. Aconitine. j- Iodoform, arseniate of iron. Arseniate of caffeine. Arseniate and salicylate of quinine. Salicylate of ammonia. « H /Dominant > g ) / Want of appetite . o< Constipation t— I w Local inflammation H Local atony . ^h \ Variant. ( Slow cicatrization Somnolence . < Purulent infection H ^Septicaemia . ELEMENTS OF DOSIMETRIC PRACTICE. 265 Fever, Typhoid.— Science, in spite of its extensive investigations and profound discussions, has not yet been able to determine the causal element of this dis- ease, the treatment of which is about to be referred to. It would appear that the pathogenic element resides in a living agent, which originates either in man or ex- ternal to him, and is developed and proliferated within his intestines, poisoning the organism until, as a result, there is one of the severest diseases with which human- ity is afflicted. The effects of this intoxication are especially mani- fested by exaggerated bodily heat, and by rapid and profound diminution of the strength. If, therefore, we seek to eliminate the morbific agents with the material which serves as soil in which they may develop, to neutralize those which we can not eliminate, to lower the hyperthermia, and to prevent or effectually over- come the adynamia, the disease will be reduced to its simplest expression. Its duration will, of necessity, be abbreviated, and by suppressing the morbid ele- ments which give to it its gravity, we transform it into a benign disease, with a mortality which is much less frightful. The dominant indications naturally follow from these simple pathological considerations. The intoxication from typhoid fever does not take place in the same manner as in the eruptive fevers. On the other hand, the poisoning appears to be gradual and progressive, and to result from an increasing absorp- tion of toxic principles, rather than from a rapid infec- tion of the entire organism with microbes. As a thera- peutic corollary, it follows that an active intervention, in order to be effective, should begin with the first days of the infection ; also, that the diagnosis is difficult in the first stage of the disease, which is characterized by oscillations of the temperature, with an upward ten- dency. By late interference the opportunity for being truly useful is lost; on the other hand, the disease may be checked by early interference, and then the 266 ELEMENTS OF THERAPEUTICS AND PRACTICE. doubt may arise whether the condition would really have developed into typhoid fever. The prodromic signs and the course of the disease during the first few days are sufficiently characteristic to put the physician upon his guard, and compel him to act at the proper moment in as resolute and energetic a manner as if the disease were entirely established. The principal indi- cations to be satisfied are the following : 1. To relieve the digestive organs of all fermentable materials. The Sedlitz Chanteaud, by its mild and moderate purgative action, by its slightly bitter taste which is gradually tolerated without any difficulty, and by its defervescent properties, is the agent which should be preferred. A small teaspoonful in water in the morning, or a large spoonful dissolved in water and taken during the day, will be sufficient for ordi- nary doses, but the quantity must be regulated by the intensity of the symptomatic diarrhoea of the disease. 2. To neutralize morbific agents. This indication, which is fundamental, will be satisfied by the use of antiseptics and parasiticides. The selection of the means is a very important matter, for those agents should never be chosen which depress the vital forces too much, or which irritate the gastro-intestinal canal, the vitality of which has been so profoundly affected. Phenic acid, salicylic acid in large doses, the prepara- tions of cinchona, etc., in spite of their advantages, have this decided disadvantage. In addition to the alkaloids, which are all parasiticides to a greater or less degree, we should give the. sulphide of calcium, in two-granule doses, every two hours ; or, the salicylate of quinine, in one- to three-granule doses, every two hours. 3. To moderate the hyperthermia. This necessity, which is universally recognized, and is observed in all forms of treatment, arises not only from the fact that prolonged hyperthermia is an element of danger, but also from the fact that reduction of the fever has a very favorable influence upon adynamia and all the conse- ELEMENTS OF DOSIMETRIC PRACTICE. 267 quences of the morbid process. The method of seeking to obtain this result, by the use of large doses of qui- nine> is not the best one, for it implies considerable disturbance to the organism, and its use must be inter- rupted in order to avoid inconveniences which are per- fectly apparent. Defervescence should be obtained gradually, and therefore only such doses as are abso- lutely required should be given, lest the adynamia be thereby increased ; on the other hand, the dose should not be less than is required, otherwise the medication will be ineffective. The adaptation of the doses to the resisting power of the disease, that is to say, dosimetry, could not be improved upon in these cases. The plan should be fractional and repeated doses, simple and pure remedies, the introduction into the stomach of those things only which are necessary, and in doses which will not interfere with the absorptive capacity ; and this plan can not be violated without injury to the patient. In many cases it will be proper to dissolve the granules in water, or in water mingled with wine or milk, because the irritability of the intestinal tube is such that the granules will quickly pass through it undissolved, not finding sufficient fluid to dissolve them. We should also remember that the entire quan- tity of medicine which is taken into the stomach, even if in solution, is not effective — a portion of it is dis- charged ; and hence we can not use doses which, under other conditions, might be tonic, but in this disease will barely produce the desired effect. The deferves- cent agents which are used in dosimetry, and the supe- riority of which has been demonstrated by experience, are aconitine, veratrine, digitaline, hydroferrocyanate of quinine, or salicylate of quinine. The quinine is used on account of its antiperiodic effects, the others because of their influence upon hyperthermia. They should be given in combination, as in that way their effect will be found to be more prompt and more cer- tain, and, besides, given in this way their absorption 268 ELEMENTS OF THERAPEUTICS AND PRACTICE. is more probable tlian if any equivalent dose of a single substance is given. The frequency of the doses must be regulated by the intensity of the fever, and, above all, by the results which are obtained. When begin- ning the use of defervescents, we should administer them every quarter of an hour until the thermometer indicates a remission. During the first few days th& treatment is intended to be abortive, and, if the case is taken in season and the treatment is faithfully carried out, it will be followed by the most gratifying results. After this first period has passed, it will no longer be possible to abort the disease, and our efforts must be expended in the prevention of excessive temperatures. Then it will suffice to give defervescents every hour, with longer intervals at night, when remission would naturally occur. This plan of defervescent treatment may require continuance for several days ; but it must be kept up until its effect is produced, unless there is a con tra-indi cation of greater weight. In the author's experience it has been tried for eight days in succes- sion, and, when hope was beginning to fail, the change came rapidly. This result could have been attained in no other way than by obstinate persistence. Variety and versatility in the plan of treatment almost always are a source of sorrow. An illustration may be given in the following case : The fever was well defined, had reached its second stage, and presented grave symp- toms. The dosimetric plan of defervescent treatment dissipated the symptoms referable to the nervous sys- tem, the tongue became clean, the urine clear, and the temperature was reduced, but beyond this no improve- ment could be obtained, the defervescence remaining incomplete. In spite of persistent treatment, the con- dition could not be changed. It was not a dangerous one, but it was quite unusual that it should resist so long, though the cause, probably, was that the treat- ment had been begun too late. Upon the ground that the resistance of the fever might be due to insufficiency ELEMENTS OF DOSIMETRIC PRACTICE. 269 of the medication, the old-fashioned (non-dosimetric) means of treatment were tried. The sulphate of qui- nine and the decoction of quinquina were given in allo- pathic doses. One day of this treatment, which is justly called incendiary, was sufficient to change the condition and bring the patient back again to the first condition of the disease. The tongue became dry, the fever increased, delirium returned ; in a word, the gravity of the case became such that it was decided to return to the dosimetric treatment, and to be more patient in the future. From the foregoing it will ap- pear that typhoid fever must not be considered as a disease which can be overcome in a few days. We must be satisfied with a simplification of the cases, a removal of the severe symptoms, and must leave the rest to the natural evolution of the disease, because lesions which have already been established must un- dergo certain absolutely essential conditions of repair. Jugulation of the disease is possible in its first stage ; after that has passed we can only hope to lessen the severity of it. In the majority of cases it may be said that typhoid fever, treated according to dosimetric prin- ciples, is to the same disease, treated by other methods, as discrete variola is to the confluent form. It is the same disease, and is subject to the same phases, but with great difference as to the suffering, the gravity, and the mortality which attend it. 4. To oppose adynamia. This indication may be satisfied by avoiding violent remedies, and giving the patient a diet which is suitable to his digestive ability, by moderating the cause of weakness, and giving neu- rosthenic remedies in liberal doses, especially the arseniate of strychnine, of which one granule may be given every hour. Strychnine is the tonic par excel- lence, and its superiority is of that kind which builds up without producing irritation ; however long it may be used, the tissues will not become congested, and no lesion will be evident, even from toxic doses. It is a 270 ELEMENTS OF THERAPEUTICS AND PRACTICE. truly dynamic medicament, and might be considered almost a specific for typhoid fever. The secondary indications are more numerous than the primary, and among them are some which are rarely met, because if the treatment has been well carried out they do not appear. The books on pathology should give special attention to the association of the symptoms, and should separate clearly those which are essential from those which appear only as the result of our therapeu- tic inefficiency. Unfortunately, the pathologists men- tion in their books all the symptoms which are possi- ble, all consequences which are imaginable, not even excepting death, in connection with diseases which are susceptible of cure. Chapters which are terminated with directions respecting treatment should never con- found the natural evolution of a disease with its course when modified by the intervention of art. The epis- taxis, which may appear either at the beginning or in the course of the disease, should not be ignored ; in the first case, it will be a source of weakness to the patient, in the second it will denote, in addition, a grave dyscrasia. Ergotine is the proper remedy on both occasions ; but, in the second, it should be asso- ciated with the arseniate of iron or the arseniate of strychnine. Two or three granules of the ergotine may be given every quarter of an hour until the effect is obtained. Cephalalgia may usually be relieved with aconitine. Should its intensity be such that it resists the anticongestive power of that alkaloid, the bromide of camphor may be given in addition, in three-granule doses, every quarter of an hour. The same may be said with respect to the treatment of delirium which was said concerning cephalalgia. In addition, half a granule of hyoscyamine every hour will have a very soothing effect upon the cerebral functions. The treat- ment for hyperthermia has already been alluded to. In some cases, cold or lukewarm baths at regular intervals will be proper to reduce the heat. Ablutions with cold ELEMENTS OF DOSIMETRIC PRACTICE. 271 water and with vinegar are also very useful, not only to diminish the heat, but also to preserve the functions of the skin in the best possible condition. If hygienic regulations concerning the skin are appropriate in a state of health, how much more during disease ! Pul- monary lesions in this disease are so frequent that they may serve as a means of diagnosis. Digitaline and strychnine, which have already been mentioned as filling important indications, have also their particular application in the disorders of the respiratory appara- tus. Should the local pulmonary lesions become severe, or resist the use of defervescents, bryonine may be associated with them, which has the property of in- ducing resolution of broncho-pulmonary inflammations without aggravating the morbid condition in the intes- tine ; one granule may be given every two hours. Vaso-motor paralysis, which is the result of the nu- merous and severe conditions prevailing with this dis- ease, may be treated with two granules of ergotine and two of strychnine every two hours. The active princi- ples of ergot, aside from their power over this form of paralysis, have a remarkable influence upon the course of the fever. For meteorism, one granule of the hypo- phosphite of strychnine should be given every two hours, together with occasional enemata of cold water. If the cardiac complications are of an ataxic character, they may be regulated by digitaline ; if they are only atonic, caffeine or its salts may be given in two-granule doses every hour. Intestinal haemorrhages indicate ergotine, and ice both internally and externally. Ene- mata of ergotine are also useful ; each one may be com- posed of ten grammes of ergotine and twenty of water. The diarrhoea, if it is held in control, is serviceable ; if it is excessive, it results in great weakness. Morphine must be used with great caution, as it readily excites congestion of the nervous centers; codeine or cotoine should be used in preference, two granules being taken every hour. The renal complications call for great 272 ELEMENTS OF THERAPEUTICS AND PRACTICE. prudence in the treatment, and the frequent use of the thermometer. They are almost always caused by the passage of infectious elements through the urinary filtering apparatus, and will only disappear when the pathogenic cause of the disease is overcome. The in- dication for the elimination of these elements or their residue may be met by digitaline or Sedlitz Chanteaud. In addition to these drugs we may give, during the declining period of the disease, two granules of benzoic acid or of benzoate of soda four times daily. Eschars [upon the skin — Trans.] are rarely seen in patients with this disease, because the adynamia and the dura- tion of the disease do not often lead to such a degree of disorganization. In cases in which they have occurred they may be dressed with absorbent cotton dipped in a one-per-cent solution of hydrate of chloral. Convales- cence is often marked by very severe accidents. The digestion may be improved by the use of two granules of pepsin and two of quassine with each meal. The arseniate of iron and the hypophosphites of lime and soda should also serve as elements in the reconstructive treatment, two to four granules of each being given three times daily. Should suppuration occur, we should administer two granules of iodoform with two of the arseniate of strychnine four times daily ; and, should the process become an extensive one, we should add three granules of the sulphide of calcium three or four times daily. For paralysis we should use two granules of phosphoric acid three times daily, or two to four granules of the phosphide' of zinc three times daily. The mental perturbations may result from material lesions or from such as are purely dynamic. In the first case we should give two granules of iodoform and two of the arseniate of soda four times daily, to mod- ify the nutrition ; in the second case the vaso-motor troubles should be met with one granule of the hypo- phosphite of strychnine and one of hyoscyamine, three or four times daily, and three granules of ergotine three ELEMENTS OF DOSIMETRIC PRACTICE. or four times daily. The foregoing enumeration of the possible indications is very incomplete, but the object has been to call attention only to those which are most frequent. The others, which are rare under any form of treatment, become still more so if an abortive plan of treatment is adopted at the beginning. Infectious element j Sulphide of calcium, salicy- ( late of quinine. Sedlitz Chanteaud. Arseniate of strychnine. Aconitine, digitaline, vera- trine, hydroferrocyanate of quinine. Ergotine. Bromide of camphor. Hyoscyamine. j Defervescents, warm baths, { cold ablutions. Bryonine. Ergotine. j Hypophosphite of strychnine, ( cold enema ta. Caffeine, digitaline. Ergotine, ice. Codeine, cotoine. Benzoic acid, benzoate of soda. Hydrate of chloral (topical). ( Quassine, pepsin, arseniate of iron. I Hypophosphites of lime and [ soda. {Iodoform, arseniate of strych- nine. Sulphide of calcium. Phosphoric acid, phosphide of zinc. Iodoform, arseniate of soda, strychnine, hyoscyamine, ergotine. Fever, Yellow. — Yellow fever is a disease which is evidently infectious, and a parasitic agent has been sought as its cause. Some investigators profess to have found the microbe which answers such a requirement in rice. The analogies of this disease with bilious re- mittent fever lead one to suppose that the dominant of the treatment is found in the salicylate of quinine, on account of the antiparasitic and antiperiodic properties of that salt. During the entire duration of the disease, 18 f Dominant. ( Adynamia Fever .... > ''Epistaxis. Cephalalgia Delirium . . q( Hyperthermia . o W p-i Pulmonary complications Vaso-motor paralysis Meteorism I Cardiac complications Enterorrhagia . Diarrhoea .... Variant. < Renal complications Eschars .... Convalescence . Suppuration . Paralysis .... ^Mental perturbations 274 ELEMENTS OF THERAPEUTICS AND PRACTICE. therefore, until the period of declension, two grannies of it should be given every half -hour. Its intense rhachialgia calls for two granules of the hydrobromate of cicutine every half-hour. The fever must be treated with one granule of aconitine and one of veratrine every half-hour until it has been sufficient- ly reduced. Should nausea and vomiting interfere with the regularity of the defervescent treatment, two granules of codeine should be added every half -hour, or one of hyoscyamine every hour. One granule of strychnine may also be given every hour to increase the tolerance of the remedies and to prevent adynamia. If the adynamia is severe, we must give one granule of phosphoric acid every two hours. For the haemorrhages, which announce themselves by the black vomit, we should use two granules of er- gotine or two of salicylate of iron every half-hour. Should melsena occur, the same treatment is indicated ; but the prognosis becomes very grave. Insomnia and delirium call for the use of two gran- ules of the bromide of camphor every quarter of an hour. Should there be suppression of urine from renal fault, two granules of scillitine may be given every hour ; if the anuria results from paralysis of the bladder, the catheter must be used, and strychnine resorted to. To diminish thirst and excite hepatico-intestinal action, Sed- litz Chanteaud dissolved in a large quantity of water may be used for an ordinary drink. During convalescence, two to four granules of quassine and a like quantity of the arseniate of quinine may be given three times daily. Dominant. Infectious element /Cephalalgia . Rhachialgia . Fever . Variant. \ Nausea and vomiting Haemorrhage Insomnia Delirium Anuria . ^Adynamia . Salicylate of quinine. Citrate of caffeine. Hydrobromate of cicutine. j Aconitine, veratrine, hydrofer- ( rocyanate of quinine. ] Sulphate of strychnine, hyos- | cyamine. Ergotine, salicylate of iron. Bromide of camphor. Scillitine. Arseniate of strychnine. Phosphoric acid. ELEMENTS OF DOSIMETRIC PRACTICE. 275 Gangrene of the Lungs. — Necrosis of the pul- monary tissue can be cured only by elimination of gan- grenous portions, and cicatrization of the cavity which results from such elimination. The dead tissues can not be restored, and therefore therapeutics has no field for action in respect to the principal lesion. As necrosis is due, however, to feeble vitality of the tissues, and as the tissues which are still uninvolved share in this feebleness to a greater or less extent, we should use all diligence to increase the general vitality and the resist- ance of the tissues in the vicinity of the gangrenous portion. It is only in this way that we can aid Nature effectively in her efforts at elimination and regenera- tion. Adynamia, therefore, should be treated with the hypophosphite of strychnine, combined with the salicy- late of ammonia, two granules of each being given every hour. The prostration which the patients experience should be treated with phosphoric acid, an agent which has great dynamophoric power, two granules being given every two hours. For the thoracic pains we should give two granules of the hydriodate of morphine every half -hour, or one of cicutine at similar intervals until relief is experienced. The fetid condition of the breath and of the expectoration will be overcome by the continued use of iodoform or of sulphide of calcium, one granule being given every half- hour. As to the cough, expectoration may be facilitated by the use of benzoate of ammonia or of bromide of camphor, three granules being given every two hours. Haemorrhage is always a matter of grave importance, not only on account of the persistence by which it is sometimes characterized, but also because it intensifies the prostra- tion and adynamia. We should attempt to check it with three granules of ergotine every quarter of an hour, combined with one granule of the sulphate of strychnine every quarter of an hour. The fever, which is often very high, tends greatly to increase the ady- namia. It should be treated with one granule of aconi- 276 ELEMENTS OF THERAPEUTICS AND PRACTICE. tine every hour until the hyperthermia is reduced. After this end has been attained, two to four granules of the salicylate of quinine may be given every hour. Diarrhoea, which is the result of the adynamia and the elimination of the septic products, calls for three to five granules of the salicylate of iron, and an equal quantity of the subnitrate of bismuth, three or four times daily. During the period of repair, we may aid the process by which new tissue is formed by giving two granules of the arseniate of iron and two of iodoform five times daily. The diet should be liberal and nourishing, and a sufficient quantity of generous wine or of cognac should be supplied. OH ; /Dominant. Variant. Adynamia . I Prostration Thoracic pain Fetid breath Cough Haemorrhage Fever Diarrhoea . Cicatrization j Hypophosphite of strychnine, salicy- ( late of ammonia. Phosphoric acid. Hydrochlorate of morphine. Iodoform, sulphide of calcium, j Benzoate of ammonia, bromide of \ camphor. Ergotine, sulphate of strychnine. Aconitine, salicylate of quinine. j Salicylate of iron, subnitrate of ( bismuth. Iodoform, arseniate of iron. Gastralgia. — Gastralgia, cardialgia, gastrodynia, etc., as it is variously called, is a form of neuralgia which is produced as a result of the want of equi- librium in the innervation of the stomach, and which radiates, to a greater or less extent, along the distribu- tion of the vagus and the cceliac plexus. This idea of a want of equilibrium between the nerve-forces is one which has prevailed during every epoch of the history of medicine, and has served as the basis of the striatum and laxum theory of Themison. In fact, the constant observation of the processes of nature reveals and im- poses such a notion. In all perturbations which are purely dynamic, an increase or diminution of the influ- ence of the nerves is always observable, and its phe- nomena have been carefully investigated by contem- porary workers, such terms as inhibition and dyna- ELEMENTS OF DOSIMETRIC PRACTICE. 277 mogeny, vaso-constrictor and vaso-dilator nerves, etc., being used to signify the elements which are involved and the processes in which they participate. To this physiological dichotomy there is a corresponding thera- peutic dichotomy ; to the striatum there is a counter- part in hyoscyamine ; to the laxum in strychnine. The functional lesions may, as a rule, be effectively opposed by one of these two agents, or by both at once, because it rarely happens that a compensatory spasm does not correspond to atony, just as to congestion there is al- ways a correspondent relative anaemia of the organs near which the hypersemia occurs, and from which the excess of blood has been borrowed. Gastralgia is due to exaggerated irritability, whether from the applica- tion of stimulants to the gastric mucous membrane or from a want of equilibrium. In other words, it is de- termined by the diminution of the general tone, such as follows, for example, the influence of depressing moral conditions, essential anaemia, chlorosis, etc. The dominant should, therefore, take cognizance of this pathogenic process, and hence the antispasmodic action of hyoscyamine will not always suffice to rapidly over- come the cramps in the stomach ; its combination with strychnine is often indispensable to restore the physio- logical equilibrium of the forces. When the gastralgia is caused by the irritating action of food or drugs, we should begin to soothe the contractility of the stomach by the use of one granule of hyoscyamine every quar- ter of an hour, or by means of its congeners, the sul- phate or valerianate of atropine or daturine, having first cleansed the gastro-intestinal canal by means of Sedlitz Chanteaud. If, on the other hand, the gastralgia is due to influ- ences of a depressing character, we should add, from the beginning, one granule of strychnine every half- hour, or of brucine if the patient is of a very impres- sionable disposition. As the neuralgia is due not only to perturbations of contractility, however, it is often 278 ELEMENTS OF THERAPEUTICS AND PRACTICE. indispensable to consider perturbations of sensibility, using for that reason the hydrobromate or the hydro- chlorate of morphine. The pain which results from the excessive sensibil- ity is sometimes so severe as to cause lipothymia of an alarming character. In such cases two granules of morphine, with two of caffeine, used every ten minutes, will quickly produce relief. Vomiting, which is sometimes of service by en- abling the stomach to relieve itself of the exciting cause of the trouble, but which almost always increases the nervous troubles, may be treated with three gran- ules of morphine and three of atropine every half- hour. Dyspepsia, which is now the cause and again the effect of gastrodynia, calls for two granules of the ar- seniate of soda with each meal. If dyspepsia exists, gas- tralgia may recur frequently, but with attacks which become less and less severe. In such cases two or three granules of the cyanide of zinc may be used before each meal. Arthritis, and particularly that form which is known as biliary lithiasis, is often present with gas- tralgic attacks. Aside from the use of soothing reme- dies, we should employ in the intervals two granules of the carbonate or the benzoate of lithia with each meal. Gastralgia may also be present as a manifestation of hysteria, or as an accident of chronic myelitis. In the first case three granules of the bromide of camphor three times daily will be the proper remedy ; in the second, two or three granules of cicutine three times daily. A stubborn form of gastralgia is also a frequent complication of anaemia, and it is the more significant as it interferes with regularity in the ingestion of food. Iron is indicated in such cases on account of its in- fluence upon the blood, and is well tolerated if the gas- tralgia is due to no other cause. One or two granules ELEMENTS OF DOSIMETRIC PRACTICE. 279 of the valerianate, and a like quantity of the arseniate of iron, may be given in such cases three times daily. If the gastrodynia is very troublesome, two granules of codeine may be given with each dose of the iron, or two granules of the arseniate of manganese may be given with each meal. Certain forms of gastralgia recur periodically, without reference to the time when food is taken into the stomach. For such cases three granules of the hydrobromate of quinine may be given every two hours, or one gran- ule of arsenious acid four times daily. It is superflu- ous to add that the cause of gastric neuralgia must be sought with the greatest care in order to decide upon the appropriate treatment. The essential conditions for the insurance of a cure will consist in the use of food which is easily digested, abstinence from tea, cof- fee, tobacco, and alcohol, and the suitable employment of hydrotherapy. < /Dominant. J Want of e( l uilibrmm in the Variant. I nervous sj /Lipothymia Vomiting Dyspepsia Arthritis Hysteria Myelitis Chlorosis \ Periodicity stem i Hyoscyamine. } Strychnine. Caffeine, morphine. Atropine, morphine. Arseniate of soda. Carbonate of lithia. Bromide of camphor. Revulsives, cicutine. Valerianate of iron. Hydrobromate of quinine. Gastritis, Acute. — Acute catarrhal gastritis is rela- tively a rare condition. It should not be compared with toxic gastritis, and its treatment should be varied with the cause which produces it. Phlegmonous gastritis can only be treated symptom- atically, and medical intervention is not of very great value. In acute gastritis the inflammatory element predominates. It should be treated with one granule of aconitine every half -hour, and, after the fever has subsided, with one granule of veratrine every quarter of an hour. The treatment should be begun with a purgative dose of Sedlitz Chanteaud, which may be 280 ELEMENTS OF THERAPEUTICS AND PRACTICE. made more agreeable to the taste by the addition of sugar and lemon-peel. If the fever is characterized by remissions, a granule of the hydroferrocyanate of quinine may be given with the defervescents every half -hour. The stomach sometimes rejects these medicaments, and compels an interruption of the treatment before any result has been obtained. In such cases the gastric irritability may be quieted by the use of two granules of codeine every quarter of an hour. The same agent will relieve the pain by which gastritis is characterized, unless it is intense, in which case a granule of the hydro chlorate of morphine must be given every half-hour. The sa- burral condition, which often remains after deferves- cence has occurred, calls for one granule of quassine every two hours. Constipation must be treated with Sedlitz ; diarrhoea with two granules of brucine and two of codeine every two hours. When the fever is high, delirium is sometimes de- veloped ; the treatment should then be eight granules of the bromide of camphor with sufficient aconitine every two hours. The cephalalgia which accompanies the fever will usually yield to aconitine ; but, should it continue after the fever has disappeared, two gran- ules of the citrate of caffeine may be given every half- hour. In some cases the patients will get well much more quickly if an emetic is given at the beginning of the disease. Such cases are not usually pure forms of gas- tritis, but are rather subacute catarrhal conditions which are converted into febrile forms of gastritis. In such cases, therefore, we may give three granules of emetine, dissolved in warm water, every ten minutes until the desired effect is obtained. In the more acute cases an emetic is rarely indi- cated. We should be guided in this matter by the condition of the tongue : if it is covered with a thick ELEMENTS OF DOSIMETRIC PRACTICE. 231 coating of a whitish or yellowish color, emetine is indi- cated ; but if it is red at the borders and more or less dry at the center, vomiting may do much harm. Rather than excite vomiting in the latter class of cases, we should give aconitine and Sedlitz Chanteaud and ex- pect the best results. 23 /Dominant. Variant. Inflammatory element ' Hyperthermia Remittent fever Cephalalgia . Vomiting Pain . Saburral condition Diarrhoea Constipation \ Delirium Aconitine, veratrine. Aconitine. Hyclroferrocyanate of quinine. Caffeine. !• Codeine. Sedlitz Chanteaud, quassine. Codeine. Sedlitz Chanteaud. Bromide of camphor. Gastritis, Catarrhal.— This affection (erribarras gastrique) is a mild inflammatory condition of the gas- tric mucous membrane. It generally runs an apyretic course, and in itself is without gravity ; but it may be transformed into an intense gastritis, into gastroenteri- tis, or typhoid fever. It is one of those diseases which are held up by physicians who believe in the expectant method of treatment as an illustration of the useless- ness of medical interference. The frequency with which this disease is incom- pletely cured, or its cure is retarded, and the aggra- vated state which it sometimes assumes from the most insignificant causes, teaches us that it should never be neglected, but should be attacked as vigorously as if it were a severe disease from the beginning. The saburral condition of the digestive organs is an indication for a saline laxative — for example, Sedlitz or citrate of magnesia — in order to relieve the intestinal canal of the alimentary detritus and the mucus which it may contain. Subsequently, as soon as possible, one or two granules of veratrine should be given every half- hour or every hour, according to the degree of toler- ance. Usually the tongue becomes clean within twenty- four hours from the time that treatment is begun, the 282 ELEMENTS OF THERAPEUTICS AND PRACTICE. appetite returns, and a cure is evident. Yeratrine has a particular action upon the gastric mucous membrane, producing a substitutive irritation and exciting the secretion of the gastric juice, which had been sus- pended. If the appetite continues unimproved, however, and the stomach still performs its functions badly, the gas- tric atony being a hindrance to prompt and easy diges- tion, two granules of quassine should be given four times daily. The frontal or supraorbital cephalalgia, and the vertigo which are not of infrequent occurrence in these cases, will disappear after the administration of a few doses of the valerianate or the citrate of caffe- ine, two granules being given every half-hour. Vomit- ing, whether of spontaneous origin or provoked by the inappropriate use of veratrine, which will prevent us from continuing the use of that remedy until its de- sired effect can be obtained, may be treated with two granules of codeine and one of strychnine combined with the veratrine. Imperfectly digested food or the irritant action of the gastric mucus will cause intestinal or hepatic hyper- secretion, which will be manifested by a more or less abundant diarrhoea. This condition may be readily controlled by the suitable use of Sedlitz Chanteaud, with two granules of pepsin at each meal. Only such food as can be easily digested should be given while the secretion from the gastric glands is deficient — such foods, for example, as milk and soups, one or two gran- ules of pepsin with each meal being given to supply the natural deficiency. The general debility which often follows this disease, however rapid its cure may have been, requires the incitant action of one or two granules of arseniate of strychnine three times daily. In some cases the use of food will excite a mild condi- tion of fever ; for such cases, three to five granules of the salicylate or the hydroferrocyanate of quinine should be given three times daily. ELEMENTS OF DOSIMETRIC PRACTICE, 283 " Dominant. Inflammatory element . Veratrine. /Anorexia . . Quassine. Vomiting . . Codeine. J Cephalalgia . Caffeine. Variant. ( Saburral condition . Sedlitz. Diarrhoea . . Pepsin. General debility. . Strychnine. \ Febrile attacks . . Salicylate of quinine Gastritis, Chronic. — Chronic catarrh of the stom- ach results chiefly from two sources — atony of its con- tractile elements, and deficient secretion of the glands which furnish gastric juice. Difficulty in digestion, which arises from the combined action of these two morbid factors, aggravates the existing irritation and exaggerates the secreting power of the gastric glands which furnish mucus. The dominant will consist, therefore, in increasing contractility by means of bru- cine and strychnine, in facilitating digestion by the administration of pepsin, and in relieving the stomach of undigested food and unnecessary mucus by the ad- ministration of Sedlitz Chanteaud or emetine. To in- crease tonicity, hygienic means are not less efficient than treatment by means of drugs. Not only should the stomach be relieved of excessive labor, but its ordi- nary function should be assisted, if possible, in order that such an economy of work may be transformed into a capitalization of force. The sense of weight in the region of the stomach, which patients with this disease experience after eating, almost always comes from the feeble contractile power of a dilated stomach. This disagreeable condition may be relieved by the very moderate use of food and drink, and the administration of three to five granules of euonymine or elaterine with each meal. The pain which accompanies intestinal di- gestion may be relieved by the use of three granules of codeine or cocaine every half -hour. Palpitations and yawning are reflex phenomena which result from the pressure of gas which has been generated in the stom- ach. Two or three granules of strychnine, three times daily, will furnish the best means for relieving them, as 284 ELEMENTS OF THERAPEUTICS AND PRACTICE. the resistance of the muscular coat of the stomach will thereby be increased and distention prevented. The effect of this treatment will also be to ward off hypo- chondria, from which patients with this disease so fre- quently suffer. Acid eructations are the result of fer- mentation in the stomach. For their relief, two or three granules of the arseniate or the salicylate of soda may be given, three times daily, or the alkaline mineral waters may be used. Vomiting of the food should be treated with three granules of pepsin with each meal. It is almost always due to deficiency of the gastric se- cretion. Vomiting which is due to an excess of mucus in the stomach may be treated with two to five granules of quassine, an hour before each meal. The same drug will improve the appetite in cases in which there is re- pugnance to food ; but, if the loss of appetite is due entirely to disrelish for food on account of buccal ca- tarrh, two granules of veratrine, half an hour before each meal, will give prompt results, and will also over- come constipation, which may coexist. The cephalic congestion which accompanies the work of digestion, and which is the cause of headache, vertigo, etc., re- quires two granules of aconitine before each meal, and two of caffeine or guaranine every half-hour until the desired effect is obtained. Flatulence of intestinal ori- gin is due to inertia of the muscular fibers which enter into the structure of the intestine. The excito-motor agents, which have a tonic action upon the intestine, are indicated for this paresis. Two granules of strych- nine may be given three times daily, or three of jalapine or of colocynthine with the same frequency. The diar- rhoea should be treated with three granules of brucine or of narceine every two hours. Constipation requires different remedies, according to the exciting cause. Usually it may be corrected by using two to four gran- ules of podophyllin or veratrine every evening, and a small spoonful of Sedlitz Chanteaud in the morning. Hypochondria, which has a decided tendency to pro- ELEMENTS OF DOSIMETRIC PRACTICE. 285 duce disrelish for the food, and to make the digestion sluggish, should be treated by moral stimulation, exer- cise, and two or three granules of hyoscyamine daily. Chronic gastritis, in the absence of irremediable lesions, can always be cared by a proper choice of remedies, and by perseverance in their use, and in a hygienic regimen for a sufficiently long period. Strychnine. j§^ I Dominant. P5^ OH IB u Variant. ( Atony Insufficiency as to the se cretion of pepsin . Excess as to the secretion of mucus ^Feeling of heaviness Pain. Palpitations Yawning . Eructations Cephalic congestion Vomiting . Anorexia . Intestinal flatulence Diarrhoea . Constipation . Hypochondria . [• Pepsin. I Sedlitz Chanteaud. Euonymine, elaterine. Codeine, cocaine. Sulphate of strychnine. Salicylate and arseniate of soda. Aconitine, guaranine, caf- feine. Pepsin, quassine. Quassine, veratrine. Sulphate of strychnine. Brucine, narceine. Podophyllin. Hyoscyamine. Glossitis. — Inflammation of the tongue may be superficial or deep. If it is superficial, it is not a con- dition of any particular gravity, and may be relieved by the use of a few granules of aconitine, which will act upon the inflammatory condition. The case is not the same if the inflammation is extensive, for then sup- puration frequently follows, and the patient may die of asphyxia. In such cases prompt interference is re- quired, for the progress of the disease is rapid. Medi- caments must be given in solution, and as frequently as the severity of the case demands. The fever, which is sometimes very high, may be relieved by the use of one granule of aconitine every quarter of an hour until defervescence results. A concentrated solution of co- caine (1 : 15) should be used locally to relieve pain, and also to produce ischsemia in the tongue. Ptyalism may be relieved by the use of one granule of atropine every two hours. Suppurative glossitis calls for the 286 ELEMENTS OF THERAPEUTICS AND PRACTICE. use of iodoform and arseniate of quinine, two granules of each being required every two hours. Should the volume of the tongue be greatly increased, it will not only prevent deglutition, but it will also interfere with respiration, and this condition will be aggravated by the compression which is exercised upon the vessels by inflammation of the cervical glands, which may occur simultaneously. If asphyxia is imminent, the swollen tongue should be relieved as rapidly as possible, either by deep scarifications, or by the application of leeches to the organ itself or to the retro- and submaxil- lary regions. In extreme cases tracheotomy should be performed as the last resort to prevent fatal as- phyxia. w5 ' Dominant. Inflammatory element . Aconitine. H a /Fever . Aconitine. CO 1 Pain . Cocaine. o k Variant. ( Ptyalism . Atropine. Suppuration . 1 Asphyxia . Iodoform, arseniate of quinine. O . Leeches, incisions, tracheotomy. Goitre, Exophthalmic (Basedow's Disease). — The primordial lesion in exophthalmic goitre is in the sympathetic system. In consequence of this, the de- pendent cardiac and cervical vaso-motor action is par- alyzed, and dilatation of the arteries which are con- trolled by these nerves follows. The means which should be used in the treatment of this paralysis are ergotine and sulphate of quinine in large and long-con- tinued doses. The two agents may be associated, but it is better to use them alternately from week to week, giving, for example, three granules of strychnine three to iiYe times daily for two or three weeks, and then five granules of ergotine three to five times daily for an equally long period. Should the tonics to the vascular system be in- effective, the palpitations may be relieved by the use of two granules of digitaline three or four times daily, until relief is obtained. The vascular ectasis may be benefited by the use of three granules of cocaine three ELEMENTS OF DOSIMETRIC PRACTICE. 287 to five times daily, its astringent action re-enforcing that of the dominant. The exophthalmia, which de- pends upon the same fundamental cause, and is a source of great annoyance to the patient by reason of the lesions which produce insufficiency of the eyelids, demands the use of morphine combined with the domi- nant, and two granules should be administered every quarter of an hour. If by the use of this agent the cephalic troubles are increased, it should be replaced by the sulphate of calabarine, three granules of which may be given three or four times daily. Conjunctivitis, which will appear sooner or later as a result of exoph- thalmia, should be treated with aconitine three or four- times daily. Dyspnoea will be diminished by the use of one granule of cicutine or of valerianate of atropine every half -hour. Insomnia should be treated with two granules of the bromide of camphor, or of Gregory's salt, every quarter of an hour, until a hypnotic effect is obtained. The delirium, which may be more or less accentuated, is caused by hyperemia of the cranium, consecutive to cerebral excitation. One granule of hyoscyamine given every hour will almost always re- store rest in the two hemispheres. Vomiting, which may be due to changes in the sympathetic, or is a symptom of cerebral disorder, requires the use of one granule of atropine every quarter of an hour, combined with three granules of quassine. The haemorrhages, which are very frequent in the last stage of this dis- ease, being the necessary consequence of the vascular atony and the prolonged ectasis, should be treated with subcutaneous injections of ergotine, the following for- mula being suggested, viz. : Ergotine (Catillon's) 1 gramme. Distilled water 12 grammes. Glycerin 3 " If the granules are preferred, three may be given every quarter of an hour. The ansemia, which is some- times the cause and sometimes the effect of the disease, 238 ELEMENTS OF THERAPEUTICS AND PRACTICE. should be treated with, two or three granules of the arseniate of iron, three times daily. Hygienic meas- ures, based upon the pathogenic idea of the disease, will consist in rest for the body and the mind, without entirely excluding attention to the affairs of life, in a moderate amount of exercise, and, in the early stages of the disease, in hydrotherapy. Stimulants should be avoided, as their use is always followed by depressing effects ; this remark applies to tea, coffee, alcohol, tobacco, and strong condiments. The diminution of the work of the digestive apparatus has an important bearing upon the restoration of the functional force of the sympathetic. The diet should be nourishing in character and abundant in quantity, but the food should always be readily digestible. BO o X Dominant. Paralysis of vaso-motor nerves / Palpitations Vascular ectasis Exophthalmia Conjunctivitis Variant. ( py s P noe . a • v Insomnia . Delirium Vomiting . Haemorrhage Anaemia Ergotine, strychnine. Digitaline. Cocaine. Morphine, strychnine. Aconitine. Cicutine. Bromide of camphor. Hyoscyamine. Atropine, quassine. Ergotine. Arseniate of iron. Gout. — This specter to the rich and scourge to the sensual is tending to disappear in proportion as equal- ity is being attained by the subdivision of capital and labor. We are yet far from the ideal of the socialists, however, and for that reason the disease still prevails with a certain class of people who require more work of their stomach than of their hands. The etiology and pathology of gout may be sketched in a few words, in accordance with the observation of the past and the present. Diminution of exercise and excess in the use of food results in an incomplete combustion of azotized matter, which accumulates in the blood and determines an excessive development of uric acid, which is the efficient cause of the disease. This is not the only cause for the accumulation of uric acid, how- ELEMENTS OF DOSIMETRIC PRACTICE. 289 ever, for its production may be normal in quantity, and uricsemia be established, owing to deficient elimi- nation on account of renal lesions. The system being saturated with uric acid and with nitrogen, and the usual emiinctories being no longer capable of eliminat- ing them, the work is forced upon other organs, which are unused to the task, and in which the patient expe- riences more or less violent pain, inflammation, etc. There is, therefore, for gout, an efficacious preventive treatment, purely hygienic in character, and consisting, as to its details, in abundance of exercise and spare diet, especially with reference to nitrogenous food. This plan of treatment would be equally curative if habits of intemperance were not so difficult to over- come. If we could inspire the patient with the passion of avarice, or convince him that his bad habits should be given up, as the causes of his disease, we would accomplish more for him than by prescribing all sorts of drugs for the cure of gout. In the plan of treat- ment all dangerous and inefficient remedies must be avoided, as they will only tend, by prolonged use, to in- tensify the disease and increase the disorder of the digestive apparatus. The therapeutics of gout will be reduced to very narrow limits if we wish to make use of the only remedy which is really of any service. Col- chicum is considered by many as a specific for this dis- ease, and it is the only substance the results of which are not too uncertain. The variability in its composi- tion and its activity, whether given in substance or in the various preparations which are in the market, have led many practitioners to abandon its use in favor of a more or less disguised expectant plan of treatment. Colchicum acts principally by its analgesic, deferves- cent, and cholagogue properties. The last of these explains the efficiency which it sometimes has in gout. The influence of the liver upon the production and excretion of urea is well known, and therefore all sub- stances which have a perceptible influence upon the 19 290 ELEMENTS OF THERAPEUTICS AND PRACTICE. secretion of bile have an action which is no less ap- parent npon the coefficient of nric acid which is con- tained in the blood. Whatever be the mechanism of the action of colchicum, its advantageous results are undeniable, and it would be used more frequently were it not for the disadvantages which have been alluded to, in the specimens which are obtainable. None of these disadvantages appertain to colchicine. That which can be said of it in respect to the treatment of rheumatism is equally true with reference to gout. It is quite true that colchicum contains other alkaloids in addition to colchicine. What difference does that make, however, if colchicine contains all the advanta- geous and none of the disadvantageous properties 3 Let us disregard colchiceine and the other alkaloids, of the properties of which we are ignorant, but continue to use colchicine, with the action of which we are ac- quainted, and of which we could not deprive ourselves without at the same time being disarmed in the pres- ence of two common and painful diseases, for which our patients demand a prompt relief. The curative treatment of gout means the treatment of the attack. But by attack we should not only understand the elim- inative process which is localized in the articulations, but also the visceral troubles, of variable form, which precede it or alternate with it. The attack is manifest when the quantity of uric acid becomes excessive. We should therefore strive to increase its elimination by all the passages when the organism begins to yield to the uricsemia. The diuretics, purgatives, and diapho- retics are useful so long as the attack is not well pro- nounced, but after that point has been reached the cholagogues alone will give results which are apprecia- ble. The attack is almost always announced by dis- order of digestion. If we are wise enough to interpret the cause of the dyspepsia, and do not allow the golden moment to pass by, we may succeed in aborting the attack by means of a simple purgative. Among the ELEMENTS OF DOSIMETRIC PRACTICE. 291 different purgative agents, podophyllin should be given the preference on account of its decided cholagogue action. Five-granule doses, three or four in number, may be given at intervals of half an hour in the even- ing, before the final meal, and the following morning a small dose of Sedlitz Chanteaud will excite diuretic action and increase the purgative action of the podo- phyllm. Should we be unsuccessful in aborting the attack, or should we not have time to prevent it, w T e should begin the use of colchicine, administering two granules every two hours until either a purgative or an emetic effect has been obtained. This effect of the alkaloid should not frighten us, but, on the contrary, should be considered desirable, for it always coincides with a notable remission of all the symptoms. After this result has been obtained we should give only a sin- gle granule every two hours, and, should the diarrhoea or the vomiting still continue, we should give a single granule only once in four hours, and continue this plan until a cure has resulted. In cases in w T hich colchicine is not appropriate we can substitute aconitine, which has analogous but less decided properties for the relief of gout. After the attack is over we should institute a hygienic and pharmaceutical treatment of such a character as to prevent a new accumulation of uric acid, which would occur with the greater rapidity as the elimination of the deleterious urates at the previous attack was less complete. A few words may be said with respect to the pharmaceutical treatment. Acute gout should be treated with alkaline waters, w T ith the alternate use of three granules of the carbonate or the benzoate of lithia, three times daily. Atonic gout should be treated with the bitter tonics, three granules of quassine or euonymine being given before each meal. The variant consists in the use of calmatives and seda- tives, two granules of codeine, tannate of cannabine, or gelsemine, being given every half-hour should the pain become unendurable. For insomnia we should 292 ELEMENTS OF THERAPEUTICS AND PRACTICE. give three granules of bromide of camphor combined with three of Gregory's salt every quarter of an hour until we get the desired result. To patients who can not endure the morphine in Gregory's salt we should give croton chloral in similar doses. Dyspepsia should be treated by the daily use of Sedlitz Chanteaud, or by three granules of salicylate of soda or of quinine before each meal. Diminution in the quantity of urine voided should be treated by the use of one granule of digita- line every two hours during the inflammatory period. It should always be remembered that the renal func- tions in gouty patients are badly performed, and that an accumulation of medicinal substances in the blood may be easily accomplished. Still that should not prevent us from giving them the drugs which are suit- able to their condition, but the doses should be dimin- ished and their effect should be carefully awaited. This result is reached the more quickly as the func- tions are less perfectly accomplished. Should the other physiological effects of digitaline appear before its diuretic effect, three granules of asparagine may be substituted in its place every hour, or three of arbutine every two hours. The visceral manifestations in this disease are varied in character. The nervous system is most frequently affected, under the form of migraine, which should be treated with two granules of guara- nine every hour. The respiratory apparatus may also be attacked under the form of asthma, for which we should give one granule of aconitine every two hours. If the muscular system is affected under the form of myosalgia or paralysis, we should give two or three granules of veratrine every two hours. GOUT. f Exercise, temperance, alka- ' Preventive and curative treat-! line mineral waters, Gar- ment during the remissions 1 bonate or benzoate of Dominant. ( I lithia. Curative treat- ( At the begin- j Podophyllin. ment during < ning . . { Sedlitz Chanteaud. the attacks . ( Subsequently Colchicine, aconitine. ELEMENTS OF DOSIMETRIC PRACTICE. 293 Variant. 'Atony Quassine, euonymine. A ,. , { Gelsemine, tannate of canna- Articular pams . . . -j ^ine ' T . ( Bromide of camphor, croton Insomnia . . . . -j ch l ral, Gregory's salt. 01iguria j Digitaline, asparagine, arbu- , Visceral gout , ( Migraine -] Asthma f M\'OS£ tine. Guaranine. Aconitine, benzoate of soda. Veratrine. Haemoptysis. — See Broncho-pulmonary Hemor- rhage (under Hcemorrliage). Haemorrhage, Broncho-Pulmonary o — Pneumor- rhagia differs from bronchorrhagia only in respect to anatomical situation, prognosis, and extent — as to symp- tomatology and therapeutics, they may be considered in the same chapter. The fundamental cause of haemor- rhage consists in a want of equilibrium between the resistance of the walls of the vessels and the intravas- cular pressure. Since we can not change in an instant the structure of the vascular tunics, we are limited to the exercise of our influence upon their vitality, and this may take form by exciting the contractility of their muscular elements or by diminishing the intravascular pressure, either the energy of the current being re- duced or the crasis of the blood being modified. Ergo- tine or strychnine will fill the first indication, aconitine the second, aconitine and the depletives the third. Broncho-pulmonary haemorrhage is the result of hy- per emia or of disorganization of the walls of the ves- sels on account of ulceration, atheroma, etc. Hemor- rhagic hyperemia may be either active or passive. The former indicates aconitine, which opposes itself to the hemorrhagic molimen, that is, to the fluxion which appears in the form of hemorrhage ; one granule of it may be given every half -hour. The second requires digi- taline, to aid the heart in overcoming the stasis ; one granule may be given every hour, its action being re- enforced by one granule of the sulphate or arseniate of strychnine every quarter of an hour. The hemor- rhages which are due to lesions of the vessels require 294: ELEMENTS OF THERAPEUTICS AND PRACTICE. ergotine hypodermically, one gramme of water being used to dissolve ten granules of ergotine ; or the ergo- tine may be given by the mouth, three granules being given every quarter of an hour until the desired effect is obtained. The haemorrhages which come from large vessels will not readily yield to such means, for the large vessels are poorly supplied with contractile ele- ments ; still this is the best remedy which we have, and should be employed, for we have no means of deciding as to the size of the vessel from which the haemorrhage proceeds. The cardiac excitement which almost always accompanies these haemorrhages should be soothed by the use of three granules of veratrine every quarter of an hour until the contra- stimulant effect has been ob- tained. Although this agent acts indirectly, it acts more rapidly than ergotine. One or the other may be used, according to circumstances, but in severe cases we should use both. Adynamia, which may precede or follow haemorrhage, requires the use of two granules of strychnine every three hours. The cough, however mild it may be, is an obstacle to coagulation and to haemostasis. It should be soothed by the use of two granules of morphine every quarter of an hour. Dysp- noea, which indicates an obstruction in the air-passages by the blood which has been extravasated, may be quickly overcome by giving five granules of emetine in a teaspoonful of water every ten minutes, until vomit- ing or nausea results. The clots which are retained in the alveoli will, sooner or later, give rise to a circum- scribed pneumonia, which may terminate by suppura- tion or by ulceration, and is rarely susceptible of cure. The prognosis should therefore be a guarded one, and the physician should be in readiness to apply the proper remedies with the first evidence of phlogosis. The most useful means which can be used are the defer- vescents, the revulsives, and, during the period of sup- puration, iodoform with the arseniate of quinine, two granules of each being used three to five times daily. ELEMENTS OF DOSIMETRIC PRACTICE. 295 jg /Hemorrhage from active ) Aconitine . W congestion . . . ) teH /Dominant. Haemorrhage from passive j. Dieitaline Id lesions aw . congestion Haemorrhage from vascular ) Ercotine /Cough Morphine. Dyspnoea .... Emetic. Variant. / Cardiac erethism . . Veratrine. q ^ \ Adynamia .... Strychnine. ^ W ( Defervescents. 2 VSubsequent pneumonia . •< Iodoform, arseniate of cq ( quinine. Haemorrhage, Cerebral. — How should cerebral haemorrhage be treated? The rational reply would seem to be that it should be treated both as a haemor- rhage and as a cerebral disease. Unfortunately, such a plan is not usually followed. Every one seems to for- get that apoplexy is one of the. forms by which cerebral haemorrhage is manifested, and hence, one of the prin- cipal elements of the disease being overlooked, the treatment always gives results which are uncertain, negative, or disastrous. How can we explain otherwise that, in a disease which is so severe and so well under- stood as to its pathogeny, its pathology, and its symp- tomatology, there should be so much disagreement among physicians, so that their plans of treatment, in which no one has any confidence, succeed rather by chance than as a result of conscientious and considerate application ? Trousseau, earnest though he was in seek- ing to find a specific for every disease, declines to indi- cate a treatment for sufferers from apoplexy, whatever be their condition, thereby showing his practical good sense, for apoplexy is a disease in which the excite- ment of any form of disturbance is not an insignificant matter ; and, as Trousseau recognized that all such dis- turbances must be useless, he declares that they must at the same time be dangerous. This is the only way that we can understand and explain the fact that so tireless a worker as Trousseau should advocate an ex- pectant plan of treatment, folding his arms in the pres- ence of so formidable a disease, while there was every 296 ELEMENTS OF THERAPEUTICS AND PRACTICE. inducement from without to attack it in some way or other. It would appear, however, that it is not neces- sary to make a very long search for the plan which should be adopted, in order to do what is possible for the relief of this terrible accident. Is not cerebral haemorrhage a true haemorrhage \ Is it not that which gives to the disease all its gravity % Is it not a drop of blood, more or less, effused into the brain, upon which the life or the death of the patient depends ? But, if cerebral haemorrhage is a true haemorhage, why should it not be treated as a haemorrhage % If in metrorrhagia, epistaxis, or haemoptysis, when the loss of a few grammes of blood, more or less, is not a matter of vital import- ance, the great object is to arrest the flow, why should we not have the same object in view in cerebral haemor- rhage, when death may result from the loss of one drop or even one globule of blood beyond the limit of endur- ance \ The first indication is, therefore, to arrest the haemorrhage. How % Why, just as one arrests other haemorrhages, with this conviction in addition, that there must be no experimentation in the matter. The sub- stance chosen must be an active haemostatic ; the prepa- ration which is used must be thoroughly reliable ; the avenue along which it is directed must insure the utmost freedom and rapidity of action. In menorrhagia we are in the habit of using ergot of rye, or its active principle ergotine, if we desire a rapid effect. This is the sub- stance, in fact, which will cause haemostasis of the parenchymatous vessels with the greatest rapidity ; it is, therefore, the remedy which should be employed in every case of apoplexy. While it is very active as a medicament, it has, however, two great disadvantages : The first, common to all vegetable preparations, is that it never contains fixed quantities of the active principle, so that it is never possible to say with precision just what result will be obtained from the use of a given quantity of a given preparation ; the second disadvan- tage is that it has a harmful influence upon the brain, ELEMENTS OF DOSIMETRIC PRACTICE. 297 paralyzing the action of the nervous system upon all the organs.* Ergotine, while it does not have the second of these disadvantages, does have the first, f Ergotine, in fact, is not an alkaloid, but an extract which contains a variable quantity of its active princi- ple, and is capable of being decomposed by the digest- ive fluids. The ergotines of Bonjean and Yvon are the ones which represent this variability of action most faithfully. The ergotine of Catillon is the nearest ap- proach, as to uniformity of action, to the alkaloids, and should therefore be preferred. Ergotinine is an- other preparation which is available, but its great activity prevents its satisfactory use. How should ergotine be administered in order that its effect may be immediate ? The stomach can not be relied upon in a condition like this, for, with the existing prostration of the vital forces, we can not expect much in the way of absorption. In the apoplectic state, it may be reduced to the slow action of osmosis. Preference should there- fore be given to the hypodermic method, the medica- ment, in solution, being injected into the cellular tissue. The effect by this method is obtained more rapidly than by any other. A hypodermic injection of Catillon's * Chevallay, in autopsies made upon animals poisoned with ergot of rye, constantly found engorgements of blood in the skull, the spinal canal, and the venous system, which demonstrated the stupefying action of the drug. This fact caused Bonjean to rank ergot among the narcotics as the equal of opium. t Ergot of rye contains two very dissimilar active principles— a remedy and a poison. The first is ergotine, which possesses all the properties which are serviceable in obstetrics and as a haemostatic in general. It may be administered in as large doses as eight grammes without producing toxic effects. The second of these principles is a fixed, colorless oil, which is soluble in ether and insoluble in alcohol; it can be isolated perfectly from the first, and contains all the properties which affect sensation. The reader is referred for further information upon this subject to an article by Yan Renterghem in the " Compen- dium du Medecine dosimetrique," pp. 480-515. 298 ELEMENTS OF THERAPEUTICS AND PRACTICE. ergotine having been made, we can be sure of arresting the haemorrhage as quickly as possible, thus satisfying the causal indication. But, since this haemorrhage has taken place in cerebral tissue, its effects will disclose a characteristic physiognomy, and will call for a particu- lar treatment. The shock which is experienced by the central nervous organism will disturb its functions to the extent of suspending animal life. All vital acts which are accomplished under the influence of the cerebral centers are more or less affected ; and, by thus tending to change the condition of the blood, the effect of the change is experienced in a reflex manner by the nervous system. It is therefore of great importance to restore to the nervous centers their incitability, and to preserve at the same time the normal composition of the blood. In this emergency we can obtain assistance from caffeine and its salts, the arseniate of strychnine, the cutaneous revulsives, and the intestinal derivatives. All excitants and debilitants should be absolutely avoided, for we may be sure that these antagonistic substances will facilitate the way to the most unfavor- able result of apoplexy — that is, to cerebral softening. The treatment of apoplexy from cerebral haemorrhage may be formulated as follows, viz., we should inject into that side of the head in which, judging by the de- viation of the eyes, the head, and the tongue, the effu- sion has occurred, one gramme of a ten-per-cent solu- tion of Catillon's ergotine. Every quarter of an hour we should administer one granule of arseniate of strych- nine, and one of caffeine or its salts. Sinapisms of moderate strength should be applied to the arms, the thighs, the body, and the nucha. If at the end of three hours the patient has not regained consciousness, we should repeat the ergotine as well as the granules until the desired result is obtained. After the apoplectic condition has passed away, a dose of Sedlitz Chanteaud may be given to excite purgation, and the treatment may be begun which is designed to prevent the fever ELEMENTS OF DOSIMETRIC PRACTICE. 299 which accompanies the reparative encephalitis. This will consist in the use of one granule each of aconitine, veratrine, and hydroferrocyanate of quinine every three hours. The haemostatic action should be kept up by the use of two granules of ergotine every three hours. The diet should be spare, but sufficient in quantity and quality to sustain the strength of the patient. After the fever has set in, defervescent treat- ment must be adopted, and regulated according to the intensity of the pyrexia. After the fever has been overcome, the treatment which is appropriate for pa- ralysis must be established by means of brucine and strychnine, and, to prevent recurrences of the attack, by ergotine. § [Dominant. Haemorrhage . . . Ergotine. t-3 ^ I /Want of equilibrium in the ) Caffeine and its salts, ar- ^ E2 ( [ nervous system . . ) seniate of strychnine. § 2h j Constipation . . . Sedlitz Chanteaud. K^ 1 Variant. ( ( Veratrine, aconitine. hy- Fever -j droferrocyanate of qui- ( nine. \ Paralysis .... Brucine, strychnine. Haemorrhoids. — Haemorrhoidal lesions always be- gin in the form of simple congestions. Eepeated ve- nous hyperemia results in dilatation of the veins, which continue to increase in size until true varices are formed. The congestion is due to causes which habit- ually give rise to congestion, but the dilatation of the veins, which really constitutes haemorrhoids, is caused primarily by a relaxation or atony of the vessels, which should be treated with two granules of ergotine and two of strychnine four times daily. The primary rectal congestion, as well as the hemorrhagic molimen, re- quires the use of one granule of aconitine every two hours. Haemorrhoids which are caused by the com- pressing action of abdominal tumors can be effectively treated only by the removal of the cause. When this compression is the result of a hardened fecal mass, the existing constipation may be corrected by the daily use 300 ELEMENTS OF THERAPEUTICS AND PRACTICE. of Sedlitz Chanteaud, which, in addition to its laxative property, has also the effect of stimulating the blood in respect to its affinity for oxygen, and of relieving the engorgement of the venous system. The pains which precede the hemorrhoidal attacks, which are more or less intense in character, and can not be defi- nitely located, may be soothed by using one granule of gelsemine or aconitine every hour. Dysuria will dis- appear if one granule of daturine is used every two hours until a number of doses have been taken. The spasm of the sphincter ani may be treated with the same agent, or with one granule of hyoscyamine every half -hour. Haemorrhage from the rectum is rarely beneficial, for it almost always increases the relaxation of the veins, and conduces to anaemia. Three granules of ergotine may be given for this condition every hour. A topical disinfectant application for haemorrhoids after they have reached a gangrenous or ulcerated con- dition may be made from vaseline thirty parts, pure iodine one part. The congestion of the rectum may be quickly relieved and the local vascular erethism as- suaged by the use of very hot enemata (40° to 45° C). Small pieces of ice introduced into the rectum will also give good results, but should be reserved as a haemo- static for obstinate haemorrhages from the rectum. The curative treatment for the hemorrhoidal tendency must be continued for a long time, and may be carried out after the following plan : In the morning a dose of Sedlitz Chanteaud dissolved in a large quantity of cold water may be given. Two granules of ergotine may be given before each of the two principal meals, and on alternate weeks the same quantity of sulphate of strychnine may be substituted for each dose. Upon retiring, two granules of aconitine may be given with two of digitaline. Stimulants should be abstained from, and very active exercise should be taken. If, in spite of the use of Sedlitz Chanteaud, constipation con- tinues obstinate, three granules of podophyllin may ELEMENTS OF DOSIMETRIC PRACTICE. 301 be used every evening, or ten of leptandrin every morn- ing with the Sedlitz Chanteaud. Grave hemorrhoidal lesions, whether due to the frequently recurring haem- orrhages, and the inflammations which are associated with them, or to the spasmodic or mechanical difficulty which has interfered with regular defecation, require surgical treatment. One of the most efficacious and least dangerous of such means consists in the forcible dilatation of the sphincter, the patient being anesthe- tized. 03 ( Congestion .... . Aconitine. 2 'Dominant. -j Atony . Strychnine. o ( Compression . Sedlitz Chanteaud w ( / Pseudo-neuralgia . Gelsemine. O Dysuria .... . Daturine. ^ Variant. I Spasm of the sphincter . Hyoscyamine. 3 \ Rectal congestion . Aconitine. ^ Rectal haemorrhage . . Ergotine. w \ Gangrene, ulceration . . Antiseptics. Heart, Dilatation of the. — See Cardiectasis. Heart, Valvular Lesions of the. — There is no class of diseases which proves better than this the necessity that a true plan or system of therapeutics should be directed solely at vitality. In cases in which there are lesions of the cardiac orifices, therapeutics is completely disarmed in so far as any ability to modify them is concerned. It does intervene, however, and it is right that it should do so, but in a purely dy- namical manner. Thus it acts upon the cardiac mus- cle in its functional capacity, moderates or excites it, according to the exigencies of the condition, and so compensates in an indirect manner for the organic lesions which are manifestly irremediable'. In how many cases does endocarditis become chronic, after having passed a more or less acute stage — cases in which it might have been made to disappear without leaving any traces if the morbid phenomena had only been controlled at the beginning of the disease ! It is painful to see the time for intervention slip by without anything being done, and the means of relief reserved 302 ELEMENTS OF THERAPEUTICS AND PRACTICE. for the last stages of the disease. However active those means may be, they can then only give results which are ephemeral and insufficient. These lesions will be referred to in this article as the organic lesion of the orifices, without particular specifications, for the thera- peutic indications are the same, whether there be ste- nosis or insufficiency, whether the obstacle to the cir- culation is in one cavity or the other, or at the point of communication of the heart with the great vessels. This organic lesion requires to be studied in each of the morbid phases which it induces in the cardiac mus- cle. The resistance which the heart experiences in forcing the blood into the circulatory tree calls for efforts which are too great for the organo- functional equilibrium. The repetition of these exaggerated con- tractions gradually leads to muscular hypertrophy. The contractile elements, in order that equilibrium may be restored, are developed in excess, compensation being established at the price of a new lesion, which corrects the first. In cases in which pregnancy obtains, as the obstacle disappears at the time of delivery, the hypertrophy will also cease, and the cardiac muscle will regain its former structure and force. An exag- geration of dynamic capacity produces a lesion of structure, which disappears when the requirements are lessened. A clearer example (than this disease) could not be found of the process by which chronic diseases are established, nor a more evident indication of the course which should be followed in order to cure them, namely, to excite vital modifications. As the extent to which hypertrophy may be carried is limited, the organ will become fatigued should the resistance continue ; the muscular nutrition then becomes perverted, and granulo- fatty degeneration is the result. Then the contractile energy diminishes ; the heart is no longer able to force the blood with the same facility through the open ori- fices, nor to contract with sufficient force when the blood accumulates in its cavities, on account of the ELEMENTS OF DOSIMETRIC PRACTICE. 303 insufficiency of the valves. The lesions are no longer compensated, and asystole begins. Therapeutic inter- vention has not the same effect in these two different phases of organic lesions, or the perturbations which they produce. They must, therefore, be considered separately. Compensatory Lesions. — The treatment for com- pensatory lesions is entirely of a preventive character. The patient experiences no suffering, and all the func- tions are performed with regularity. But the compen- satory process can not continue indefinitely, and will end the quicker as the heart becomes the more fatigued in its work. Hygienic methods exercise a preponderant influence in this condition. Every exciting moral im- pression, all functional excitement from physical over- work, should be carefully avoided. Exercise should not be violent, fatigue should be warded off as much as possible. A temperate climate in a level and shady locality should be selected for a home, and the patient should not be obliged to climb stairs. No stimulating food should be used — no coffee, tea, or alcohol. The diet should be a spare one, that the circulation may not be interfered with by dilatation of the stomach. The use of tobacco should be limited to a very small quantity, or should be given up altogether. The con- dition of the blood must be improved as much as pos- sible by the use of suitable food, or by giving one gran- ule of the arseniates of iron and antimony three times daily. Fatigue arising from overwork in the contrac- tility of the heart-muscle may be relieved by giving three granules of the arseniate of strychnine every evening as an incitant. Two to four granules of aconi- tine and digitaline, taken as calmatives every evening, will make the heart less sensitive to the action of stimu- lants, whether of internal or external origin, which can not be avoided in the course of ordinary life. Aconitine and digitaline, even in very small doses, have an effect which is decidedly favorable ; and this is not suprising 304 ELEMENTS OF THERAPEUTICS AND PRACTICE. when we reflect upon the bad effects which are some- times produced by apparently inoffensive stimulants like tea, tobacco, etc., notwithstanding the fact that we may have been using them habitually. Non- compensatory Lesions. — When, in spite of muscular hypertrophy, the cardiac impulse is no longer sufficiently forcible to overcome the obstacle at the mitral opening, the blood begins to stagnate, and this condition gradually extends to the entire circulatory system. From this stagnation, passive congestions in different organs result, their functions being profound- ly changed ; and the morbid state is the more aggra- vated as the congestions take place in important organs. The congestions induce dropsical conditions in various parts, and the patient usually dies as a result of these. Life ends, therefore, as the result of a series of per- turbations, the first of which is insufficiency of the car- diac energy, and the last the dropsical infiltration of all the tissues. By avoiding the first of these, by success- fully opposing the tendency to failure of the systolic power, we can prevent at the same time the appearance of all the other morbid phenomena. The fundamental indication is therefore to increase the energy of the heart by inciting its vitality, and by preserving its muscular integrity and the force of its innervation. Medication of a neurosthenic character should there- fore be established, with the precaution that incitation and not excitation is required, for the latter will give only a transitory advantage which will soon be followed by vital depression. When the period of compensa- tion has passed, we must try to restore the equilibrium by the use of heart tonics. Digitaline, strychnine, and guaranine are the means which should be used in com- bination or alternately, according to the exigencies of each case. Digitaline may be given in two-granule doses two or three times daily ; it may be associated with caffeine, live granules being given with each dose, and the quantity may be gradually diminished as the ELEMENTS OF DOSIMETRIC PRACTICE. 305 pulse indicates greater vigor and regularity in the car- diac action. In order to sustain the regulating action of the digitaline, three granules of strychnine may be given every other night, five of guaranine being given on the alternate nights. Should the conditions of con- gestion become aggravated, the situation will become less hopeful, for all visceral complications are signifi- cant. Should stasis of the cerebral circulation occur, there will be a constant tendency to somnolence, for which we should give two granules of the valerianate or the arseniate of caffeine every half -hour, but without discontinuing the strychnine and digitaline. In some cases there is, on the other hand, persistent insomnia, for which relief must be given as speedily as possible. Two granules of cicutine may be given hourly, or three of croton chloral every half -hour. With very nervous people it may be better to give the bromide of camphor in three-granule doses every quarter of an hour until a hypnotic effect is obtained. Delirium in these cases may be best treated with digitaline, if the heart is sus- ceptible of its regulating action ; otherwise, two gran- ules of aconitine or hyoscyamine may be given three or four times daily. Ursemic accidents, which should not be confounded with the phenomena of delirium which result from cerebral stasis, are the result of renal lesions, and require to be treated with saline laxatives. Pul- monary congestion requires the use of revulsives, or one granule of aconitine combined with one of strych- nine every hour. The manner in which the urinary function of the kidneys is performed during the admin- istration of alkaloids must be carefully watched ; not with the view of discontinuing their administration, however, for they always give good results, but to cal- culate approximately the rapidity of their action, so as to be informed as to the probability of their accumula- tion, and to anticipate surprises, which, however, can never be irreparable if one practices the dosimetric method. This caution is necessary, because we can ob- 20 306 ELEMENTS OF THERAPEUTICS AND PRACTICE. tain the desired result with much smaller doses than would be required if the kidneys were performing their function physiologically. Thus, in cases in which there is albuminuria and a considerable diminution in the quantity of urine discharged, not more than three or four granules of aconitine should be given ; while, if diuresis is in a normal condition, one granule may be given every hour until the desired result is obtained. Expectoration may be modified by the use of three granules of the benzoates at intervals of three hours, or one of atropine three times daily. Cough requires narceine, codeine, or Gregory's salt ; two granules may be given every half-hour. Haemoptysis should be treated with three granules of ergo tine every quarter of an hour, or, if the case is urgent, with hypodermic injections. Hepatic congestion may be rapidly modi- fied by the use of cholagogues. Two dessertspoonfuls of Sedlitz Chanteaud should be dissolved in half a litre of water and taken, and at intervals of an hour three granules of podophyllin may also be given. In twenty- four hours it will be found that the volume of the liver is much diminished. Likewise two granules of colchi- cine may be used hourly until a drastic effect has been obtained, but the result of this treatment is not so positive ; it is better to reserve it for those cases in which icterus is present. The regular use of Sedlitz Chanteaud should be advised during the entire course of these diseases, for, by its purgative and diuretic effect, it retards the progress of the lesions and tends to prevent complications. Dropsy is the natural con- sequence of the congestions which characterize heart lesions. On the one hand, we should seek to increase the tonicity of the heart, and, on the other, to excite such action as will produce the removal of the effused serum. The skin, the kidneys, and the intestines are the three avenues along which this action must be ac- complished. The means for producing diaphoresis are very uncertain, and should they be retained they may ELEMENTS OF DOSIMETRIC PRACTICE, 307 exert a very harmful action upon the heart. In cases in which diaphoresis is indicated by so powerful an agent, we may use six granules of nitrate of pilocar- pine every ten minutes until the result is obtained, or five milligrammes may be given hypodermically every quarter of an hour. Aconitine will produce diuretic effects which are more constant, but at the cost of car- diac depression. Diaphoresis having been produced, we should at once give sulphate of strychnine in order to attenuate the disadvantages of the diaphoretics, and preserve the advantage which has been gained. Two granules may be given every hour. Diuresis may also be excited by a milk diet, which is especially advan- tageous if albuminuria is present, and by the use of arbutine at intervals of two hours. The same agents which were recommended to relieve hepatic congestion may also be used to excite the discharge of the dropsi- cal effusions by way of the intestines. While these means are being used we should be especially careful that the strength of the patient be not thereby drawn upon to any important extent, and that the digestive power be maintained, for otherwise asystole, which is always imminent, would be precipitated. Nothing need be said at this time concerning the various proced- ures in the way of local treatment for dropsy. Such methods include paracentesis, puncture, the use of capillary cannulse, etc., and are all sufficiently well described in the classical works on medicine and sur- gery. The object of this article is simply to indicate the method of treatment according to the dosimetric system. Lesions of the aortic orifice differ sufficiently as to their symptomatology and their treatment to merit separate consideration. When obstructive lesions of this orifice are compensated by hypertrophy, the resulting disturbance is not severe, but aortic insuffi- ciency will rapidly give rise to accidents, of which the principal ones are manifested by cerebral anaemia, and by lesions which are especially caused by distention 308 ELEMENTS OF THERAPEUTICS AND PRACTICE. and irritation of the nerves. The hypertrophy, in its compensatory role, must be sustained by heart tonics and sedatives, as was indicated for lesions of the mitral orifice. The cerebral anaemia, which is manifested by vertigo, intellectual debility, lipothymia, pallor of the face, etc., may be more effectually relieved by mor- phine than by any other drug. Either the hydro- bromate, the hydriodate, the hydrochlorate, or Greg- ory's salt may be chosen, two granules being given every half -hour. Abuse of this drug, however, neces- sitates larger and larger doses, until morphinomania is added to the disease which primarily called for relief. It should not be forgotten that the medication which has been recommended is only palliative, and that it must be reserved for those cases in which the anaemia has become dangerous or insupportable. A different salt of morphine should be used from time to time, relief should be sought occasionally by resorting to the horizontal position, or, again, five or ten drops of nitrite of amyl may be inhaled from a handkerchief, this variety of procedure being adopted so as to avoid the contracting of the morphine habit. Irritability of the disposition may be relieved by using three gran- ules of one of the alkaloids of opium with three of the bromide of camphor, three times daily. Thoracic neu- ralgia may also be relieved by morphine revulsives, iodoform, hyoscyamine, or the valerianate of atropine. Two granules of either of these agents may be used three times daily, or one granule every half -hour until the desired effect is obtained. Angina pectoris is one of the most dangerous complications of lesions of the aortic orifice. Pathologists do not agree in regard to its pathogenesis. All the indications lead to the belief, however, that it is merely a spasmodic neurosis of the heart, and this hypothesis is confirmed by the excel- lent results which follow the use of antispasmodics. One granule of hyoscyamine, daturine, or atropine, given every quarter of an hour, combined with three ELEMENTS OF DOSIMETRIC PRACTICE. 509 granules of the hydrobromate of morphine, or half a centigramme of the hydrochlorate of morphine and half a milligramme of the sulphate of atropine, dis- solved in water and injected subcutaneously at inter- vals of half an hour, will usually bring relief from this severe condition. Inhalations of nitrite of amyl and the prolonged use of electricity will also give good re- sults. Dyspnoea may also be relieved by the use of three granules of morphine, alone or in combination with the hydrobromate of cicutine or with aspidosa- mine. The last-mentioned drug may be used alone or with adonidine, which has a diuretic action. Both of them have been recently introduced into the dosimetric arsenal, being prepared in granules which contain one milligramme each. It is believed that they will be found indispensable in the treatment of diseases of the heart. Such are the most important symptomatic in- dications which are to be filled in the treatment of these diseases, which are as common as they are difficult to completely cure. ORGANIC DISEASES OF THE HEART. Lesions of the Mitral Orifice. Compensatory hypertrophy- Tonics Sedatives . Somnolence Cerebrai . . -{ Insomnia . Delirium . f Oppression J Expectoration 1 Cough [ Haemoptysis Cholestasis Icterus j Oliguria } Albuminuria Means for exciting diaphoresis Means for exciting diuresis . p Purgation Pulmonary Hepatic . V Renal . Arseniate of strychnine, arseniate of iron. Aconitine, digitaline. Digitaline, caffeine, strychnine, guaranine. Valerianate or arseniate of caf- feine. Cicutine, croton chloral, bromide of camphor. Digitaline, aconitine, hyoscya- mine. Revulsives, aconitine. strychnine. Benzoates, atropine. Narceine, codeine, Gregory's salt. Ergotine. Sedlitz Chanteaud, podophyllum Colchicine. Sedlitz Chanteaud, arbutine. Aconitine, digitaline. Nitrate of pilocarpine, milk diet. Arbutine, adonidine. j Podophyllin, Sedlitz Chanteaud. ( Colchicine. 310 ELEMENTS OF THERAPEUTICS AND PRACTICE. Lesions of the Aortic Orifice. ( Hydrobromate of morphine, atro- Angina pectoris . . . . -j pine, nitrite of aruyl, galvanic ( current. Cerebral anaemia . . . . Salts of morphine, Gregory's salt. Neuralgia Morphine, iodoform, hyoscyamine. Dvsnncea i M° r P nme > hydrobromate of cicu- ^ P ( tine, aspidosamine. Helminthiasis (Intestinal Worms). — There are three species of intestinal worms which are more fre- quently found than any others — lumbrici, oxyuri, and taeniae. The oxyuri, which have a length which does not exceed ten millimetres, are habitually found in the rectum of children, and from that organ they sometimes migrate into the vagina. The pruritus which is occa- sioned by their presence causes nervous irritation, and may lead to onanism. Our aim should therefore be to exterminate them. Since this affection is exclusively a local one, it should be treated by local means — that is, by enemata or suppositories. For children who are not utterly unmanageable, an enema, the basis of which is the following formula, may be used : ^ Glycerinae, Aquae purae aa grammes xl. Calcii sulphidi in granulis . . . No. xx. Sig. : Triturate and use as an enema. If this means can not be conveniently employed we must use mercurial ointment, applied with the finger upon the surface of the anus and rectum. Irritation of the nervous system, caused by the pruritus of the anus or vagina, may be treated, in children one or two years of age, with one granule of the bromide of camphor every two hours. Lumbrici are usually twenty-five to thirty centi- metres in length. They are developed from ova in the water which is drunk by children rather than from improper alimentation. It may be assumed as a prin- ciple that some children are more susceptible to their development than others — that is, poor nutrition is fa- vorable to their development. The treatment consists ELEMENTS OF DOSIMETRIC PRACTICE. 311 in the use of means which will poison the parasites, so that they may be ejected with the faeces. The most active agent for accomplishing this purpose, and the one which is most frequently employed, is santonine. The dosage should be large, for the object is to destroy the parasite in the medium in which it lives. Ten to fifteen granules of santonine should be given in the morning, and again in the evening, and the following morning a dose of Sedlitz Chanteaud should be given. No more doses of santonine should be administered, as it will irritate the intestine and produce a more serious result than would be produced by the worms. In ad- dition to santonine, the effect of which is sometimes uncertain, other alkaloids may be used, which also pro- duce good results, but are not to be considered purely as anthelmintics. Among such agents are picrotoxine, two or three granules of which may be used once daily, and sulphate of strychnine, one or two granules of which may be used once or twice daily, in place of the santonine. Two or three granules of the protiodide of mercury may also be used with advantage twice daily, and, unlike calomel, it will not be likely to produce stomatitis. Taeniae require a different mode of treatment from the other parasites. Kousseine and the tannate of pel- letierine are obtainable from the dosimetric arsenal for their destruction, but very large doses are required. The necessary dose of tannate of pelletierine is thirty centigrammes, which is the equivalent of three hundred granules. The latter may be taken in solution, and this method will often be the preferable one, on account of the prevailing prejudice in favor of the granules. Half an hour after taking the solution one or two spoonfuls of Sedlitz Chanteaud may be taken, especially if the patient is of a full habit. The paralyzing effect of the pelletierine upon the intestine almost always retards the action of the purgative ; it will therefore be advisa- ble to administer two or three granules of the sulphate 312 ELEMENTS OF THERAPEUTICS AND PRACTICE. of strychnine with the pelletierine, which will increase its action as a tsenicide and prevent the disadvantages which have been mentioned. Strychnine may also be used with podophyllin as a tsenicide ; two grannies of each may be given hourly, but the treatment should not be continued during more than twenty-four hours. While this plan of treatment is less certain than the previous ones, it will be found serviceable in some cases. Two days before a tsenicide is given, one should prescribe a laxative dose of Sedlitz Chanteaud, and for nourishment only liquids should be taken. By this plan the action of the tsenicide will not be interfered with by fecal contents of the intestine. Indications for the variant are occasionally present. Colic may be relieved by the use of two granules of tannate of canna- bine every half -hour. For vomiting, one granule of the sulphate of atropine should be given every hour. Ptyalism will yield to the use of one granule of hyos- cyamine every two hours. For insomnia two granules of croton chloral should be given every half -hour, and for convulsions three of the valerianate of zinc every half-hour. The dominant will suffice, in most cases, to dispel reflex phenomena, and they will cease entirely with the cause of the irritation. Sublata causa, tollitur effectus (if the cause is removed the effect will disappear). C Mercurial ointment, enemata con- taining sulphide of calcium, water, and glycerine. Strychnine, santonine, Sedlitz Chanteaud, picrotoxine. Tannate of pelletierine, Sedlitz Chanteaud, sulphate of strych- nine, podophyllin. Tannate of cannabine. Sulphate of atropine. Hyoscy amine. Croton chloral. Valerianate of zinc. Sulphate of strychnine. Hemicrania. — Certain diseases are considered in- curable simply for the reason that they resist all the Oxyuri ^DOMIXANT. ( Lumbrici . < t— i H 1 , Taeniae £f ( Colic. Vomiting . H Variant. ( Ptyalism . K » "" Insomnia . Convulsions Paralysis . ELEMENTS OF DOSIMETRIC PRACTICE. 313 means which have heretofore been used to cure them. This conclusion is not a logical one, for the impotence of our efforts does not prove the invulnerability of the disease, but the weakness of our attack. We should therefore distinguish, in therapeutics, those diseases which have merely resisted the means which have been used for their cure, from those which are quite insus- ceptible of being cured, so as to encourage experiment- ers in their investigations upon the action of drugs in certain fields which have heretofore been considered beyond the reach of medical aid. Fighting against the impossible is absurd, but all attempts in undiscovered territory are permissible and meritorious. Unfortunately, the habit of pathological anatomists has been to turn the attention of observers rather to- ward the irreparable results of disease than toward their first causes and the means for treating them, which has happened to the detriment of physiology and therapeutics. While the study of organic lesions has enriched the museums with the most exquisite histo- logical specimens, the chapter upon pathogenesis has remained stationary, and the literature concerning the treatment of diseases has not been enriched by a single durable formula ; for, remarkable as it may seem, the more one occupies himself with the pathological anat- omy of a morbid condition, the less he dreams of solv- ing the question as to its treatment. This is not alto- gether surprising, however, for, after a disease has been pronounced incurable by high authority, it is natural that those who admit such authority should withdraw from therapeutic investigation of the case and devote themselves exclusively to its anatomical aspects, thus transforming human medical science into special zoology. For a time, medical progress, like other dis- coveries, was due to chance. Experimenters took as guides in their investigations certain relations of simi- larity as to form, color, name, etc. The results were as ridiculous as could have been expected from such a 314 ELEMENTS OF THERAPEUTICS AND PRACTICE. plan. Now, thanks to the light which has been shed upon physiology by the work of learned men, and to the precise means which chemistry has provided in the alkaloids, of which pharmacodynamics teaches us the actual effects, therapeutic investigations, placed upon a rational basis, should lead to results as certain as they are useful. Dosimetry, enlightened by physiology, armed with definite chemical principles, and reassured by clinical experience, gives an example of investiga- tion in the direction of therapeutical progress, and the proof that such progress may be realized. It would ap- pear that, with a knowledge that there are perturbing forces which produce disease, and the discovery of the vital action of medicaments, the problem is reduced to its simplest form. Unfortunately, there is not unanim- ity of opinion in the battalion of physiologists, and a study of the divergences upon physiological questions might be written, like the one which Burggraeve has written with reference to the differences among allo- pathic practitioners. In the midst of the labyrinth of opinions upon the pathogeny of migraine, we must seek first for the thread of Ariadne in order to arrive at the truth. We shall no longer be obliged, then, to retain the word incurable, which is written by some pathologists upon the banner which floats above the domains of this disease. Jaccoud, at the end of his article upon migraine, states that art is powerless to abridge the duration of the sufferings of those who are its subjects. Littre and Robin, in their " Dictionary of Medicine," state that, in general, periodic migraine re- sists the action of medicaments. In spite of the great respect which the author has for the authorities which have been mentioned, he can not help finding the asser- tion of Jaccoud too positive. The physiology of disease can not be well studied if it is not based upon an exact and complete symptomatology. Now, in this as in all nervous diseases, nothing is so difficult to find as a satisfactory description of symptoms, not of those ELEMENTS OF DOSIMETRIC PEACTIOE. 315 which characterize the migraine, but of those which constitute it. The mobility and the subjectivity of the greater number of nervous disorders, and the im- possibility of laying one's hands upon them, explain the insufficiency of the descriptions of the pathologists as to the manner in which they manifest themselves. It is not by means of one observation, but by repeated ones, that we can feel a certainty as to our knowledge of the different manifestations of different diseases. Thus we can find three distinct periods in the history of the physiology of migraine. In the first, which we can call the idealistic period, migraine is attributed to sympathy between the brain and the stomach. This opinion is defended by William Dale, who thus considers a simple etiological circumstance as a sufficient inter- pretation of the genesis of the disease. Clifford Allbutt and Niemeyer also think that migraine depends simply upon troubles of the abdominal viscera. This theory does not at all explain the nature of migraine ; it only informs us that these troubles may precede or accom- pany the attack in the head. Other authors refer to other organs as the point of departure for the symptoms in migraine, but without demonstrating its real nature. Tissot, Lebert, and Wepfer say that it is a neuralgia of the supraorbital nerve. Piorry localizes it primarily in the iris ; Hasse in the trigeminal ; Romberg and Calmeil in the cerebral substance. Anstie passes into the region of hypothetical anatomy when he assures us that this neuralgia is due to atrophic molecular irrita- tion of the roots of the trigeminal. Such is the period of hypothesis. With Du Bois-Reymond another period begins, during which observation which is more subject- ive in character makes its appearance. This learned physiologist observed in his personal exxDerience cer- tain symptoms which caused him to conclude that migraine is due to an exaltation of the cervical sympa- thetic. He observed in the course of the attack that the temporal artery became retracted, the countenance 316 ELEMENTS OF THERAPEUTICS AND PRACTICE. pale, the pupil dilated, the globe of the eye retracted, and that, by compressing the spinous processes of the vertebrse corresponding to the cilio-spinal region of the cord, a i>ain of a more or less acute character was excited. These symptoms were compared with the troubles produced in animals by electrization of the cervical por- tion of the sympathetic, and were found to be similar, thus leading him to the conclusion which has been stat- ed. In the opinion of Bu Bois-Reymond, therefore, migraine is an irritation — that is to say, a spasmodic condition of the organs which are involved. Mollen- dorf, on the contrary, holds an opinion which is op- posed to the foregoing. He found by examining the fundus of the eye that the arteries of the retina, in place of being contracted, were very much dilated ; this, added to the fact that the painful side of the head was frequently bathed in sweat, and that compression of the carotid diminished the pain, led him to the con- clusion that migraine, instead of being the result of irritation, was, on the contrary, the result of a tempo- rary paralysis of the cervical sympathetic. This con- clusion is diametrically opposed to that of Du Bois-Rey- mond ; but, as it is based upon unquestionable obser- vations, it should be accepted. The opposition between these two observers is rather apparent than real, and is perfectly comprehensible if we consider that Du Bois- Reymond's observations upon himself were made with difficulty in the course of an attack. The symptoms which he describes and interprets are referable there- fore to the beginning of the disease ; while Mollendorf, making his observations upon another individual, did not have the opportunity of being present at the first stage of the disease, and consequently his observations and the conclusions which he draws from them refer to its period of continuance or of decline. Hence, two dis- tinct phases must be conceded to migraine. The opin- ion which belongs to the third or eclectic period of the history of this disease is that which is held by Jaccoud, ELEMENTS OF DOSIMETRIC PRACTICE. 317 Latham, Eulenburg, Gutmann, Poincare, etc. The theory of Leveing, which attributes the condition to a plethora of the nervous system, explains nothing and makes nothing clear. Hervez de Chegoin, by introduc- ing the vascular element into his explanation of certain symptoms peculiar to this disease, has taken a step in the right direction ; but he has not taken into consid- eration the facts observed by Du Bois-Reymond. Poin- care, of all authors, is the one whose explanation seems the most rational, and the most acceptable to the au- thor of this book, and he accordingly adopts the fol- lowing statement as to the genesis of migraine : The nervous fluid being disturbed in its regular distribu- tion, owing to different circumstances, the cervical sym- pathetic is irritated as a result, and tetanization of the contractile elements which depend upon it follows. The most common causes of this disturbance are ex- cesses at table, inanition, over-use of the eyes, very penetrating odors, vigils, prolonged intellectual labor, and changes in certain normal functions. This tetani- zation may be compared with the period of chill in fevers. The irritation extending to the smooth muscu- lar fibers of the vessels, causes their retraction, and, in consequence, ischsemia of the organs to which they are supplied. The sensorial and intellectual troubles at this period of the disease have no other cause. The semi- amaurosis, the difficulty in perceiving sounds, the intellectual feebleness, find in the weak condition of the blood, followed by the weak condition of the nerves, a plausible explanation. The pain which accompanies these symptoms is attributed to compression upon sen- sitive nerves by contraction of the walls of the vessels, and is analogous to the condition which obtains in uterine colic. In this first period the cause of the pain, therefore, is a spasmodic irritation which has its seat within the vascular walls. The duration of this first period varies greatly, but it is usually short. To the irritation the opposite condition follows, as is the rule 318 ELEMENTS OF THERAPEUTICS AND PRACTICE. in all nervous manifestations. To exaltation succeeds paralysis ; to tetanization, relaxation ; to ischsemia, con- gestion. By admitting the existence of vasodilator nerves, we are enabled to say that excessive irritability gives rise to paralysis of the vaso-constrictors, and in consequence to the preponderance of the vaso- dilators, which act when they are not in condition of equilib- rium with their antagonists. The phenomena peculiar to the second period are analogous to those of febrile reaction. It is at this time that dilatation of the retinal vessels may be observed, heat and redness of the coun- tenance, the ears, and the conjunctivse ; also the excre- tion of sweat, tears, saliva, of a large quantity of clear urine, and a large quantity of bile which, by entering the stomach, excites nausea and vomiting. Congestion of the retina and labyrinth produces subjective sensa- tions of light and auditive hyperesthesia. The hyper- semic brain becomes fatigued by the slightest intellect- ual effort. The pain in the head persists, but assumes another character and another origin. It is no longer the constrictive pain, such as was felt at the beginning of the attack, but a pain of an expansive character, which is suggestive of the throbbing of an artery, and should be attributed to the distention of the perivascu- lar tissue of the branches of the fifth pair. The longer duration of this stage, as compared with the first, sug- gests that in each attack there are paroxysms during which the phase of irritation gradually becomes less prominent, on account of the progressive obtunding of nervous irritability ; while, for the same reason, the sec- ond period develops increased sensitiveness to each successive exacerbation. This physiological analysis indicates clearly the treatment for each period. Some considerations may serve the better to establish our therapeutic plan, and confirm what is about to be said concerning the genesis of migraine. Every irritation of a part which is remote from that which is likely to be the seat of the disease is capable of aborting the at- ELEMENTS OF DOSIMETRIC PRACTICE. 319 tack by nervous transposition and derivation of the blood. This fact is observed in the result of the inges- tion of alcohol, wine, or coffee, as well as in the appli- cation of cutaneous revulsives. Coitus will sometimes relieve migraine at the outset. All these means are antispasmodic, and accord with the results obtained by Piorry, who rubbed the eyelids with a concentrated solution of the extract of belladonna. If the patient is seen during this period, we should therefore advise the use of hyoscyamine, bromide of camphor, valerianate of caffeine, benzoate of ammonia, etc., in frequent doses, for this period is usually of short duration. In the second period or period of paralysis, as in that of febrile reaction, we should give strychnine to incite vital force, aconitine to relieve hyperemia, salts of quinine for their antiperiodic effect, and occasionally digitaline, if the pain is manifestly increased by arterial pulsations. These medicaments being designed to overcome the primary elements of the disease, other remedies, which are secondary, may be neglected. As the attacks suc- ceed each other with a certain regularity, we should not forget the preventive treatment, so as to guard against their recurrence. The diagnosis from an etio- logical standpoint is of great importance at this junct- ure, in enabling one to oppose to the determining and predisposing causes the means which will eliminate them. If hemicrania is idiopathic, the use of hyoscya- mine and valerianate of caffeine will overcome the sus- ceptibility of the sympathetic. Hydrotherapy and exercise are also very useful auxiliaries. One of the remedies which is often used, though its mode of action can not be explained, is guaranine, which gives excel- lent results in doses of two granules every half -hour, not only during the paroxysm, but also in the intervals. As a preventive to additional attacks, four granules may be used three or four times daily. This treatment should be continued for a long time, not being suspend- ed abruptly, but by gradually diminishing doses. Un- 320 ELEMENTS OF THERAPEUTICS AND PRACTICE. der the influence of guaranine, which certainly acts in a complex manner, the attacks become less frequent and less severe, and the disease becomes quite endur- able. These results show that Jaccoud has been un- wise in condemning patients to await with all possible patience the natural termination of their sufferings, the means of relief being within their grasp. In the the author' s experience, one lady who had been a great sufferer from migraine was freed from suffering for forty days by the aid of sea-baths and two granules of hyoscyamine daily. Another lady who has short but very frequent attacks, which sometimes recurred in the same day, was entirely relieved after having taken for eight days five granules of aconitine with five of arseniate of quinine daily. Hyoscyamine was tried in this case during the congestive period of an attack, but it only aggravated the pain. Gr. F. Brizuela reports, in No. 20 of the "Revista de Me- dicina Dosimetrica," published in Madrid, the case of one of his neighbors who had suffered, from the age of twenty years, with intermittent attacks of mi- graine, without definite periods for their recurrence, the attacks never lasting less than thirty hours. By taking one granule of aconitine and one of caffeine every quarter of an hour, he was able to limit the dura- tion of the attacks to two hours, at the end of which time he could eat without rejecting his food, as had always been his previous custom. Patients with this disease should know that progress has been made in therapeutics, and that they are indebted to the illus- trious author of dosimetry for this progress. What is true in respect to this disease is also true of others, which increases the obligation to him both for the pres- ent and the future. Physicians of whatever school should never forget the wise observation of Arago, "The man who uses the word impossible, in any de- partment outside of the mathematical sciences, is defi- cient in wisdom." ELEMENTS OF DOSIMETRIC PRACTICE. 321 /r>~„™.^ m (Want of dynamic ) «*Sl ™l"ZZw^T". \ G 8.2 Hyoscyamine, bromide of cam- Spasm . . . \ phor, benzoate of ammonia, ( valerianate of caffeine y ) Paralysis . . Arseniate of strychnine. ' \ Congestion . . Aconitine. Ej q Periodicity . . Valerianate of quinine. \ Cardiac excitement Digitaline. Hepatitis, Interstitial {Cirrhosis of the Liver). — Sclerosis is preceded by a process of congestion which is necessary to the proliferation of the connective tis- sue. After the condition of hypertrophy has been reached, we can do nothing to effect a transformation in a retrograde direction. There are non-definite le- sions, pathological cicatrices, which it is beyond our power to remove. The opportunity for intervention by therapeutic means does not exist, therefore, when the disease is already established ; but, on the other hand, it does exist during the preparatory pathogenic period, when the condition of health is being transformed into that of disease, and when new portions of the organ are still undergoing attack. It is the successive aggra- vations of this condition which finally bring about the fatal issue. The course is clearly indicated — namely, to oppose the hypersemias and avoid their repetition. The dominant treatment for interstitial hepatitis may, consequently, be confused with that for congestion of the liver, which has been considered in another chap- ter. Aconitine should form the basis of the anti-con- gestive treatment, and it at once satisfies two important indications. The first refers to the hyperemia, which it may dispose of before there is new proliferation of connective tissue. The second refers to its action as a cholagogue, and thereby as an incitant to the secretion of bile. On the one hand, it diminishes vitality in the connective tissue ; on the other, it increases it in the parenchymatous tissue. It thus establishes an equi- librium, which resembles, as closely as may be, the physiological equilibrium. The hyperemia is to be attacked by administering aconitine in one -granule 21 322 ELEMENTS OF THERAPEUTICS AND PRACTICE. doses every hour, or every half -hour in cases in which there is an excited state of the circulation in general, or pain and great increase in the volume of the liver in consequence of the increased flow of blood to the organ. In cases in which the hyperemia is not very pro- nounced, and the symptoms do not indicate extensive trouble in the circulation, there is still no reason for neglecting the condition, for, though the hyperemia be not extensive, it is an insidious condition, and is subject to frequent repetitions. In such cases aconitine should be given in moderation, but for a long time, per- haps, in two-granule doses two or three times daily. If the administration of the aconitine can not be contin- ued for a long time, it may be alternated with colchi- cine in similar doses, the effect of the latter being more decidedly cholagogue and less anti-congestive. Strych- nine should be used constantly, in order to fix the seda- tive effect which is produced by the aconitine, and also to prevent renewed hyperemia, which may be produced as a result of extreme vaso-motor atony. The attention of the physician should be fixed almost exclusively upon this portion of the pathological field, because it is the only one upon which the victory can be dis- puted. The professors of the official school, realizing the weakness of their instrumentalities in treating or- ganic lesions, proceed, like ourselves, to the treatment of the dynamic perturbations which precede them. Dujardin-Beaumetz says, concerning this subject : "In the interstitial inflammations which result in sclerosis, we can only reach the element of congestion which pre- cedes the organization of connective tissue. That which is true of the liver, in this respect, is true also of inter- stitial nephritis and of sclero-myelitis, in which the in- flammatory process is the same. After proliferation of the connective-tissue cells has been established, it is impossible to destroy the tissue by therapeutic means, and restore hepatic cells (to the liver), Malpighian bodies (to the kidneys), or nerve structure (to the spinal ELEMENTS OF DOSIMETRIC PRACTICE. 323 cord)." The proliferation of the connective- tissue ele- ments causes displacement of the other anatomical ele- ments which enter into the organization of the liver. The vascular supply becomes insufficient, the blood- current becomes obstructed, passive congestion is estab- lished in all the ramifications of the vena porta*, and this congestion, by preventing intestinal absorption, and interfering with peristaltic action, results in ascites and diarrhoea, which attend cirrhosis of the liver sooner or later. In order to relieve the stasis, we should seek to strengthen the heart by the use of two granules of strychnine four times daily ; and, to relieve the press- ure upon the nervous system, either diuretics and purgatives may be used in moderation, or a smaller quantity of fluids may be ingested, thus offering less to the intestine for absorption. Sedlitz Chanteaud dis- solved in a little water will be found very serviceable at such a time. For constipation, three to four gran- ules of podophyllin may be given every evening, and a spoonful of Sedlitz Chanteaud every morning. Diar- rhoea, if not profuse, may be serviceable, and calls only for the use of strychnine to establish the advantage which the patient may have derived from it ; but, if it is excessive, it will make cachexia more pronounced, and profoundly debilitate the patient. It may be mod- erated by the use of three granules of morphine every two hours, and three of pepsin with each meal. The condition of acholia results from disturbances in the secretion and excretion of the biliary fluid. Iridine is also always successful in re-establishing the flow of the bile, and three to ^ve granules may be given three or four times daily. Ascites calls for the same treatment as stasis of the vena porta, from which it proceeds. We can only attempt to stop its rapid development by means of strychnine. When, in spite of all treatment, abdominal dropsy threatens the life of a patient, by reason of the dyspnoea which is occasioned by it, we must practice paracentesis, being careful to avoid the 324 ELEMENTS OF THERAPEUTICS AND PRACTICE. dilated veins upon the abdominal wall which compen- sate the embarrassed portal circulation. The patient should be advised to lie upon the side opposite that of the puncture ; the wound may be cicatrized rapidly without giving way to fistulse and inflammations of the skin. Paracentesis should be preceded and followed by the administration of two granules of ergotine and two of the sulphate of strychnine every two hours to prevent the renewed transudation of the dropsical fluid. Apart from those cases in which asphyxia threatens, parencentesis may be tried as a curative means, by rea- son of the favorable modifications which it induces upon the circulation and the respiration. To warrant the operation, however, there should be some proba- bility that the liquid will not be rapidly renewed, for the patient would bear with difficulty the loss from the blood of the serum, which would result from the re- development of the ascites. The age of the patient, the condition of his strength, the development of the collateral circulation, the degree of atrophy, these are the conditions which must be consulted in deciding as to the propriety of surgical intervention. Dyspepsia calls for quassine to stimulate contractility, and pepsin to replace the gastric juice, which has been changed in quality with the congested condition of its mucous membrane. Sedlitz Chanteaud may be used daily to relieve the digestive canal of any imperfectly elaborated food which it may contain. Cirrhosis, whether due to stasis of the portal circulation, which will facilitate enterorrhagia, or to that particular dyscrasia which is accompanied by hemorrhages at particular parts of the body, should be treated, in case haemorrhage does occur, with three granules of ergotine every quarter of an hour. If hepatitis is due to the action of malarial influence, haemorrhage may be more easily arrested by giving twenty granules of the sulphate of quinine three times daily. In enterorrhagia we should associate digi- taline with the ergotine, giving one granule every hour. ELEMENTS OF DOSIMETRIC PRACTICE. 325 If the haemorrhage proceeds from a dyscrasia, two granules of the salicylate of iron may be given every half-hour. Dominant. I Variant. Hyperemia /Stasis of the tion . Constipation Diarrhoea \ Acholia . Dyspepsia Dyspnoea Ilasmorrhage portal circula from sttibis from dvscrasia Aconitine. Strychnine, digitaline. Sedlitz Chanteaud. { Podophyllin. \ Sedlitz Chanteaud. Strychnine, morphine. Iridine, euonymine. j Pepsin, Sedlitz Chan- ( teaud, quassine. Paracentesis. Ergotine, digitaline. ( Ergotine, salicylate of -] iron, sulphate of qui- Hepatitis, Suppurative. — Abscess of the liver may be caused by direct irritation, as by a biliary cal- culus, or by the irritation of septic agents brought from distant organs, as in cancer of the stomach, ulcerative colitis, etc. The discovery of the pyogenic microbes (streptococcus and staphylococcus) seems to be about to replace the old metastatic theories with more rational ideas, which will more satisfactorily explain the facts which have been observed. The dominant in hepatitis varies with the phase of the disease. In the dynamic period, when vaso-motor paralysis opens the morbid scene, we should give a granule of strychnine every half-hour to overcome the paralysis, and Sedlitz Chan- teaud to cause elimination of the irritating agents. The second indication will be filled by the use of five gran- ules of calomel every hour, or two of colchicine every two hours, until a cholagogue effect is obtained. When paralysis results in hyperemia, which is quickly trans- formed into inflammation, one granule of aconitine and one of strychnine should be used every half -hour until there is a remission of the symptoms. The chills which come at the beginning of the disease should be treated with the arseniate of strychnine until a reaction is ap- parent. The fever, which is almost always severe, pro- ceeds by intermittent or remittent attacks, with evening 326 ELEMENTS OF THERAPEUTICS AND PRACTICE. exacerbations. For the first we should give twenty granules of the salicylate of quinine at night, and for the remittent fever one granule of aconitine every hour during the attack, and the granules of the arseniate of quinine every hour during the remission. The point de cote, or pain in the liver, sometimes radiates as far as the shoulder, embarrasses the respira- tion, interferes with the patient's movements, and, by the increased flow of blood which it excites, increases the inflammatory condition. It should therefore be carefully antagonized with two granules of the hydro- chlorate of morphine every quarter of an hour. The dry cough which accompanies this condition, and is called the hepatic cough, may be soothed by the use of two granules of the hydrobromate of morphine every quarter of an hour. The vomiting, which is usually present in the first days of the disease, is the result of reflex irritation, and may be checked by the use of two granules of codeine, or two of the tannate of cannabine, every half -hoar ; it may also be due to direct irritation from the presence of the bile. In the latter case Sedlitz Chanteaud would be preferable to the sedatives. Icterus is only of secondary importance. In chronic hepatitis interference on account of this symptom is sometimes required, on account of its duration and the anxiety which it causes the patient. Two granules of calomel and two of arseniate of soda, given five times daily, will cause a rapid disappearance of this symptom. When there is no longer any doubt as to the presence of pus, surgical intervention will be necessary, whether the cavity be freely opened, with strict antiseptic pre- cautions, or a spontaneous discharge of the pus be fa- cilitated by the application of Vienna paste to the sur- face of the abdomen over the liver. The opening should be treated with antiseptic irrigations, drainage-tubes being retained in the wound. Whether the abscess open spontaneously or be opened by surgical means, internal treatment should precede and accompany the ELEMENTS OF DOSIMETRIC PRACTICE. 327 evacuation of the purulent accumulation. One granule each of iodoform and arseniate of soda every two hours to check suppuration, and two of arseniate of strych- nine every three hours to overcome adynamia and pros- tration, should be given regularly and persistently. The colliquative diarrhoea and hectic fever which ac- company chronic hepatitis leave little hope for a favor- able issue of the disease. In some cases the combina- tion of sulphate of strychnine and cotoine in two-granule doses every two hours, together with the principal treatment, will assist in bringing about a recovery. During the entire course of the disease a milk diet must be used almost exclusively, or at any rate there should be abstinence from the use of stimulating sub- stances. The relation which exists between gastro- duodenal irritation and inflammatory conditions of the liver is well known. H few f Vasomotor paralysis T> ^j Elimination of septic mat- I Hyperemia, inflammation /Chills . Intermittent fever . Remittent fever Pain in the liver Hepatic cough . Vomiting Icterus .... Suppuration . Adynamia Diarrhoea \ Variant. Arseniate of strychnine. Calomel, Sedlitz Chan- teaud. Aconitine, strychnine. Arseniate of strychnine. Salicylate of quinine. Aconitine, arseniate of qui- nine. \ Hydrochlorate of mor- \ phine. \ Hydrobromate of mor- l phine. Sedlitz Chanteaud, codeine. Calomel, arseniate of soda. Iodoform, arseniate of soda. Arseniate of strychnine, j Sulphate of strychnine, co- ( toine. Hydrocephalus (Serous Apoplexy). — Dropsy of the brain may be either congenital or acquired. From the clinical point of view, the disease may be consid- ered as chronic and acute, the congenital form being the chronic one. Acquired or acute hydrocephalus alone calls for particular investigation. The principal causes of encephalic dropsy are either mechanical or dyscrasic. The first consist in obstacles to the venous circulation of the brain, and may be either within or 328 ELEMENTS OF THERAPEUTICS AJSTD PRACTICE. without the brain ; the second include all the changes and all the diseases which modify the composition of the blood, and cause serous transudation. A third group of causes — the dynamic — should also be admitted, which consist in an atony or relaxation of the capilla- ries ; and this group is really the most important, for it may include the other two. Neither transudation from dyscrasic origin nor dropsy from venous stasis would be produced if the vascular tone were always sufficient to resist intravascular pressure. The principal domi- nant should therefore always attack this fundamental lesion, and ergotine and strychnine will perfectly satis- fy the indication. Two granules of each may be given every half-hour in acute cases ; three to five of each daily in chronic ones. For children, brucine is prefer- able to strychnine, because, as it is less active, its ac- tion may be better graduated. The variant should change with the variety of the hydrocephalus. Three varieties may be considered — the apoplectic, the rapid, and the slow. In the apoplectic form, the effusion may occur suddenly, or it may be added to a pre-existing effusion, so as to produce within a short time great compression upon the nervous centers contained in the brain. The symptoms include annihilation of the func- tions of the nervous system, which is described under the name of the apoplectic condition. The diagnosis between serous apoplexy and other apoplectic condi- tions almost always presents great difficulties. Ergotine is appropriate for serous as well as for sanguinolent effusions, and should be used in all cases ; but its regu- lar and rapid action can only be depended upon by using it hypodermically. If the differential diagnosis can be made, it will be proper to administer a two-per- cent solution of muriate of pilocarpine hypodermically, which will cause the removal of the serum rapidly and in large quantity. This result having been obtained, the ergotine and strychnine treatment must be contin- ued, in order to secure the advantage obtained. In the ELEMENTS OF DOSIMETRIC PRACTICE. 329 rapid form of hydrocephalus, there is more time for therapeutic intervention. The treatment is the same, but the alternating conditions of excitation and depres- sion also indicate quinine. In the period of excitation, three granules of the hydrobromate may be given every half-hour, and in the period of depression, the valeri- anate in similar doses. Yertigo often accompanies the slow form of hydrocephalus. It should be treated with caffeine, in three-granule doses every hour. Aside from the action of caffeine upon the cerebral functions and its dynamophoric properties, it also acts as a diuretic. The general paralysis and obtuse sensations, which are the result of compression of the brain, may be modified by the use of brucine in three-granule doses every two hours. Convulsions, which may interrupt the monot- ony of the slow form of the disease, should be treated with bromide of camphor in two-granule doses every half-hour, combined with brucine and sulphate of strychnine, one granule of each every hour. Treatment which is designed merely to remove the serum should not be practiced, because it only tends to increase the vascular atony. If, however, it is the only thing which can be done, we should first strengthen the patient with neurosthenic means, and then use purgatives, diu- retics, sudorifics, etc. m g \ Variant. o Q y Convulsions g /Dominant. Vascular atony . . j Er |^ e ' /Serous apoplexy Excited condition . Alternating with depres sion Vertigo . General paresis Pilocarpine. Hydrobromate of quinine. Valerianate of quinine. Caffeine. Brucine. Bromide of camphor, sulphate £h N ' ' ' ) of strychnine. Hydrophobia. — Thanks to the labors of Pasteur, we now know that hydrophobia is due to the develop- ment of a microbe within the nervous system, which microbe he has discovered and cultivated. The pre- ventive treatment, consisting in inoculation, thus be- comes a very simple matter, and justifies the hope that 330 ELEMENTS OF THERAPEUTICS AND PRACTICE. hydrophobia in man may in the f uture be of exception- al occurrence. Unfortunately, elements are still wanting which ap- pertain to the preservative value of attenuated virus which has been the means of inoculation after a bite has been received, and still more so in those cases in which hydrophobia actually exists. The preventive dosimetric treatment should have for its object opposi- tion to the development of the virus and diminution of the nervous impressionability of the patient, so as to put off or at least to diminish the violence of the at- tacks when the disease exists. After the bite itself has been suitably treated, we should endeavor to destroy the microbes, which may not have been reached by the local treatment, by saturating the organism with sul- phide of calcium, which is the best parasiticide with which we are acquainted. The drug should be given with great regularity, and with as much persistence as if an eruptive fever were being treated, one or two granules being given every quarter of an hour, and the patient being kept under its influence two to four days, according to the probabilities with reference to the inoculation, the number, situation, and gravity of the bites being considered. We should also give alternately, in two-granule doses twice daily, atropine and cicutine as long as is necessary to insure complete tranquillity. After the disease has manifested itself, the dominant will be five granules of the sulphide of calcium every half -hour, to neutralize the virus which is disseminated through the nervous system ; atropine being added in one-granule doses every half -hour until its physiologi- cal effect is obtained, and then being renewed after this effect has passed away. As the virus changes the character of the secretions by its own nutrition and the modifications in nutrition which it brings about in the organism, its elimination by all the emunctories should be favored. For this end diuretics and purgatives should be given, and the indication will be fulfilled by ELEMENTS OF DO SIM ETUI G PRACTICE. 331 using a spoonful of Sedlitz Chanteaud every two hours. During the period of melancholy, when the nature of the disease is suspected by the patient, the dominant should be used with great activity, for it is only during this stage that it can be used with regularity. The de- pressing character of the morbid phenomena of this period calls for the use of the salicylate of ammonia in three-granule doses every hour, and this in addition to its exciting action will also aid the action of the domi- nant. In the second period, the readiness with which spasms are excited being one of the most frequent causes of the patient's sufferings, we should, if possible, re-enforce the action of atropine with daturine, or with bromide of camphor if a further use of the mydriatics is not advisable. Atropine may be given in one-granule doses every half -hour until the physiological effect is obtained ; camphor or croton chloral may be used in three-granule doses every half-hour until a sedative effect has been obtained. The paralytic period which follows the great loss of vital force indicates hypophos- phite of strychnine and phosphoric acid in doses con- taining two granules of each every half -hour. When pharyngeal or other spasms of the respiratory passages interfere with the ingestion of medicaments, we must use hypodermic and rectal injections. This plan of treatment may seem too energetic, but unfortunately the author has seen in three fatal cases that death is the rule of this disease, which is so rapid that it must be attacked unsparingly and without hesitation. Whatever plan of treatment be devised, experience has proved that the best chances for success exist no more after the melancholic period has passed. f Parasitic element . D »--H^tt a S,- the prod I ucts of elimination f Period of melancholy Period of spasm . Variant. Period of paralysis Sulphide of calcium. Atropine. Sedlitz Chanteaud. Salicylate of ammonia. Daturine, bromide of camphor. Hypophosphite of strychnine, phosphoric acid. 332 ELEMENTS OF THERAPEUTICS AND PRACTICE. Hyperemia, Meningo-spinal. — Meningo- spinal congestion sometimes occurs as an independent and isolated condition ; it is usually united to other lesions, however, especially to spinal meningitis. The dominant consists in the use of aconitine, which, in addition to its effect upon the hyperemia, is an ex- cellent sedative to the nervous centers, either directly by its sedative action upon the nerves, or indirectly as a moderator of the circulation. The congestion may be active, supplementary, or passive. Active congestion is produced by the irritant action of infec- tious agents, as occurs, for example, in variola. The sulphide of calcium should be combined with aconitine, to antagonize simultaneously the physio-pathological and the etiocratic elements. When the congestion is due to the action of cold, diaphoretics are indicated, and one granule of aconitine with ^ve of pilocarpine may be given every quarter of an hour until the desired effect is produced. If the congestion is due to the ac- tion of heat, the same diaphoretics may be used, and Sedlitz Chanteaud may be added for its refreshing in- fluence upon the blood. The supplementary conges- tions which may be due to suppression of the menses will yield to the action of veratrine, which at the same time will tend to re-establish the suppressed function. Two granules of veratrine should be given with one of aconitine, every half -hour, or every hour, according to the urgency of the case. If the congestion is due to the suppression of a hemorrhoidal flux, the daily use of Sedlitz Chanteaud should be resorted to, together with three granules of bryonine every two hours. The passive congestions which are due to obstruction in the venous circulation may be treated in different ways. The end which should always be sought is the restora- tion of the circulation to its normal condition, and the stimulation of the vessels of the cord, which have been dilated and paralyzed by the excessive pressure of the volume of blood which they contain. To accomplish ELEMENTS OF DOSIMETRIC PRACTICE. 333 this end, two granules of digitaline and two of the sul- phate of strychnine should be given two to four times daily. Intense pain in the lumbar region should be treated with one granule of hyoscyamine and one of cicutine every half-hour until relief is obtained. Retention of urine resulting from torpor in the innervation of the excretory apparatus calls for the use of hypophosphite of strychnine, three granules of which may be given every hour ; in some cases it will be well to add a granule of daturine every hour until mydriasis results. For the paraplegia, two granules of phosphoric acid, three to five times daily, will be ap- propriate ; or, in recent cases, three granules of ergotine every two hours. Cold, warm, or hot baths will be found useful as auxiliaries to this plan of treatment. MENINGO-SPINAL HYPEREMIA. Dominant. Hyperaemia Aconitine. Causal Variant. A^f,-,^ ™r,™o ( From infection . . Sulphide of calcium. tiSS l \ From C0ld * ' * titrate of pilocarpine. * ( From heat . . . Aconitine, Sedlitz Chanteaud. [From cessation of the [ v D ™tr'n n Supplementary J menses . . . f veratrme - congestion . 1 From cessation of the / jr; nu t. ^ i * [ hemorrhoidal flux . [ Sedlitz Chanteaud, bryonme. Passive rone-ps ( From obstruction in the j_ Digitaline, sulphate of strych- *.:„_ ° s venous circulation . \ nine. tion From muscular efforts . Ergotine. Symptomatic Variant. .Radiating lumbar pains . . . Hyoscyamine, cicutine. Retention of urine . ... j D f t ry C Tnine yP ° Ph0Sphite ° f Paraplegia Ergotine, phosphoric acid. Hyperkinesia, Cardiac (Palpitations of the Heart). — Exaggeration in the number or the force of the cardiac pulsations constitutes hyperkinesia. But, in order that this may amount to a condition of dis- ease, the patient must be conscious of his trouble, and 334: ELEMENTS OF THERAPEUTICS AND PRACTICE. really suffer from it. The condition appears to be a convulsive one of the cardiac muscle, which affects, to a greater or less degree, the entire organism. What- ever the cause of the palpitations may be, the essential lesion is a dynamic perturbation, for the effect is not a constant convulsive condition of the heart ; neither is the patient conscious of his trouble at all times. To relieve the irritability of the heart, or the nervous cen- ters which animate, should be the object of treatment, and consequently the dominant established upon this hypothesis should be associated with the treatment for the other lesions. One granule of strychnine, with one of hyoscyamine, three or four times daily, by restoring the dynamic equilibrium, will usually constitute the principal treatment, and for many cases it is all that will be necessary. There are particular indications for the mechanical modifications caused, in some cases, by a diminution, and in others by an increase of pressure. In the first case we should give two or three granules of the arseniate of iron three times daily to increase the volume of the circulating fluid, and two or three gran- ules of the arseniate of strychnine three times daily to increase the vascular tone and restore the normal press- ure. In cases of the opposite character, two granules of digitaline and two of sulphate of strychnine should be given two or three times daily, to bring about an equilibrium between the force of impulsion and the vascular pressure. The changes in the innervation consist of vaso-motor atony, which calls for two or three granules of ergotine and an equal quantity of the ar- seniate of strychnine three times daily, and nervous irritability, which may be quieted by the use of three granules of the monobromate of camphor three or four times daily, or by similar quantities of codeine. Modi- fications in the quantity and quality of the blood have a noteworthy influence in the production of hyper- kinesia. Chlorosis, anaemia, and plethora are fre- quently the cause of palpitations. Chlorosis and anse- ELEMENTS OF DOSIMETRIC PRACTICE. 335 mia should be treated with two granules of the valeri- anate of iron and two of arsenious acid three times daily, while plethora, as a cause of hyperkinesia, will yield to the influence of Sedlitz Chanteaud and two granules each of aconitine and veratrine three times daily. The hygienic treatment will consist in pro- tecting the heart from anything which may tend to irritate it. Tea, coffee, alcohol, coitus, moral emo- tions, and tobacco are all agents which tend to the production of palpitations, and should be careful- ly abstained from under any and all circumstances. The symptomatic variants will rarely require our at- tention in the treatment of this condition ; it will be occupied, in the main, with the causal indications. Sometimes, however, particular symptoms will furnish the occasion for particular treatment. Thus, should dyspnoea be a source of annoyance to the patient, we may give two granules of the hydrobromate of cicutine every half-hour until relief is obtained. Lipothymia will demand the immediate use of one granule of phos- phoric acid every five minutes. The periodic occur- rence of the attacks which is sometimes noticeable will indicate the use of three to five granules of the hydro- bromate or the valerianate of quinine three times daily. Other indications will sometimes arise, and they must not be neglected. For example, helminthiasis may cause palpitations, which will be more or less trouble- some, and for this condition ten granules of santonine should be given every evening. Constipation may also be a complication, and this should be treated with three to five granules of podophyllin every evening, or by the daily use of Sedlitz Chanteaud. There are also reflex palpitations, which are always due to nervous irritability, besides many other varieties which are too well known to require particular mention. It may be desirable, however, to call attention to those which are caused by gastric disorders, especially such as arise from dilatation or flatulence. 336 ELEMENTS OF THERAPEUTICS AND PRACTICE. /Dynamic modifi- cations . Mechanical modi- fications . Modifications of innervation . Modifications the blood HYPERKINESIA. Want of dynamic equi- \ librium . . . | Diminished pressure Increased pressure . Vaso-motor atony . Nervous irritability . Anaemia . Plethora . Dyspnoea . Lipothymia Periodicity Helminthiasis , Constipation* Hyoscyamine, strychnine. Arseniate of iron, arseniate of strychnine. Digitaline, sulphate of strychnine. Ergo'tine, sulphate of strychnine. Bromide of camphor, co- deine. Valerianate of iron, arseni- ous acid. Aconitine, veratrine, Sed- litz Chanteaud. Hydrobromate of cicutine. Phosphoric acid. Valerianate of quinine. Santonine. j Podophyllin, Sedlitz Chan- { teaud. Hypertrophy, Cardiac— Hypertrophy of the heart is the result of an irritation of its muscular tissue, of a nutritive character, resulting from an excess of work, which may be caused by an interference in the circula- tion of the blood propelled by the ventricles, or by an excitation which is purely of nervous origin. Hyper- trophy, in so far as it is a compensating lesion, is a salutary modification of the normal structure, an effort to restore the physiological equilibrium by adapting the organ to its function, and to that extent it should be appreciated. Sometimes, however, it exceeds the necessities of the case, and this excess becomes a dis- ease which we must moderate, not only because it im- poses a useless restraint upon the patient, but because we ought to reserve the proliferative force of the organ- ism for that epoch — which may not be remote — when we shall need its assistance. Hypertrophy which fol- lows hyperkinesia should always be antagonized, be- cause it is a useless change, an aggravation of its origi- nal cause, and far from being a compensatory condition, as it is when valvular lesions are present. Hypertrophy of the contractile elements of the heart maybe modified by veratrine, an agent which has the greatest influence ELEMENTS OF DOSIMETRIC PRACTICE. 337 upon muscular nutrition. It may be given in large doses, which should be regulated, however, by the state of the pulse and the cardiac force. In general terms, two to three granules may be given three to five times daily, until the state of the pulse indicates its with- drawal. Excess of vascular pressure, caused by con- gestion within the cranium or elsewhere, should be treated with aconitine and Sedlitz Chant eaud. Two granules of aconitine three to four times daily will be equivalent to a bloodletting, and Sedlitz, by the transu- dation which it provokes to the surface of the intestinal mucous membrane, will diminish the vascular pressure and regulate all the functions. A dessertspoonful may be given every morning. Epistaxis may be of service in relieving cephalic hyperemia ; but, if this natural means of abstracting blood is not indicated, we should use ergotine in doses of three granules every half-hour. Vertigo should be treated with purgatives and the valerianate of caffeine. The use of Sedlitz Chanteaud should also be insisted upon, and its effect may be in- creased by using three to five granules of podophyllin every evening. Caffeine should also be used with mod- eration — that is, in doses of two granules every quarter of an hour. Aconitine is equally useful for vertigo, especially when this is accompanied by headache, one granule being given every half-hour. A hard and vi- brating pulse, denoting an excitation of cardiac con- tractility, and a considerable increase in arterial press- ure, calls for Sedlitz Chanteaud and emetine, two gran- ules of the latter being given every hour until the cir- culation is quieted. Palpitations may be controlled by using two granules each of digitaline and arseniate of antimony, two to three times daily. Dyspnoea and thoracic oppression, indicating broncho-pulmonary con- gestion and weakness of the respiratory apparatus, should be treated with three granules each of apomor- phine and nitrate of pilocarpine every two hours. After the functional troubles have been quieted, we should 22 338 ELEMENTS OF THERAPEUTICS AND PRACTICE. m Muscular hypertrophy /Excess of vascular pressure Cephalic congestion . Epistaxis . \ Variant, i Vertigo . Hard and vibrating pulse . W Palpitations ^Dyspnoea . . . . seek to preserve the physiological equilibrium and pre- vent fatigue of the heart by giving two to four granules of aconitine every evening, with an equal quantity of digitaline and arseniate of strychnine, and in the morn- ing a small dose of Sedlitz Chanteaud. By these means we can keep the patient in a relatively comfortable con- dition for a very long time. The hygienic treatment should, of course, harmonize with the pharmaceutical. Veratrine. j Sedlitz Chanteaud, aconi- \ tine. Ergotine. j Podophyllin, aconitine, ( valerianate of caffeine. Sedlitz Chanteaud, eme- tine. Digitaline, arseniate of antimony. Apomorphine, nitrate of pilocarpine. Hysteria. — Hysteria is a type of affections which are purely of nervous origin, and is caused by a par- ticular predisposition to a want of dynamic equilibrium. An attack may be caused by a perturbation of any character whatsoever, and it may take a thousand forms, from a simple change of mood to the most vio- lent convulsions, ecstasy, etc. The general treatment of hysteria should consist, therefore : 1. In restoring the equilibrium of the vital dynamic condition. 2. In suppressing the exciting causes. The first indication may be filled by the observation of a rigorous physical and moral regimen, and by the use of the proper alkaloids. Aconitine, digitaline, hy- oscyamine, and strychnine should be given every even- ing in doses of two to four granules of each, the treat- ment being commenced, however, by using the smallest quantities of each, and gradually increasing it until the quantity indicated has been reached. This treatment should be continued a long time, and the dosage may be diminished as the symptoms are ameliorated. Should ELEMENTS OF DOSIMETRIC PRACTICE. 339 congestion occur frequently, we should press the ad- ministration of aconitine ; should the heart be very- excitable, we should adopt the same course with digi- taline ; if the patient should be very feeble, we should increase the quantity of strychnine ; if spasms are fre- quent and constitute the principal trouble, we should give without hesitation a very strong dose of hyoscya- mine, provided there is no peculiarity on the part of the patient to contra-indicate its use. The second indi- cation, to suppress the exciting causes, is equally im- portant. Everything should be avoided, therefore, which would excite an attack — not only an attack of a pronounced character, but also one which, from its slight intensity, might be overlooked. Frequently hys- teria is caused by constipation, ulceration of the neck of the womb, laborious digestion, stimulating or innu- tritious food, or entozoa. The treatment should be fol- lowed up without interruption or abatement of care. It must not be forgotten that one attack predisposes to others, and that the longer the interval between con- secutive attacks, the better will be the prospect of a radical cure. With advancing age, hysteria will disap- pear ; the same result may also be obtained by proper treatment : in both cases a certain period of time is an indispensable element of success. During the attacks, there is little that the physician can do. After having arranged the patient so that she can not harm herself and can properly perform the different physiological functions, he may interfere in the manner which is pre- scribed in the various classical treatises ; but he will rarely be able to shorten the duration of the attack. He may reach the conclusion that an aborted attack never leaves a patient in good humor ; and, on the other hand, by a kind of disastrous compensation, exposes her to a series of violent attacks. It would seem as if the system needed to get rid of a superfluity of force, which results in an absence of dynamic equilibrium, before that equilibrium can be restored. There are 340 ELEMENTS OF THERAPEUTICS AND PRACTICE. cases, however, in which intervention is required, more for the sake of the patient's family than on account of the exigencies of the disease. In such cases we should give two granules of bromide of camphor every half- hour, dissolved in a teaspoonful of cold water or similar quantities of piperine. Some symptoms require par- ticular treatment by means of local applications, such as metallotherapy, electricity, hydrotherapy, etc. By treatment with alkaloids, we can often obtain results, however, which could not be obtained by external treatment. We shall therefore indicate in a few words the principal agents which may be used to oppose the different symptoms. One important symptom of hys- teria consists in contractures, which are sometimes very persistent, and we should never count upon their spon- taneous resolution. Success in treating them will be influenced to a great degree by the promptness with which treatment is begun. One granule of hyoscya- mine should be given every quarter of an hour, or three of croton chloral with the same frequency. For the paralyses we should give two granules of phosphoric acid or of phosphide of zinc three or four times daily. Hyperesthesia may be treated with local stimulant ap- plications and the internal use of two granules of cicu- tine every hour until relief is obtained ; for anaesthesia we should give five granules of nitrate of pilocarpine three to four times daily, combining with it three gran- ules of valerianate of zinc three times daily. "^ /Dominant \ Want °f nervous equi- ( Aconitine, digitaline, hyoscya- 2 ' ' t librium . . 1 mine, arseniate of strychnine. PS H pH Wariakt Contractures Paralyses \ Hyperesthesia Anaesthesia . Hyoscyamine, salts of atropine. ( Phosphoric acid, phosphide of ( zinc. Cicutine, croton chloral. Nitrate of pilocarpine, valerian- ate of zinc. Icterus. — Icterus is a symptom which is common to different morbid conditions, but must be studied by itself, for it requires particular treatment not only when it is a feature of a disease which has been correctly ELEMENTS OF DOSIMETRIC PRACTICE. 341 diagnosticated, but also when it belongs to diseases which have not been recognized, or concerning the di- agnosis of which there is doubt. It may be due to the retention of bile in the biliary ducts, or it may occur when there is no retention of bile. Retention is due to different causes — obstruction, inflammation, spasm, ex- ternal pressure. Obstruction is almost always caused by biliary calculi, which prevent the passage of the bile into the intestine. Its treatment consists principally in the use of cholagogues, or podophyllin in five- gran- ule doses once or twice daily, and suitable mineral waters. Inflammation diminishes the caliber of the canals, and also gives rise to obstruction on account of the resulting exudate, thus causing catarrhal icterus. As this inflammation is almost always due to the ex- tension of a gastro- duodenitis, the protopathic lesions must be carefully treated. A milk-diet and two gran- ules of cotoine every two hours will fill this indication. Catarrhal icterus itself should be treated with two gran- ules of calomel and two of arseniate of soda every two hours. Icterus may also result in consequence of the retention of bile on account of spasm, this variety being known as nervous icterus. A granule of hyoscyamine every three hours and saline laxatives (Sedlitz Chan- teaud) will quickly restore the flow of the bile. Reten- tion may also be caused by the pressure which may be exercised by tumors of different kinds upon the ex- cretory canals. The removal of the cause, and the use of strychnine to aid the fibro-muscular coat in over- coming the obstacle, constitute the most rational treat- ment. Icterus which is manifested when there is no retention of bile (the fseces giving evidence of biliary influence, while in cases of retention they are white and clay-like) may be due to polycholia — that is, ex- aggeration of the bile- secreting function — so that the canals can not entirely evacuate themselves into the intestine, whence resorption follows just as in cases of retention ; or it may be due to toxaemia, either because 342 ELEMENTS OF THERAPEUTICS AND PRACTICE, the changed functions of the canals permit an abnormal resorption, or because the red globules are destroyed, their hsemaglobin being changed in the blood into bilirubin. In this latter class are included the grave forms of icterus which appear to be produced by in- fectious intoxication of a parasitic character. The analogy which this form presents, as to its symptoms and progress, with the symptoms and progress of many other infectious diseases, warrants this hypothesis. It would, therefore, seem reasonable that the salicylates, especially the salicylate of quinine, and possibly the sulphide of calcium as well, should be useful in these cases. As to the variant, the following indications are to be filled : Constipation should be treated with three to five granules of podophyllin twice daily, and in the morning a spoonful of Sedlitz Chanteaud. The dys- pepsia, which is due to a deficiency of bile, the latter causing unusually rapid decomposition of the contents of the intestine and imperfect elaboration of the food, may be modified by the use of three granules of quas- sine and three of elaterine before each meal. Pruritus, which accompanies icterus, and is sometimes almost unendurable, may be relieved either by taking two granules of croton chloral every quarter of au hour until relieved, or by acetic-acid baths, a quarter of a liter of acid being used to fourteen liters of warm water. The diminution in the number of pulse-beats which is produced by the action of the biliary acids, and the hypochondria which has such a depressing action upon the patients, may be treated with two to three granules of the arseniate of strychnine three times daily. Haemorrhages call for a combination of two granules each of arseniate of strychnine and ergotine every two hours. Chronic icterus has two particular indications which should not be overlooked. The first consists in inciting the contractility of the fibro-mus- cular tunic of the biliary passages to compensate the atony which results from dilatation of the canals in ELEMENTS OF DOSIMETRIC PRACTICE. 343 consequence of the accumulation of bile. The second is the necessity for destroying the bilirubin which is in the blood by pulmonary oxygenation. For the atony two granules of strychnine four or five times daily may be given ; for the failure of oxygenation, exercise, gym- nastics, inhalations of oxygen, or aerotherapy may be prescribed. Dominant. ( Variant. ( ICTERUS. Obstruction. ( From retention j Inflammation of bile Spasm. Compression Without reten-( Pol > Tcholia ' tion of bile . "j Toxaemia ( Infection . /Constipation . Dyspepsia Pruritus . Diminution of the pulse Hypochondria . Haemorrhages . ^Retention of bilirubin j Cholagogues, benzoate of / lithia. Cotoine, milk diet. Calomel, arseniate of soda. ( Hyoscyamine, Sedlitz Chan- | teaud. Strychnine, j Podophyllin, Sedlitz Chan- ( teaud. Arseniate of strychnine. Salicylate of quinine. { Sedlitz Chanteaud, euony- 1 mine, podophyllin. Quassine, elaterine. Croton chloral. Arseniate of strychnine. j Sulphate of strychnine, ergo- ] tine. Exercise, diuretics. Incontinence of Urine. — This condition may come from such different causes that it should properly be considered as a symptom and not a distinct disease. Its frequency, however, compels all authors to make particular allusion to it, and to give it a particular place in their nosological classifications, and, in addition, to prescribe the treatment which is appropriate for it un- der different circumstances. Most of the cases which are met in practice belong rather to surgical than med- ical affections. Others, on the contrary, which are in- cluded under the term nocturnal incontinence, have nothing to do with surgery, and come entirely within the domain of medical therapeutics. This class of cases is especially referred to in this chapter, but advantage is also taken of this opportunity to observe that, in surgical cases, the surgeon should take pains to remedy the condition which affects the vitality of the diseased 344: ELEMENTS OF THERAPEUTICS AND PRACTICE. organs, if lie does not wish to replace the existing dis- ease with one which is more severe. Permanent cathe- ters, for example, are dangerous in these cases, for the urine becomes readily changed, and phosphatic salts are deposited around the catheter, which may become foci for the development of calculi, while the urethral and vesical mucous membranes may also be inflamed by the prolonged contact with them of a foreign body, and complications which are more or less grave may result. The methodical evacuation of the bladder, in place of the natural evacuation, may be substituted in cases in which there is paralysis of the organ, for in this way overdistention of the organ, with consequent re- laxation of its muscular fibers, may be avoided. Strych- nine and ergotine are the drugs which should be used in treating this condition. In these cases, as in cases of paralysis of the sphincter, these two drugs may be depended upon, a cure being a question only of time and dosage. In many cases among the aged the author has seen the paralysis disappear when a return of ves- ical contractility could not be anticipated, and this from the use alone of these two drugs. Strychnine must be given in constantly increasing doses ; ergotine, on the other hand, must be given at intervals, in order to avoid a possible capillary gangrene. In nocturnal incontinence the use of strychnine will constitute the treatment of the dominant, because there can be no in- continence without a certain degree of relaxation of the sphincter. In many cases, however, it is not this re- laxation nor the atony of the sphincter which causes the unconscious discharge of the urine, for it may be due to a change in some of the vital elements which are concerned in the normal discharge of the urine, the physiological equilibrium being thus disturbed. The factors which are concerned in the emission of the urine are several, and include the chemical compo- sition of the urine and its quantity, the degree of irrita- bility of the mucous membrane, the nerves which trans- ELEMENTS OF DOSIMETRIC PRACTICE. 345 mit impressions from the perix>hery, and the nerv- ous centers which transform them into sensation ; the brain, which perceives the sensation ; the will, which directs the contraction of the muscles ; the sphinc- ter, which opposes the passage of the urine ; and the muscular tunic of the bladder, which overcomes this resistance. If there is increase or diminution in any of these elements in the excretory act, the emission of urine will cease to be normal. Should the sphinc- ter offer less resistance than is normal, the urine will pass off involuntarily. Such cases may be readily cured by strychnine and by hydrotherapy, which will increase the resisting force of the sphincter. With children it is well to take the precaution to cause them to arise and evacuate the bladder in the middle of the night, so as to prevent too great an accumulation within it. If, on the other hand, the brain no longer recog- nizes the necessity of emptying the bladder, there are means which are very efficacious for remedying this defect. Atropine and caffeine, given at bedtime in gradually increasing doses, will accomplish excellent results, and this treatment should be continued until a cure is effected. In most cases two to three granules of atropine, and four to six of caffeine, given every evening in one dose, or in several should the patient be inclined to wakefulness, will be sufficient to effect a cure for this trouble, which, though it may not appear to be of great gravity, should be attended to, for it may lead to spermatorrhoea, and even to epilepsy. In other cases the brain is conscious of the necessity for evacua- tion of the bladder, but the child (if it be a child) can not exert sufficient will-power to overcome the muscu- lar inactivity which accompanies sleep. Corporal pun- ishment in such cases usually does little good. Vesi- cants applied over the sacral region are sometimes effective, but the use of caffeine is preferable, and the requirement that the child should completely empty his bladder as often as he is compelled to rise from his 346 ELEMENTS OF THERAPEUTICS AND PRACTICE. bed. In other cases the sensitiveness of the vesical mucous membrane is increased, either from the excess of irritant properties in the urine, as an excess of uric acid, or from irritation proceeding from neighboring organs — for example, the irritation caused by ascarides, indigestion, etc. In such cases small quantities of urine produce the same impression upon the bladder that is produced by large quantities in the normal con- dition, and, as a result, the sensibility of the brain is blunted by the frequent repetition of the same impres- sion. Three to six granules of cicutine and of bromide of camphor may be given daily, five to eight of santo- nine and of calomel twice daily, six of the benzoate of soda and of asparagine daily, and, if the conditions in- dicate, two granules of pepsin and of iron with each meal, and Sedlitz Chanteaud in sufficient quantity. INCONTINENCE OF URINE. 1st. From the Forced Opening of the Sphincter and the Urinary Passages (Incontinence from Regurgitation). ( Methodical evacuation of the Paralysis of the bladder . . . < bladder by surgical means, ( strychnine. Hypertrophy of the prostate . . j M ^^ evacuation > er S otine ' Obstacles in the urethra . . . Surgical intervention. 2d. From Permanent Opening of the Sphincter (True Incontinence). Paralysis of the sphincter . . . j ffi^ of strychnin* Organic lesions of the prostate . . Do /; sal decubi t us > treatment of Foreign bodies Treatment of the cause. 3d. From Intermittent Opening of the Sphincter (Essential, Nocturnal, or Infantile Incontinence). Atony of the sphincter . . . | ^^^^^^' C-bral torpor I^Sr Torpor of the will .... | Mo^and preventive means. ( Fr a°c?d 6XCeSS ° f UrIC [ Benzoat ' e of lithia ' Increase in the Ascarides m th ' e rec I > i Y»rn rnhlhtTT r\T ( irritability of ( ^ J- Santonine, calomel, the bladder changes in digestive j Lactate of iron, pepsin. \ power . . . ( Sedlitz, etc. ELEMENTS OF DOSIMETRIC PRACTICE. 347 Indigestion,, — Difficulties in the digestion of in- gested food may arise from excess as to their quantity, from the accidental absence of the gastric juice, or from suspension of the peristaltic motion of the stomach. When the quantity of food or of drink has been too great, the two other conditions of apepsia mentioned may be realized ; for, on the one hand, the usual quantity of the gastric juice will not suffice to effect chymification of the unusual quantity of food, and, on the other, mechanical dilatation of the stomach will weaken the energy of its contractility and produce temporary pa- ralysis. The means to be employed in the different conditions will differ in accordance with the cases. If indigestion is due to an excess of peptonizable food, three granules of pepsin may be given every half -hour. If the excess consists of starchy foods we should give the same quantity of diastase. Gastric atony, which always accompanies this form, should be treated with two grannies of quassine every quarter of an hour. If indigestion is caused by excitement of the reproductive apparatus, by violent disturbance of any kind, etc., a granule of sulphate of strychnine should be given every quarter of an hour, and nourishing food in small quantities. For the intense headache which sometimes accompanies indigestion, a granule of caffeine should be given every half -hour. If the circulation of the brain seems to be affected, apomorphine should be adminis- tered hypodermically, to excite vomiting, if this result has not been obtained by other means, such as putting the finger down the throat, tickling the palate, etc. After the attack has been brought under control, we should give Sedlitz Chanteaud to relieve the digest- ive canal of any undigested food which may remain, and to overcome the saburral condition which follows these disorders of digestion; two granules of quas- sine should also be given before each meal to restore to the stomach the energy which was suspended by its overwork. 348 ELEMENTS OF THERAPEUTICS AND PRACTICE. rh r -n™™ » „m \ Gastric atony Quassine. ™. r Dominant, j Apepsia * ^^ ^^ 2o J I Cephalalgia Caffeine. O |n L Variant, -j Apoplectiform condition . . Emetics. £} ( Saburral tongue .... Sedlitz Chanteaud. Infection, Paludal. — There is no doubt but that miasmatic intoxication results from the presence in the organism of a poison which is produced in marshy and other places where decomposition of vegetable matter is freely taking place. The toxic agent must be a liv- ing organism, for the regularity in the periodicity of the attacks can on]y be explained by considering such a cause. The dynamic perturbations whicji this agent produces are related to the vaso-motor system, as is evidenced by the contraction in the peripheral vessels and the congestion of the spleen. As a causal domi- nant, quinine should be given to antagonize the infec- tion, for experience has shown that it is the most prompt in its action, and the most efficient of all the agents which have been proposed for malarial or paludal poisoning. As a vital dominant, we should give strychnine, the excito-motor properties of which are sufficiently known. Large doses of quinine are, as a rule, useless and even dangerous. Three to six granules of the hydroferrocyanate of quinine every hour, combined with one of the arseniate of quinine, will usually be sufficient to rapidly control the periodicity of the attacks. The hydroferrocyanate may be re- placed by some other salt of quinine if the indications warrant it. In the neuralgias of malarial origin the hydrobromate will be preferable, in spasmodic condi- tions the valerianate, and in rheumatic conditions the salicylate, the dose of each being three to five granules daily. If we seek to apply a still more active means of treatment without increasing the doses of quinine, six to eight granules of arsenious acid daily may be added. If the digestive organs are in bad condition, the tongue being heavily coated, constipation being present, etc., the treatment should be commenced with an emetic, ELEMENTS OF DOSIMETRIC PRACTICE. 349 for otherwise we could have no assurance that the medicaments would be absorbed. For this purpose three granules of emetic may be given to an adult every ten minutes ; to a child, emetine in similar quantities, being careful to dissolve the drug in a little water be- fore administering it, that the effect may be more prompt. If the gastric disturbance is not decided, a large spoonful of Sedlitz Chanteaud dissolved in sugar- water or in a bitter infusion may be all that will be re- quired. During the chill we should give one-granule doses of phosphoric acid or hypophosphite of strych- nine every half -hour until reaction occurs ; the shorter this stage, the less intense will the disease be, and the easier its cure. During the febrile stage we should use a granule of aconitine every half- hour, and continue it until sweating commences. In the sweating stage we should return to the strych- nine, and begin the antiperiodic treatment with quinine and arsenious acid. The headache, which is sometimes intense and may be aggravated by large doses of qui- nine, which also causes insomnia with consequent fatigue and weakness of the patient, should be treated with two granules of arseniate of caffeine every hour. If there is anorexia even during the apyretic period, three granules of quassine should be given before each meal. The appetite must not be neglected even in cases in which the appearance of the tongue contra-indi- cates the use of solid food. The repetition of the febrile attacks, and the destruction of the red corpuscles by the paludal poison, will quickly cause a condition of anaemia for which one should give one to ten granules of arseniate of iron daily. If haemorrhages occur, we should administer three granules of ergotine and three of sulphate of quinine every quarter of an hour. In that variety of malarial poisoning which yields the so-called pernicious fever, quinine is still the sovereign remedy, but as time is precious in such cases, and as we can not always be certain of gastro-intestinal absorp- 350 ELEMENTS OF THERAPEUTICS AND PRACTICE. tion during the attack, the lactate or hydrobromate of quinine must be given hypodermically. Remittent fever requires the same treament as intermittent, but it is less urgent in character because the progress of the disease is slower. In this condition we may use a granule of strychnine every two hours daily, and, in the course of a day, thirty or forty granules of the hydroferrocyanate, the sulphate, or the salicylate of quinine in addition. Masked or larval fevers, when their true nature is recognized, are treated in the same way as the regular forms. It must not be forgotten that periodicity in the attacks, which most frequently occur between midnight and midday, is the character- istic which will lead us to a knowledge of the true character of the disease. A successful result of the use of antiperiodic agents will remove any doubts as to the diagnosis which may have existed. 'Dominant. • i Paludal miasm 1 Vaso-motor paralysis Quinine, arsenious acid. Strychnine. Arseniate of strychnine. Headache Arseniate of caffeine. ^H Anorexia Quassine. \ Variant. ( Gastric disorder . \ Sedlitz Chanteaud, emetic. ( Emetine. Hyperthermia Aconitine. Anaemia Arseniate of iron. \ Haemorrhage Ergotine, sulphate of quinine Infection, Purulent. — See Traumatic Fever. Laryngitis, Acute Catarrhal {Stridulous Laryn- gitis, Pseudo- Croup). — Acute inflammation of the larynx, whether due to internal or external causes, should be treated with aconitine, which is not only the antiphlogistic agent par excellence, but has the addi- tional merit of almost always satisfying the causal in- dication, because the greater number of cases of acute laryngitis are due to suppression of the perspiration, which is restored by the use of only a few granules of aconitine. This drug should, therefore, have the pref- erence in all acute cases, one granule being given every half -hour until a sedative or diaphoretic effect is ob- ELEMENTS OF DOSIMETRIC PRACTICE. 351 tained. Subacute laryngitis, in which the pain is slight and the fever moderate, does not require such active treatment ; one granule every two hours will suffice. The fever of this condition will also yield to the influ- ence of aconitine, which should be administered until defervescence has occurred. After the fever has abated, the symptoms may be treated in succession. Cough and hoarseness should be treated with one granule of one of the active principles of opium and one of iodo- form every quarter of an hour until relief has been ob- tained. Codeine should be preferred to the other active principles of opium if a child is being treated, Greg- ory's salt if the cough is of moderate intensity in an adult, and the hydriodate of morphine if the cough is continuous and fatiguing. Iodoform, which is useful for hoarseness, is in many cases offensive to sensitive patients. In such cases two-granule doses of benzoic acid every hour should be substituted. The granules should be dissolved in the saliva before being swal- lowed, in order to get the benefit of their local action. The collections of mucus which adhere to the vocal cords are sometimes the cause of suffocation, especially in children, on account of the mechanical obstruction to the entrance of air which they offer. Even in the severest cases we may administer emetine in three- granule doses, dissolved in warm water, giving it every ten minutes until the patient vomits. By this means the exudation will be dislodged, and facility of respira- tion will be restored. If the case is not urgent, instead of exciting vomiting, we should trust to the slower but equally effective action of sulphide of calcium, which may be given in two-granule doses every hour to aid in breaking up the accumulations of mucus, and hasten the resolution of the inflammation. The presence of an exudate, or excessive irritability of the larynx, will produce, especially in children, a kind of dyspnoea, which is caused by spasm of the glottis. This condi- tion bears the name of stridulous laryngitis, or pseudo- 352 ELEMENTS OF THERAPEUTICS AFD PRACTICE. croup. A granule of hyoscyamine every hoar, or half a granule for children under six years of age, or two granules of the sulphide of calcium every half-hour, will promptly relieve this condition, which is always painful, and sometimes is dangerous. The headache which occurs in the first days of the disease may be relieved by the use of two granules of caffeine every hour, or three of the bromide of camphor every hour. Pain in the larynx will not necessarily require treat- ment, especially if the patient is wise enough to abstain from talking ; should medication be required, however, three granules of codeine may be given every half-hour until an anodyne effect is obtained. Spasmodic laryn- gitis is sometimes repeated in a manner which plainly shows its intermittent character. This periodicity may be controlled by the use of three granules of the hydro- bromate of quinine and one of hyoscyamine every three hours. With laryngeal inflammations the more fre- quent their recurrence the greater the susceptibility to additional attacks. In order to overcome this suscepti- bility to impressions of cold, two granules of arseniate of strychnine and two of sulphide of calcium should be given three times daily for a long time. Hydrotherapy and light clothing, by fortifying the skin against ex- ternal impressions, are excellent adjuvants to internal treatment of a preventive character. cq / Dominant. Inflammatory element Aconitine. ^^ I Variant. /Cough Hoarseness . Mechanical dyspnoea Spasmodic dyspnoea Headache Fever . Pain Intermittence Codeine, Gregory's salt. Iodoform, benzoic acid. Emetine, sulphide of calcium. Hyoscyamine. Caffeine. Aconitine. Codeine. Hydrobromate of quinine. Catarrhal P-disposition j ™£^* Laryngitis, Chronic. — Chronic inflammation of the larynx may be simple or constitutional, and may or may not be accompanied with ulceration. The ul- ceration is the consequence of the long duration of the ELEMENTS OF DOSIMETRIC PRACTICE. 353 disease, and should be treated topically in addition to the internal treatment which is directed toward its cause. The local treatment may consist in the use of a spray containing equal parts of sulphur- water and tar- water. The internal treatment includes both the domi- nant and the variant, the former being the most impor- tant and the most efficacious. If the laryngitis is purely of a catarrhal character, we may give two granules of sulphide of calcium and two of helenine three to five times daily. Revulsives, hydrotherapy, and a suitable change of climate will also be of great service. Laryn- gitis which depends upon a general disease should be treated in accordance with the nature of the primary complaint. Syphilitic laryngitis of the first period should be treated with two to five granules of the pro- tiodide of mercury three times daily, or with two to three granules of the biniodide three times daily. Syphilitic laryngitis of the secondary period should be treated with three to five granules of iodoform three times daily, while upon the ulcerations Yan Swieten's solution should be applied. Laryngitis of the tertiary period is almost always caused by suppurating gum- mata, and should be treated with two to three granules of iodoform and the same quantity of arseniate of soda three times daily. Laryngeal tuberculosis and laryn- gitis in tuberculous subjects may also be modified by the use of iodoform, three granules being given every three hours, with two of the arseniate of soda or of iron three or four times daily. Laryngitis which is the re- sult of variolous pustules may be treated with repeated doses of sulphide of calcium, one to three granules being given every half -hour ; this drug also tends to attenuate the infectious element of the disease. Laryn- gitis which accompanies typhoid fever and typlius ex- anthematicus should be similarly treated, two granules of the salicylate of ammonia every hour being added. The dysphonia of the disease will rarely require par- ticular treatment. Two granules of tannic acid four 23 354 ELEMENTS OF THERAPEUTICS AND PRACTICE. times daily will modify the vitality of the larynx, and will prove very useful by its local astringent action. The cough and pain, which may be very troublesome to the patient, may be relieved by the use of two gran- ules of the hydrobromate of morphine every quarter of an hour until relief is obtained. Dyspnoea may result from several causes, of which stenosis of the larynx is the principal one, and this may be due to particular lesions or to the accumulation of exudate. Emetine in doses of three to five granules every ten minutes until vomiting results, followed by two granules of the sul- phate of strychnine every hour, constitute the best means for relieving the dyspnoea. Should suppuration follow the chondritis and perichondritis, two granules each of iodoform and arseniate of soda may be given three or four times daily. The foregoing suggestions as to treatment should be followed out for a long time, and accompanied with suitable hygienic pre- cautions. 8^ && Hi ►h / Dominant. Variant. Catarrhal element f Syphilitic . Infectious J Tuberculous element I Variolous . [ Typhous . Dysphonia . Cough .... Pain .... Dyspnoea i Suppuration. Helenine, sulphide of calcium. Iodoform, mercury. Iodoform, arseniate of soda. Sulphide of calcium. Salicylate of ammonia. Tannic acid. >■ Hydrobromate of morphine. Emetine, sulphate of strych- nine. Iodoform, arseniate of soda. Laryngitis, Stridulous. — See Acute Catarrhal Laryngitis. Leucocythsemia. — Leucocythsemia implies a con- dition in which the number of the white blood-globules is greatly increased and the red globules greatly di- minished. This permanent excess and disproportion of the leucocytes are due to functional and nutritive irri- tation of the haematopoietic organs, and require the administration of two granules of hydrobromate of cicutine and of iodoform five times daily. The physic- al and moral prostration which is experienced by suf- ELEMENTS OF DOSIMETRIC PRACTICE. 355 ferers with this disease should be met by the adminis- tration of two granules of the arseniate of strychnine three to five times daily. The anorexia, which tends greatly to aggravate the disease, will be relieved by giving two to four granules of quassine a short time before each meal. For the constipation, three to five granules of podophyllin should be given each evening. Should diarrhoea occur, and this is not unusual, espe- cially when the chyliferous ducts are attacked, three granules of pepsin should be given with each meal to facilitate digestion, and two granules of the hydriodate of morphine every two hours, that the food may be de- tained in the alimentary canal a sufficient time to insure absorption. For the accompanying ulcerative stomati- tis, we should use suitable mouth- washes and two gran- ules of the lactate of iron every two hours. Dyspnoea, which results from the absence of a vehicle for the oxy- gen which is inspired by reason of the diminution of the red globules, and frequently on account of the swelling of the bronchial glands, should be treated with inhalations of oxygen, which is the only means by which the patient can be rapidly relieved. Swelling of the spleen, the liver, and the glands should be treated by the dominant, to which three granules of ergotine three to five times daily may be added. The results which are produced by quinine in analogous conditions may induce us to try it in this, and three granules of the hydrobromate may be used every two hours. Fever is almost always present toward the end of the disease, for which one granule of quinine is indicated every two hours or less, according to the degree of hyperthermia. For haemorrhage, which sometimes occurs, we should give three granules of ergotine every two hours, adding in appropriate cases two granules of the phosphate or valerianate of iron every two hours. Hydrotherapy, exercise, and change of air are hygienic means which must not be overlooked in the treatment of this dys- crasia. 356 ELEMENTS OF THERAPEUTICS AND PRACTICE. d /Dominant. ^Variant. ( Irritation of the hsemato poietic organs / Prostration Anorexia . Constipation . Diarrhoea . Ulcerative stomatitis Dyspnoea . Glandular swellings Fever Haemorrhage . Hydrobromate of cicutine, iodoform. Arseniate of strychnine. Quassine. Podophyllin. Hydriodate of morphine. Lactate of iron. Inhalation of oxygen. Ergotine. Aconitine. Ergotine. Leucorrhoea. common to vaginitis and to chronic metritis. Leucorrhoea is a symptom which is In the first case, the vaginal hypersecretion has little effect upon the general condition, and is scarcely to be con- sidered as a disorder ; in the second, it is accompanied by rapid loss of strength, capricious appetite, nervous troubles, both of sensibility and motility, and is a true morbid condition, which requires for its cure a rational, energetic, and persevering plan of treatment. Examina- tion with the speculum should always precede a course of treatment, and frequently one will find ulcerations, granulations, foreign bodies, etc., which must be suit- ably treated before general treatment is instituted. The difficulties which are encountered in manipulations of this kind furnish a motive for the careful examination of the physical properties of the white material which is discharged as the first step in therapeutic action. Leucorrhoea, which continues or increases with the ap- proach of the menstrual period, demonstrates that con- gestion is the primary morbid process ; whether this congestion is active or passive can not be said, because the characteristic signs are wanting. Apparently the condition is one of atonic hyperemia, or of lymphatic congestion, rather than a true afflux of blood to the vaginal mucous membrane. The excito-motor action of ergotine upon the genital organs indicates it as the dominant in this condition, and with it strychnine may be associated. Two granules of each, either separate- ly or combined, may be given four times daily. For topical applications any of the astringents may be used, ELEMENTS OF DOSIMETRIC PRACTICE. 357 though tannin is to be perferred. A mixture of three grammes of tannin and thirty of glycerin may be used to saturate pledgets of cotton wool, and the latter be introduced in sufficient quantity into the vagina and retained for twenty -four hours. Yaginal injections with a solution of borated chloral are also useful, espe- cially if the discharge is offensive. Anaemia and chlo- rosis, whether acting as cause or effect of this condition, should be treated with arseniate of iron and other ap- propriate means. (See Ansemia.) The debility which always accompanies this condition, to a greater or less degree, should be treated with one granule of the ar- seniate of strychnine four times daily. Irritability, melancholy, and other neuropathic conditions which are seen in connection with leucorrhcea, will disappear under the use of three granules of bromide of camphor three to four times daily. Palpitations, which are almost always caused by dex>ression of a moral char- acter, indicate the use of two granules of caffeine four times daily, or three of valerianate of caffeine four times daily. For gastralgia two granules of valerianate of zinc should be given three times daily, or two of the cyanide of zinc before each meal. Constipation, which is so common in all conditions in which there is loss of nervous equilibrium, should be treated with two gran- ules each of hyoscyamine and veratrine morning and evening. Quassine may be given to regulate the appe- tite, which is often capricious. Leucorrhcea of long duration is sometimes complicated with prolapses of the vagina, and may be relieved by the use of ergotine and strychnine, as already indicated, together with ap- propriate local means for overcoming muscular relaxa- tion. A condition of herpes often contributes to the persistence of chronic vaginitis, and should be treated with two granules of sulphide of calcium five times daily. The lymphatic diathesis should be treated with iodoform combined with the arseniates. Yisible results may be expected after a few weeks of treatment with 358 ELEMENTS OF THERAPEUTICS AND PRACTICE. two granules of iodoform, two of arseniate of iron, and three of ergotine daily. But, if this plan of treatment does not result in diminution of the discharge, it will be almost useless to resort to any other, for the result will be equally negative. In rebellious cases it may be well to try the effect of injections of nitrate of silver, in the hope of modifying the condition of the mucous membrane. This plan should only be resorted to in exceptional cases, for great inconveniences are associ- ated with it, and its efficiency is more than doubtful. \ Variant. ( Dominant. Atonic hyperemia /Anaemia Debility Irritability . Palpitations . Gastralgia . Constipation . Irregular appetite Prolapse of the vagina Herpetic diathesis Lymphatic diathesis Ergotine, strychnine. Arseniate of iron. Arseniate of strychnine. Bromide of camphor. Caffeine, j Valerianate of zinc. \ Cyanide of zinc. Hyoscyamine, veratrine. Quassine. Ergotine. Sulphide of calcium. Iodoform, arseniates. Lithiasis, Biliary.— Biliary lithiasis results from the precipitation of some of the elements of the bile, calculi being formed, which will vary in size from the head of a pin to a hen's egg. The cause of this pre- cipitation may be a relative disproportion in the dif- ferent elements of the bile or the presence of mucus in the bile-ducts, the mucus serving as centers around which concretions are formed in a manner analogous to the formation of thrombi in the vascular system. All the conditions which concur in increasing the quan- tity of cholesterin (e. g., expenditure of nerve-force), in producing biliary stasis (e. g. , insufficiency of food), in causing hyperemia of the liver (e. g., a sedentary life), as well as the modifications of the secretions which are included under the general term of arthritic diathesis, are predisposing causes which must be taken into consideration in arranging a plan of treatment. The principal indications which must be considered in the treatment of this disease may be reduced to two : ELEMENTS OF DOSIMETRIC PRACTICE. 359 1. To facilitate the removal of calculi which are already formed. 2. To prevent the formation of new calculi. To satisfy the first indication, we have two classes of agents, one of which is used to diminish the volume of the concretions, and the other to enlarge the caliber of the canals which are to be traversed. Science does not yet possess unfailing means for dissolving biliary calculi, except as they are to be found in the sodium waters of Vichy, Carlsbad, and Gerez. These waters have an incontestable efficiency, which is proved by the number of cases in which calculi have been elimi- nated after their use ; and this must be taken as a proof that their elimination has been facilitated by a diminution in their size. As a substitute for these waters, we may prescribe the salts of lithia, six to ten granules of the benzoate being given daily, or four to six granules of the carbonate, the benzoate being pre- ferred, because it is both cholagogue in its action and lithontriptic. The biliary canals are furnished with a fibro-muscular tunic, are therefore contractile, and are, in addition, abundantly supplied with sensory nerve- filaments. If the calculi are subjected to the slightest arrest in their passage, spasm and violent pain in the liver are the result, which render their elimination still more difficult. The spasm should be treated with hy- oscy amine or its congeners, valerianate of atropine and daturine, one granule being given every quarter of an hour when the hepatic colic is intense, or two granules twice daily if the pains are less severe, but of frequent occurrence. The pain which is due to the spasm, and also serves to intensify it, should be treated with three granules of the hydrochlorate or the hydrobromate of morphine every quarter of an hour. The morphine will also serve to check the vomiting, which is another symptom ; but, should the stomach be so sensitive that the medicaments are rejected before there is any opportunity for their absorption, morphine combined 360 ELEMENTS OF THERAPEUTICS AND PRACTICE. with atropine should be injected subcutaneously in doses of fifteen or twenty drops of the following : ^ Morphinge hydrochl 0*10 gramme. Atropine sulph 0*01 " Aquae destil 20*00 grammes. The pain may be so severe as to cause lipothymia or syncope. In such ca,ses, no uncertain remedies are al- lowable ; and hence, if lipothymia is present, the evi- dence of musculo-nervous atony, a granule of hyoscya- mine and one of arseniate of strychnine should be given every half-hour to restore the equilibrium, and allow the calculi to proceed on their way without affecting the vitality of the fibro-muscular tunic. Gastralgia should be treated in precisely the same way as hepatic colic, the cause being the same. It frequently happens with patients who are the subjects of biliary lithiasis that there are attacks of intermittent fever which occur regularly at four or five o'clock in the afternoon. They are caused by the irritation of the calculi, which is ag- gravated by the hepatic hypersemia which accompanies the labor of digestion. For this complication we should use two granules of aconitine three times daily and two of arseniate of quinine every hour. To prevent the formation of new calculi we should use the same means as are used for their solution ; but, above all things, we should carry out the hygienic indications which are made manifest by a study of the predisposing causes. Influenced by such an investigation, we would be like- ly to advise very active exercise, vegetable diet, the daily use of Sedlitz Chanteaud, of sulphate of soda, or of purgative mineral waters which contain this salt — for example, Pullna, Hunyadi Janos, etc. — tranquilli- ty of mind, and such intellectual labor as shall not cause fatigue. The daily use of the cholagogues in small quantities, which shall not irritate the gastroin- testinal canal, is proper. Three granules of podophyl- lin may be taken every evening, ten of euonymine before dinner, five to eight of iridine, or ten to twenty ELEMENTS OF DOSIMETRIC PRACTICE. 361 of hydrastine or leptandrine in two equal doses daily. All of these drugs excite evacuation of the bile without increasing the number of the biliary salts. They may therefore be used for a long time without fear of pro- ducing harmful irritation, if care is taken to change them from time to time. Quassine also excites the se- cretion of the bile, though to a lesser degree ; it has the additional advantages of increasing the appetite and regulating the digestion, which are not to be despised in the case of patients who are afflicted with this dis- ease, and are often in a condition of absolute cachexia. K*^ / Dominant. Biliary concretions . j Benzoate of lithia. ( Alkaline mineral waters. %< /Spasm Hyoscyamine. <7$ Pain. Hydrobromate of morphine. / Vomiting . Morphine, atropine. ffl^ \ Variant. \ Febrile attacks. Aconitine, arseniate of quinine. 1-3 ( Podophyllin, euonymine, iri- \ Biliary stasis . •< dine, hydrastine, leptandrine, ( quassine. Lithiasis, Renal. — The treatment of renal lithiasis follows the same rules as that of biliary lithiasis. The difference in the cause and the chemical composition of the calculi, however, requires certain modifications of those rules. Renal lithiasis may be divided into acid and alkaline varieties, the first being of uric- or oxalic- acid origin, the second of calcareous or ammoniacal. The treatment should have for its object, first, the ex- pulsion of the calculi which have formed ; second, the antagonism of the causes which produce the calculi, that no more may be produced. In order to expel cal- culi from the kidneys, we should use diuretics as phys- ical agents, solvents as chemical agents, and mydriatic antispasmodics as dynamic agents. Diuretics are prop- er in all cases ; but they must be used only at proper intervals, and always with moderation, so as not to fatigue or irritate the organ. The diuretic which is most certain in its action, the most decidedly physio- logical, and the best tolerated, is good drinking water. By its action in increasing diuresis it may be hoped 362 ELEMENTS OF THERAPEUTICS AND PRACTICE. not only that the nriniferous tubes will be dilated, but also that the calculi will be expelled by pressure, and that the lubricating action of the water will facilitate their progress. The chemical means for dissolving cal- culi are of little importance. With the exception of lithia and the alkaline mineral waters, little benefit can be expected from the so-called lithontriptics. The al- kalies should be given dosimetrically — that is, in small and frequently repeated doses. The action of alkaline waters taken in this way and at the springs where they are produced is certainly excellent, and almost always causes the ready expulsion of calculi of larger or small- er size. Lithia may be given, under the form of gran- ules of the benzoate or the carbonate, in three-granule doses, three or four times daily. Large doses are use- less, for they do not find in the economy sufficient quantities of free carbonic acid to dissolve them. These agents are of particular usefulness in the uric-acid lithi- asis, but also in the oxalic-acid form. The suppression of the causes, which is always necessary in any rational plan of treatment, is absolutely indispensable in this condition ; for, since oxaluria is the evidence of a di- athesis which is caused by the use of certain articles of food which contain the abnormal elements in large quantities — such articles, for example, as sorrel and onions — all that will be necessary to cause the disap- pearance of the diathesis will be that the patient ab- stain from these articles of food. The alkaline varieties of lithiasis should receive treatment with three granules of salicylic acid three times daily, or similar quantities of salicylate of lithia. Benzoic acid may also be used with advantage in three-granule doses three or four times daily. The object of the dynamic means of treat- ment is to dilate the canals in which the calculi are en- gaged, and thus facilitate the progress toward the blad- der. Such means may consist of hyoscyamine in two- granule doses two or three times daily, or sulphate of atropine in one- to two-granule doses three times daily. ELEMENTS OF DOSIMETRIC PRACTICE. 363 The arthritic diathesis predisposes to the formation of calculi. For those who are so affected we should pre- scribe plenty of exercise, sobriety at the table, modera- tion with respect to the sexual appetite, and the use of two to three granules of colchicine every evening. In the variant we meet with conditions of such importance that the patient not only demands relief from them in certain cases, but regards them as the most severe, most painful, most intolerable, and most rebellious of his troubles. Of the conditions referred to, colic is the one which is of most frequent occurrence as well as the most painful. It is the result of the sensitiveness and contractility of the ureters, and it is due to these char- acteristics that small calculi, which may be rough and uneven, cause much more intense pain than larger ones, which are smooth and more or less polished. For the pain we should give three granules of the hydrobromate of morphine every quarter of an hour, and for the spasm one of hyoscyamine every half-hour. The vom- iting which almost always accompanies the colic will also be benefited by this treatment. Rarely will it be necessary to use these alkaloids hypodermically. The vesical and rectal tenesmus will diminish as the hyos- cyamine is the more efficient in its action. The hyos- cyamine may be replaced by daturine, one granule being given every hour until the desired effect is obtained. Lipothymia, which may be converted into fatal syn- cope if the colic is of an intense character, should be treated with two granules of the arseniate of strychnine every quarter of an hour, and a free but judicious use of sedatives, especially of morphine. Convulsions, which may also be the result of intense suffering, must be treated with anodynes, to which three-granule doses of the bromide of camphor every ten minutes may be added. Hematuria in these cases will yield to three- granule doses of ergo tine every half -hour, or the same drug may be injected hypodermically. Inflammatory symptoms, of which the most common are those which 364 ELEMENTS OF THERAPEUTICS AND PRACTICE. are indicative of pyelitis, may be treated with one- granule doses of aconitine every two hours, the dose being increased if the case requires it. Dysuria or anuria will require the use of diuretics. Simple water with two granules of arbutine every two hours will fa- cilitate the excretion of urine. Hydronephrosis is the result of distention of the kidney in consequence of the retention of urine ; it can only be remedied by surgical means. ( Uric-acid calculi / Acid ) lithiasis 1 1 Dominant. / Alkaline lithiasis Oxalic-acid calculi . Calcareous calculi . Ammoniacal calculi \ Variant. ( ' Spasm Pain .... Nausea and vomiting Vesical tenesmus Convulsions Lipothymia Haematuria Pyelitis . Dysuria Hydronephrosis Carbonate and benzoate of lithia, alkalies. Diuretics, removal of the causes. \ Benzoic acid, mineral \ acids. Salicylic acid, salicylate of lithia. Daturine, hyoscyamine. j Hydrobromate of mor- \ phine. Morphine. Hyoscyamine. j Anodynes, bromide of \ camphor. Arseniate of strychnine. Ergotine. Aconitine. Arbutine. Surgical means. LumbagOo — See Rheumatism. Malaria. — See Paludal Infection. Meningitis, Cerebral. — The different varieties of meningitis may be considered, from a therapeutic stand- point, as essentially but one. In fact, whether we have simple, tuberculous, cerebral, spinal, or cerebro-spinal meningitis, we have the same element to tight in all of them — that is, the inflammatory element. In granular or tubercular meningitis, however, there is another ele- ment which is of great importance, but therapeutics is forced to neglect it, not only on account of the weakness of the arms which she wields against it, but also because it is generally the repeated inflammatory attacks which, above all other things, cause the danger which resides in this second or tubercular element. In how many cases, after an inflammatory attack has subsided, the ELEMENTS OF DOSIMETRIC PRACTICE. 365 patient regains the appearance of health in spite of the persistence of the granulations, until a new inflamma- tion brings back the entire morbid scene ! The symp- toms of meningitis may be divided into two series, which constitute two allied phases. The first series presents symptoms of excitement which result from the hypersemic condition of the meninges ; the second, which is the natural consequence of the first, is derived from all the depressing results which follow every form of excessive excitement. By cutting off the inflamma- tion, which is accomplished by preventing hyperemia, we get control of the disease, in so far as the existing therapeutic agents will admit of such an event. In acute meningitis the dominant will, therefore, consist in the use of aconitine, in one-granule doses every quar- ter of an hour, until a decided antiphlogistic effect has been obtained. In chronic meningitis, and among those individuals who are predisposed to the disease by he- reditary or other influences, a plan of preventive treat- ment must also be adopted to prevent cerebral conges- tion, and for this purpose we should give three granules of cocaine three or four times daily, the effect of this drug being to relieve the congestion of nervous centers. Two to four granules of digitaline, with an equal quan- tity of aconitine, may also be given at bedtime, to allay the irritation which is so apt to be present at that time. Tuberculous meningitis can be cured. This assertion is based upon incontestable proofs pertaining to patho- logical anatomy. But to accomplish this result it is indispensable that for a long period there should be no aggravation of the existing lesions, which might quickly destroy the good effects of months of treatment. Here- in lies the great value of preventive treatment, when it is carried out for a sufficient length of time, and is re- enforced by appropriate hygienic, physical, and moral precautions. The abolition of the granulations (tuber- cles) can be tested by the same means as are used in testing for scrofula. It is not necessary to limit one's 366 ELEMENTS OF THERAPEUTICS AND PRACTICE. efforts to the treatment of lesions which are already- developed ; we should also improve the entire organism, so as to prevent the development of new lesions. To accomplish this end we should give three granules of juglandine three or four times daily, with two granules of iodoform and two of a suitable salt of arsenic three times daily. In some cases the intensity of the symp- toms will compel us to use other remedies than those which have been indicated in the treatment of the vari- ant. For the fever we should use aconitine persistently, and if there is no abatement after several days of treat- ment a granule of digitaline and one of vera trine should be added every quarter of an hour. If the fever is more or less intermittent we have a right to suspect that it may be of a pernicious character, and treat it with large doses of quinine ; five granules of the hydrobromate, with five of the hydroferrocyanate, may be given every quarter of an hour, a granule of the arseniate of strych- nine being added to each dose, not only on account of its energetic antiperiodic effect, but also because it will intensify the effect of the quinine. The troublesome headache of this disease should be treated with three granules of the bromide of camphor every half -hour, if aconitine does not suffice to allay it. Hyoscyamine will arrest the vomiting, but its physiological effects must be noted, for their intensity and the rapidity with which they are produced will vary greatly in different indi- viduals. In children we should begin by giving half- granule doses every half -hour, increasing or diminishing the quantity according to the effects which are first produced. Constipation may be corrected by the daily use of Sedlitz Chanteaud and one to three granules of hyoscyamine and of brucine every evening. For the contractures one granule of valerianate of atropine may be given every half -hour in acute cases, two granules three times daily in chronic ones, precautions with re- spect to tolerance of these different drugs being ob- served in all cases. The delirium will often disappear ELEMENTS OF DOSIMETRIC PRACTICE. 367 after defervescence has been accomplished by the aconi- tine ; if it persists, however, three granules of the bro- mide of camphor may be given every hour, or we may apply ice or iced water to the head. During the con- vulsions one to three granules of veratrine may be given every half-hour, unless the stomach should be unable to bear it, vomiting being excited. In such a case one granule of hyoscyamine should be given in preference every half -hour, or two granules of croton chloral every quarter of an hour. The paralyses may be either tem- porary or permanent. The former will yield to the use of one or two granules of the hypophosphite of strych- nine or of brucine every two or three hours. The same agents should be used during the entire period of de- pression, the activity of the treatment being regulated by the state of the pulse, and phosphoric acid being added if the vitality is much depressed. Permanent paralyses — that is, those which have already existed for some time when treatment is begun — will only be relieved, if at all, by the long-continued use of electro- therapy and suitable neurosthenic agents. Revulsives are of no use for this condition ; bloodletting is danger- ous ; the iodide of potassium, which is used so exten- sively by the official school, may be profitably replaced with iodoform, of which two to five granules may be given three times daily. H i— i i— i w ( pq ( Inflammatory element . Dominant. •] Meningeal granulations ( Scrofula ( Fever . Intermittent attacks \ Variant. Cephalalgia . Vomiting Constipation Photophobia Delirium Contractures Convulsions . Temporary paralyses ^ Chronic paralyses Aconitine. Juglandine. Iodoform, arseniates. Aconitine, digitaline, veratrine. Hydrobromate and hydroferro- cyanate of quinine. Bromide of camphor. Hyoscyamine. Se'dlitz Chanteaud, hyoscya- mine, brucine. Daturine. Aconitine, bromide of camphor. Valerianate of atropine. Veratrine, croton chloral. Hypophosphite of strychnine, brucine. Electricity, strychnine, phos- phoric acid. 368 ELEMENTS OF THERAPEUTICS AND PRACTICE. Meningitis, Spinal,— In cases in which spinal meningitis is a primary and isolated condition, it should be attacked energetically, to prevent the inflam- mation from extending to the tissues which surround the inflamed meninges. This consideration is of the greatest importance, because, while meningitis is fre- quently curable, myelitis has not so favorable a prog- nosis. The dominant will consist in the use of aconi- tine until it has effected the complete subsidence of the inflammatory symptoms. The aconitine should be given with the view of checking the disease if possible, and, therefore, it should be administered every quarter- hour or every half -hour until the physiological or thera- peutic effects appear, which indicate that the activity of the treatment may be moderated. In chronic men- ingitis the treatment should not be as energetic as in the acute form ; consequently, we should give only two granules of aconitine three or four times daily, adding thereto as modifiers of the nutrition two-granule doses of arseniate of soda and of arseniate of strychnine three times daily. A rise in the temperature indicates a com- bination of the defervescents, aconitine, digitaline, and veratrine, one granule of each being given every quar- ter of an hour or every half -hour until the temperature is reduced. After this end has been attained, two gran- ules of the hydrobromate and of the hydroferrocya- nate of quinine should be given every half -hour to pre- vent the recurrence of the fever. The pain in the spinal cord, and radiating from it, is due to the ex- tension of the irritation and the compression of the sensory-nerve roots. In this condition we should add to the dominant the bromide of camphor in three-gran- ule doses every half-hour, or one granule of cicutine every quarter of an hour until a sedative effect has been obtained. Contractures, as well as dysphagia, dysp- noea, and spasmodic retention of the urine and faeces, are due to hyperkinesia, which is caused by irritation of the motor roots of the cord. Such a condition of ELEMENTS OF DOSIMETRIC PRACTICE. \M excitement may be relieved by using one grannie of hyoscyamine every two hours, or two of croton chloral every half-hour. For the hyperesthesia we should use two granules of the tannate of cannabine every half- hour, and for the paraplegia, which is almost always due to disturbance in the cord, revulsives and brucine internally, three or four times daily. m /Dominant. fell P3 \Variant. Inflammatory element I Fever . Pain Contractures Dyspnoea J Dysphagia . Retention Hyperesthesia \ Paraplegia . Aconitine. Aconitine, veratrine. Digitaline, quinine. Bromide of camphor, cicutine. Hyoscyamine, croton chloral. Tannate of cannabine. Brucine. Metritis,, — Acute inflammation of the uterus may arise from various causes, the most frequent of which are irritations which follow parturition. The presence of tumors, the retention of the menstrual fluid, and the use of irritant injections may also cause this condition. In the puerperal condition a chill, indicating the in- vasion of inflammation, should be the signal for begin- ning the treatment. We should seek to overcome the vaso-motor paralysis, which is the first cause of con- gestion, by the use of one granule of strychnine and one of phosphoric acid every quarter of an hour until reaction is established. After the febrile condition is established, which indicates that congestion has become inflammation, we should give one granule of aconitine every quarter- or half -hour until defervescence occurs. If the pulse is frequent and violent, we should combine with the aconitine one granule of digitaline every half- hour until the number of the pulsations has diminished. The febrile movement is often of an intermittent char- acter, and this symptom indicates the use of the hydro- ferrocyanate of quinine in two-granule doses every half-hour. The hypogastric pain, which in almost all cases radiates toward the lumbar region, the inguinal 24 370 ELEMENTS OF THERAPEUTICS AND PRACTICE. region, etc., may be relieved, after the inflammatory element has been brought under control, by two gran- ules of the hydrobromate of cicutine or of croton chloral every half -hour. The constipation and diarrhoea will require the use of Sedlitz Chanteaud, at first in a purga ? tive dose, and afterward in small quantities. The vom- iting which appears as a reflex symptom of the uterine lesions may be checked by the use of two granules of the hydrochlorate of morphine every quarter of an hour, or three granules of codeine every ten minutes if the former is contra- indicated. Metritis often affects the sensibility of the rectum and bladder, causing a painful tenesmus, which will require for its relief a granule of hyoscyamine every two hours or less, ac- cording to the violence of the contractions. During the menstrual period the haemorrhage in some of these cases is sufficiently severe and protracted to require the use of means for arresting it. For such cases three granules of ergotine and three of the sulphate of qui- nine may be given every half -hour, the intervals be- tween the doses being gradually lengthened, as the cir- cumstances permit. Rest in bed and a suitable diet are indispensable to the rapid cure of acute metritis. Chronic metritis may be catarrhal or parenchymatous. This distinction, which is made by the pathological anatomist rather than by the clinician, depends upon the predominance of lesions in the mucous membrane in the one case, and in the interstitial tissue in the other. With respect to their symptoms, the two forms of disease are distinguished by a difference as to the frequency and the abundance of their haemorrhages, the quantity of the mu co-purulent discharge, and the degree of curability, the symptoms being more pro- nounced in the parenchymatous variety. The chronic form of the disease is due to a want of vaso-motor vital- ity. The dominant should, therefore, be the arseniate of strychnine or ergotine, two granules being given three or four times daily. The general debility, which ELEMENTS OF DOSIMETRIC PRACTICE. 371 is a not infrequent accompaniment, should be treated with the salts of strychnine, while the anaemia, which is always more or less pronounced, calls for the salts of iron. The palpitations and dyspnoea, which are the result of a want of equilibrium in the nervous system, which attends all uterine diseases, become less trouble- some if a few granules of digitaline are taken daily ; two granules might be taken morning and evening. Irascibility and a tendency to hysteria may be modi- fied by exercise, by suitable diversions, and by the use of three granules of the bromide of camphor or of caf- feine three times daily. Want of regularity in the evacuation of the bowels should be persistently treated with the daily use of Sedlitz Chanteaud, either alone or associated with three to five granules of veratrine or podophyllin at night. Want of appetite should be treated with three granules of quassine or cubebine be- fore each meal ; a voracious or perverted appetite with three of codeine before each meal. For hypogastric pains, especially if they are characterized by exacerba- tions or radiation, two granules of tannate of cannabine should be given every half-hour until relief is obtained. Tenesmus should be treated with one granule of hyos- cyamine or one of sulphate of atropine every half-hour, as in the acute form of the disease. For an exagger- ated muco-purulent uterine discharge, we should give two granules of tannic acid four times daily, or two granules of iodoform and two of arseniate of iron three times daily, especially if the patients be of the lym- phatic diathesis. Metrorrhagia, which is sometimes quite troublesome, may be treated with ergotine ; but this does not always give the results which are desired, because the newly- formed blood-vessels in the adventi- tious tissue which pertains to the disease contain no contractile elements, and hence are not acted upon by the ergotine. Local haemostatics will, therefore, be required, such as ice, perchloride of iron, etc. For the irritability of the uterus two granules of cicutine may 372 ELEMENTS OF THERAPEUTICS AND PRACTICE. be given three times daily. If the proliferation of con- nective tissue has been very active, occlusion of the os internum may have resulted, with retention of the products of exudation. These can be removed by the use of the sound. Such are the means for treating the different forms of this disease, which is always a rebel- lious one. In some cases the cause must be sought in a particular diathesis appertaining to the individual, and treated with the proper remedies. All other agents, with the exception of hydrotherapy and some others of that order, should be avoided as very uncertain and often dangerous. METRITIS. Acute. Dominant. Inflammatory element . Aconitine. / Chill ' Strychnine, phosphoric acid. Variant. ( Frequency of the pulse Febrile intermittence . Radiating hypogastric pain Constipation or diarrhoea . Vomiting .... Rectal or vesical tenesmus . \ Menorrhagia Digitaline. Hydroferrocyanate of quinine. j Hydrobromate of cicutine. ( Croton chloral. Sedlitz Chanteaud. Hydrochlorate of morphine. Hyoscyamine. Ergotine, salts of quinine. Chronic (Catarrhal and Parenchymatous). Dominant. Paralytic element /Anaemia General debility . Palpitations, dyspnoea Hypochondria Constipation Want of appetite Variant. ( Hypogastric pain Tenesmus . Muco-purulent discharge Metrorrhagia Uterine irritability ^Retention of secretions Arseniate of strychnine. Salts of iron. Arseniate of strychnine. Digitaline. Caffeine. Sedlitz Chanteaud. Quassine. Tannate of cannabine. Hyoscyamine. Tannic acid, iodoform, arseni- ate of iron. Ergotine. Cicutine. Use of sound. Metrorrhagia. — Metrorrhagia may be due to an excessive flow of blood to the uterus, which, by undue dilatation of the vessels, forces its way out, and thus terminates a powerful active congestion ; or to a lesion of the vessels, which may vary as to character, but which makes their walls less resistant than usual, and thus causes a haemorrhage with or without increase of intra- ELEMENTS OF DOSIMETRIC PRACTICE. 373 vascular pressure. The type of the first form of haemor- rhage is menstruation ; of the second, the haemorrhage from cancer of the uterus. In both cases the haemor- rhage is due to a want of vascular resistance, and to weakness in the contractile power of the coats of the vessels. The dominant in metrorrhagia will therefore be filled by medicaments which directly excite vascular contractility or the contractility of the uterine tissue, which by contracting will compress the torn vessels and diminish their caliber, thus facilitating the forma- tion of clots and leading to complete haemostasis. Ergotine, strychnine, and quinine are the agents which correspond to these indications, aconitine being associ- ated with them whenever hyperaemia is manifest. Three to five granules of ergotine should be given with one of sulphate of strychnine every quarter of an hour until the haemorrhage begins to abate ; then the inter- vals between the doses may be lengthened, and the medicaments be finally discontinued when the danger seems to be over. The quinine should be given as a synergist of the ergotine ; three granules of the hydro- ferrocyanate or the valerianate being given every quarter of an hour, if there is any pain ; similar quanti- ties of the hydrobromate, if there are irregular contrac- tions ; and live granules of the sulphate at a dose in other conditions, the dosage being gradually dimin- ished, and the intervals lengthened as the effect be- comes more evident. After haemostasis has been obtained, quassine and arseniate of iron should be given to hasten convalescence. For some days after the haemorrhage has occurred, the patient may be in a state of physical and moral prostration. At such times straining at stool must be carefully avoided, and Sedlitz Chanteaud may, at this juncture, be taken with advan- tage to facilitate intestinal evacuations. An auxiliary agent of tried efficiency consists in the use of vaginal douclies of water as hot as can be borne by the patient. In addition to removing the accumulated clots from 374: ELEMENTS OF THERAPEUTICS AND PRACTICE. the vagina, they will relieve the congestion of the sur- rounding tissues and facilitate uterine contractility. Ergotine, strychnine, quinine. Aconitine. Hydrobromate of quinine. Quassine, arseniate of iron. Sedlitz Chanteaud. i j f Dominant. Muscular atony O m J f Hypersemia .„ ( Hvdrobromateof mor- Pam j phine. Fever Aconitine. Suppuration .... j Iodoform, arseniate of 1 L ( quinine. Hemorrhage .... Ergotine. I Sequelae j Iodoform, arseniate of Orchitis. — Orchitis is almost always caused by direct irritation or by transmission by continuity of tissues. Acute orchitis is usually recovered from spon- taneously in seven to fifteen days, unless injurious treatment is resorted to, or there is a want of care and attention to hygienic rules which are indispensable. In spite of the frequent resolution of acute inflamma- tion of the testicle, however, it sometimes passes into the chronic state, its cure thus becoming a more labori- ous process, and at others it may terminate by sup- puration, gangrene, or degeneration. But, even apart from such unfavorable terminations as those which were last mentioned, the disease is sufficiently severe and the time sufficiently long in which patients must lie in bed to prevent relapses, that one should seek to abridge it as much as possible, by the means which may be furnished by dosimetry. The aim should be, 396 ELEMENTS OF THERAPEUTICS AND PRACTICE. therefore, not only to diminish the duration of the dis- ease, but also the probabilities of a less favorable termi- nation than resolution. In acute orchitis we should combat the inflammatory element with aconitine from the beginning. The treatment should be the more active as the disease trenches the more upon the general condition. If there is fever with a strong, hard, and accelerated pulse, a granule of digitaline should be added to the aconitine, each being given every half-hour until a defervescent condition is established. If there is no febrile reaction, two granules of aconitine may be given four times daily, as an anticongestive. The pains, which are due largely to the unyielding character of the inflamed tissues, may be relieved with one granule of cicutine every hour, and if the pain has a spasmodic character a granule of hyoscyamine may be given every two hours with satisfactory results. The nausea and vomiting which sometimes accompany the first stage of the disease should be treated with one granule of hyoscyamine and three of the hydrochlorate of mor- phine every hour until relief is obtained. In the sub- acute and chronic conditions, two granules of the sul- phate of strychnine should be given four times daily to hasten the process of resolution. The local applica- tion of compresses saturated with cold water, in addi- tion to the internal treatment, will have an excellent antiphlogistic and tonic effect. The daily use of Sedlitz Chanteaud is indispensable to prevent the bad effect which may be produced by constipation or hsemor- rhoidal congestion. Suppuration calls for surgical in- terference, but one should not overlook the advantages which may also be obtained by the use of two granules of iodoform combined with two of the arseniate of iron, of soda, or of quinine, three or four times daily. Surgi- cal attendance will also be required if a case terminates in gangrene, and in addition one may give two granules of the salicylate of ammonia and two of salicylic acid four times daily. ELEMENTS OF DOSIMETRIC PRACTICE. 397 m I Dominant. Inflammatory element H Pain g ( Spasm . q Variant. / Nausea, vomiting Dh I j Suppuration Gangrene Aconitine. Cicutine. Hyoscyamine. Morphine, hyoscyamine. Iodoform, arseniate of quinine. ( Salicylate of ammonia. ( Salicylic acid. Osteocopic Pains.— See Syphilis. Ovaritis, — Simple acute inflammation of the ovary has the same dominant which other diseases have which are characterized by this morbid process. Aco- nitine, in doses as frequent as the severity of the case demands, will therefore form the basis of treatment. Should ovaritis appear suddenly and inexplicably, especially in women who also present the phenomena of rheumatism, a granule of colchicine should be com- bined with one of aconitine, and be given every half- hour, or less frequently if the fever does not exceed 38*5° C. The symptoms of ovaritis are almost always the same as those of metritis, and can only be differen- tiated from them by localization of the pain, which should be limited to one of the iliac regions in ovaritis, but may occupy the entire hypogastrium in metritis. These pains should be promptly relieved by using three granules of the hydrochlorate of morphine and one of hyoscyamine every half -hour. For the fever we should give aconitine, adding hydroferrocyanate of quinine if there are intermissions in the case. Nausea and vomiting will not only fatigue the patient, but will aggravate the abdominal trouble, and interfere with the regularity of the treatment. They may be treated with three granules of codeine every ten min- utes. Sedlitz Chanteaud should be used freely as an ordinary beverage, a soupspoonful being given in a glass of sweetened water which may be flavored with lemon or orange peel. Ovaritis which occurs during menstruation, and is especially apt to be associated with dysmenorrhea, is sometimes accompanied with severe haemorrhages. In such cases the treatment with aconitine should be supplemented by the haemostatic 398 ELEMENTS OF THERAPEUTICS AND PRACTICE. action of ergotine, three granules being given every quarter-hour. Contractions of the rectum and bladder will require the use of daturine in one-granule doses every half-hour. Should the ovary suppurate, two granules of iodoform with two of the arseniate of qui- nine should be given five times daily. If the ovaritis is not checked, it sometimes passes into the chronic condi- tion, for which the dominant is ergotine in two-gran- ule doses four times daily. The secondary indications will vary greatly, according as there is simple inflamma- tion or the development of cysts, and according to their volume, their position, their adhesions, etc. The most frequent indications are those which are here de- tailed. For constipation, which is almost always pres- ent, we should give three to five granules of podophyl- lin every evening, and in the morning half a spoonful of Sedlitz Chanteaud. The podophyllin may be alter- nated from day to day with veratrine in doses of three to five granules, or leptandrine, ten granules. To over- come the vesical tenesmus, daturine may be alternated with gelsemine. Enemata of very hot water (40° to 45° C.) will usually be found very useful for this cause of dysuria. The dyspnoea may be relieved by the use of two granules of cicutine four times daily, or two of digitaline every three hours, until the pulse shows that a decided effect has been produced. Dyspepsia will require three granules of quassine before each meal, and three of pepsin after each. Should cedema be manifest, it will almost always be due to compression upon the veins by the enlarged or enlarging cyst, and should be treated with strychnine and digitaline, that the heart may have additional force to overcome the obstacles which oppose themselves to its propulsive en- ergy. The more voluminous cysts require ovariotomy, which becomes a necessity when the diagnosis is no longer doubtful. Every moment lost after that step has been reached tends to diminish the chances of suc- cess from the operation. As the cyst enlarges, the ELEMENTS OF DOSIMETRIC PRACTICE. 399 chances of success become more precarious on account of the injuries which result to the abdominal viscera from its presence. The author has seen atrophy of the large intestine to such a degree that it presented no more than a fifth of its normal volume, this result be- ing due to the pressure of a large ovarian cyst. When the lesions can be remedied by operative means alone, all delay is harmful, and sometimes even irreparable. OVARITIS. Acute. Dominant. I Simple [ Rheumatic • Aconitine. Aconitine, hyoscyamine. / Pain . Morphine. Fever j Aconitine, hydroferrocyanate of " ( quinine. Codeine. Sedlitz Chanteaud. Variant. ( Nausea and vomiting Constipation . Metrorrhagia . , Ergotine. Tenesmus , Hyoscyamine. \ Suppuration . • Iodoform, arseniate of quinine. Chronic. Dominant. Hypertrophy . Ergotine. / Constipation . j Podophyllin, leptandrine, vera- * l trine. Vesical tenesmus Daturine. Variant. / Dyspnoea . Cicutine. Dyspepsia Quassine, pepsin. (Edema . Strychnine, digitaline. \ Enlarged cyst . Ovariotomy. Ozsena. — See Rhinitis. Palpitations of the Heart. See Hyperkine- sis. Pancreatitis. — The diseases of the pancreas, which as yet have not been thoroughly investigated, are almost always consecutive to other morbid conditions, and rarely require particular treatment. The symptoms which are suggestive of pancreatitis are pain of a more or less constant character in the region of the umbili- cus and the epigastrium, which should be treated with three granules of codeine or morphine three times daily ; liquid stools which look like saliva, which would probably be modified by the use of one granule of atro- 400 ELEMENTS OF THERAPEUTICS AND PRACTICE. pine every two or three hours ; and dyspepsia, espe- cially after the use of hydrocarbonaceous food, for which three granules of diastase may be given after each meal. PANCREATITIS. Dominant Treatment of the primary disease. ( Pain Codeine, morphine. Variant. < Serous diarrhoea . . Atropine. ( Dyspepsia .... Diastase. Parotitis (Parotiditis).— Inflammation of the pa- rotid glands may be idiopathic or a complication in many of the infectious diseases, and in the latter case appears to be caused by elimination of the delete- rious products formed by the virulent agents. When it is idiopathic it is not usually a condition of grave im- portance. The predominant symptoms are those of any other condition of fluxion, the volume of the inflamma- tory products being governed by the intensity of the process of serous transudation. One granule of aconi- tine, combined if necessary with one of the sulphate of strychnine, every two hours, or more frequently if fever is present, will quickly relieve the difficulty in the circulation. Parotiditis which follows infection of the organism requires the sulphide of calcium if the disease appears in the first stage of the infection, or the nitrate of pilocarpine if it occurs during the period of elimination. The dose of each should be two granules every hour. The pain is not intense in all cases. In those cases in which it is intense, two granules of the tannate of cannabine may be given every hour, or one of hyoscyamine every two hours. The disordered con- dition of the digestive function should be treated with appropriate doses of Sedlitz Chanteaud. Dyspnoea and delirium, which are usually caused by compression of the vessels of the parotid glands, indicate disgorge- ment by means of leeches, or the use of two granules of colchicine every two hours until purgation results. The suppuration may be diminished by the use of two ELEMENTS OF DOSIMETRIC PRACTICE. 401 granules of iodoform and two of the arseniate of qui- nine four times daily. The accumulations of serum which take place in other organs may be treated with five granules of the nitrate of pilocarpine every quarter- hour, or two of colchicine every hour. Dominant -i Inflammat0I T element ' ( Infectious element Fever . Pain Gastric disorders Variant. ( Dyspnoea Delirium Suppuration Serous fluxion Aconitine. Sulphide of calcium. Aconitine. Tannate of cannabine. Sedlitz Chanteaud. Colchicine. Leeches. Iodoform, arseniate of quinine. Nitrate of pilocarpine. Pericarditis and Endocarditis. — Pericarditis may be primary or secondary. The former is much the rarer, and yet may be the more easily recognized from the beginning ; the course of the latter is insidious for a longer or shorter period of time, and, when at length the condition is evident from the subjective symptoms, it is too late to completely repair the damage which has been done. Hence, the evident duty of the physi- cian is to seek carefully for inflammation of the peri- cardium in all cases in which it is likely to be present, and to be always on his guard for its appearance. The inflammatory element of the disease in its acute form should be met with aconitine ; and the more re- cent the disease, and the more pronounced its symp- toms of excitation, the more active should the treat- ment be. In the chronic form of the disease aconitine should not be used, especially if the contractile force of the heart is diminished. In such a case the inflam- matory element is supplanted by the paralytic, and aconitine should therefore be replaced by two granules of the arseniate or the hypophosphite of strychnine four to six times daily. With respect to the variant, the fever must be vigorously met by the use of digitaline com- bined with aconitine and strychnine, one granule of each being given every half-hour or less frequently, according to the condition of the pulse and the eleva- 26 402 ELEMENTS OF THERAPEUTICS AND PRACTICE. tion of the temperature. The combination of defer- vescents in the treatment of acute diseases of the heart should be managed with great prudence. The effect which is obtained will not be the total effect of the synergic agents, but there will be as many effects as there are agents employed. These agents must, there- fore, be so administered as to exercise a regulating action upon each one of the organs or systems upon which this action is particularly directed. Thus the quality and the number of the pulsations must govern the administration of digitaline, the temperature must govern the use of aconitine, the contractility that of strychnine ; consequently the three defervescents must not be associated imprudently, and they must be given only as each has its particular indication. This advice, which is important in all antiphlogistic treatment by means of defervescents, is of particular importance in the treatment of acute diseases of the heart. If the thoracic pain is severe, it may be relieved by the use of two granules of cicutine every half -hour. Should the pulse become vibratile and very full, the cardiac ex- citability may be diminished by the use of two gran- ules of digitaline three or four times daily ; the danger of a corresponding depression after this treatment must be borne in mind. If the pulse is very feeble, sulphate of strychnine is urgently indicated, or caffeine, two granules of either being given every half-hour. Dys- phagia, which is an important sign, not only as an in- dicator of the presence of the disease, but also as an evidence of spasmodic irritation of the vagus, should be treated with one granule of hyoscyamine every two hours. Insomnia, which will quickly reduce the strength and contribute to cardiac ataxia, should be treated with three granules of the hydrobromate of morphine every quarter of an hour, or similar doses of croton chloral. Dyspnoea may come from several causes, but is almost always due to more or less pro- nounced systolic weakness, and should be treated with ELEMENTS OF DOSIMETRIC PRACTICE. 403 two granules of apomorphine and two of caffeine every half-hour. Excellent results may also be obtained from the use of digitaline with the other remedies. Hic- cough, which is very annoying, and which also inter- feres with the regularity of the circulation, should be treated with one granule of atropine every hour. In- stead of the alkaloid atropine, one of its salts may be used. Dropsy of the limbs and of the viscera requires, above all things, the heart- tonics digitaline, caffeine, and strychnine, and diuretics scillitine and Sedlitz Chanteaud. Two to three granules of the scillitine may be given three times daily, and of the Sedlitz a small spoonful in the morning. Simple endocarditis requires the same treatment as pericarditis. The principal in- dications and means of treatment are common to the two diseases. In chronic endocarditis, however, the nutrition of the heart should be modified by the use of two granules of the arseniate of soda and two of the arseniate of antimony three times daily. Infectious endocarditis is extremely dangerous, and a tonic treat- ment alone is appropriate. Two granules of salicylate of ammonia and two of iodoform, combined with two of arseniate of strychnine every hour, may be given with suitable defervescents if the temperature is elevated. In spite of the most judicious treatment patients with this disease rarely recover. Inflammatory element . / Dominant. \ Variant. / Fever . Thoracic pain Fullness of pulse . Weakness of pulse Dysphagia . Insomnia i Dyspnoea Hiccough Dropsy . Adynamia . Hyperplasia . ( Aconitine, arseniate of strych- ] nine. Digitaline. Cicutine. Digitaline. ( Sulphate of strychnine. ] Caffeine. Hyoscyamine. Hydrobromate of morphine, Apomorphine, caffeine. Atropine. ( Caffeine, digitaline, strychnine. \ Sedlitz Chanteaud, sciilitine. ( Salicylate of ammonia. < Iodoform, arseniate of strych- ( nine. j Arseniates of soda and anti- { mony. 404 ELEMENTS OF THERAPEUTICS AND PRACTICE. Peritonitis. — Peritonitis may occur as a simple in- flammatory process, as an accompaniment of general or local infection, and as a consequence of such dyspa- sias as the tuberculous, the cancerous, as an accom- paniment of Bright' s disease, etc. The dominant will vary with the determining causes ; if the disease is a simple inflammation, aconitine will be required ; if due to infection or the dyscrasias, it will require the treat- ment of the disease which is the exciting cause. Pri- mary peritonitis manifests itself in a positive and un- mistakable manner. The patient is seized with violent chills, with intense fever, and with severe pain in the abdomen. At the commencement of the chill one should give one granule of the sulphate of strychnine and one of phosphoric acid every quarter of an hour until reaction occurs. After reaction has been estab- lished the fever will be high, and there must be rapid interference in order to check it ; we should therefore give one granule each of the defervescents aconitine, digitaline, and veratrine every quarter of an hour, and two of the hydroferrocyanate of quinine every half- hour, adding every hour one granule of strychnine to overcome the vasomotor paralysis. The pain is always extremely severe, and this is a symptomatic indication which must never be neglected, for it not only tends to aggravate the inflammatory condition, but also to de- prive the patient of the strength which is so necessary to enable him to undergo the difficulties which threaten him. The abdominal pain, therefore, should be treated with two granules each of the tannate of cannabine and two of the hydrobromate or the hydrochlorate of mor- phine every quarter-hour. Meteorism, which is caused by the distention of the paralyzed intestine with gas which has been generated therein, should be treated with two granules of ergotine every half -hour, or with larger doses of strychnine. Constipation is also a re- sult of intestinal paralysis ; or there may be diarrhoea, as a result not only of atony of the sphincter, but of ELEMENTS OF DOSIMETRIC PRACTICE. 405 hypersecretion from the irritation resulting from flux- ion pertaining to the mucous membrane. Both consti- pation and meteorism should be treated with Sedlitz Chanteaud and strychnine given simultaneously. If diarrhoea is present, there is no need of taking active steps to check it until the disease itself is checked, unless there is evidence that the patient is being ex- hausted by it, in which case the doses of morphine must be sufficient to check hypersecretion. Vomiting, which is a reflex effect produced by irritation of the nerves in the region which is involved, may be controlled by the use of two granules of morphine and one each of hyos- cyamine and strychnine every half-hour. Hiccough, which is due to irritation of the diaphragm, the in- fluence being transmitted from the inflamed peritoneum which covers the lower surface of that muscle, may be arrested by the use of one granule of hyoscyamine every half -hour. Such a result is obtained with the greater difficulty in cases in which the increase of abdominal pressure embarrasses the respiration and the circula- tion. The principal indication is to produce a tonic action upon the vagus nerve, which presides over the principal thoracico-abdominal functions, and this may be best effected by using two granules of strychnine every half-hour. The strychnine will have the addi- tional advantage of opposing paralysis of the diaphragm, which may be excited by inflammation of its serous membrane. Chronic peritonitis, which is usually of a tuberculous character, should be treated with vesicants locally, and the persistent use of iodoform, the arseni- ates of iron and of soda, or the arseniate of quinine. Two granules of each should be given three to five times daily. The disease becomes more severe with each succeeding attack. During the acute phase of the attack, defervescent agents should be actively used, but only with the view of retarding the prog- ress of the disease, which must inevitably have a fatal issue. 406 ELEMENTS OF THERAPEUTICS AND PRACTICE. {Inflammatory element Dyscrasic and infectious elements . Chills Fever Pain / Meteorism . \ Variant. ^ Constipation Diarrhoea Vomiting Hiccough Cardio-pulmonary plications . Chronic peritoniti Aconitine. Treatment of the primary dis- ease. Sulphate of strychnine, phos- phoric acid. Aconitine, digitaline, veratrine. Hydroferrocyanate of quinine. Sulphate of strychnine. Hydrobromate of morphine. Tannate of cannabine. Ergotine, sulphate of strych- nine. Sedlitz Chanteaud. Hydrochlorate of morphine. Hydrochlorate of morphine. Hyoscyamine, sulphate of strychnine. Hyoscyamine. Arseniate of strychnine. Iodoform, arseniates, revul- Phthisis. — See Tuberculous Disease. Plethora. — If the sanguiue disposition is becoming less and less common both, in the city and in the coun- try, the plethoric condition is becoming still less com- mon. Plethora is in reality only an exaggeration of the sanguine temperament. Just as the nervous diath- esis is only an exaggeration of the nervous tempera- ment, and the lymphatic diathesis an exaggeration of the lymphatic temperament, so plethora is an advanced stage of the sanguine temperament. It can not be said that it is a true morbid state, nor yet that it is an ex- cessive degree of health, but it is a condition of health in which disease may be said to be imminent. An ex- tremely plastic condition of the blood, its richness in red globules — conditions which are disproportionate to the wants of organic nutrition — these constitute pleth- ora. The manifest indications are to increase the con- ditions of elimination and diminish the ingestion of assimilable material. Aside from the proper modifica- tions as to regimen and exercise, the refreshing influ- ence of Sedlitz Chanteaud should be obtained, and the work of the circulation should be modified by the in- fluence of two granules of aconitine and two of digita- ELEMENTS OF DOSIMETRIC PRACTICE. 407 line morning and evening. When there is a tendency to congestion of the head, which is indicated by som- nolence, injection of the conjunctivae, redness of the face, rumbling in the ears, etc., a granule of the citrate of caffeine should be given every half-hour, and one or two doses of aconitine and digitaline. The disposition to hyperemia of the lungs, which is manifested by op- pression in breathing, palpitations, etc., may be treated with two granules each of aconitine, veratrine, and digitaline three times daily. After hyperemia is estab- lished, a few leeches may be used upon the affected parts, after which anticongestive means may be used until the pulse is softer in character, and the danger of congestion in the more important viscera is past. PLETHORA. t-v j Suitable diet, Sedlitz Chanteaud, ( aconitine. Variant \ Cephalic hyperemia . Citrate of caffeine. ' ( Thoracic hyperemia . Digitaline, veratrine. Pleuritis. — Pleuritis may proceed either from ex- ternal or internal causes. Pleuritis of internal origin may proceed from a general disease, such as rheuma- tism, albuminuria, the eruptive fevers, and infectious diseases, from lesions of tissues contiguous to the pleura, the inflammatory process extending to the lat- ter, or from injury to the latter from the development of morbid products. Pleuritis of external origin may result from traumatism or from the effect of cold, with or without the suppression of the perspiration. The disease may be acute or chronic. The latter variety may have the characteristics of a chronic disease from the beginning, or it may follow the acute form. In- flammation of the pleura, with reference to the quan- tity and nature of its exudates, may be considered clinically under two forms — the proliferative, or dry, and the exudative, or effusive. The first may be con- sidered an abortive form of the second. From pro- liferative pleuritis to purulent pleuritis there is a 408 ELEMENTS OF THERAPEUTICS AND PRACTICE. series of morbid transformations which succeed each other in natural order, and are like the successive steps in a plan which is in process of evolution. As the last of these steps is one which indicates a great degree of gravity, we should spare no efforts to break the series and check the disease at the beginning, so as to avoid the consequences, as grave as they must be, which are likely to follow when an expectant plan of treatment is carried out. In the first phase of the dis- ease, whatever be its primary form, we should not lose an instant in endeavoring to accomplish its control. Statistics show that pleuritis is fatal in a larger per- centage of cases than it used to be, and this can be accounted for only by the injurious effects of the ex- pectant plan of treatment. The physicians of the dosi- metric school in its earlier periods, notwithstanding the imperfection of their methods for checking this disease, had better success, and their results were more satisfactory than those which were obtained by the followers of actual science. The latter were armed with means for treating the disease during its last period, but were unable to do anything when the dis- ease was still without threatening features, when the lesions were such that they could be repaired, and when a restoration from a pathological to a physiological condition could easily be accomplished. Therapeutics should always aim to be preventive, and not be limited merely to the prevention of death, but, on the contrary, it should prevent the phenomena which lead to it. When a patient with pleuritis summons a physician in the earliest stages of his disease, and, notwithstanding, presents the symptoms of purulent pleuritis after a cer- tain length of time, it can be almost affirmed that his unfortunate condition is due to the negligence of his physician. If the physician will use defervescent agents in a methodical manner, he will not be compelled to resort to trocars and aspirators, and it should always be his aim to avoid the latter means. The statistics of ELEMENTS OF DOSIMETRIC PRACTICE. 409 actual science ought not to be somber ; it should not boast of its progress while compelled to blush at its clinical results. The dominant in acute dry pleuritis is that which is common to all inflammatory affections. But in this case aconitine must not only be used as a febrifuge ; it must also be used as an anticongestive. The elements of inflammation must be attacked vigor- ously — congestion with aconitine and digitaline, vaso- motor paralysis with strychnine — and this treatment must be continued not only until the fever has ceased, but as long as the organism will tolerate it. One granule of each may be given every fifteen minutes, or at longer intervals if such is the indication. Vesicants and blood- letting are absolutely contra-indicated, the former be- cause they increase the existing pain and add an in- flammation to one which is already present, the latter because it weakens the patient too much and leaves him in a bad condition for undergoing the resorption of the exudates which have already been formed. Bloodletting is useful only at the time of invasion of the inflammatory state, but one is seldom called to see a patient at that time. On the other hand, leeches and wet cups may be very serviceable in making the in- ternal antiphlogistic treatment more effective. Pleuritic pain, or costalgia, should be promptly treated with hypodermic injections of the hydrochlorate of mor- phine, or by the application of leeches. Internally, we may combine with the defervescent agents one or two granules of cicutine, or its hydrobromate, every half-hour until the pain is relieved. It must not be forgotten that pain is both a cause and an effect of in- flammation. Dyspnoea may follow violent pain and fever, and if these two elements are brought under con- trol the dyspnoea will cease with its causes. If special treatment for it were indicated, we should give aspidosa- mine or picrotoxine. In chronic proliferative pleuritis, chronic anticongestive means of treatment must be em- ployed, two granules of aconitine and two of arseniate 410 ELEMENTS OF THERAPEUTICS AND PRACTICE. of strychnine being nsed three times daily. This form usually results from some complicating element, and we may be compelled not infrequently to give two granules of the arseniate of iron and two of iodoform three or four times daily as modifiers of the newly formed tissues which result from the disease. Kevul- sives upon the skin are also appropriate for this con- dition — for example, tincture of iodine, iodized cotton, and the actual cautery, their action upon the vital forces being both a general and a local one. The thoracic pains which frequently accompany this form of the disease may be relieved with two granules of cicutine three or four times daily. At the end of the proliferative period we find an effusion in the form of a fibro-serous exudate. The exudative period is not of long duration, because the pleura rapidly absorbs the material which is deposited upon its surface. If absorp- tion does not go on rapidly, the exuding process being more intense than the absorptive one, or if absorption is interrupted by the formation of false membranes which are interposed between the absorbing vessels and the exuded material, the volume of the latter may be- come quite large. In the former case, the pleuritis re- mains acute, the dominant being the same as in dry pleu- risy. The fever frequently assumes an intermittent type, and one of the salts of quinine becomes indispensable. Either the hydroferrocyanate, the hydrobromate, or the sulphate may be given in three-granule doses every three hours. The cough, which tends to increase the inflammation, should be treated perseveringly with two granules of the hydrobromate of morphine every twenty minutes ; or three-granule doses of codeine, Gregory's salt, or narceine may be given at the same intervals. Dyspnoea may result partly from fever and partly from compression. In the latter case, the indication is to exert a tonic action upon the lungs, that they may be the better enabled to accomplish their function and resist the pressure which is caused by the effusion. ELEMENTS OF DOSIMETRIC PRACTICE. 411 Agents for accomplishing this purpose are apomorphine, hypophosphite of strychnine, and brucine, one to three grannies being given every two honrs. The exudate in chronic pleuritis may be fibro-serous, or it may be pu- rulent. If the effusion is serous, absorx^tion may be prevented by an atonic condition of the vessels of the pleura. The circulation of the respiratory apparatus should therefore be modified with picrotoxine, and the pneumogastric be incited to action by strychnine and apomorphine. Strychnine may be given in two- or three-granule doses every two hours until the face is somewhat congested. Apomorphine may be given in two-granule doses, with like quantities of caffeine, arbu- tine, and adonidine, four to six times daily, for their tonic and diuretic effects. The intermittent fever, which is not uncommon in chronic pleuritis with effusion, may be treated with three granules of the arseniate of quinine four times daily, or twenty granules of the salicylate of quinine twice daily. If the effusion is very abundant, dyspnoea and displacement of the heart demand surgi- cal interference. Thoracentesis should be performed only in cases in which the effusion is considerable and threatens life. The evidences of this effusion are com- plete silence upon auscultation, dullness on percussion over all or nearly all the anterior aspect of the thorax, the absence of vocal vibrations, and a feeling of fullness, which is evident to palpation, in the intercostal spaces. The indications for the operation and the steps which are to be taken are well described in "Clinique thera- peutique " of Dujardin-Beaumetz. If after the first thoracentesis neither the thoracic walls nor the pulmo- nary tissues return to their original position, it will be useless to repeat the operation, and a fatal issue will be hastened by the loss of strength which the operation necessitates. Thoracentesis should be preceded and followed by the liberal use of the incitants apomorphine and strychnine, so as to assist the pulmonary tissue in overcoming the inertia and want of expansibility 412 ELEMENTS OF THERAPEUTICS AND PRACTICE. which result from prolonged compression. Pleuritis with purulent effusion is accompanied by hectic fever, anorexia, sweating, etc. Before resorting to an opera- tion, which is about the only thing which can be done, as a last resort, the activity of the digestive function should be stimulated by using three granules of quas- sine three times daily ; and preventing purulent infec- tion by giving five granules of the salicylate of quinine and two of aconitine twice daily. After the operation, two granules of iodoform, with one of arseniate of iron and one of arseniate of strychnine, should be given twice daily, to arrest pyogenesis. If the acute pleuritis is diaphragmatic, the functions of the phrenic nerve may be interfered with, and a particular line of treat- ment required. Sedatives should be used freely with defervescents and antispasmodics, three granules of veratrine being given every half -hour until vomiting or contro-stimulation is produced ; also, one granule of hyoscyamine every two hours until a decided mydriatic effect is obtained. The cause of the pleuritis may also indicate a particular variant in its treatment. Thus, the treatment of pleuritis which is caused by cold should be six granules of the nitrate of pilocarpine every quarter-hour, or, if given hypodermically, twenty granules in a gramme of distilled water. Rheumatic pleuritis calls for the particular effect of colchicine. Pleuritis which is due to albuminuria, tuberculosis, or the eruptive fevers, should be treated mainly with in- testinal and cutaneous derivatives, and by the treat- ment of the cause. ELEMENTS OF DOSIMETRIC PRACTICE. 413 DOSIMETRIC TREATMENT OF PLEURITIS. Dominant. Inflammatory Cement | SnTpt^of^nnL. Variant. A. With Reference to the Nature of the Exudation. Proliferative or dry pleu- ritis . aS / Hyperthermia "3 J Dyspnoea ^ ( Costalgia ■g j Thoracic pains . 2 I Lymphatic diathesis \o I 2 / Fever . ( Continued Pleuritis with effu- sion . Cough Dyspnoea \ Costalgia Aconitine. Aspidosamine. j Hydrobromate of cicu- ( tine. Cicutine. j Arseniate of iron, iodo- \ form. Aconitine. . \ ( Hydroferrocyanate, sul- ( Intermittent ■< phate, or hydrobro- ( mate of quinine. \ Morphine, narceine, co- ' I deine. ( Fever . . Aconitine, veratrine. . < C Apomorphine, hypo- ( Compression -j phosphite of strych- ( nine. Cicutine. Thoracentesis, diuretics. Fibro-serous effusion . branes Purulent uf- (£££» fusion . | Sweating Suffocation Intermittent ( Arseniate or salicylate fever . } of quinine. Pseudo-mem- J picrotoxine> Surgical means. Quassine. Atropine. B. With Reference to Situation. Veratrine. matic pteHS™ * ' ^ or ? hine - litis I Dyspnoea Cicutine. ' [ Hiccough Hyoscyamine. "nio-r.i-.vorr f Contractures " Mental disturbance C. With Reference to Causation. Pleuritis from cold Nitrate of pilocarpine. Rheumatic pleuritis Colchicine. Infectious pleuritis Sulphide of calcium. Diathetic pleuritis (Derivatives, anticausa- r ( tives. Pleurodynia.— See Rheumatism. Pneumonia. — The dominant in pneumonia must conform to the pathogenic idea which we have concern- ing the disease. To most pathologists pneumonia means only a simple inflammation ; to others it is an infectious disease, the result of a poisoning of the or- 414: ELEMENTS OF THERAPEUTICS AND PRACTICE. ganism by a specific agent, discovered by Friedland- er, and named by him pneumococcus. Under the first hypothesis, the inflammatory element demands aconi- tine ; nnder the second, the infectious element compels us to use the parasiticide par excellence, sulphide of calcium. Pneumonia is the type of inflammations, not only on account of the intensity of the inflammatory process and the extensive area of tissue attacked, but especially on account of the vascularity of the pulmo- nary tissue. All the therapeutical considerations to which Burggraeve was the first to call attention as re- sulting from experimental physiology are applicable to pneumonia. Thus, in the first phase of the inflam- mation, the phase of vaso-motor paralysis, the arseni- ate of strychnine and phosphoric acid are especially indicated ; unfortunately, however, this phase has usu- ally been passed when the physician is called, the in- flammation is already established, and the treatment required is entirely different. Aconitine, the antihy- persemic medicament par excellence, gives, in inflam- matory conditions, results which are the more excellent as the organs attacked are the more vascular. But, though the effect of the drug is rapidly produced, the congestion reproduces itself with equal facility. For this reason we should not only combine the defervescent remedies in our plan of treatment, but we should con- tinue their use in gradually decreasing doses, and fix their effect by means of the neurosthenic agents brucine and strychnine. The immediate relation which exists between the pulmonary circulation and the heart compels us to consult the state of the pulse in order to insist upon one or another of the defervescents, accord- ing to the nature of the predominant symptoms. Thus, when the pulse is large, strong, and of good tension, two granules of veratrine should be given every quarter- hour ; if the pulse is very frequent, a granule of digitaline should be given every half-hour until the number of pulsations is lessened. If the heart-force ELEMENTS OF DOSIMETRIC PRACTICE. 415 seems to be diminishing, one to two grannies of strych- nine may be given every half-hour. The nse of aconi- tine, on the other hand, must be regulated by the thermometer ; one granule may be given every quarter- hour if the temperature exceeds 39 '5° C, every half- hour if it is 39° C. or under. If the infectious nature of pneumonia is assumed, and there are numerous and excellent reasons for such an hypothesis, one granule of the sulphide of calcium may be given every quarter- hour. This agent is very efficient as a defervescent ; its elimination by the bronchial mucous membrane fa- vors solution of the exudate which results from the dis- ease, thus making it an excellent expectorant, and as a diaphoretic it corresponds to the causal indication. In no case can the sulphide of calcium do harm, what- ever be the conception of the jDathogenesis of the disease. Among the indications of the variant that which is most noticeable is a decided chill, if we are called at the be- ginning of the disease. To meet this symptom one gran- ule of sulphate of strychnine combined with one of phos- phoric acid should be given every quarter of an hour until reaction occurs. The pain in the side, which may be regarded as an intercostal neuritis, should be treated persistently with three granules of hydrobromate of morphine every quarter of an hour. The violence of the pain tends greatly to increase the dyspnoea, the pulmonary congestion, and the circulatory disturbance in general. Should the physiological effects of the morphine be apparent before its therapeutic effects, and compel us to suspend its use before its beneficial effects have been realized, it may be replaced by two to four granules of the tannate of cannabine every quarter- hour, or two of cicutine every half -hour. In the early stage of pneumonia, wet cups may be used with advan- tage. The dyspnoea, which is caused not only by pain, fever, hypersemia, and diminution of the area of the re- spiratory field (which also diminishes the coefficient of oxygen for the red corpuscles), but also by troubles in 416 ELEMENTS OF THERAPEUTICS AND PRACTICE. the heart-action, must be treated with digitaline to regu- late and strengthen the heart-muscle, in addition to aconitine and morphine, which respond to other indi- cations. The cough, which assumes different charac- ters in different stages of the disease, should be treated, during the fever, with Gregory's salt or iodoform, and codeine, two granules of each being given every quarter- hour until this symptom is relieved. If the cough is caused by difficulty in expectorating the inflammatory accumulation, we should give two or three granules of scillitine, emetine, or arseniate of antimony every two hours ; or one of emetic every two or three hours, alone or combined with two of codeine, in case there is gastro- intestinal intolerance. Emetic and emetine can rarely be given to children, especially to nursing children. Their action is too depressing for very sensitive or- ganisms, and this statement applies equally in cases in which they excite vomiting, and in cases in which they do not. If there seems to be a necessity to resort to their use, they should be given in very small quanti- ties, combined with brucine or caffeine, which will in- crease the expectorant action and diminish the depress- ing effect. Emetine may be replaced by scillitine, kermes mineral, or lobeline, one granule being given every two hours. Bromide of camphor and helenine are also excellent expectorants, and may be used with- out danger, two granules of either being given three to live times daily. If there is adynamia, or fear that it may supervene, the hypophosphite of strychnine should be given without apprehension. It should be given in doses of two or three granules every hour until the pulse recovers its normal vigor. Such treatment is especially applicable in the pneumonia of the aged, and it has been successfully treated by the author by this method in all cases in which it has been seen sufficiently early. Success with any method of treatment is always the best guarantee of its efficiency. In all cases, how- ever, the greatest vigilance is indispensable ; all possi- ELEMENTS OF DOSIMETRIC PRACTICE. 417 ble hypotheses must occur to the mind, and all must be carefully analyzed, in order that each exigency may be met as soon as it occurs. It must also be remem- bered that pneumonia may exist in the aged for several days before any outward symptom presents itself. The cough in such cases may be insignificant or without positive characteristics ; there may be neither dyspnoea, anorexia, pain in the side, nor fever. The thorax must be carefully auscultated for its physical signs. A con- dition which is often attributed by the aged to consti- pation may be pneumonia, the grave character of which becomes manifest only when adynamia has generalized its symptoms. The hypophosphite of strychnine, regu- larly given night and day, generous wine, and a nour- ishing diet, may cure this disease, which is usually considered of grave import, because one always defers intervention until it has become incurable. As an ex- pectorant and anticongestive, two granules of bryonine or two of apomorphine may be given every two hours with good results. Should expectoration continue to be difficult, and asphyxia be threatened from obstruc- tion of the bronchi, emetic may be given, preceded, however, by strychnine, as in this way the dangers which usually attend its use during the adynamic period may be avoided. Mild delirium, which is symp- tomatic of cerebral anaemia, may be treated with two granules of caffeine every half-hour, or with similar doses of bromide of camphor. This symptom is not of particular importance, and calls only for a suitable reparative diet. Active delirium, which is of frequent occurrence among alcoholic subjects, is due to a want of cerebral stimulation. To restore the equilibrium, port or madeira wine diluted with water, so that an existing gastro-intestinal catarrh may not be aggra- vated, should be administered, or one granule of hyos- cy amine every two hours. Icterus, which is due to catarrh of the biliary ducts, from extension of the gas- tro- duodenal inflammation, or from irritation produced 27 418 ELEMENTS OF THERAPEUTICS AND PRACTICE. by localization of the infection of the liver, calls for two granules of colchicine every two hours if the first of these two conditions obtains, or two granules of calo- mel every two hours until the dejections have regained their normal dark color. Gastro-intestinal catarrh, and the necessity of facilitating the elimination of the pneu- mococcus, require the use of Sedlitz Chanteaud, the dosage to be regulated by the conditions of each case. When asphyxia announces an approaching fatal ter- mination from vital depression, oedema, or pulmonary stasis, large blisters should be used, and the hypophos- phite of strychnine, as has already been indicated. It is only in such a condition that vesicants are useful, their function being to excite vaso-motor contractility, and to diminish the obstruction to the pulmonary cir- culation. If the disease follows its regular course, vesicants are not only useless, but they increase the suffering of the patient, expose him to the risk of tak- ing cold, aggravate the causes of dyspnoea, and con- tribute notably to the appearance of albuminuria. Should pneumonia terminate in abscess, three gran- ules of iodoform and two of arseniate of soda may be used every four hours. During convalescence the reparative forces should be stimulated by means of quassine to increase the appetite, and brucine to strengthen the lungs, two granules of each being given before meals ; two granules of arseniate of iron should also be given with each meal to supply the red globules with iron. The ordinary classical treatment of pneumonia does not deserve the confi- dence of the physician, bleeding, emetics, etc., being condemned by statistics. The expectant plan is the one upon which physicians of the official school rely, while they prefer to do nothing and await a favorable turn of the disease. Let us leave them to their blindness and impenitence, and do our duty by employing our certain, effective, and harmless methods. ELEMENTS OF DOSIMETRIC PRACTICE. 419 {Infectious element Pneuraococcus Inflammatory element /Chill . Pain in the side . Dyspnoea Violent cough Difficult expectoration Variant. ( Adynamia . Full pulse . Weak pulse . Mild delirium Active delirium . Icterus . Elimination of the in fectious agent . Asphyxia Abscess Convalescence Sulphide of calcium. Aconitine. Sulphate of strychnine. Hydrochlorate of morphine. Digitaline, morphine, cicutine. Codeine, iodoform. Scillitine, arseniate of anti- mony, emetine, emetic. Wine, 'iodoform, arseniate of strychnine. Digitaline, veratrine. Hypophosphite of strychnine. Caffeine, bromide of camphor. Wine, hyoscyamine. Colchicine, calomel. Sedlitz Chanteaud. Vesicants, strychnine. Iodoform, arseniate of soda. Quassine, arseniate of iron. Pneumorrhagia. — See Broncho-pulmonary Haem- orrhage (under Hemorrhage). Pollutions, — See Spermatorrhoea. Pseudo-croup. — See Acute Catarrhal Laryngitis (under Laryngitis). Purpura Haeniorrhagica.— See Scorbutus. Rhachitis. — Podiatrists are not in accord with re- spect to the true cause of rhachitis. "While some con- sider that it depends upon and is one of the symptoms of hereditary syphilis, others affirm that syphilis is not at all necessary to its production, and that it results entirely from faulty nutrition, the organism excreting an excessive quantity of the inorganic elements which enter into the composition of the skeletal system. This opinion seems a reasonable one, and it is for that reason that the use of granulated phosphate of lime is recom- mended, a small teaspoonful to be taken with each meal. The hypophosphites of soda and lime will also fulfill this indication, and will have the advantage of not fatiguing the digestive organs, which sometimes hap- pens after large doses of phosphate of lime. Two gran- ules of the hypophosphite should be given at each meal. It is evident that this treatment must be con- tinued for a long time, these agents being considered 420 ELEMENTS OF THERAPEUTICS AND PRACTICE. as foods rather than as medicines. It must not be ex- pected that the organism can repair in a few days ex- tensive disorders of nutrition. The variant in this dis- ease has a manifest importance, since the greater num- ber of the symptoms which accompany it are the cause of serious troubles of nutrition, which must be avoided with the most assiduous care. If insomnia is an element of trouble, the child should receive two to four granules of codeine at bed-time. The fever which accompanies the appearance of acute rhachitis should be treated with half a granule of aconitine every hour, more or less, according to the condition of the temperature. After the period of invasion there may be other attacks at irregular intervals, which should be treated with one or two granules of the hydroferrocyanate of quinine every two hours. The muscular debility and general prostration which accompany this disease should be treated with neurosthenics, the most appropriate of which is brucine, which should be given three to five times daily. Codeine should also be given to control vomiting in one- or two-granule doses, and as often as is indicated by the urgency of the case. Sweating, which is more or less profuse in character, is a promi- nent symptom, especially during sleep, and tends to weaken the patient and predispose him to bronchitis and other catarrhal affections. For this condition we should give one to four granules of agaricine every evening. Diarrhoea, which results from intestinal atony and imperfect digestion, indicates one granule of phosphate of iron before each meal and two of pep- sin after each meal. Convulsions, which may proceed from different causes, may, nevertheless, all be cured by the use of two granules of the bromide of camphor and two of the valerianate of zinc every half-hour. Though it is not necessary to consider hereditary syph- ilis as the essential cause of this disease, nevertheless it furnishes conditions which are favorable to its devel- opment and which greatly aggravate the situation of ELEMENTS OF DOSIMETRIC PRACTICE. 421 the patient ; it should be persistently treated by means of one granule of the biniodide of mercury two to four times daily. If, for any reason, it is deemed proper to suspend the use of the mercury, iodoform may be given in doses of one or two granules three times daily. The foregoing directions will prove of little benefit un- less they are supported by the observance of suitable hygienic measures, new disorders being developed with great readiness when the departure from the physio- logical condition has reached a certain stage. m Dominant. Variant. ( Dystrophy as to cal careous elements / Insomnia . Fever Weakness . Vomiting . Profuse sweating Diarrhoea . Convulsions \ Hereditary syphilis Phosphate of lime. Hypophosphites of lime and soda. Codeine. Aconitine, hydroferrocyanate of quinine. Brucine. Codeine. Agaracine. Phosphate of iron, pepsin. Valerianate of zinc, bromide of camphor. Biniodide of mercury. Rheumatism. — Pathologists are yet far from a perfect knowledge of the manner in which rheumatic diseases are constituted. Therapeutics can, therefore, dispense with an analysis of these contradictory theo- ries, since, if any one of them were true, it would de- stroy all the others and remove all doubts. Truth has for its characteristics unity and simplicity ; if a propo- sition can be contested, it is because it is either false or incomplete. It is repugnant to the scientific spirit of the day, however, to throw itself into the arms of empiricism. Reason must always struggle in its search for truth, and the intellect is compelled to take as a support an hypothesis which, without explaining all the facts at issue, will at least serve as a guide in the most of its endeavors. Such a method is the best one, after careful examination, for reaching the grand road which leads directly to the source of the true light for which we may be searching. The study of rheumatism shows that two conditions are essential to its produc- 422 ELEMENTS OF THERAPEUTICS AND PRACTICE. tion : 1 . Predisposition. 2. A determining cause. Pre- disposition consists in a chemical modification of the fluids of the body, uric or lactic acids being present in excess. The determining cause is unknown, but it would seem to be of an infectious nature. The similar- ity of the symptoms in true rheumatic arthritis and in blenorrhagic arthritis, in which the gonococcus is the true cause ; the facility with which rheumatism ap- pears in persons who are predisposed to it, in conse- quence of a simple change in the external surround- ings ; the fact that cerebral rheumatism may be cured by the use of cold baths ; the duration and course of the disease when it is left to a spontaneous evolution ; the multiplicity of its localizations ; the unquestion- able influence which is exerted upon it by the salicy- lates, the action of which is antizymotic ; all these con- siderations conduce to the opinion that rheumatism is due to an unknown zymotic agent, which is developed as the blood is modified by an excess of certain organic acids. However this may be, it is certain that the phy- sician is more fortunate in possessing a medicinal agent for the cure of rheumatism, the eflicacy of which has been proved, than in possessing a theory which is capa- ble of clearing away all doubts and explaining all phe- nomena. We can pass, therefore, to the study of the best means for treating and checking rheumatism, re- serving for a final consideration the explanation of their therapeutic action. The most varied methods have been used in the treatment of acute rheumatism, hav- ing nothing in common but their want of efficacy. It is only within the last few years that therapeutics has possessed a class of agents of recognized value — namely, salicylic acid and the salicylates. After a few days of treatment with these agents, the pain will be dimin- ished, the fever will disappear, and it will appear that the disease has been brought under control. But, aside from these advantages, there are certain disadvantages connected with the use of either the acid or its salts. ELEMENTS OF DOSIMETRIC PRACTICE. 423 The doses must be very large, for it is necessary that the patient be saturated with the drug until the desired effect is obtained. The digestive organs will not always tolerate such excessive dosing, and it sometimes hap- pens that the physiological effects anticipate the thera- peutic, and thus leave the physician completely dis- armed and helpless, the patient being unrelieved, in- stead of obtaining a prompt and durable relief. The advantages which may be obtained are also only transient ; the slightest negligence on the part of the patient, the premature suspension of treatment, which should be continued for a long time, may give rise to a relapse which may prove much more rebellious than the first attack. Besides, intoxication may easily occur if the organs of elimination are not functionating prop- erly. Among the alkaloids may be found certain agents which are as effective as the salicylates, and even much more certain in their action. The author would prefer colchicine to the salicylates in the treatment of all rheu- matic affections, whether they involve the articulations, the serous membranes, or the nerves. Colchicum has always been used for gout, and, according to some au- thors, with an effect which is almost specific. It has not the same reputation for relieving rheumatism, al- though it would seem to be indicated for this as well as for gout. Its analgesic, antithermic, and derivative properties should indicate its use to fulfill all necessary requirements. The fear of giving such an active remedy until its full effect is obtained, the varying energy of its preparations, and the appearance of certain unpleas- ant symptoms, explain its limited use. The populariza- tion of the alkaloids had the advantage of recalling into use a great number of excellent drugs which had been abandoned on account of the imperfection and irregularity of the preparations in which they appeared, and also because the other elements which were asso- ciated with the useful alkaloid in the given plant dis- turbed the action of the alkaloid by their action, and 424: ELEMENTS OF THERAPEUTICS AND PRACTICE. nullified its results. The action of colchicine, however, is simple, evident, and prompt. In all cases of rheu- matism, whether simple or complicated, acute or chronic, colchicine may be given in accordance with two differ- ent methods — viz., the acute or active treatment, if the case is an acute one or an exacerbation of a chronic one ; the slow treatment, if the disease follows the usual chronic course. In the active treatment, two granules of colchicine should be given at intervals of two hours until the therapeutic or physiological effect is obtained, the former being indicated by a cessation of the pain, the latter by diarrhoea, and perhaps by vomiting of bile, following the administration of the medicine. Both these effects are usually obtained simultaneously. This result having been obtained, the medicine must be continued at the same intervals, but in doses of only one granule. By this means the excessive discharge of bile will quickly be controlled, the therapeutic effects continuing. The author has seen neither re- lapses nor aggravation of the disease after the treat- ment has been discontinued. In addition to the use of colchicine, the patient must abstain from the use of acid in all forms, including wine, which always contains tartaric acid, because acids will decompose the alka- loid and transform it into another, which is much less powerful in its effects. For diet, soups and milk should be given in acute cases ; in chronic ones we should simply insist upon abstinence from indigestible and irritating food. In the treatment of chronic cases, which include those which are accompanied by more or less continuous rheumatic pains, which may not be of great severity, and those which are accompanied by the presence of nodes, four to six granules of colchicine should be given daily. The physiological effect with such dosage is not apparent ; the therapeutic effect be- comes manifest after some time, but the treatment must be continued with regularity and perseverance. In st)me cases a succedaneum of colchicine will be of ELEMENTS OF DOSIMETRIC PRACTICE. 425 service, the most useful one being veratrine, which re- sembles colchicine in many respects. It may be given in doses of two granules every half-hour, the general di- rections which were given for colchicine being also ap- plicable in respect to veratrine. The action of colchi- cine may be re-enforced by that of veratrine, two granules of each being given every two hours, or by the salicylates, three of the salicylate of soda or of quinine being given at intervals of two hours. In nodose rheu- matism, two granules of arseniate of soda may be given three times daily with an equal quantity of colchicine ; or the colchicine may be replaced with three granules of iodoform three times daily, and the arseniate of soda by three granules of the cyanide of zinc three times daily. This treatment should be continued for months, or even years. The author has almost entirely given up the treatment of rheumatism by external ap- plications, no advantage having ever been obtained from the various sedative, stimulant, anodyne, and re- vulsive applications, which are useful only to draw away the patient's attention from his immediate suffer- ings, and which exjDose him to relapses. In monar- ticular rheumatism, whether acute or chronic, subcuta- neous injections of colchicine may be made, four gran- ules of the colchicine being dissolved in a gramme of distilled water. According to 0. Hayfelden, of St. Petersburg, these injections have an almost miraculous effect, although the tissues may be somewhat irritated. Douches, sulphurous and saline baths, electrical appli- cations, etc., have indications and advantages which need not be insisted upon. After having thus estab- lished the treatment of the dominant, it will sometimes, though not often, be necessary to have recourse to other medicinal agents to combat troublesome symptoms. For the pain of this disease, we may combine with the dominant two-granule doses of cicutine hourly, or one of morphine every quarter-hour, or the morphine may be given hypodermically. Should the fever exceed 426 ELEMENTS OF THERAPEUTICS AND PRACTICE. 39° C, one granule each of aconitine, veratrine, and digitaline may be given at intervals of one honr or more, but this must not imply any interruption in the administration of the colchicine, which should be con- tinued in accordance with the rules which have been given. Should there be the element of periodicity in the pain or the fever, we should associate with the other remedies the salicylate of quinine in doses of three to five granules at intervals of two hours. Sweat- ing may sometimes be too profuse and require treat- ment ; for this purpose a granule of atropine may be given every two hours until either the physiological or the therapeutic effect is obtained. Anaemia, which rarely occurs among those who are treated according to the principles of dosimetry from the beginning of the dis- ease, should be treated with the salicylate of iron and a strengthening diet. The cutaneous eruptions, which sometimes alternate with the rheumatic attacks, may be readily cured with colchicine. Pruritus should be treated with three-granule doses of the hydrobromate of cicutine every half -hour. The complications, endo- carditis, pleuritis, peritonitis, pneumonitis, and menin- gitis, should receive the same treatment as that which is used for the inflammation of the joints, that is, col- chicine, and the variable symptoms arising from the complications by the variant which is appropriate for each. Rheumatic encephalopathy is the gravest of all the complications which may occur, and was long con- sidered quite incurable. The danger in encephalopathy consists in hyperthermia. In this condition hesitation is not to be thought of, and we should at once make use of a combination of all the hypothermic agents in as active a form of treatment as possible, for this com- plication may be fatal in the course of a few hours. Two granules of aconitine should be given with four of veratrine, one of digitaline, and two of colchicine every half -hour, the quantity of each substance and the in- tervals between the doses being regulated by the effects ELEMENTS OF DOSIMETRIC PRACTICE. 427 which are produced. The value of cold baths must not be overlooked ; in many cases they will prove the only means of preserving health. In all cases the thermome- ter must be resorted to as a guide for regulating the treatment. The temperature of the bath should be 25° C, and this may be kept constant either by the ad- dition of cold water or ice. The patient should remain in the bath until his temperature is considerably re- duced. After having been dried and rubbed, he should receive stimulating drinks ; should the tempera- ture rise again, the baths should be repeated until the bad symptoms have disappeared. The author hesitates to advise the simultaneous use of the cold baths and the dosimetric treatment by means of defervescents. He has never adopted this plan in his own practice, though it has been done with advantage by other phy- sicians. In any case in which either of these methods used alone does not produce the desired result, the cir- cumstances of the case will indicate whether he should resort to extreme measures and combine internal with external measures of refrigeration. It is of great im- portance that no time be lost in moderating the febrile condition, whatever method be employed. The author will not attempt to explain the manner in which cere- bral rheumatism may be cured by means of refrigerant remedies, but will simply conclude this chapter by attempting to explain the action of colchicine. The most evident action of colchicine is that of a cholagogue. Is it the excessive biliary and intestinal secretion that it excites, which, by modifying the condition of the blood, removes the elements which convert it into a medium that is suitable for the development of the rheumatic condition % Is it its irritating action upon the intestine, which, by removing the inflammation in the joint, dis- sipates the arthritis \ Does it relieve the pain by act- ing upon the general sensibility? Or is it a combi- nation of these effects which, by attacking the disease in its principal constituent elements, destroy it, dissolve 428 ELEMENTS OF THERAPEUTICS AND PRACTICE. it, or check it ? The recognized efficiency of antimony in the treatment of rheumatism seems to justify the lat- ter view, but the parallelism is entirely in favor of colchicine, which appears to have particular properties as an anti-rheumatic agent. The local action of colchi- cine, which Hayfelden has declared to be admirable, justifies the hypothesis that this agent possesses cer- tain specific properties. Acute rheumatism . / Dominant. f Ordinary Chronic rheu- form . matism [ Nodose \ Variant. ( j Colchicine, veratrine, sali- "j cylates. (■ Colchicine, cyanide of zinc. ( Colchicine, arseniate of -j soda. ( Iodoform, cyanide of zinc. Pain Cicutine, morphine. Continued \ Ac ™itine, veratrine, digi- tanne. Salicylate of quinine. Atropine. Salicylate of iron. Colchicine. Hydrobromate of cicutine. Fever Periodic Profuse sweating Anaemia Eruptions . Pruritus . Carditis Pleuritis . Peritonitis Pneumonitis Meningitis V Cerebral rheumatism Colchicine, aconitine. Variant as in each disease taken by itself. Defervescents, cold baths. Rhinitis (Coryza). — Acute rhinitis may proceed from several causes, the most common of which consists in atmospheric changes, and this is the one which it is most important for the physician to recognize in prac- tice. Coryza is the type of catarrhal diseases. With- out danger when it is simple and properly treated, it may become the cause of different annoying conditions if it is allowed to pass into the chronic state, whether from disregard of the proper hygienic and pharmaceu- tical means of treatment, or from neglect of the indica- tions furnished by any morbid condition whatsoever which maintains it or predisposes to it. However be- nign this inflammation may be, we should not leave it to take its natural course, which frequently does not result in complete resolution. Besides, the longer a coryza lasts the more chances are there for successive ELEMENTS OF DOSIMETRIC PRACTICE. 429 relapses, not to speak of the baneful influence which it may have upon contiguous organs — the pharynx, con- junctivae, ears, larynx, bronchi, etc. The dominant in- dication in acute rhinitis is to combat the catarrhal inflammation by the use of one granule of aconitine every hour, and to restore the suppressed perspiration by means of six granules of the nitrate of pilocarpine every quarter-hour until diaphoresis results. Perspi- ration having been excited, aconitine is to be continued. Aconitine does not limit itself to assisting this diapho- retic action and opposing the inflammation of the nasal mucous membrane ; it will promptly relieve the head- ache and counteract the catarrhal fever. After the antithermic effect has been obtained, aconitine may be alternated with the hydroferrocyanate of quinine, three granules being given every two hours. The acute pe- riod of the disease is quickly followed by that of mu- cous secretion, and the function of secretion and elimi- nation may be aided by the use of three to five granules of the sulphide of calcium every two hours, or two granules of helenine every three hours. Should the secretion be too abundant a granule of atropine every three hours will promptly modify it. Epistaxis at the beginning of the disease is almost always useful, but, should it become troublesome, three granules of ergo- tine may be given every quarter-hour until hsemostasis results. Infants at the breast, being very sensitive to the action of cold, are also very susceptible to coryza, At this early age the disease is not without gravity, on account of the obstacle which obstruction of the nares offers to the act of sucking. The application of fatty substances to the root of the nose, over the frontal sinuses, and within the nares, will promptly restore the ability to breathe through the nose. Persons who are subject to catarrhal troubles ought, especially during the winter and spring, to use habitually two granules of strychnine and two of aconitine at bedtime, and Sed- litz Chanteaud early in the morning. Hydrotherapy, 430 ELEMENTS OF THERAPEUTICS AND PRACTICE. in the form of daily intranasal injections of cold water, will also be found serviceable. Acnte coryza, in con- nection with infectious diseases, requires no particular treatment in addition to that which is directed toward the principal morbid condition. The sulphide of cal- cium should be the dominant in such cases. Chronic rhinitis is almost always due to some diathetic fault, and especially to scrofula. Three granules of iodoform and two of the arseniate of soda three or four times daily, saline baths, nutritious diet, cod-liver oil, and astringent tonic wines, are the most efficient means for the successful treatment of chronic rhinitis of scrofu- lous origin. Herpes and syphilis often render this con- dition an incurable one. For such cases the antiher- petic and antisyphilitic agents are indicated. Ulcerative coryza or ozsena is caused by an ulcerated condition of the nasal mucous membrane, which results in a fetid condition of the air which is expired through the nos- trils, although the latter condition may be present even if the ulcers are absent, owing to putrefaction of the muco-purulent secretions of the nasal mucous mem- brane. The internal treatment should be that of simple chronic coryza, but the local trouble should be treated by local applications of antiseptic agents, the best of which are the following : (1) IJ Iodoformi porphyrisati, Bismuthi subnitr., Aluminis pulv., aa partes sequales. M. et ft. pulvis. (2) 9 Aquse, Liq. Goudron aa q. s. M. (3) ^ Potassse permang 1 gramme. Aquse 100 grammes. M. Sig. : First inject plain water into the nostrils, then follow with the foregoing. (4) ^ Yaselini 25 grammes. Calomelani 2 grammes. M. Sig. : Introduce into the nostrils upon cotton. ELEMENTS OF DOSIMETRIC PRACTICE. 431 Acute rhinitis Dominant. Variant. RHINITIS. Catarrhal element Nitrate of pilocarpine. Infectious element Aconitine. Chronic rhini- f Scrofulous element j Io *°^ rm ' arSeniate ° f tis (simple! Herpetic element Arsenious acid. or ulceraO i , Protiodide of mercury, tive) . . I Syphilitic element -j iodoform. I Cephalalgia Aconitine. ( Hydroferrocyanate * 1 quinine. ] Sulphide of calcium. * \ Helenine, atropine. Epistaxis Ergotine. Fetid secretions .... Antiseptic errhines. Intermittent fever . \ Catarrhal secretion of Rubeola. — This disease is considered a benign one by many writers, but it deserves a certain degree of attention on account of the dangers which attend either the expectant plan of treatment or any other method which is inappropriate to the nature of the disease. Sporadic cases are properly designated by the name which the Italians give to the disease — morbillo, that is, the slight or insignificant disease; but when the disease becomes epidemic it may be one of the most destructive as to its termination, from the complica- tions which are associated with and follow it, if not from the evolution of its parasitic elements. It is not neces- sary, at this time, to criticise the work which has been done with reference to the proper treatment of this dis- ease. We can limit ourselves to the opinion of Franz Mayer, professor of the diseases of children at Saint Anna's Hospital for children in Vienna, and which is given in Hebra's "Treatise on the Diseases of the Skin " : " We do not know of any medicament which will guarantee a favorable termination to measles. This opinion resul ts from a comparison of cases which have followed their course without medical treatment, with other cases treated by both old methods and new. In whatever way one may treat them, the result is always the same. In all cases, it will be proper to refrain from using diaphoretics and alteratives, for, though they may facilitate to a certain degree the 432 ELEMENTS OF THERAPEUTICS AND PRACTICE. natural course of the evolution of the eruption, they may also favor the development of certain complica- tions. With reference to the consequences, it must not be forgotten that affections of this kind are frequently the result of scrofula, tuberculosis, ansemia, or poor food. The use of medicaments internally, which is in- dicated by the existence of one of these conditions, will almost always prove useless on account of the rapid progress of the complications." The conclusion from this passage, which is an expression of the senti- ments of the great majority of regular practitioners, is therefore in effect : Complications are to measles as effects to their causes— for the causes, apply the expect- ant plan of treatment ; for the effects, use ineffective treatment. Dosimetry is more logical as well as more humane. With this system of treatment the problem is to eliminate the causes so as to prevent the primary effects from being produced ; then, if primary results have occurred, to treat them and prevent secondary ones. Of what use is pathology, why do we study the succession and dependence of morbid phenomena, if no practical advantage can be drawn, if we must be lim- ited to the contemplation of the natural course of diseases? In the zymotic, parasitic, infectious dis- eases, etc., the knowledge of the primordial pathologi- cal cause imposes an indication of great importance— namely, the extirpation of the microbes which are dis- tributed through the system of the patient. In the present state of science prophylactic treatment consists in inoculation with the virus of the disease which has been so attenuated as to produce harmless results ; curative treatment should find a bactericide which will be effective in its action upon microbes, and will be tolerated by the organism. If this fundamental indica- tion is filled, it is evident that the therapeutic problem will be much simplified, for the task will then be to seek for agents to eliminate the residue of the invading mi- crobes, and to sustain Nature in her efforts to heal ELEMENTS OF DOSIMETRIC PRACTICE. 433 their ravages. Sulphide of calcium, the bactericide which is so effective in the treatment of variola and croup, if employed in accordance with rules which are indispensable for obtaining the desired effect, will be equally successful in the treatment of rubeola. Infec- tion by this disease, which is less violent, less general, and less acute than variola, requires a no less active treatment than variola if one would destroy it in a few hours. It is not necessary to repeat the pathogenic considerations which are given at length under the head of variola ; they will apply equally in this disease with reference to the administration of sulphide of cal- cium. In rubeola the plan of aborting the disease is not often necessary, because the period of invasion is usually longer and the precursory symptoms less char- acteristic than is the case in variola. In the period of invasion we should therefore give one granule of the sulphide of calcium every half -hour or every quarter- hour, according as the condition is more or less remote from the period of eruption. In this period we should satisfy the more urgent indications of the variant. We should give aconitine if the temperature is high or if there is delirium or convulsions, combining it with the bromide of camphor or croton chloral, in two-granule doses every hour, if perturbations of the nervous sys- tem follow the fever. The violent headache should be treated with one granule of caffeine every half-hour, the cough with one granule of codeine every quarter-hour, and the paroxysms of spasmodic suffocation with one granule of hyoscyamine every hour. If we are called to a case during the period of eruption we should con- tinue the use of the sulphide of calcium, for the funda- mental indication still exists ; we may give it, however, in one-granule doses every hour. In that form of the disease in which the function of elimination seems to be localized in the respiratory apparatus, we must treat the prostration and ward off collapse by the use of one granule of brucine or of the hypophosphite of 28 434 ELEMENTS OF THERAPEUTICS AND PRACTICE, strychnine every hour, and we should facilitate expec- toration by means of one granule of emetine, kermes mineral, or scillitine, every two hours. In the neurotic or ataxo-dynamic form of the disease, we should use, in a liberal manner, arseniate of strychnine, phosphoric acid, and valerianate of quinine ; one granule may be given every hour. Generous wine or quinquina, in small and often repeated doses, are also excellent aux- iliary means of treatment. In the hemorrhagic form, the chances of recovery are few, and the best plan is to prevent the occurrence of the disease by the use of bac- tericides. Should it actually occur, however, we should give one granule each of ergo tine, tannic acid, and sali- cylate of ammonia. In the period of desquamation, the dominant is furnished by the asthenic condition, and should be satisfied with quassine and strychnine. The variant will have reference to the persistence of certain symptoms which denote that elimination con- tinues in progress at certain points in the organism. We should give Sedlitz Chanteaud, colchicine, benzoic acid, or the benzoates, to stimulate the functions of the emunctories. Such is the rational treatment of rubeola, which has been demonstrated by practical experience to be the most effective. A few years ago, when the author was still occupied with practice in the regular school, he assisted in the treatment of an epidemic of rubeola in which the mortality was greater than in an epidemic of variola, in which he was also concerned. All the patients died from the sequela, which were bronchitis or enteritis. Since that time all the sporadic cases in the author's practice have been treated with the sulphide of calcium, with the result of modifying the course of the disease. In three or four days after the eruption appeared, the patients were able to be about. Not long ago the author was called to see a patient who presented the most pronounced symptoms of rubeola which he had ever seen. The fever reached 40° C, the conjunctivae were injected, and there was ELEMENTS OF DOSIMETRIC PRACTICE. 435 continuous weeping ; there was a hoarse cough and coryza, the eruption was prominent, being abundant upon the limbs, but very slight upon the trunk. A gran- ule of the sulphide of calcium was ordered every hour. On the following day great improvement was manifest ; the con junc tivse were white and had only the normal quantity of moisture, the coryza had disappeared, the eruption was less prominent, but the cough still con- tinued to fatigue the patient, and the temperature had reached 38 '5° C. Two days afterward the disease seemed to be entirely overcome. This result may not have been due to the treatment alone. The disease would probably have been of a benign character, but it is certain that the influence of the drug upon the prog- ress of the disease was a positive one for good. RUBEOLA. Dominant. Parasitic infection Sulphide of calcium. 1st period : Invasion. 2d period : Eruption. 3d period : Desquamation. Variant. Fever Cough Pseudo-croup Cephalalgia. Delirium, convulsions Capillary bronchitis (pul- monary form) . Ataxo-adynamic condition (neurotic form) Epistaxes, hematuria, pete- chias (hemorrhagic form) f Asthenic condition -j Retention of the products of infection Aconitine, salicylate of quinine. Codeine. Hyoscyaraine. Caffeine, guaranine. Bromide of camphor, cro- ton chloral. Brucine, hypophosphite of strychnine, emetine, scil- litine. Phosphoric acid, valerian- ate of zinc, generous wine, quinquina. Ergotine, salicylate of am- monia, tannic acid. Quassine, strychnine. Sedlitz Chanteaud, colchi- cine, benzoic acid, ben- zoates. Scarlatina. — Scarlatina, like the other eruptive fevers, is due to the infection of the organs by a par- ticular microbe, the destruction of which may be ac- complished by means of the sulphide of calcium, which acts not only to cure the patient, but also tends to pro- tect those who are exposed to the morbid germ. The 438 ELEMENTS OF THERAPEUTICS AND PRACTICE. internal disinfection should be carried out with the same earnestness and by the same method which is advocated for variola, that is, one granule of the salt every quarter-hour, whether the patient be a child or an adult, only short intervals being allowed, when the system seems to be saturated with hydrogen sulphide. In addition to the dominant, which is indispensable and may be used during the entire course of the disease, other agents must occasionally be employed to fill secondary indications, but this will occur, as a rule, only in cases in which the dominant has not been used from the beginning to control the pathogenic element. In the period of invasion it may happen, in certain cases, that the chill, on account of its violence, will demand the use of the neurosthenic agents, especially the arseniate of strychnine, in one-granule doses every quarter-hour, in order to diminish the vaso-motor pa- ralysis which follows this spasmodic condition. When the invasion is suspected, the salicylate of quinine, in one-granule doses every quarter-hour, may be advan- tageously combined with strychnine. Cephalalgia and fever may be relieved by aconitine, one-granule doses being given at such intervals as may be indicated by the temperature. If the fever exceeds 39*5° C, we should give aconitine every quarter-hour, being satis- fied with a moderation of the temperature which shall approach the normal, since the sulphide of calcium has a true defervescent action in such cases, by controlling the parasitic infection. When the patient complains of pain in the throat, he should be instructed to dissolve a granule of aconitine in the mouth at suitable intervals, which will rapidly soothe the irritation of the pharynx. Should the angina become worse, three granules of cocaine may be given every half-hour until a sedative effect is obtained. Non-suppurative parotiditis should be treated with two granules of the nitrate of pilocar- pine every half-hour, to facilitate the elimination of the virus of the disease ; while the suppurative form may ELEMENTS OF DOSIMETRIC PRACTICE. 437 be treated with one granule each of iodoform and arseniate of quinine every hour. Adenitis of the cervical glands should be treated in the same way. In the very grave forms of the disease, the nervous agita- tion, delirium, and ataxia may be relieved with two granules of the bromide of camphor every half -hour. The convulsions, should they not yield to the use of the camphor, may be treated with two granules of the valerianate or the hydrobromate of quinine every quarter-hour. For somnolence or the comatose condi- tion, two granules of caffeine or of one of its salts may be given every quarter-hour. For adynamia, two granules of the arseniate of strychnine should be given every two hours, or, if the progress of this con- dition is a slow one, caffeine and generous wine may be administered. Vomiting at the beginning of the disease is not significant, but, should it occur after the eruption has appeared, it would indicate that the digestive canal was taking part in the work of depura- tion, which should be facilitated by the use of Sedlitz Chanteaud. The act of vomiting, which fatigues the patient and aggravates his general condition, may be checked by the use of two to four granules of codeine or Gregory's salt every half -hour. Cutaneous and in- ternal haemorrhages are of grave prognostic signifi- cance. Two to four granules of ergotine, with one or two of salicylate of iron every hour, are means which offer the best results. Attacks of syncope are due to infectious myocarditis. The tonicity of the heart may be increased by using three granules of caffeine and three of ergotine every half-hour. Diphtheritic de- posits upon the tonsils and pharynx should be treated locally with applications of lemon- juice, and three granules of nitrate of pilocarpine should be taken in- ternally every two hours to facilitate the separation of the false membrane. Gangrenous conditions should be treated with two granules of salicylate of ammonia and two of quinine every hour. Albuminuria, anasarca, 438 ELEMENTS OF THERAPEUTICS AND PRACTICE. and ursemic accidents should receive appropriate diu- retic and laxative treatment ; for example, one granule of digitaline and one of aconitine three times daily, or two granules of asparagin every hour ; and a dessert- spoonful of Sedlitz Chanteaud in a glass of water as an ordinary beverage. The benzoates are also useful when the albuminuria has begun to diminish, two granules being given four times daily. Great care must be taken to avoid chilling the cutaneous surface, or pre- venting in any way the process of elimination by the other emunctories. ! Dominant. Infectious element Sulphide of calcium. /Chills . Arseniate of strychnine. < Headache Salicylate of quinine. ft Fever . Aconitine. En Angina Cocaine. 5( Parotiditis . Nitrate of pilocarpine. Cervical adenitis . Iodoform, arseniate of quinine. < Nervous agitation ) V Bromide of camphor. o Ataxia . Delirium Convulsions . Valerianate of quinine. \ Variant. { Somnolence . Caffeine. Adynamia . Arseniate of strychnine. Vomiting j Sedlitz Chanteaud, codeine. ( Gregory's salt. Haemorrhage Ergotine, salicylate of iron. Syncope Ergo tine, caffeine. Diphtheritic deposits Nitrate of pilocarpine. Gangrene { Salicylates of ammonia and of ( quinine. Albuminuria ) Digitaline, aconitine, nspara- ) gine, Sedlitz Chanteaud. ^Anasarca Sclerosis of the Brain. — See Chronic Encephalitis. Scorbutus and Purpura Hemorrhagica, or WerlhofPs Disease. — Scorbutus and purpura should be studied together, since they differ only in the acuity of their progress and the rapidity with which they are established. It might be said that purpura is acute scorbutus, or, on the other hand, that scorbutus is chronic purpura. Let us endeavor to find the true cause of this disease, as well as its fundamental lesions. Up to the present time we are entirely ignorant of the conditions which excite this change in the health. We know that it appears under the influence of bad hygi- ELEMENTS OF DOSIMETRIC PRACTICE. 439 enic conditions, and that alimentation bears a particu- lar relation to it ; but it is often observed, also, after depressing experiences of a moral nature, and some- times without anything in the previous history of the patient which could be taken as a clew. From its usual etiology, from its symptomatology, and from the result of certain modes of treatment, it may be con- cluded that the primordial cause of scorbutus is a hy- posthenic condition of the venous system. The domi- nant should consist, therefore, in the use of ergotine and the lactate or salicylate of iron, one granule of each being given every two hours. The normal solution of the perchloride of iron may also be used in doses of thirty or forty drops daily. Pains in the extremities may be relieved by the use of three granules of the hydrobromate or the valerianate of quinine every hour. For constipation, five granules of podophyllin should be given two or three times at intervals of two hours. The diarrhoea, which is almost always of a fetid char- acter, may be controlled by using three granules of the salicylate of quinine or three of tannic acid every two hours. Syncope, which is very dangerous in the ady- namic condition of the patient, should be treated with three granules of caffeine every five minutes, or with subcutaneous injections of ether, half a gramme being injected every half-hour until a satisfactory result has been obtained. For haemorrhages we may use five granules of ergotine with one of sulphate of strychnine every quarter-hour. Not infrequently there are spasms which are due to stimulation of the muscles by the de- teriorated blood. If they are painful or very vio- lent, one granule of valerianate of atropine should be given every half-hour until relief is obtained. The stomatitis does not require any particular treatment. Some topical application of a disinfectant and astrin- gent character should be used, however, to improve the circulation of the gums, and prevent the ulcerations and haemorrhages which frighten so many patients. 440 ELEMENTS OF THERAPEUTICS AND PRACTICE. Dominant. Venous hyposthenia / Pain . Constipation Diarrhoea This indication may be met by occasionally dissolving in the mouth a granule or two of iodoform and brucine, or rinsing out the mouth with an alcoholic solution of chlorate of potash of the strength of 15 : 200. The vegetable acids, antiscorbutic plants, etc., need not be used, for nothing but a vague tradition as to their spe- cific properties sanctions their use. Ergotine and iron are the true remedies for this disease, and they have been tried by different therapeutists with a uniform degree of satisfaction. Ergotine, iron. Valerianate of quinine. Podophyllin. j Salicylate of quinine, tannic ( acid. ( Syncope . . . Caffeine, injections of ether. Hemorrhage . . | Ergotine, sulphate of strych- Spasm .... Valerianate of atropine. \ Stomatitis . . • Iodoform, brucine. Scrofula. — The cause of scrofula is still unknown. The parasitic theory which places it by the side of tu- berculosis, although very seductive, does not explain all the facts of the disease. The facility with which some of its symptoms are relieved — for example, the conjunctivitis — by the use of saline baths appears to indicate that the disease proceeds principally from an atonic condition of the lymphatics, which gives rise to irregularities in the lymph circulation, which are mani- fested by engorgements with inflammation and subse- quent suppuration. The primordial lesion, according to this hypothesis, is a functional perturbation, which consists in a general hyposthenia, more pronounced in the lymphatic system than in any other. The result of the use of stimulating medicaments supports this supposition, and, therefore, we can establish as the dominant juglandine and phosphoric acid. The prep- arations of Juglans regia are to be classed among the bitter astringents, and the antiscrofulous properties of the drug have been known for a century. Baumes, Negrier, and Pouguet have carefully studied the results ELEMENTS OF DOSIMETRIC PRACTICE. 441 of this treatment, and are in harmony in recognizing it as superior to all others. The variability of action of the preparations which are made from this plant, and the intolerance of the stomach for an irritant agent which must be continued for a long time, explain the oblivion into which these preparations had fallen. The alkaloid, which is without these inconveniences, enables us to continue the use of the drug as long as is neces- sary ; but it must be remembered that the first effects are always produced slowly, and that it is indispensa- ble that we persevere in its use for a long time. Three to four granules should be given three times daily be- fore each meal. Phosphoric acid is equally useful for this disease on account of the general stimulation which is produced, by which also the lymphatic system is benefited. Phosphorus has long been regarded as one of the best remedies for scrofula, but it has incon- veniences which do not exist in phosphoric acid. We can begin by using two granules three times daily, gradually increasing the dose if a favorable result is not obtained at the end of three or four weeks. The lymphatic diathesis is an almost inseparable companion to the scrofulous. This predisposition likewise serves as an obstacle to the cure of the latter. Should it show itself, it should be treated with a combination of iodo- form and arseniate of iron if it appear in the torpid form, or with arseniate of soda if in the irritable or erethistic form, two granules of each being given three times daily. In cases which are attended with sup- puration we should persevere in the use of the domi- nant, giving two granules of iodoform, combined with two of arsenious acid, three times daily. The glands which do not suppurate may be saved by injecting six to twelve drops of Fowlers solution. Those glands which have opened should be dressed with iodoform or with glycerole of phenic acid. The local phenomena upon the skin and mucous membranes may be modified by the stimulant action of sulphide of calcium, two or 442 ELEMENTS OF THERAPEUTICS AND PRACTICE. three granules being given f onr times daily. The local developments in the skeleton will require, in addition to the dominant, iodoform and hypophosphite of strych- nine ; for the local develoiDments in the viscera we should use iodoform and arseniate of strychnine. All hygienic means which will stimulate the circulation will greatly aid the pharmaceutical treatment. Gym- nastics, exercise in the open air, sunshine, cold baths, etc., should form a part of every plan of treatment. The diet should be substantial and varied, condiments being allowed in moderation. The appetite should always be watched, and, if it should appear to fail, it may be stimulated by means of three granules of quas- sine or of pipeline before each meal. Dominant. Atony of the lymphatics Jnglandine, phosphoric acid. 'Lymphatic j Torpid . Arseniate of iron, iodoform, diathesis ( Irritable . Arseniate of soda, iodoform. Anorexia . . . Quassine, piperine. Suppuration . . Iodoform, arsenious acid. Localizations upon the "1 mucous membranes . J VVaeiakt. ( Lo s c k a t a - tions - llpo - nth ; ^Sulphide of calcium. Localizations in the j Iodoform, hypophosphite of skeleton . . . / strychnine. Localizations in the \ Iodoform, arseniate of strych- viscera . . . \ nine. Septicemia. — See Traumatic Fever (under Fever). Spasm of the Glottis. — Spasm of the glottis is a contraction of the vocal muscles which results from exaggerated excitability of the spinal nerves. As the spasm lasts only a few minutes, one has no time to interfere ; the attack either ceases or destroys the pa- tient before the surprise which it excites has passed away. The treatment should have for its end, there- fore, the diminution of nervous excitability ; for, as the disease is rarely limited to one attack, and as there are always long intervals between the first attacks, we ought not to give way to an inaction which may result fatally. On the other hand, we should profit by this interval, and give atropine for a long time in doses proportionate to the age and tolerance of the patient ; say, from half ELEMENTS OF DOSIMETRIC PRACTICE. 413 a granule to a granule two or three times daily. Con- stipation, which is the most frequent cause of the con- dition, should be treated with one to three granules of podophyllin once daily ; or the bowels of young chil- dren may be regulated by the use of three granules of jalapine once or twice daily. These attacks sometimes recur with a certain periodicity, in which case we should administer one granule of hydroferrocyanate of quinine every two hours during the forty-eight hours which follow the spasm. This dose may be doubled or even trebled for children more than two years of age. If the attacks are repeated at regular intervals of greater du- ration, with the atropine we may combine two granules of the hydroferrocyanate or the hydrobromate of qui- nine three times daily. During and after the spasm, contractures and convulsions sometimes occur. Two granules of croton chloral or of bromide of camphor may be given every quarter-hour, or oftener, for the first, and two granules of the valerianate of zinc every half- hour or one of phosphoric acid every two hours for the convulsions. The phosphoric acid is especially useful in eclampsia of a severe form in delicate chil- dren. If the spasm continues very long, apncea and asphyxia will result. The only way to interfere with the necessary rapidity is to cause ether to be inhaled, or to excite the nerve force at another point by the aid of Mayor' s hammer or by burning a small quantity of alcohol upon the skin. GO ffi f Dominant, J Excitability of the Variant. nerves Convulsions Contractures Constipation Apncea . Asphyxia . Recurrences P inal [Atropine. Valerianate of zinc. Croton chloral. Podophyllin. Ether, Mayor's hammer. Ilydroferrocyanate of qui- Spermatorrhoea. — Spermatorrhoea is a functional lesion, quite analogous to incontinence of urine, and might with greater propriety be called incontinence of 444 ELEMENTS OF THERAPEUTICS AND PRACTICE. semen. It should be considered as diurnal and as noc- turnal spermatorrhoea. The nocturnal variety is essen- tially caused by congestion of the genito-urinary organs which, by the centripetal impressions which they send to the cerebro-spinal system, produce erotic dreams in the brain, and excite in the cord the centers which de- termine erection of the penis. This congestion results most frequently from distention of the bladder by an accumulation of urine. The principal indications, there- fore, will be — 1. To urinate as often as necessary during the night, and to drink but little at the last meal. This precau- tion will often suffice to prevent pollutions, which al- most always occur in the morning when the bladder is full. 2. This susceptibility of the bladder to congestion and tendency to seminal discharge certainly proceed from atony of the excretory canals, from weakness of the muscular coat of the bladder, and from failure in the vaso-motor force of its vessels. It is therefore in- dispensable that an excito-motor be administered which shall be capable of furnishing to these elements the force by which they are deficient. Therefore, the sul- phate or hypophosphite of strychnine, ergotine, or bru- cine will constitute, with the other neurosthenics, the dominant of the treatment. Aconitine will have a spe- cial influence upon the hyperemia of the bladder. 3. Another element which contributes to the morbid condition is the exaggeration of the vesical sensibility and the increase of reflex action, by virtue of which ejaculation is accomplished. Cicutine should therefore be associated with the dominant in the plan of treat- ment, which thus becomes a complex one; and, in- deed, dynamic lesions in themselves are complex. The treatment should therefore consist in the use of two or three granules of strychnine with each meal, together with three granules of ergotine, and at bed-time three granules of cicutine and two of aconitine. It often ELEMENTS OF DOSIMETRIC PRACTICE. 445 happens that the patient, unaware that the bladder is full, does not awaken sufficiently to urinate, and, the urinary secretion continuing, the pollution takes place as has been explained. The cerebral torpor, which be- comes the more pronounced the more frequent the pol- lutions, should be treated with two granules of atropine at bed-time and two more in the middle of the night. Diurnal pollutions are of much greater gravity and more rebellious than nocturnal ones. Not only do they destroy the vitality of the patient more quickly, but they are the evidence of a more profound perturbation of the nervous forces. For this condition we should use curative means with the greatest perseverance, be- cause the consequences are often disastrous, whether they lead to marasmus and phthisis or to suicide or mental disorders. In this condition the vital force should be increased by every means. For loss of appe- tite we should give three granules of quassine or two of piperine before each meal. Apepsia, which tends to debilitate the patient and aggravate the spermatorrhoea, should be treated with three granules of pepsin after each meal. Impotence, which is the inevitable conse- quence of weakness in the genital organs, will disappear entirely or in part, after the cure of the spermatorrhoea, by the prolonged use of three granules of the hypo- phosphite of strychnine two or three times daily. Gen- eral debility is very decided after this condition has lasted some time. When it appears, we should pre- scribe two granules each of the arseniate of iron, ar- seniate of strychnine, and phosphoric acid with each meal. Fecal retention must be carefully avoided, so much the more because spermatorrhoea conduces to irregularity in the evacuations of the bowels. The pa- tient should take a small spoonful of Sedlitz Chanteaud in water every morning, and, if this does not suffice, three granules of podophyllin or of vera trine every evening. The diet should be tonic and analeptic, but not stimulating. Sponge-baths, exercise in the open 416 ELEMENTS OF THERAPEUTICS AKD PRACTICE. Dominant. Variant. air, and rigorous avoidance of all erotic imaginations are indispensable hygienic requirements. The hyper- secretion of the vulvo-vaginal glands produces in women nocturnal pollutions, which may induce great debility. Tonic treatment with strychnine and iron, and five granules of bromide of camphor at bed- time, will usu- ally control this condition. j Arseniate of strychnine. ( Ergotine. Cicutine. Aconitine. Atropine. Quassine, piperine. Pepsin. Hypophosphite of strychnine. Sedlitz Chanteaud. Arseniate of iron. Arseniate of strychnine. Phosphoric acid. Splenitis. — Splenitis is rarely diagnosticated in the acute condition. The vascularity of the organ indicates aconitine and ergotine. In most cases splenitis is seen in its chronic form as the result of repeated congestions of the organ, and due particularly to malarial poisoning. The condition of the blood and of the splenic circula- tion must be modified, the first by the use of the arseni- ates of soda and quinine, and the second by the use of ergotine and the arseniate of strychnine. Hsemate- mesis, the most important complication of this disease, should be treated with three granules of ergotine every quarter-hour, or by suitable hypodermic injections of the same agent. Atony . Reflex hyperesthesia Vesical hyperemia / Cerebral torpor . Loss of appetite . I Apepsia ( Impotence . Fecal retention . General debility . Dominant -S Aconitine > ergotine, arseniate of strychnine. Variant. \ Paludal infection ( Haematemesis . Arseniate of soda, quinine. Ergotine. arseniate of Stomatitis, Aphthous (Aphthce). — The nature of this disease is still imperfectly known. It may be that the ulcerations of the mouth are due to a herpetic erup- tion analogous to herpes of the skin, or they may be due to infection of the mouth, and sometimes the entire ELEMENTS OF DOSIMETRIC PRACTICE. 447 gastro-intestinal tract, by a parasitic element of un- known nature. The discrete variety of aphthae appears to be only an attenuated and sporadic form of the con- fluent variety, the latter always possessing a certain degree of gravity, and sometimes appearing as an epi- demic. The sulphide of calcium, whether as an anti- herpetic or an antiparasitic agent, should be used in preference to other means in all cases of aphthous sto- matitis. The granules may be dissolved in the mouth, in order to take advantage of their topical effect, unless there are some contra- indications to such practice. Un- der the latter condition a few granules of salicylate of soda or of salicylic acid may be used instead. The sul- phide may be administered in doses of one or two gran- ules every hour or every two hours. For the fever we should give a granule of aconitine every hour ; we will also obtain its local action upon the heated and hyper- aemic mucous membrane by allowing the granule to dis- solve in the mouth. The same effect may be obtained by allowing two granules of cocaine to dissolve in the mouth every hour, and their anaesthetic effect will fa- cilitate secretion or mastication. For the severe pain of this disease two granules of codeine or morphine may be given every half-hour, either for its topical effect or as a general analgesic. Though there may be salivation, it is not usually so decided as to be trouble- some to the patient. Should it become so we may give one granule of hyoscyamine every half-hour. Adyna- mia, which is present only when the aphthae are con- fluent or secondary, should be treated with two granules of sulphate of quinine every hour, or with one of phos- phoric acid every two hours. The digestive troubles, which almost always precede or accompany the aph- thous eruption, should be treated with a small spoonful of Sedlitz Chanteaud every morning, and two granules of quassine every three hours, together with a few swallows of some alkaline mineral water. Should the vesicles be opened, they leave ulcerations which usually 448 ELEMENTS OF THERAPEUTICS AND PRACTICE. cicatrize rapidly. In some cases, however, the repara- tive process is a slow one, and then it is well to allow two granules of tannic acid or iodoform to dissolve in the month every two or three honrs. Aphth.se which are the result of general diseases indicate primarily the treat- ment of those diseases, the cause being thus removed. m 1 Domi W H ( nant. Parasitic element . Sulphide of calcium. / Fever . . Aconitine. [ Buccal irritation . Cocaine. W Pain . . Codeine. ^ Variant. ( Salivation . . Hyoscyamine. "s \ Adynamia . . Sulphate of strychnine. Digestive troubles . Quassine, Sedlitz Chanteaud. \ Ulcerations . Tannic acid. Stomatitis, Catarrhal {Simple or Erythematous). — The causes of this condition are numerous, but, what- ever they be, they must be suppressed, as well to obtain a prompt cure as to avoid recurrences, which are always liable to occur as long as the cause persists. Usually simple idiopathic stomatitis results from the presence of an irritating body — for example, dentition, dental caries, etc., or from a gastric catarrh which has extend- ed to the buccal mucous membrane. Stomatitis has for its essential process, therefore, the inflammatory one. The dominant should consist of one granule of aconitine every two hours, which may be dissolved in the mouth in order to utilize its topical effect. Cocaine, by virtue of the ansemiating effect which it has upon tissues with which it comes in contact, may be equally useful. Three granules of it may be given at once, and they should be held in the mouth as long as possible, in order to obtain the full benefit of their local effect. The drug should be given every hour or every two hours, according to the severity of the case. Pain and burning in the mouth may be relieved by allowing two granules of codeine to dissolve slowly in the mouth every half -hour. For the fever, which is usually ephemeral and not very intense, we should give one granule of aconitine every half -hour until defervescence occurs. Should ptyalism become excessive, it may be modified by using one gran- ELEMENTS OF DOSIMETRIC PRACTICE. 449 ule of hyoscyamine every three hours. If gastric dis- order is present Sedlitz Chanteaud should be used ; it may be that the stomatitis is only a manifestation of the gastric trouble. SIMPLE STOMATITIS. Dominant. Inflammatory element .... Aconitine, cocaine. fPain Cocaine. VAT>TAvrrr J Fever Aconitine. variant. < p tyalism Hyoscyamine. [ Gastric disorder Sedlitz Chanteaud. Stomatitis, Mercurial. — When mercury is elimi- nated by the salivary glands, stomatitis of greater or less severity results from inflammation of the mucous mem- brane after the process has attained a certain degree. The most useful means for treatment are those which favor the elimination of the mineral by stimulating the salivary, urinary, enteric, and cutaneous secretions. For this purpose chlorate of potash has a reputation which is unquestionable. It should be given in doses of four to eight grammes daily, dissolved in two hun- dred to three hundred grammes of water, and taken in small doses every two hours. Five granules of nitrate of pilocarpine four times daily will furnish a suitable substitute for the potash salt, if for any reason the latter is contra-indicated. Sedlitz should be taken every day to increase the elimination by the kidneys and intes- tines. The pain may be soothed by using three gran- ules of cocaine every half-hour dissolved in the mouth or dissolved in a teaspoonful of water before they are taken. In addition to its analgesic action, the cocaine will rapidly relieve the tissues of their congestion, and by this means also the local pain will be relieved. The dryness of the mouth will be lessened by dissolving in it one granule of aconitine every two hours. Ulcera- tions which are slow to cicatrize should be touched with perchloride of iron in strong solution, or with the solid stick of nitrate of silver. Ptyalism, which is not only annoying but a decided source of weakness, may 29 450 ELEMENTS OF THERAPEUTICS AND PRACTICE. be relieved by using one granule of sulphate of atropine or one of hyoscyamine every two hours. The fever, which sometimes is very high, may be moderated by using one-granule doses of aconitine, the intervals to be regulated by the elevation of the temperature. The fetidity of the breath may be overcome by chewing one or two granules of iodoform every two hours, which, in addition to its local antiseptic action, has a very useful tendency to facilitate the elimination of the mercury. The anorexia and difficulty in masticating call for the exclusive use of liquid or semi-solid food. Two granules of quassine given four times daily may remedy this difficulty. The diarrhoea should not be interfered with unless it is compromising the strength of the patient ; in that case, two or three granules of the hydriodate of morphine should be given every two hours. Mercurial stomatitis is followed by a condition of profound ansemia, which may be remedied by the use of the incitants of vital force and pills of the iodide of iron. An essential condition to the success of this treatment manifestly consists in a suspension of the use of mercury. The mineral may gain access to the interior of the body through the skin, the digestive or- gans, or the respiratory apparatus. Poisoning may be due to one's occupation, to medical treatment, or to accident. As a preventive plan we should use mercu- rials only in small doses and with occasional intermis- sions, the condition of the gums being frequently examined so that treatment may be suspended if neces- sary, or, at least, so that chlorate of potash may be combined with the mercury. The use of the potash salt is not without disadvantages, for by concealing the first effects of mercurial intoxication it causes us to run the risk of passing the stage in which the toxic effects are curable, and, besides, deprives us of one of the best means which can be used to combat hydrar- gyrism. In fact, when the chlorate of potash is impo- tent to prevent the manifestation of mercurial stomati- ELEMENTS OF DOSIMETRIC PRACTICE. 451 tis, its impotence will persist when mercurial poisoning has actually occurred. It would seem to be better to allow very active substances to produce their proper effect at the suitable time rather than to arrest or ob- scure its appearance, and so deprive us of that informa- tion which is necessary that we may know when to suspend their use. So ! Dominant. Variant. ( ( Nitrate of pilocarpine. Elimination of mercury < Chlorate of potash. ( Sedlitz Chanteaud. I Pain . Cocaine. Dryness of the mouth . Aconitine. Ulcerations . j Topical use of perchloride of ' I iron or nitrate of silver. Ptyalism Hyoscyamine. Fever . Aconitine. Fetid breath . Iodoform. Anorexia Quassine. Hydriodate of morphine. Diarrhoea y Anaemia Iodide of iron. Stomatitis, Pultaceous {Maguet, Athrepsia). — The nature of this disease is now well known. It is due to the growth of Oidium albicans in a medium which is favorable to its development. One of the necessary conditions to its culture is a medium which has an acid reaction, and, as the buccal mucous mem- brane in badly nourished children has an acid reaction, the same being true with all persons whose digestive functions and nutrition in general are not up to the normal standard, muguet is developed primarily in children at the breast, and secondarily in adults who are more or less cachectic. In most cases this form of stomatitis has a grave prognosis, for it indicates that there is a decided disturbance of nutrition in those who are its subjects. It is believed that O'idium albicans is transmitted only by contact, which is an argument in favor of the plan of treatment which is here advised. There are two fundamental indications in this disease : one is suggested by the conditions of receptivity, the principal of which is a diminution in the vitality ; the other is responsible to the parasitic character of the morbific agent, which compels us to have recourse to the 452 ELEMENTS OF THERAPEUTICS AND PRACTICE. parasiticides. In the first case, we should give, to small children, one granule of brucine three to five times daily ; to adults, two granules of the arseniate of strych- nine three to five times daily. After taking the granules, one should take a swallow of some alkaline mineral water, or they may be dissolved in such a medium before being taken if the age of the child indi- cates that they be taken in solution. The second indi- cation should be satisfied with sulphide of calcium as a topical antiparasitic agent, three to five granules be- ing taken after meals, and oftener if necessary, dis- solved in an alkaline water or in the oil of sweet almonds. For adults, two granules may be given from time to time, being either chewed or dissolved in the mouth. This remedy may be taken without hesitation, and it will assist the local treatment. Muguet of the oesophagus, stomach, and intestine especially will be benefited by this treatment. Salicylic acid and the salicylates may be used instead of the sulphide of cal- cium, but the latter is to be preferred. The buccal catarrh which precedes the appearance of the pultaceous patches should be treated, from its beginning, with half a granule of aconitine (for infants at the breast) every two or three hours. Aconitine may also be given in solution in order to utilize its local action. The nitrate of pilocarpine, which is eliminated by the salivary glands, is also a very useful remedy, for it has a favor- able influence upon the cause of the disease, and facili- tates the healing of the ulcerated patches. One granule should be given every two hours. Irritation and pain in the mouth, which often act as an obstacle to suc- tion and to the swallowing of the milk, may be relieved by two granules of cocaine every two hours, dissolved in a spoonful of water. Yomiting and diarrhoea will rapidly weaken children, and thus increase the morbid receptivity. Brucine and codeine are the most suitable agents for this condition, especially if the children are naturally robust, one granule of each being given every ELEMENTS OF DOSIMETRIC PRACTICE. 453 three hours. If the children are feeble, two granules of the salicylate of soda or of iron may be given in preference every three hours. The choleriform condi- tion, which is characterized by fluidity and great frequency of the stools, by rapid emaciation and chilli- ness of the surface of the body, should be rigorously treated with the hydrochl orate of morphine, the doses being carefully regulated by the age of the patients. For children under two months of age, half a granule may be given every two hours ; for children of two years or under, one granule every three hours. Circum- anal erythema, which is caused and aggravated by the alvine evacuations, may be relieved by applications of vaseline or a solution of tannic acid, five granules being dissolved in a little water, and thus applied to the irri- tated surface. Cutaneous ulcerations indicate a grave condition with respect to nutrition and assimilation, and depend less upon muguet than upon an abnormal condition which Parrot has termed atlirepsia. For this condition we should give tonics internally, and ap- ply iodoform and bismuth in equal parts externally. The hypothermia which is the ordinary accompaniment of choleriform diarrhoea, but which may also occur alone, should be treated with one granule of phosphoric acid every two hours, or with external means for excit- ing peripheral vitality, such as warm baths, sinapisms, etc. Ordinary hygienic precautions must be thoroughly carried out, and particularly must cleanliness of the mouth be insisted upon. Oidium albicans . . j Su / a P t ^ de ° f Calcium ' Salicy - g«5 oh Eh Eh S £° f Dominant. Variant. / Lowered vitality . . j B ™ e ' arseniate of strych- I Buccal catarrh . . i Aconitine, nitrate of pilocar- ( pme. Buccal irritation . . Cocaine. Vomiting and diarrhoea Brucine, codeine. Choleriform condition . Hydrochlorate of morphine. Erythema around the j Tannic acid . anus . . . . ( Cutaneous ulcerations . Iodoform. V Hypothermia . . Phosphoric acid. 454: ELEMENTS OF THERAPEUTICS AND PRACTICE. Stomatitis, Ulcero - membranous (Stomacace, Noma, Gangrenous Stomatitis, Pseudo-membranous Stomatitis, Ulcerative Stomatitis, Diphtheritic Stoma- titis). — Ulcerative stomatitis, by its epidemic and con- tagious properties, by its prodromic signs and well- defined localization, must be regarded as an infectious disease, the agent of which is still undiscovered. The infectious element must be combated with two gran- ules of the sulphide of calcium every half -hour dis- solved in the mouth, unless the patient's repugnance to the disagreeable taste can not be overcome. If the fever is high, a granule of aconitine may be given every hour, combined with arseniate of strychnine, that the defervescent effect may not be too depressing. If the fever is of slight intensity, and is attended with remis- sions, three granules of the salicylate of quinine every half -hour should be preferred. The pain in the cheeks, which is sometimes severe, may be quieted with three granules of codeine in solution every two hours. The fetid condition of the breath, which is sometimes sug- gestive of gangrene, may be modified by chewing two granules of iodoform every hour. One granule of atro- pine every three hours will relieve the ptyalism. Adenopathy pertaining to the submaxillary and parot- id glands shows the infectious character of the buccal lesion, and indicates in the one case a favorable, in another an unfavorable progress of the disease. Should it be terminated by suppuration, iodoform may be given to hasten the resolution of the glandular engorge- ment. Ulcerations should be treated locally or inter- nally with chlorate of potash, the influence of which upon the process of cicatrization is decided. Teaspoon- ful doses may be given of a solution of four to eight grammes in two hundred grammes of water. For the anorexia three granules of quassine may be given three or four times daily. The alimentation of the patient must be reparative in character, in order to anticipate and prevent adynamia, which often occurs in connec- ELEMENTS OF DOSIMETRIC PRACTICE. 455 Infectious element Sulphide of calcium. Fever . j Aconitine, salicylate of qui- ' \ nine. Codeine. Buccal pain . Fetid breath Iodoform. Ptyalism Adenopathy . Sulphate of atropine. Iodoform. Ulcerations . ( Chlorate of potash. ' ( Nitrate of pilocarpine. Anorexia Quassine. k Adynamia . Arseniate of strychnine. tion with this disea.se. When the strength is begin- ning to fail, or even from the beginning of the disease, two granules of the hypophosphite or the arseniate of strychnine should be given every three hours. Proper hygienic regulations play an important part in effecting a en re of this disease. Pure air and isolation of the patients are indispensable to rapid and certain recov- ery. Jc*m I "Dominant. la i o nH \ Variant. ( & m Km 2^ &K Syphilis. — To some writers syphilis is a disease the ultimate cause of which is unknown ; to others, the disease is due to an infection of the organism by a mi- crobe (coccus), which has been carefully investigated by Marcus and Tornery. It is an unquestionable fact, however, that the cause of syphilis may be treated suc- cessfully with mercury. Therapeutics, convinced of the efficiency of the mercurials for neutralizing the syphilitic virus, is as efficient as it is empirical in its action, or, looking at the matter from another stand- point, it conforms itself to the course which is imposed upon it by the existence of a particular microbe. The dominant of the treatment is, therefore, clearly indi- cated. In every period of the disease mercury is use- ful, and constitutes the basis of the best plans of treat- ment. In tertiary syphilis, however, iodine seems to be preferable, either because it gives new activity to the mercury which has already been introduced into the system, or because, by actively modifying the nu- trition, it causes a morphological regeneration of the diseased tissues, or because it has in its turn a particu- lar action upon the specific infection at this period in 456 ELEMENTS OF THERAPEUTICS AND PRACTICE. the history of the microbes. Various methods of intro- ducing mercury into the system have been tried. The endermic and the dermo-pulmonary methods should be rejected, because they do not admit of graduation of the doses, which is an important point in the treat- ment. The only methods which should be accepted are those in which the medicaments are administered by the mouth or hypodermically. The first is the milder, and is generally the more acceptable to patients. It should be preferred except in cases in which the di- gestive organs will not tolerate it, or the urgency of the case demands the use of the subcutaneous method. Dosimetry makes use of three compounds of mercury — calomel, the protiodide, and the biniodide, the last two being used in almost all cases. Iodoform, either alone or combined with one of these salts, will be found very serviceable in the tertiary period. Mercurial treat- ment should be commenced as soon as one is certain that syphilitic infection has occurred, conclusive evi- dence being furnished by a chancre or the specific rose- ola. We should at once give the protiodide in doses of five granules two or three times daily. They should be taken with the meals or in milk, to prevent disturb- ance of the digestive organs, in all cases in which a prompt modification of the disease is demanded, or in which the patient, too much influenced by the primary lesions, has not the patience to await the effects of long- continued treatment. In other cases smaller doses may be given, the treatment being continued a long time ; two granules three times daily will suffice. Should the protiodide cause gastro-intestinal disturbance, it may be replaced by the biniodide in similar doses. Should the intolerance persist, two granules of the hydrochlorate of morphine or three of codeine may be given with each dose of mercury. This plan of treat- ment will generally suffice for all cases of syphilis. The difficulty is in continuing it a sufficiently long period of time. The author objects to interruptions in ELEMENTS OF DOSIMETRIC PRACTICE. 457 the treatment, believing that it is better to continue until a complete cure has been obtained, unless one is compelled to discontinue for a while to avoid the physi- ological effect of the mercury. Iodoform should be given in doses of three to ten granules three times daily in those cases of tertiary syphilis in which mercury is inappropriate. If iodoform can not be given continu- ously, it may be alternated with iodide of potassium in solution, taken in milk. The solution should contain : 5 Aquse destil 250 grammes. Potass, iod 15 " A large spoonful may be taken at suitable intervals in a swallow of milk, the quantity of the solution being gradually increased to the limit of toleration. Among the many accidents accompanying syphilis, a few may be mentioned which call for particular treatment in addition to the dominant. Syphilitic iritis is frequent- ly accompanied with photophobia and violent peri- orbital pains, which are a source of great distress to the patient. For this symptom a granule of daturine should be given every hour until relief is obtained. Even should the iritis be unaccompanied by such disa- greeable symptoms, its cure may be hastened by add- ing one or two granules of hyoscyamine to each dose of the mercurials. The osteocopic pains must be treated with iodoform and iodide of potassium, and, for the vari- ant, with three granules of the hydriodate of morphine every half -hour during their continuance. The disap- pearance of the papules and the ulcerations may be hastened by local applications of Yan Swieten's solu- tion, or of a solution of ten granules of the protiodide in a little water. Buboes should be treated during the febrile stage by defervescents. During the stage of suppuration they may be dressed with glycerole of phenic acid ; while the patient may take for internal treatment two granules of arseniate of soda and two of iodoform four times daily. The infecting chancre should be dressed with iodoformized ether, 5 : 100, es- 458 ELEMENTS OF THERAPEUTICS AND PRACTICE. pecially if it shows any irregularities of contour. If the bottom of the ulcerated surface is regular, iodoform or calomel in powder may be applied. The soft chan- cre requires scrupulous cleanliness, and, if cicatrization is delayed, tannic acid or sulphide of calcium in pow- dered form. Anaemia, which is of frequent occurrence in syphilitic patients, should be treated with quassine and the arseniate of strychnine. The same treatment would be appropriate if the chancre were phagedenic ; but this form usually occurs only in broken-down con- stitutions, in which the suffering has been of long dura- tion or the treatment has been unsuited to the case. Cerebral syphilis requires a particular form of treat- ment on account of its gravity and the rapidity with which its phenomena are developed. Hypodermic medication must be used in this form of the disease, the injections being made deeply into the cellular tissue. The following formula should be used : 9 Peptoni (Catillon) in pulv 0*30 gramme. Ammonii chlor. puri 0*30 " Hydrarg. bichlor 0*20 " Glycerinse 5*00 grammes. Aquae destil 15-00 " Each injection should contain ten milligrammes of the mercurial salt. If for any reason this method can not be used, three granules of the protiodide should be given every half- hour, the interval being gradually increased as an effect is produced, and the treatment being continued until all danger is over. All the differential characteristics of the lesions of this disease, which can distinguish them from similar lesions in other diseases, should be carefully studied by the physician. They are often very obscure, and their true character may only be discovered by their destructive action, or their resist- ance to all forms of treatment until the specific one is employed. In women the primary infection may be kept secret, or it may be that inoculation has been so ELEMENTS OF DOSIMETRIC PRACTICE. 459 slowly followed by constitutional disturbance that seri- ous disease has not been suspected. In some cases the disease is associated with disorders of the nervous sys- tem, and in others by other phenomena ; in all cases, however, the disease does not yield until the treatment which is appropriate to this disease is used. t t -f u v~ / t? i- \ Protiodide and biniodide • Infection by j Recent . . j f me (Dominant. - the coccus j . , ,. ! Biniodide hi mercnrv of syphilis ( Long standing } Rnd iodoform< I Intolerance of the digestive j Codeine, hydrochlorate organs f Photophobia . Iritis J ^ eural g ia Variant. ( 1 Myosia . [Conjunctivitis Osteocopic pains, nocturnal paroxysms, with insomnia . ( Fever . Adenitis . -| ( Suppuration . Cerebral syphilis \ Anemia 1 of morphine. Daturine. Valerianate of atropine. Hyoscyamine. Aconitine. I Hydriodate of morphine. j Aconitine, hydroferro- ( cyanate of quinine. ) Arseniate of soda. } Iodoform. Active internal treat- ment. Hypodermic injections of the ammoniacal pep- tonate of mercury. \ Quassine, arseniate of I strychnine. Tetanus, — The lesion of innervation by which the reflex excitability of the cord is increased, and which is known in pathology under the name of tetanus, is not yet sufficiently understood as to its pathogenesis to enable us to thoroughly understand its nature. The study of its various causes only enables us to arrive at the conclusion before mentioned, and upon that we shall base the dominant indication, which is to soothe and diminish the irritability of the cord, the center which receives the particular irritation transmitted by the injured nerve, and from which the impulses to the convulsions that are characteristic of tetanus proceed. If the receptive condition of the central organ could be abolished or sufficiently repressed, the reflex contrac- tions would cease, and the disease would then be re- duced to the morbid work localized in the injured pe- ripheral nerve. If we are not able to cure the disease, 460 ELEMENTS OF THERAPEUTICS AND PRACTICE. we can at least arrest its progress and eliminate the principal symptoms. In attempting to accomplish this end, we should use persistently four granules of the bromide of camphor every hour, or every half-hour if the case is very severe or very rebellious, adding there- to the medicaments which are indicated by the variant. Thus, when the pain becomes very severe, whether it be due to the contractions or be located in the injured nerve, two granules of cicutine or the hydrobromate of morphine should be added every half -hour. Violence and frequent repetition of the convulsions should be re- pressed with antispasmodics and musculo-paralyzants. Two granules of hyoscyamine, croton chloral, and vera- trine should be given every hour until the desired effect is obtained. Yeratrine will also modify the excess of heat, and hyoscyamine will overcome the constipation. For the hyperthermia we should give one granule of aconitine every hour as long as the temperature is not above 39° C, and every half-hour when it exceeds that point. Congestion should be treated by the same means ; when it is due to fatigue or ataxia of the heart, a granule of digitaline should be added every hour until the pulse becomes regular. Paralysis, the most frequent forms of which are those which affect the bladder and rectum, should be treated with one granule of the arseniate of strychnine and one of phosphoric acid every two hours. For constipation, which is some- times very obstinate, live granules of podophyllin should be given with a teaspoonful of Sedlitz Chan- teaud three or four times at intervals of half an hour. In some cases the paroxysms are more or less periodic in character, indicating three granules of the hydrobro- mate of quinine every hour. If the condition of the patient is such that the regular administration of the medicaments is not possible, we must seek to soothe him by such means as will permit the application of the treatment. The prolonged use of electricity and the employment of enemata of hydrate of chloral may ELEMENTS OF DOSIMETRIC PRACTICE. 461 be of service in inducing a remission, advantage of which must be at once taken by beginning a systematic attack upon this terrible disease. j Exaggeration of nerve I irritability ^ / En Eh Dominant. ^Variant. { Pain Convulsions . Hyperthermia Congestion . Paralysis Constipation Intermittence of the ) Bromide of camphor. j Hydrobromate of morphine. ( Cicutine. Hyoscyamine, croton chloral. ) Aconitine, veratrine, digita- \ line. Arseniate of strychnine, phos- phoric acid. Sedlitz Chanteaud. podophyllum Hydrobromate of quinine. * paroxysms Tuberculosis. — See Tuberculous Disease (under Disease). Ulcer, Gastric. — Ulcer of the stomach may be due to different causes, all of which are reducible to atony of the organ or to a want of nutritive force. At the beginning, such ulcerations present nothing peculiar ; subsequently they become round and perforating, this peculiarity being given to them, according to many pathologists, by the action of the gastric juice, which corrodes the submucous tissues by means of its digest- ive properties. The dominant will consist, therefore, in augmenting the vitality of the mucous membrane, on the one hand, by means of the excito-motors, one or two granules of strychnine or two or three of brucine being given three times daily ; and in neutralizing, on the other hand, the digesting action of the gastric juice. Unfortunately, it is not easy to satisfy this sec- ond indication. Physiology has not yet discovered any substance which can prevent the action of the gas- tric fluid, and we know that it covers the mucous mem- brane to a greater or less degree, even if there is no food in the stomach to excite its secretion, as after a prolonged fast. The alkalies produce slight results, and only when taken in large doses do they modify the composition of the gastric juice. This is an ob- stacle to their use, for patients who suffer from this disease are usually in a state of profound anaemia, 462 ELEMENTS OF THERAPEUTICS AND PRACTICE. which is a contra-indication to the extensive use of alkalies. We are therefore restricted to a limited diet — for example, a diet of milk — food being taken by the mouth only at long intervals. Such a plan of alimentation may be supplemented by means of rectal enemata of peptone if they can be tolerated. The re- strictive action of atropine upon the secretions may be used to diminish the secretion of gastric juice, this agent responding also to other important indications of the variant. For example, it will relieve epigastralgia, the pathogenesis of which is uncertain, but which seems to be due principally to the irritant action of food upon nerves which have been laid bare in the course of the ulcerative process, and to their lengthen- ing and compression in consequence of the peristaltic movements of the stomach. Three granules of the hy- drochlorate of morphine every quarter-hour, associated or alternated with one of the sulphate of atropine every half -hour, will usually relieve the severity of the pains. These anodynes should be frequently changed in order to retain their usefulness. It is important that the pa- tient be relieved, because the frequency, the duration, and the intensity of the gastralgia are causes which concur in inducing cachexia. In some cases the ab- sence of pain implies absence of vomiting as well, and in these the food which is taken does not produce an excessive degree of distress. As alternates to mor- phine, one may give three granules of cocaine, three of codeine, or two of cicutine every half -hour until relief is obtained. Vomiting may also be treated by the means which have just been referred to. Gastrorrhagia or hsematemesis may be treated with five granules of ergotine dissolved in a little cold water every quarter- hour, or hypodermically with a ten-per-cent. watery so- lution of the same agent. Melsena of a temporary char- acter is evidence of gastrorrhagia which has already been brought under control, and therefore does not require the use of haemostatics ; but, if it should be repeated, ELEMENTS OF DOSIMETRIC PRACTICE. 463 ergotine must be given for several days, for we are ignorant of the precise cause for the extravasation of blood, and, besides, such losses are of serious impor- tance to the patient in his debilitated condition. Five granules of ergotine should be given, therefore, at in- tervals of three hours. The anaemia, which is almost always present when the disease is far enough advanced to be diagnosticated, on account of the changes in the digestive apparatus, should be treated with the lactate, the arseniate, or the perchloride of iron. Quassine may be indicated if it is necessary to stimulate the appetite, or to gently incite the stomach to contractility. Consti- pation, which adds to the discomfort of the patient, and may also induce attacks of gastralgia, should be treated with three to five granules of podophyllin every evening, or ten of euonymine once or twice daily. Hygienic precautions must also be enforced for a Ions: time. ^^--Iv^x f ato„ y ga : tric 2 j / Epigastralgia ta \ f Vomiting of food juice . Alkalies. . Strychnine. Hasmatemesis Variant. ( Anaemia Melaena Digestive disorders Morphine, hyoscyamine. Morphine, atropine. Ergotine, ice. Salts of iron. Ergotine. Quassine. Podophyllin. ^ \ Constipation Urethritis and Vaginitis. — Urethritis may be simple or virulent. Simple urethritis is established in the same way as any other inflammation of mucous membrane, with this difference, that it lasts longer on account of the repeated aggravation which is due to the passage of the urine. It may be treated at the begin- ning like any other catarrhal inflammation, with aconi- tine in doses which should be governed by the violence of the inflammatory process and the febrile state. The character of the urine must be changed in order that it may offer the slightest possible hindrance to the cure of the disease. To accomplish this end three granules of benzoate of soda or of benzoic acid should be taken after each micturition, and alkaline waters should be 464: ELEMENTS OF THERAPEUTICS AND PRACTICE. used for ordinary drinking purposes. The use of ex- ternal emollients must not be neglected in the first or acute stage of the disease. Painful erections should be treated with the bromide of camphor every half-hour, and spasm at the neck of the bladder with one granule of hyoscyamine every two hours, or oftener if there is true dysuria. After the first period, if the blennorrhagia continues, three granules of cubebine should be given after each micturition, and in chronic cases two gran- ules of piperine four times daily. Arbutine and helenine are also useful means for relieving the blennorrhagic discharge. Either of them should be given in doses of three to 1\nq granules three to five times daily. With persons of lymphatic diathesis urethritis may easily become chronic and rebellious to all direct treatment. In order to obtain a result promptly in such cases the general nutrition must be modified by means of an ana- leptic diet and the prolonged use of two granules each of arseniate of iron and iodoform, three times daily. Virulent urethritis is due to contact with a parasite which bears the name of gonococcus. It should be at- tacked locally with injections of permanganate of pot- ash (one half gramme to one gramme in one hundred grammes of water), or with three granules of sulphide of calcium (repeated with sufficient frequency), tritu- rated in the fluid portion of each injection. Chronic gonorrhoea should be treated locally with injections of lactate of quinine (1 : 100), or with tannic acid in solu- tion, three granules being dissolved for each injection. Subacute or chronic vaginitis should be treated with the same means, the local treatment being slightly varied. Tampons of charpie or of cotton- wool should be introduced into the vagina, soaked with one of the following solutions, viz.: 5 Chloral hydrate 1 gramme. Aquae destil 100 grammes. 5- Resorcin 1 gramme. Aquae destil 100 grammes. ELEMENTS OF DOSIMETRIC PRACTICE. 465 Ijfc Tannin 6 grammes. Glycerinae 100 grammes. The doses of these agents must be gradually increased until the disease is brought under control, and then as gradually diminished to prevent recurrence. BLENNORRHAGIA FROM URETHRITIS OR VAGINITIS. Simple Acute Subacute or Chronic Dominant Variant Fever . Erections Irritating Dominant f Spasmodic dysuria Variant J D y suria from clos " vanant < mg of the canal . [_ Lymphatic diathesis Virulent. Aconitine. Aconitine. Bromide of camphor. Benzoates and alkalies. Cubebine, piperine, arbutine, helenine. Hyoscyamine. Elastic sounds. Arseniate of iron, iodoform. f Dominant Acute I Variant Subacute ( Dominant or -j Chronic ( Variant . C Injections of permanganate of J potash. * 1 Injections of sulphide of cal- [_ cium. { The same variant as in simple ' ( acute blennorrhagia. j Injections of lactate of quinine. ' ( Injections of tannic acid. j The same as the variant in sim- * ( pie chronic blennorrhagia. Uterus, Cancer of the.— When degeneration of the tissue of the neck or the body of the uterus is established, not much can be done in the way of restor- ing them to their normal condition. While we under- stand that a cure is possible, we are ignorant of the means by which it may be obtained. We should there- fore concentrate our attention in order to find a suitable plan of preventive treatment for women who are pre- disposed, whether by hereditary influence or by a me- tritis of long duration, to this disease. Means which favor assimilation, which make the blood more plastic, and the functions of the nervous system more perfect in their action, should be perseveringly employed to accomplish this end with any and all in whom a tend- ency to this disease is suspected. Arseniate of soda, arseniate of strychnine, iodoform, and ergotine are the 30 4:66 ELEMENTS OF THERAPEUTICS AND PRACTICE. agents which must be introduced into the body in order to modify the diseased tissues, and the vitality which gives them their abnormal existence. Hydrastine has seemed to be effective in delaying the progress of de- generation in some cases, when given for long periods of time. It may be used in doses of four granules, three times daily, combined with or alternated with iodoform and arseniate of soda. The haemorrhages must be controlled by using three granules of ergotine every quarter-hour, or by applications of dilute per- chloride of iron. The pain, which is sometimes intol- erable, may be modified by using two granules of cicu- tine hourly, or two of gelsemine every half-hour, or two of hydrochlorate of morphine every quarter-hour. It is well to change the narcotic from time to time, in order to avoid multiplying the doses. For the anorexia two or three granules of quassine or piperine should be given before meals. The fetid character of the discharges may be overcome by injections of permanganate of pot- ash (20 : 500). For the diarrhoea three granules of bru- cine and three of the hydrochlorate of morphine should be given every two or three hours. Similar doses of tannic acid may be substituted for the alkaloids, if they are required at very short intervals. In the first period of the disease some results may be expected from this treatment, but after it has reached a certain stage of development we must be contented with simply a pal- liative treatment. fe^ ' Cancerous degeneration Hydrastine. 62 c -1 / ' Dominant. ■ Dyscrasic state of secretions . the [• Iodoform, arseniate of soda. Hypertrophy Ergotine. O^ I Haemorrhage Ergotine. 5 25 Pain Gelsemine, cicutine. EH i Variant. / Anorexia Quassine. 1 Fetid discharges . Disinfectant injections. , Diarrhoea \ Brucine, morphine, tannic } acid. Vaginitis. — See Urethritis. Variola. — " Everything has been said in respect to variola, and yet everything still remains to be said. In ELEMENTS OF DOSIMETRIC PRACTICE. 467 fact, with regard to its etiology, our ignorance is com- plete. Are bacteria or mbriones its cause or its effect ? That is the question." With the foregoing words Burg- graeve begins some observations upon an article on variola, written by Hahn, of Marseilles. The great pathogenic and therapeutic question of the day con- cerns variola. Few are the diseases for which we pos- sess certain and effective remedies ; some of them are treated by us with agents, the action of which is un- known to us ; in others the treatment is a rational one, and is founded upon clear and well-defined pathogenic indications. If, therefore, we subtract those diseases in which the treatment is of a specific character, the diseases which remain can be treated in only two ways — that is, by having regard either to their etiological or their symptomatic indications. Dosimetry fre- quently makes use of symptomatic therapeutics in the absence of the pathogenic variety, but its aim is always to seek to replace the first by the second, which follows a surer and a clearer way. The treatment of variola up to the present time has been symptomatic rather than really pathogenic, because the pathogenesis is still deficient as to the clearness which is necessary to fur- nish unquestionable indications. It is not designed in this place to presume to solve the doubts of the pa- thologists in regard to the nature of variola, nor to justify the opinion of Hallier or Lebert by individual microscopical investigations, and give an opinion as to the vegetable or animal nature of the microbes to which the origin of the contagion is attributed. If, however, we compare the results obtained from the culture and inoculation of microbes with the phenomena which occur in variolous patients, we are compelled to admit the analogy which exists between these two classes of facts, and, supporting ourselves upon the principles of experimental philosophy, so admirably demonstrated by the immortal Claude Bernard, to admit, in addition, the parasitic nature of the primordial cause of the dis- 468 ELEMENTS OF THERAPEUTICS AND PRACTICE. ease, for winch we shall seek to establish in this chap- ter a rational plan of treatment. The pathogenic indi- cation rests, therefore, in the choice of an agent which is able either to destroy the micrococcus of the disease, or to furnish to or remove from the organism a sub- stance which will render it unsuitable for the culture of bacteria or the germination of inoculated spores. Besides, as the evidence of contagion is manifest only after the development of the first germs, it is necessary to find an agent which is sufficiently diffusible to pene- trate all the elements of the body, and attack each in- dividual microbe. The compounds of sulphur, which have a well-known antizymotic power and are very diffusible, are certainly the most appropriate agents for combating the invasion of the bacteria of variola. The results obtained by Fontaine in the treatment of diphtheria, and by Henrique Gabaldon in the treatment of aphthous stomatitis, have suggested the idea of using sulphide of calcium as the dominant in variola. The great power of this agent as a bactericide can not be denied, and it was introduced, or, at any rate, popular- ized, by the adherents of dosimetry. The results which the author has obtained have been so satisfactory that he thinks he is justified in using them as an argument in favor of the parasitic nature of the efficient cause of this disease. Naturam morborum ostendit curatio (Treatment reveals the nature of diseases). Up to the present time, alike in the most severe and the most benign cases, the physician is compelled to admit the impotence of his means of treatment. The belief in fatalism has not yet disappeared from the field of medi- cal science. It is still believed that it is impossible to diminish by a single day the prearranged duration of diseases. Patients with variola are told that they must traverse a certain number of periods of so many days each, and therapeutics thus seems to sustain the popu- lar proverb which affirms that there is scarcely a day's difference between the duration of a disease which is ELEMENTS OF DOSIMETRIC PRACTICE. 469 treated and one which is left to itself. And one mnst not say that we can at least act npon the complications of diseases, and bring them to a happy end, even if we can not intervene in respect to duration. There is no proof of this, and such a capability by the side of the incapability referred to would be a plain absurdity. He who can guide a runaway horse ought also to be able to check and stop him. The author disagrees en- tirely with this profession of medical nihilism, which -first gives birth to and then sustains an irrational and routine system of therapeutics. Now that science has other means, and is making other discoveries, we are especially happy in announcing the good news. Our colleagues are supplicated to abandon the unhappy skepticism to which they have hitherto been con- demned, and our patients are assured that therapeutics has ceased to be a myth ; for them, also, the days of fatalism have disappeared. The following remarks will have particular reference to the treatment of variola. The empirical and exciting remedies gave way to those which, it is true, were inoffensive, but they were also useless. Preparations of quinquina, opium, and alco- hol were replaced by infusions of violets, of linden, and of saffron. It is difficult to say why the latter should be preferred to the former. Both varieties, used with- out confidence and without reason, have no other object but to amuse the imagination of the patient and calm the impatience of his family, and respond neither to any scientific indication nor to the obligations of con- science on the part of the physician. And thus one goes from one experiment to another, from a fruitless attempt to a discouraging disillusion, and then to skepticism, all of which is not only a crime for the present of the medical profession, but is also a peril for its future. Faith, like incredulity, is contagious, and, when this incredulity penetrates the public mind, it takes the name of science, which is able to struggle against charlatanism only when there remains to it, in 470 ELEMENTS OF THERAPEUTICS AND PRACTICE. default of charity, a little faith and a glimmering of hope. The certainty of success, which the author be- lieves is possible by interfering in the course of variola with certain medicaments until the disease is aborted, makes it a duty with him to insist minutely upon the way in which the dominant should be applied. In order that a plan of treatment may be perfect, it must fulfill two conditions, viz., it must be rational and it must be effective. Common sense will decide as to the first, and the facts in the case will demonstrate the second. To decide whether a therapeutic application is rational, it is necessary to know, first, the nature of the disease ; second, the natural properties or the physiological ef- fects of the remedy which is being used. We ought therefore to have clearly in mind the essential cause of variola, and the effects produced upon it and upon the organism by the sulphide of calcium, a substance to which the preference which it deserves is now accord- ed, after various experiments of a comparative nature. Variola is a disease which is caused by very minute organisms or their germs, which are free in the atmos- phere, and circulate around man in great numbers. Man is exposed to infection from them, as they are in contact with his epidermis, by absorbing them with his food or with the air which he respires. Whether these organisms traverse the intact integument or take ad- vantage of a solution of continuity to penetrate the tissues, it is certain that in order to multiply they must have particular conditions of temperature and chemical combination, in default of which they die. The union of these conditions which are essential to the life and propagation of the parasites of variola is termed recep- tivity. Just as certain seeds will germinate only in the presence of certain meteorological conditions and in certain soils, so organic receptivity is necessary in order that the introduction of morbific germs be fol- lowed by disease. This explanation furnishes the key to the contagious and infectious properties of disease, ELEMENTS OF DOSIMETRIC PRACTICE. 471 and also shows us why everybody is not attacked by the disease, why vaccine is useful, and why the disease seldom attacks the same person twice. Vaccine and variola, by changing the fluids of the body more or less fundamentally, render it less susceptible to a second attack, the first parasites having absorbed certain ele- ments which furnish their natural alimentation. This is the reason why certain plants can not be cultivated successfully several years in succession in the same soil, the first cultures having absorbed all or nearly all the existing material which is essential to their germi- nation and development. The germ having been in- troduced into an organism in which it finds a medium suitable for its existence, quickly multiplies with the exuberance which is peculiar to all these minute beings, which seem to seek in their marvelous facility in repro- duction a compensation proportional to the smallness of their size. It is during this period of incubation that it would be easy to eliminate the disease, if we had the means for destroying all the ovules. But as the organism does not complain, and gives no indica- tion of what is going on in the depths of its tissues, and, moreover, as it seems to be easier to poison a parasite than to deprive its eggs of the power of repro- duction by the use of suitable agents, it would appear to be neither practical nor logical to advise a preserva- tive means of treatment. When the period of incuba- tion is ended, the morbid scene really begins. The parasites, millions of which are at work in the interior of the organism, naturally excite an active irritation in the cells, which irritation is manifested by fever, pains in the head, and other symptoms less constant in their manifestation. This is the period of invasion. These microscopic organisms or microphytes, eager for air and light, accumulate near the surface of the body, thus determining certain changes which mark the be- ginning of another period, called the period of erup- tion. Divided into groups and fixed in the skin or the 472 ELEMENTS OF THERAPEUTICS AND PRACTICE. mucous membrane, they remain there for some time, exciting a suppurative inflammation which constitutes pustulation ; this is only an effort on the part of the organism to eliminate the living or dead bodies of the parasites, and restore the tissues in which they have developed to their primitive condition of integrity and health. With regard to the sulphide of calcium, it participates in the antiparasitic properties of all the derivatives of sulphur, which are decomposed either provisionally or finally, and liberate hydrogen sul- phide. The sulphide of calcium is constantly liberat- ing hydrogen sulphide, and the promptness and cer- tainty with which its ingestion is followed by eructa- tions and the characteristic odor of the gas are sufficient proof that the decomposition in question is going on. Sulphide of hydrogen instantly destroys the lower forms of animal life, and if it were inhaled in sufficient vol- ume it would also destroy the higher forms of animal life as well. Its application in the treatment of variola may therefore be understood, and if we add that this gas, on account of its diffusibility, can penetrate every tissue and cell of the body, and in particular can pene- trate the surface and be eliminated with the virus of the disease, better than any other product of sulphur, we shall have given the reasons in brief for giving this agent the preference. The indication, furnished by a knowledge of the nature of variola, being to kill all the parasites as soon as they begin to multiply, that is, as soon as the fever appears, and the sulphide of calcium being an agent which can destroy them, it would ap- pear that the conclusion might be drawn that the appli- cation of this medicament to this disease is a rational procedure. Is this treatment efficacious % Do the facts show that sulphide of calcium in small doses will miti- gate the disease, and in large doses will destroy it? Do they show that if it is not given before the germs multiply it has little influence upon the disease, and that if it is interfered with too soon it (the disease) will ELEMENTS OF DOSIMETRIC PRACTICE. 473 reappear % Experience, repeated in different places and on different occasions, enables the author to answer these questions in the affirmative. After what has been said in regard to the nature of the determining cause of variola and the properties of sulphide of calcium, certain rules will follow to which the treatment must be conformed in order to be really efficacious. These rules, which might appear to be of secondary impor- tance, are on the contrary quite essential, and, with- out careful observance of them, the results would not only be doubtful, but they might not be produced at all. 1. The treatment must he begun wlien the nature of the disease is suspected. During an epidemic, chills followed by fever, and acute pain in the head, though there may be no symptom indicating a localization of the disease, will furnish sufficient motive for institut- ing treatment, and, if this is begun in time, the febrile symptoms of the invasion will almost always be dissi- pated, and the eruption be prevented. If it is remem- bered that the parasites announce their multiplication by the symptoms mentioned, and that the more numer- ous they are the sooner they will work their way to the skin, it will be evident that the opportunity of destroy- ing them at the beginning should not be lost, and that our action should be the more energetic as the period for the eruption approaches. To allow the disease to be established is to lose the best, not to say the only, means for overcoming it easily. 2. The treatment should be so conducted as to sat- urate the organism with the parasiticide. It is evi- dent that the microbes which produce the disease are distributed in all the tissues and involve all the or- gans, and, consequently, that it is necessary to give the sulphide in sufficient quantity to impregnate the entire organism. 3. The organism must continue in this condi- tion of saturation until it is certain that the de- sired effect has been obtained. If this were not done 474 ELEMENTS OF THERAPEUTICS AND PRACTICE. the microbes which remained would profit by the armistice which was extended to them, and continue their disastrous invasion, which our imprudence would have made successful, and which would neutralize all the preceding efforts. Besides, as the sulphide of cal- cium, or the hydrogen sulphide which it liberates, is rapidly eliminated by the skin or by the lungs, if we cease the administration of the remedy, the organism will in a minute be completely at the mercy of the enemies which are attacking it. 4. Even after the eruption has commenced it can be made td retrograde as long as there is no effusion of liquid in the swellings. The result in such cases can not be accurately predicted, at least with regard to the complete disappearance of the eruption. Rigorous treatment may be very useful, however, possibly by transforming a confluent into a discrete eruption, and attenuating the disease so that it may be reduced even to a varicella of greater or less severity. The general symptoms promptly disappear, the secondary fever is avoided, and the patient is enabled to bear his disease with as little discomfort as he would a simple eruption. Contrary to that which happens in cases of variola which are untreated, or are treated by the ordinary means, the disease gets better every day, and on the eighth day of the eruption, instead of seeing the pa- tients in a disgusting condition, we find them happy and satisfied, and hopeful of soon leaving the bed which has not been for them a bed of torture. 5. After pustulation the use of sulphide of calcium will still enable us to ward off complications, to de- stroy the offensive odor, to reduce the fever, and to attenuate the severity of the disease by hastening the process of desiccation ; but its influence upon the dura- tion of the disease is not so decided as it is in those cases in which it is taken earlier. 6. Sulphide of calcium being a substance icliicli has a disagreeable odor, and being required in small ELEMENTS OF DOSIMETRIC PRACTICE. ±75 doses frequently repeated, no preparation of it seems to be more suitable than the dosimetric granules. The granules contain one centigramme each of the sub- stance ; patients can take them without trouble, and their great solubility enables one to take them at very short intervals. 7. The character of the treatment must be regu- lated by the effect which it is designed to accomplish. If the patient is still passing through the period of invasion, no eruption having appeared, or the erup- tion being still slight, no time must be lost, and the patient must at once receive one or two granules of the remedy, the dose being repeated every quarter-hour . If the patches of eruption have already appeared, we will be compelled either to seek to retard the disease or to limit ourselves to its attenuation. In the first case we should still give the sulphide of calcium every quarter- hour, re-enforcing its action if necessary by means of salicylic acid. In the second case we should give the granules every half-hour or hour, according to the diffusion of the eruption and the degree of attenuation which is desired. It will be observed that no indica- tion has been given as to the limit of the dosage — one or two granules should be given each time ; and this plan should be continued until the desired effect has been obtained. It must be understood, however, that the maximum of saturation is indicated by the vomit- ing of biliary matter, preceded by a feeling of oppres- sion in the stomach. When these symptoms are present it is not necessary to stop the treatment altogether, for this would be equivalent to rendering all the advantage previously gained of no avail ; instead of this, the granules should be given at intervals of half an hour, which will generally suffice to remove all the symptoms of intolerance. After a few hours the doses can again be given at intervals of a quarter of an hour, the object being to keep the organism in a condition of saturation with the drug, without which complete success will 476 ELEMENTS OF THERAPEUTICS AND PRACTICE. always be a matter of doubt. An evidence of the ac- tion of the drug which is frequently seen is profuse perspiration, especially at night. The patient may take soup, milk, or water while he is undergoing medi- cation with the sulphide of calcium, without any dis- advantage ; the only danger is that which will come from an interruption of the treatment. Should the fever reach 39 -15° C. to 40° C, and perspiration be de- layed, a granule of aconitine should be given with the calcium every half-hour, and this, by moderating the fever, will facilitate diaphoresis, and soothe the patient. After the disappearance of the fever and the other symptoms, and when we are sure that the organism has come out of the struggle victoriously, we must give Sedlitz Chanteaud to relieve the intestines of the resi- due of the septic material which has resulted from the fever, and to eliminate from the system the mater ies peccans, in the shape of the remains of the infecting parasites, by which means the patient will be delivered from many dangers and spared many sufferings. Chil- dren should be treated in the same general way as adults, that is, the remedy must be continued until the result ' is obtained. Usually the evidences of saturation will be apparent with them much sooner than with adults, but we must not be frightened by that. The author has given sixty to one hundred and forty granules of the sulphide daily, in doses of one or two granules, without cause for regret, and without particular in- convenience to the patients. An erroneous idea, sustained by tradition but not by facts, may give rise to the fear that this treatment would, sooner or later, prove harmful to those who use it. Usually it is such opinions, which have no substantial foun- dation, which escape logical discussion and the con- trol of facts. As the marine algce, suspended in the water, yield readily to the impulse of the waves and the force of the currents, but never abandon their first position, so is it preconceived ideas and errors which ELEMENTS OF DOSIMETRIC PRACTICE. 477 do not defend themselves before reason and experience, and still are none the less active and respected as authorities of great value. The spirit of modern times repudiates a bare hypothesis, and considers only ob- servation and reason. Observation and reason are on our side, and enough has been said to remove all doubt in this respect. Nevertheless, let us seek to remove all scruples, and to those who object that a variola, the development of which is prevented, may be a source of injury, it may be said in reply : (1) That in the period of invasion, since no variola has been formed, no variola can have entered the organism. (2) That in the period of eruption, since there are not yet any prod- ucts of exudation in the skin, but only a collection of small localized hypersemias, the striking back of the vesicles is neither to be feared nor even possible, for the vesicles do not yet exist. The danger is not greater than in a case of spontaneous cure of an urticaria. (3) That in the periods of vesiculation and pustulation, the resorption of the contents of the pustules is a matter of great danger ; but that just in these periods we are unable to repress the disease. If this point is reached the disease must run its course ; and, if our action at this time is of no value, it is also not harmful. (4) That the disappearance of the maculse, the vesicles, or the pustules being a gradual process, and provoked by internal treatment followed by profuse sweating, does not at all resemble that which occurs when the vesicles appear suddenly and in obedience to external influences. (5) That the demonstration of facts in a matter of this kind being the most trustworthy evidence, those who are skeptical as to the value of this treatment are invited by the author to visit with him his patients who have been enabled to avoid the exudative period of the disease. For all the foregoing reasons the sulphide of calcium in sufficient doses is recommended as the dominant of the treatment from the beginning to the end of the disease, and it is advised in addition that 478 ELEMENTS OF THERAPEUTICS AND PRACTICE. it be also given as a preventive during an epidemic. While it could not be guaranteed that it will prove an effective means of prevention, it may be said that no inconvenience can attend the use of six to twelve gran- ules daily, and it must be influential in preventing the development of the microbes of this disease. It does not always suffice to control the disease rapidly and efficiently in all its periods. The different character- istics which the disease shows in different epidemics, owing to the particular conditions appertaining to the morbific agent, the condition of medium and of indi- vidual, as well as the natural phases in the evolution of the disease, should enable us to decide upon the proper agents for the variant of the treatment. Should the malignant character of the epidemic or the excessive development of the bacteria be such that the sulphide of calcium is insufficient, it should be combined with salicylic acid or the salicylates, which have bactericidal properties which are unquestionable. The different phases of the disease, which must not be confused with the periods which have been established by the pathol- ogists, also have particular indications. In the phase of invasion, when there is scarcely any fever or any congestive phenomena, one granule each of the defer- vescents — aconitine, veratrine, and digitaline — should be given every hour to facilitate the appearance of the eruption and to soothe the pain, which is so trouble- some at this time. The vomiting which sometimes oc- curs during the first days of the fever may interfere with the treatment. In such a case we should give one granule of strychnine and one of hyoscyamine every half-hour, which will render defervescent treatment possible by soothing the irritability of the stomach. Troubles in the nervous system, pain, delirium, con- vulsions, and dyspnoea will also yield to defervescent agents. Pain in the back may be relieved by one gran- ule of tannate of cannabine every half-hour. When the eruption begins to appear the defervescent treat- ELEMENTS OF DOSIMETRIC PRACTICE. 479 menfc must be suspended, the sulphide of calcium and the salicylate of quinine being continued, in order to profit by the remission of fever which accompanies this period. In those cases of variola which are treated dosimetrically from the beginning, one never sees symp- toms of a particularly grave character at this period. On the other hand, both cerebral and thoracic troubles may appear at this time if patients have been treated by the expectant method, and, as in all cases in which there is visceral congestion, we should treat these troubles with strychnine and aconitine. The phase of suppuration is certainly the one which is the most perilous for the patient. Would not this be a condi- tion in which Paquet's method of overcoming acute suppuration could be applied ? Would it not be proper to administer the arseniate of quinine and iodoform from the beginning of the suppurative process ? It is for clinical experience to answer these questions. As yet the facts are too few to give an absolute reply. The sulphide of calcium must not be suspended, but may be given in smaller doses combined with the sa- licylate of quinine or of iron, strychnine being added to combat the adynamia which frequently occurs, and with serious result, at the time when the eruption ap- pears. If the fever is very high it may be moderated with aconitine and the arseniate of quinine, but without any attempt to remove it altogether. With regard to absorption, it is better to prevent any occasion for it. Asphyxia of the skin, which results from the conflu- ence of the pustules, is, of course, irremediable. Dur- ing the period of desiccation the digestive functions should be made as active as possible by means of strychnine and quassine, convalescence being thus en- couraged. Other agents may also be used for the vari- ant in addition to those which are here mentioned ; these are only the principal ones. It will rarely be necessary to formulate a complex treatment. Grave and abnormal cases will become less and less frequent, 480 ELEMENTS OF THERAPEUTICS AND PRACTICE. for therapeutic intervention is always most efficacious at the beginning of diseases, not only because the con- ditions which then obtain will then yield most readily, but also because many complications can then, be pre- vented, and in that way the gravity of the later phases of the disease can be prevented. Before the days of dosimetry the physician, like the hunter, was forced to wait patiently until the game passed his door and en- abled him to see it ; then the precipitation of the favor- able moment, the consciousness of danger, and the force of the resistance which was offered, were likely to affect the certainty of his aim, and sometimes made him the victim. Nowadays success is more sure, for, in addi- tion to new weapons of precision, we have the means of attacking the beast in his lair and killing him while he is asleep, all the doors of escape having been closed. In most cases it will be sufficient to use the sulphide of calcium with the defervescents during the invasion, and the sulphide of calcium with strychnine or quinine dur- ing the eruption. The duration of the disease, in spite of the pathologists who obstinately consider it as fixed with mathematical certainty, as if there were no such thing as therapeutics, will be much abridged by follow- ing this plan of treatment. The patient will suffer less, and the family and the physician will be delivered from the fears to which they have heretofore been subjected by a disease in which, according to Jaccoud, death is the rule and recovery the exception. Only the absolute want of efficient means can excuse the physicians of the regular school for their treatment of this disease by the expectant method. In order to have a just opinion of its gravity, we have only to find out whether it is con- fluent or discrete, and let this be the measure of its mortality. But, though we may admit that we have nothing to fear as to the result in a given case, is there no duty that we should seek to arrest its course % Has the physician no duty to perform in seeking to restore his patient to his family and society and the activities ELEMENTS OF DOSIMETRIC PEACTIOE. 481 of life as soon as possible ? There can no longer be any excuse as to the want of means for treating this disease, for dosimetry offers as good as can be desired. Con- venient and agreeable, sure and effective, pure and well prepared, what further qualities can be desired? Do they say that these agents are alkaloids — poisons? That is true for some of them but not for others, and, besides, if they are used in accordance with the rules formulated by Burggraeve, they will always prove to be remedies and never poisons. It is not sufficient to merely administer the granules, one must know how to administer them — in other words, one must be a do- simetrist. If the allopaths wish their patients to enjoy the benefits of this therapeutic reform they must aban- don the uncertain, obscure, irrational, and superstitious methods which they have followed in the past, and de- vote themselves to the study and the practice of dosim- etry. When more than two thousand physicians ex- press their satisfaction with dosimetry, it is a duty to try it, for how many methods of treatment in allopathy are there with which two thousand physicians will ex- press satisfaction ? It is necessary, therefore, to give it a trial, but to try it in a proper manner — that is, as the results of experience obtained from physiological in- vestigation should be applied — not as one is in the habit of making therapeutic experiments ; in other w r ords, it should be tried in accordance with the rules which were taught and faithfully practiced by the immortal Claude Bernard. Dominant. Variant. Parasitic infection ( Fever Vomiting . Delirium . Convulsions Dyspnoea . Rhachialgia Visceral congestion Suppuration Adynamia ^ Gastric atony . j Sulphide of calcium. \ Salicylic acid, salicylates. Aconitine, digitaline, veratrine. ( Sulphate of strychnine, hyoscya- \ mine. y Defervescents. Tannate of cannabine. Aconitine, sulphate of strychnine. Iodoform, arseniate of quinine. Arseniate of strychnine, generous wine. Quassine, pepsin. 31 482 ELEMENTS OF THERAPEUTICS AND PRACTICE. Vesania. — See Mental Alienation. Vulvitis, — Inflammation of the mncons membrane included between the labia major a and minora may- be simple or scrofulous in character ; phlegmonous, in which case it terminates by suppuration ; or gangren- ous, if a portion of the mucous membrane becomes mortified, which is usually seen only after parturition. Syphilis and blennorrhagia may also produce vulvitis, the local lesions being received upon the vulva, or being the result of extension from another portion of the genital tract. Their specific treatment has been re- ferred to in connection with other subjects. Simple vulvitis, which is usually caused by repeated irrita- tions, or by traumatisms of one kind or another, has for its dominant aconitine ; one granule should be given every two hours. The local pain may be relieved by the use of simple emollient topical applications, such as glycerin or vaseline, or sedatives, such as hydro- chlorate of morphine, in a two-per-cent ointment or solution. Phlegmonous vulvitis must be treated by surgical means, by disinfectant applications (e. g., cam- phorated vaseline), and internally by two granules of iodoform and two of arseniate of quinine every three hours. The same treatment is equally applicable to furuncular vulvitis. Should the inflammation termi- nate in gangrene, irrigations of camphorated alcohol should be made, and applications of iodoform in pow- der during the intervals. Internally two granules of salicylate of ammonia should be given every hour to counteract septicaemia. The action of the latter may be aided by the other salicylates, especially the salicy- late of quinine, three granules being given at each dose. Scrofulous vulvitis should be treated with such topical absorbents and astringents as subnitrate of bismuth, oxide of zinc, and glycerole of tannin, and the internal use of arseniate of soda and iodoform. Should the pruritus be intolerable, two granules of hydrobromate of cicutine may be given every hour. Should hyper- ELEMENTS OF DOSIMETRIC PRACTICE. 483 secretion from the mucous membrane persist after the other principal symptoms have been relieved, powdered tannic acid may be used locally, and also internally in two-granule doses four times daily. Adenitis, which often accompanies simple vulvitis, and is a simple glandular inflammation which has been excited by transmission through the lymphatic circulation, should be treated with one granule of aconitine and one of iodoform every two hours. f Simple vulvitis . . Aconitine. ai / r» , J Phlegmonous vulvitis . Iodoform, arseniate of quinine. hh Uominant. i Gan g renous vulvitis . Salicylates. jrj J [ Scrofulous vulvitis . Iodoform, arseniate of soda. 2 \ [ Pruritus . . . Hydrobromate of cicutine. ^ v tt J Hypersecretion of mu- j Tannic acid, topical use of > \ VARIANT - 1 cus . ( astringents. [Adenitis . . . Aconitine, iodoform. Whooping-cough. — Whooping-cough is one of the numerous diseases which demonstrate the fluctuations of scientific opinions and the uncertainty of therapeu- tic means. For some, whooping-cough means simply an inflammation of the interglottic ventricle ; for others, it means a spasm of the glottis, which may be simple or complicated with laryngitis. The latter attribute it to a hypertrophy of the tracheo-bronchial glands ; the former to the influence of a particular parasite. The latter is the opinion which should be accepted, because it is the only one which explains the principal acci- dents of the disease. Burggraeve states that whoop- ing-cough should be classified with diphtheria, and attributes it to the presence of a penicillium in the respiratory passages. Letzerich has been able to dis- cover and cultivate a micrococcus which appears to be the true cause of the disease. The contagious charac- ter of the disease, its symptomatology, which is so different from that which is observed in connection with other lesions of the respiratory apparatus, the regular succession of its periods of incubation, devel- opment, and disappearance, and the efficacy of anti- parasitic means of treatment, fully confirm the parasitic 484 ELEMENTS OF THERAPEUTICS AND PRACTICE. theory of the disease, and enable one to reject all others. The dominant of the treatment will, therefore, be satisfied with the sulphide of calcium, taken regu- larly and in large doses, in order to keep the organism for some time constantly in an internal atmosphere, as it were, of hydrogen sulphide. Two to five granules of this drug should be given every two hours or of tener, the quantity being regulated by the age, facility in taking it, and tolerance of the patient. Its administra- tion should be commenced when the first spasmodic attack occurs, or even during the catarrhal period if circumstances indicate the probable development of spasmodic catarrh. At the beginning of the disease we may hope to abort it by active and regular treat- ment. Harmful effects from the sulphide of calcium need not be apprehended, for there are none. There may be nausea produced by the bad odor of the eructa- tions, but that is all. Children can take the granules easily, either triturated with a little sugar or a little milk, or entire, if the children are not too small, and if they are accustomed to dosimetric treatment. To habituate children to taking remedies readily should form a part of their early education ; when they are in good health one should occasionally give them a few inert granules or globules, and teach them to swallow them without chewing them. In this way much time and trouble might be spared when they are sick. This ad- vice, which all physicians ought to give to the mothers in their clientele, may seem trifling, but its importance will be thoroughly recognized when one is called to treat a severely sick child, and medication is required which will promptly control it. If the child has previously been taught to swallow the inert granules, he will now have no trouble in swallowing the active ones ; on the contrary, one who has not been so taught will take the medicine with difficulty or not at all, and instead of improving may get worse and die, with the medicine which has been left for him within reach. The treat- ELEMENTS OF DOSIMETRIC PRACTICE. 485 ment of this disease should be governed, in some re- spects, by the period in which it is used. In the ca- tarrhal period we either know the nature of the disease or we do not know it. If we know that it is whooping- cough we should give sulphide of calcium, and, if the catarrhal symptoms are aggravated, a granule of hele- nine, which is an important agent in the cure of this dis- ease, should be added every two hours. If the diag- nosis is doubtful, we should treat the case, especially in the time of an epidemic, as if there were no doubt that it was whooping-cough. Not only is such treat- ment useful at the beginning of this disease, but it also is decidedly efficacious in all cases of simple catarrh. In the spasmodic period there is an affection of the upper portion of the larynx in addition to the funda- mental cause. The simple presence of the micrococci or their secretions produces such an irritability at the peripheral ends of the nerves that the slightest provo- cation will excite a paroxysm. Crying, motion, a deep breath, in a word, anything which displaces the mucous secretion, or anything that increases the nervous excit- ability, will suffice to bring on a new attack. This ex- citability is frequently communicated to the stomach, and vomiting occurs not infrequently with each attack of coughing. This exaggerated condition of contractil- ity should be treated with half a granule or a granule of hyoscyamine or valerianate of atropine three times daily. Should the vomiting be so persistent that the patient suffers for want of alimentation, one or two granules of morphine or codeine must be given before each meal. These remedies must be given until the patient is relieved, unless they are contra-indicated by the patient's age or the cephalic congestion which is induced by the paroxysm. Two granules of the bro- mide of camphor may also be used with advantage every two hours, its action being analogous to that of helenine. An intermittent character of the paroxysms is in some cases an indication for the use of two gran- 486 ELEMENTS OF THERAPEUTICS AND PRACTICE. ules of the hydroferrocyanate of quinine three times daily, especially when they seem to be provoked by hyperesthesia of the larynx rather than an accumula- tion of mucus. If expectoration is abundant two gran- ules of helenine should be given four times daily, and if it is very viscid in character, the helenine should be combined with scillitine. In some cases the heart be- comes very irritable or ataxic, owing to the fatigue resulting from the repeated attacks. To soothe and strengthen the heart, two granules of digitaline and two of aconitine should be given every evening. To very young children, one granule of each will be suffi- cient once or twice daily. If haemorrhages are easily excited in certain organs in connection with the parox- ysms, three granules of ergotine should be given three times daily. Loss of appetite is always a grave com- plication and must never be neglected. Two granules of quassine should be given three or four times daily, before eating. Nocturnal attacks, on account of the fear which they excite in some children, are a cause of insomnia, and this greatly aggravates the want of equi- librium in the nervous system, which is already seri- ously compromised by other morbid conditions. The child may be soothed by giving him at bed- time two or three granules of the hydrobromate of morphine, three to five granules of narceine or codeine, or five to eight of the bromide of camphor. Either of these agents may be replaced by three to five granules of cro- ton chloral every evening, if for any reason it is desir- able to make a change. As the disease passes away, that is, in its last stage, the pneumogastric nerve ap- pears to be habituated to the contact of the parasites, and consequently does not react with the same violence nor with the same tenacity when irritated. This is the time when we must aid the system to repair the loss and damage which have occurred to it in this long strug- gle. To tone up the respiratory apparatus we should give two granules of apomorphine three or four times ELEMENTS OF DOSIMETRIC PRACTICE. 487 daily. Two granules of the benzoate of soda and two of the benzoate of ammonium may also be used for the same purpose four times daily. For general debility, if the child be very young, we should give one granule of the hypophosjjhite of strychnine or of brucine three times daily. To overcome the ansemia two granules of the hypophosphites of soda and of lime should be given at each meal, and equal quantities of the phos- phate of iron. The most frequent complications are bronchitis and broncho-pneumonia, both of which are of exceedingly grave import. The ordinary treatment of these inflammations should be modified by bringing the tonics brucine and apomorphine into the list of therapeutic agents. The treatment which is recom- mended for this disease can therefore be summarized in a few words. For dominant, the sulphide of calcium combined with helenine for the catarrhal element, and bromide of camphor for the spasmodic. For variant, those agents should be used which, while increasing synergically the efficiency of the dominant, will find their particular application in the modification of the symptoms. It must also be remembered that this dis- ease is often exceedingly rebellious, now because it was not suitably attacked at its beginning, and again be- cause sufficient care has not been taken in observing the precautions which are indispensable, for it is very important that the patients should have an abundance of pure air, and, at the same time, that they should not take cold. Parents and friends, seeing no change in the patient's condition after several days of treatment, are impatient to have it changed, though they may be perfectly well aware that the disease is always of long duration. The physician must satisfy the impatience of the family by modifying the variant, but he must not interfere with the dominant. The final result will always be in favor of dosimetric treatment. The classical method of treating whooping-cough is a chaos. Owing to cul- pable condescensions and the requirements of different 488 ELEMENTS OF THERAPEUTICS AND PRACTICE. families, it no longer has any remedy in which it con- fides. It stops the use of a drug before it has produced its effects. How can any conclusion be drawn from such practice % The agents which are most approved are hydrocyanic acid and emetics. The first, advised by West, is uncertain and dangerous ; the others, while they may sometimes be useful and soothing to the patients, are in the end harmful, because they weaken and depress the activity of the pneumogastric. Only in exceptional cases, when asphyxia is extreme and suffocation imminent because the patient can not expel the mucus, are emetics indicated. In such cases three granules of emetine dissolved in a little warm water should be given every ten minutes until the de- sired relief is obtained. Emetic medication has well- defined indications, but it should never be regarded as curative treatment. WHOOPING-COUGH. Dominant. period Variant. ( Spasmodic period . Parasitic element /Catarrhal j Catarrhal element \ Spasmodic element / Spasm of the glot- tis Irritability of the larynx Intermittence in the attacks Viscid expectora tion . Inability to expec torate Cardiac ataxia Haemorrhage Insomnia Want of appetite v Vomiting / Atony of the vagus Catarrhal hyperse Period of cretion disappear- General debilitv ance • Anaemia Sulphide of calcium. Helenine. Bromide of camphor. ) Hyoscyamine, valerianate \ of atropine. j- Bromide of camphor. [ Hydroferrocyanate or hy- ) drobromate of quinine. y Scillitine. y Emetine. Digitaline. Ergotine. j Narceine, codeine, croton ( chloral. Quassine. Morphine. Apomorphine. y Benzoate of ammonia. Brucine, hypophosphite of strychnine. Phosphate of iron. Hypophosphites of lime and of soda. THE END. DOSIMETRIC LIBRARY. In order to establish the dosimetric system of medicine, it was first necessary to arrange its materia medica, and then to promulgate the method of using it. The first duty was assigned to my collaborator, Charles Chanteaud, and it is well known with what conscientious fidelity he has fulfilled his task. All physicians who have used his preparations will bear testimony as to their efficiency. Attention to the published works devolved upon me, and it can not be said that I have lost much time. It has been my task to create an entire dosimetric library. Db. BURGGRAEVE. WORKS OF PROFESSOR BURGGRAEVE. 1. — Publications be luxe. Monument to Jcnner, a magnificent quarto volume, "with a portrait of Jenner. The genius of contemporary surgery, third edition, 8vo, with portrait of Vesalius. History of anatomy, 8vo, with cuts. Course in surgery, theoretical and practical, with plates. 8vo. Studies on Hippocrates, with portrait. 8vo. Indian cholera, with plates. 8vo. Medico-ceconomic studies. The golden book of dosimetric medicine. 2. — Manuals for the use of physicians. Manual of dosimetric therapeutics, or exposition of the system and different conditions for which it is applicable. One volume. Manual of dosimetric pharmacodynamics, or mode of action of dosimetric medicaments. Manual on dyspepsia, and its treatment by the dosimetric method. Manual on fever, and its treatment by dosimetry. Manual on diseases of women, and their treatment by the dosimetric system. Manual on the diseases of children, and their treatment by dosimetry. Compendium of dosimetric medicine ; or medical, chemical, pharmaceutical, pharmacodynamical, and clinical studies, by Dr. Albert Van Renterghem, Goes (Zealand). A new practical guide to dosimetric medicine. (This is simply a very clear and concise exposition of the doctrine of dosimetry.) In press : Organon of dosimetric medicine. Second part, symptomatology. (The foregoing are merely translated titles of the original French works, which, so far as the translator is aware, have not as yet been rendered into English.) Universal repertory of dosimetric medicine. (Human and veterinary medicine comparatively considered.) A monthly journal. THE POPULAR SCIENCE MONTHLY. Established by Edward L. Youmans. EDITED BY W. J, YO UMANS. The Popular Science Monthly will continue, as heretofore, to sup- ply its readers with the results of the latest investigation and the most valuable thought in the various departments of scientific inquiry. Leaving the dry and technical details of science, which are of chief concern to specialists, to the journals devoted to them, the Monthly deals with those more general and practical subjects which are of the greatest interest and importance to the public at large. In this work it has achieved a foremost position, and is now the acknowledged organ of progressive scientific ideas in this country. 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TERMS, PAYABLE IN ADVANCE. $5 00 2 50 One Year .... -------- Six Months --------- (No subscriptions received for less than Six Months) Binding Cases (for permanent binding), Cloth, per volume - 50 The Popular Science Monthly and The New York Medical Journal to the same address, $9.00 per Annum (full price, $10.00). New York: D. APPLETON & CO., 1, 3, & 5 Bond Street A DICTIONARY OF MEDICINE, INCLUDING GENERAL PATHOLOGY, GENERAL THERAPEUTICS, HYGIENE, AND THE DISEASES PECULIAR TO WOMEN AND CHILDREN. BY VARIOUS WRITERS. EDITED BY RICHARD QUAIN, M. D., F. R. S., Fellow of the Royal College of Physicians, and Physician to tbe Hospital for Diseases of the Chest, at Brompton, etc. In one large 8vo volume of 1,834 pages with 138 Illustrations. Half morocco, price, $3.00. Sold only by Subscription. This work is primarily a Dictionary of Medicine, in which the several diseases are fully discussed in alphabetical order. 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