A text-book of practical therapeutics : with special reference to the application of remedial measures to disease and their employment upon a rational basis

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UNITED STATES OF AMERICA.

Preface To The Fifth Edition

The call for the fifth edition of The Text-book of Therapeutics within five years after the first edition appeared has encouraged the author to use every effort to make the work of practical use to the active practitioner, and has enabled him to keep the text abreast of the latest advances which are reliable. In the present edition each article has been revised, many useful suggestions added, several articles entirely rewritten, and the antitoxin treatment of diphtheria discussed.

Philadelphia, 222 South Fifteenth Street, June, 1895.

Preface To The Fourth Edition

The Fourth Edition of this work having been called for in less than four years after the appearance of the first, the Author has taken advantage of the opportunity to rewrite and add to many of the articles on drugs, remedial measures, and diseases, and to insert practical information concerning the value and prescription of the really useful new remedies. Articles on Methylene Blue, Chloralose, Pyrogallol, Condurango, Convallaria, Duboisine, and other remedies have been added to the part of the work dealing with drugs. In the part dealing with Remedial Measures other than Drugs articles have been written on Hypodermoclysis and Enteroclysis, Lavage, and upon Mineral Springs and Climatic Treatment. The latter article is not intended to be exhaustive, but to give the general practitioner an idea of the therapeutic value of certain well-known resorts, in order that he may offer rational advice to his patients as to where they should go in search of health. Several new articles in the part devoted to the Treatment of Individual Diseases have been inserted, and new or modified applications of the older remedies carefully noted throughout the entire book.

In addition to these changes, the work has been revised in such a way as to render it uniform with the new U. S. Pharmacopoeia. As that authority directs the use of the metric system, the doses of all drugs are given in both Apothecaries' and Metric weights, thus (15 to 30 grains [1.0-2.0]), so that the physician may conveniently use either system, but it is to be clearly understood that where the doses are expressed in both systems, side by side, no attempt has been made to make the metric amounts more than approximate the quantities given in Troy weight.

Preface To The Fourth Edition. 7

The fact that one fluidounce is nearly represented by 30 cc., while one solid ounce is represented approximately by 32 grammes, causes confusion. The author has therefore adopted the method advised by Oldberg in his valuable and well-known "Manual of Weights and Measures," and used 32 cubic centimetres or grammes as equivalent to 1 ounce, whether liquid or solid.

The Author desires to express his appreciation of the care with which Dr. de Schweinitz has revised the articles on Diseases of the Eye ; Dr. Hirst, those on the Puerperal State ; and Dr. Martin, those on Syphilis and Genito-urinary Diseases and Antisepsis. The articles on the treatment of diseases of the upper air-passages have been rewritten or revised by the Author.

It is hoped that this new edition will prove even more useful than its predecessors to the doctor who needs a book for ready reference in daily practice.

Philadelphia, 222 South Fifteenth Street.

Preface To The First Edition

The object of this book is to provide the physician or undergraduate student of medicine with a reliable guide in the study of Therapeutics, or the application of remedial measures for the cure of disease. It has been written because, in the belief of the author, most of the text-books on this subject treat of it as if the student were already a skilled physician or experimental pharmacologist. As a consequence, two classes of undergraduate readers exist. One finds that the mixture of science and empiricism is too difficult for him to fathom, and is hopelessly confused; the other simply learns the remedies and doses by heart, and gives drugs with little idea as to what they are to do. Further than this, the physician is often at a loss to decide when a remedy is indicated, even though his theoretical knowledge of the subject be very thorough. Thus, he is told that ammonium chloride is a remedy in bronchitis, but the exact stage at which it is to be employed is often not stated ; or he knows that digitalis does good in cases of cardiac disease, but fails to recognize the fact that it is only when compensation is lacking that the drug is needed. For this reason Part IV. has been written, not with the object of providing a rigid system for treating disease, but rather for the purpose of bringing together the best remedies, and of showing how and why they are given.

Rational therapeutics at the present day does not consist in a knowledge of doses and the materia medica, but exists as a complex art in which knowledge and its proper application, based on commonsense principles, go hand in hand. The treatment of " symptoms as they arise" by the employment of remedies recommended by some eminent authority is a variety of empiricism whose existence has

Preface To The First Edition. 9

depended largely on the fact that many physicians of the past have either been so ignorant as to be led where a writer willed, or so slothful as to be willing to let others think for them. Scientific research has so largely opened up to every one the possibility of using drugs with a distinct idea of the reason for their employment that the writer has endeavored to bring together in a readable form the combined results of laboratory and bedside experience, thinking the time ripe for such a task. It is true that several other books give, in a more or less thorough manner, a resume of the physiological action of the drugs of which they treat, but in even the best of them only the most trained student of pharmacology can discover the close relationships which exist between the results reached by the physiologist on the one hand and the clinician on the other. The two parts of the study are usually so divorced by the prolonged mental effort necessitated by the arrangement of the text that the student either ignores the physiological action for the sections on therapeutics, or crams the former to pass an examination required by the teacher whose course he must follow. As a consequence, too many physicians regard pharmacology simply as a species of mental training, or believe it to be a waste of time and energy. No one can think that the writer of this book will ever deny the value of original research or bedside experience, but he does desire to weave science and practice into so close a network that the foundations of experience may be cemented by the mortar of exact knowledge. In some instances, however, science and practice seem to be absolutely opposed, and only future research can explain the apparent contradiction

Throughout this book, in every part where drugs or diseases are considered, the writer has arranged the titles in alphabetical order, according to their English names. This has been done because it is desired to afford the reader a ready-reference book to which he may turn at short notice for desired information, for at present the state of pharmacology is so unsettled that a true classification is impossible. Thus, morphine may be classed by one writer as a nervous sedative, by another as a sleep-producer, by a third as a bitter substance, and by a fourth as a respiratory depressant. Bromide of potassium can

10 PREFACE TO THE FIRST EDITION.

with equal propriety be called a spinal sedative or a cerebral sedative, or caffeine be classed as a cerebral stimulant, a circulatory stimulant, or a diuretic.

In order to make the book more complete, the preparations of the British Pharmacopoeia have been introduced ; and with the same object in view, a dose-list of drugs, both official and unofficial, has been appended for ready reference. The subject of medical electricity has heretofore commonly found a place in most text-books on therapeutics, but has been advisedly omitted in this instance, since electrical therapeutics has outgrown any work save one devoted to that subject alone.

For many of the articles on treatment the author wishes to thank friends who have earned prominence in connection with their specialties. Thus Dr. G. E. de Schweinitz has contributed the articles on the treatment of diseases of the eye ; Dr. Edward Martin, those on the treatment of venereal diseases and on antisepsis ; Dr. Barton C. Hirst, those on the treatment of diseases of the puerperal state ; and Dr. J. Howard Reeves, the articles on the treatment of diseases of the upper air-passages. All of these articles enhance the value of the book to so great an extent that the author feels sure they will be sought out and read with interest.

In addition to the general index, a copious and explanatory index of diseases and remedies has been appended, which will prove suggestive and valuable to practitioners, and for which the author is indebted to his friend and student, Mr. J. G. Clark.

Philadelphia, 222 South Fifteenth Street.

Sept., 1890.

Part I. General Therapeutical Considerations

Before entering into a study of the action of drugs upon a living body, it is necessary that the student should possess a clear idea of what the word 4i therapeutics " means, the reason why we resort to drugs, and, more important than all, that he should grasp the limitations which govern the administration of remedies.

Two very foolish and unfounded ideas have recently been put forward by certain physicians — one being, that medical therapeutics is useless ; and the other, that this branch of medical knowledge is not advancing with so great a stride as is pathology or surgery. The individuals who laugh at the general use of drugs in disease belong to one of two classes : either they have never tried them, or if so have used the drugs ignorantly or wrongly, or else they believe that they are promulgating a new theory, and do not know that the eras of excessive dosage and of nihilism are alike relics of the past. No reform has ever attacked a crying evil without becoming excessive and absurd itself, and if successful in accomplishing its object has generally resulted not in the mere remedy of the faults it antagonized, but in so complete a reversal of popular opinion as to force its converts into ways as reprehensible as their former habits. Thus, in exactly the same manner that the excesses of Catholicism resulted in fanatical Puritanism, so did the careless methods of physicians during the past century lay the foundation for the growth of homoeopathy or therapeutic nihilism. At the present time, although we have much to learn, it can be said that we have benefited by both of these errors, and are in consequence taking a path which may be considered the happy medium.

To the majority of the readers of this book, however, the harmfulness of over-dosing is sufficiently evident, and the cry of " no drugs at all " so absurd that no rebuttal need be offered.

The statement that therapeutics is to-day more backward than are pathology and surgery is readily answered by a denial ; for the therapeutist is able to treat successfully many diseases of which the pathologist knows nothing, and is obliged to rest his treatment on empiricism simply because he cannot tell how his drugs act if the pathologist cannot tell him what the disease is. Rheumatism is a good example of this very point.

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In regard to surgery, every one must recognize the extraordinary advances made in this branch of medical science, yet comparatively few realize that it is solely by the introduction of drugs that all its triumphs are posssble. The definition of the word " therapeutics " in Billings's Dictionary is: " That branch of medical science which treats of the application of remedies to the cure or alleviation of disease," and, practically, the term is almost universally used to signify the employment of drugs for such purposes. The credit for the introduction of new instruments may or may not be accorded to surgery, but the discovery of new drugs must be accorded to therapeutics. We find, then, that ether and chloroform began to revolutionize surgery fifty years ago, and that corrosive sublimate, carbolic acid, and other drugs have revolutionized it once more within the lifetime of every one who reads this book. Cocaine has changed the entire aspect of eye surgery and other minor operations, and has immediately averted an enormous amount of pain and suffering which the surgeon could not relieve, and certainly could not remove, in the absence of its influence. To the accusation of backwardness the therapeutist can well reply by asking the champion of any other branch of medical science to put forward one discovery which equals antipyrine or acetanilide in pow r er to relieve disease or pain, or which can be applied as specifics to so wide a scope of ailments.

In the language of one of the most progressive medical men of to-day in the United States, the man who does not believe in the proper use of drugs for the cure of disease must lack the very keystone of the arch upon which all medical knowledge rests.

The ultimate aim and object of all medical thought and effort is the cure or alleviation of disease, and therapeutics is the refined product culled from every department of medical learning. Like every other thing requiring a thorough knowledge of its component parts, it is often much abused by the careless and ignorant, but is a power for good in the trained hand of the properly educated physician.

Further than this, therapeutics is the only universally used branch of medicine, for each and every branch must resort to it, and the most skilful operator who fails to treat his cases medicinally with equal skill will have worse results than he who, though bungling in his surgery, yet uses drugs intelligently after his slashing is finished.

Homoeopathy depends upon more than one reason for its existence. If infinitesimal doses are given, the patient is satisfied that he is receiving medicine, and Nature often produces her most rapid cures when left alone. Again, the entire basis of homoeopathic therapeutics rests not upon the study of the causes of diseases, but upon the symptoms which constantly present themselves. As a result of this, so many minor symptoms are relieved that the patient's comfort is ensured, and doubtless in many instances serious disorders are discovered which might otherwise be cast aside or go unseen. No detail should be too small to attract the attention of the physician, and he who exercises care in detail must reap reward in larger measure.

MODES OF ADMINISTERING DRUGS.

MODES OF ACTION OP DRUGS.

Drugs act in two ways, which are sometimes called near and remote, direct and indirect. The near, or direct, action of a drug is that influence which is felt by the exercise of its effects directly upon the tissues with which it comes in contact ; the indirect, or remote, influence is that result which comes as a sequence of its primary effect. As an illustration of this we may take the local use of cantharides. The local, near, or direct effect of this is a blister ; the remote or indirect effect is the absorption of exudations or the influencing of inflammatory processes. If pilocarpine is used, its direct effect is the sweating which ensues, while its indirect effect is the relief of dropsy through the removal of exudation by the increased action of the skin, salivary glands, and kidneys.

MODES OF ADMINISTERING DRUGS.

Drugs may be administered for the purpose of affecting the general system in many ways, but practically we employ only six methods, as follows :

1. By the mouth or stomach ;

2. By hypodermic injection ;

3. By inhalation ;

4. By the rectum ;

5. By inunction ;

6. By the endermic method.

By far the most usual manner of administering drugs is by way of the mouth, which is the most natural means of entrance into the body for foreign substances. Whenever medicines are used in this way, the physician should clearly bear in mind what the medicine is to do after it is swallowed. Thus, if the drug is intended to act directly upon the stomach, it should not be given after meals, but some time before, since the food and gastric juice may afterward so cover the gastric mucous membrane that the medicament cannot act. Thus, in the case of chronic gastric catarrh or gastric ulcer, the nitrate of silver which is used should always be given half an hour or an hour before meals. On the other hand, if an ulcer or other trouble exist in the small intestine, the pill should be given some time after meals, and, if a heavy meal is taken, three or four hours after, since under these circumstances the medicine is swept out into the intestine almost at once, without remaining any time in the stomach, where it may be chemically altered. Very often it is necessary to give a medicine soon after food is taken, in order that it may not act in too powerful or concentrated a manner upon the viscus which receives it.

The general rule, however, may be laid down that all medicines are to be taken after rather than before meals, unless a local gastric effect or very rapid absorption is desired.

Next to the use of drugs by the mouth, by far the most popular method is their administration by means of the hypodermic needle and syringe. The logic of this method rests upon the absorption of all soluble substances from the subcutaneous tissues with great rapidity. Any substance soluble enough or suspendable enough to pass through a hypodermic needle without forming an obstruction may be employed, provided it is not too irritating and that it is " clean."

The proper places to give such injections are the forearm on the extensor surface, 1 the calf of the leg, the buttock, or the broad of the back — in other words, any spot where the tissues are not dense and unyielding. The skin of the part is to be grasped or pinched up with the thumb and forefinger of the left hand and the needle sent well into this raised fold, preferably above the finger and thumb, so that the pressure of the fingers may prevent pain and the too rapid entrance of the medicine into the system. The needle should always penetrate well into the loose connective tissue, so that the liquid injected may find lodgment in the loose and spongy subcutaneous tissues without separating the skin from its rather close adhesion to the tissues below or from the blood-vessels supplying it, for if separation occurs abscess and a slough may result.

The dangers from hypodermic injections are chiefly two. First: The medicine may enter a vein, owing to the penetration of its wall by the needle, and the entire dose be carried at once, en masse, to the vital centres. Second : The solution used may not be sterile or the needle may be dirty, and an abscess may result. The first danger is to be avoided by injecting into spots not well supplied with veins, and the second by thoroughly washing both syringe and needle with water the instant before they are used, pushing a fine wire through the needle, and in some cases by soaking the latter in carbolized oil. The liquid injected may be rendered sterile by using freshly boiled water and adding thereto carbolic acid in such proportion that one-half to one drop of carbolic acid is present in each injection. It is claimed by some that this use of carbolic acid seriously hinders absorption, and in cases of urgency it should not be used. Most hypodermic syringes hold from twenty to thirty minims.

When drugs are given by the rectum, we employ them for three purposes : First, to influence the general system by their absorption ; secondly, to act locally upon any disease which may be present in this particular locality or in the colon ; and, finally, to dislodge substances or parasites which it is desired to bring away. The word "enema" is loosely used to denote all these injections, be their purpose what they may, and is synonymous with " rectal injection" or the more old-fashioned word "clyster." If nourishment is being given, the injection is called a "nutrient enema." Sometimes these injections are called "lavements."

In this mode of administration it is very necessary that the physi-

1 Hypodermic injections into the anterior aspect of the forearm often cause much pain in the hand by irritating temporarily the branches of the radial or ulnar nerves.

MODES OF ADMINISTERING DRUGS. 21

cian should use his medicaments in proper bulk ; and it may be laid down as a rule that no more liquid should be injected than is necessary to convey the medicine or food, unless the injection is for the purpose of emptying the bowel of faecal matter or other materials, or it be desired to distend the bowel in order to overcome obstruction, or to influence the colon by drugs,

The reason for this lies in the fact that any large bulk of liquid sent into the rectum so stimulates its walls by distention as to cause spasmodic contraction, with expulsion of all the rectal contents, which is just what is needed when fecal matter is to be removed, but the opposite of what is desired when retention of a remedy or food is necessary for absorption or local action. In rectal catarrh or ulcer tw T o to four ounces of liquid are usually sufficient in an adult to accomplish any medicinal influence locally or by absorption, while as a laxative enema one to two pints may be employed.

In the use of injections we frequently find that the rectum becomes irritable, and promptly resists all efforts to force the entrance of liquids or solids. This is to be avoided by giving the injection so gently that the bowel fails to recognize, as it were, the entrance of liquid, and by introducing a few drops of oil and laudanum in each injection.

A large amount of distress often follows the gradual accumulation of faecal masses in the colon which are not passed with the daily movement of the lower bowel. These can readily be removed by large injections of warm water or by the use of medicated liquids.

A very important use of injections by the rectum is in the treatment of the various causes of intestinal obstruction. Here the greatest caution should be exercised that the injection be made with all possible gentleness, and slowly, the liquid being allowed to dribble into the bowel rather than to force its way. It is dangerous to use a greater pressure than is given by a fountain syringe at the height of two or three feet, as rupture of the peritoneal coat of the bowel may occur. Where a large quantity of water is used it should be carefully warmed to 100° or a little more, and it is well to add salt to it, so that it will represent the normal saline strength of blood-serum, namely, seven-tenths of one per cent. (For use of injections in special diseases see Part IV., and for Enteroclysis, Part III.)

Suppositories are another means by which we introduce medicines into the bowel, either for local effect or to act after absorption of their contents upon the general system.

When drugs are given by inhalation they are generally employed with the object of affecting the respiratory tract alone, although there are notable exceptions to this in ether, chloroform, nitrous oxide gas, and other volatile substances. Aside from anaesthetics, we find such remedial measures adopted as the inhaling of steam laden with the drugs employed, the respiring of air loaded with the fumes of the medicament, or the inhalation of gases, and last, and most commonly resorted to of all, the use of the atomizing spray, which, if properly made and employed, so minutely divides the liquid containing the medicine that the inspired air carries it to the farthest bronchiole and pulmonary vesicle.

As an example of the rules governing the administratien of drugs in this manner we find that compound tincture of benzoin may be taken by inhaling the steam arising from hot water containing it, but cannot be used in a spray because it occludes the fine points of the atomizing tubes. In a similar manner we may inhale the smoke of belladonna or tobacco-leaves to relieve asthma, or the fumes of chloride of ammonium for bronchitis in its later stages. Finally, we find that oxygen is sometimes very useful, the gas being readily inhaled, with good results in proper cases.

The " spray " or atomizer is made in two forms — one form of apparatus being worked through the agency of compressed air, the other through the escape of steam from a small boiler. Very few of the compressed-air atomizers throw a spray fine enough to reach the deeper parts of the lung, particularly if the air is compressed by the hand.

The inhalation of moist air is very useful in bronchitis, and greatly aids other remedial measures. Steam may be disengaged in a room by means of a kettle of boiling water or by placing pieces of unslaked lime in a pan of water.

Inunctions consist in the rubbing into the skin of medicines generally of an oily or fatty nature, or which assume this character through embodiment with oil or fat. The three substances most commonly used in this way are cod-liver oil, mercurial ointment, and iodine ointment. They should always be applied on some part where the derm is thin and well supplied with subcutaneous. lymphatics, as in the axillae, the groins, or the insides of the thighs. Other substances have been and may be used by inunction : but as this method is necessarily a disagreeable and dirty one, it is rarely resorted to unless the stomach is disordered or it is necessary to push the drug into the system by every possible avenue of entrance.

The endermic method consists in the use of a blister, by means of which the epiderm is raised, when a little morphine or other alkaloid may be slipped under it and so absorbed through the true skin. It is a painful method, almost never to be resorted to, which has been entirely supplanted by the hypodermic method of medication.

Remedies are administered in a number of forms, but chiefly as follows :

Abstracts are dry powdered extracts mixed with sugar of milk until they are twice as strong as the crude drug. Abstracts are no longer official in the United States Pharmacopoeia.

Aceta, or vinegars, are solutions of drugs in vinegar or acetic acid. There are two in the United States Pharmacopoeia (Acetum Opii and Acetum Scillae) and three in the British.

Alkaloids are organic bases, generally occurring in crystalline

MODES OF ADMINISTERING DRUGS. 23

form and abstracted from crude drugs. They nearly always represent the active principle of the drug.

Aqu^e, or waters, are used as vehicles either for the dilution of strong medicines or for the purpose of carrying minute amounts of flavoring materials.

Cataplasms are not official in the United States Pharmacopoeia, but are in the British Pharmacopoeia. They are virtually poultices made of linseed-meal or of bread-crumbs.

Cerates are ointments containing wax to render them harder than would ordinary fats.

Charts, or papers, consist of bibulous paper soaked in a solution of the drug which they are meant to carry.

Confections are sometimes called electuaries or conserves, and are soft pastes which contain the drug mixed with sugar or honey.

Decoctions are solutions of drugs made by boiling and then straining while hot.

Elixirs are diluted tinctures rendered pleasant to the taste by the addition of aromatic substances and sugar.

Emplastra, or plasters, are made up of adhesive substances placed upon a backing of cloth or leather and designed to adhere to the skin, being so applied for the purpose of holding a medicinal substance in contact with the body, of acting as a protective, or of aiding in the approximation of the edges of a wound.

Extracts consist of the soluble parts of plants reduced to a semi-solid or solid condition by evaporation ; the soluble constituents being taken from the plant by water or alcohol.

Fluid Extracts are made in the same way as solid extracts, except that they are not so completely evaporated.

Glycerita, or glycerins, are solutions of various substances in glycerin — the glycerin being used as a vehicle.

Infusions are made by pouring boiling water on the crude drug and allowing it to stand for a short time until the water cools, after which the liquid is strained. Sometimes cold water is employed.

Pills are small round masses which, as a general rule, should not weigh more than three grains, in order to avoid their being too bulky. If the material is a heavy one, as much as five grains may be placed in each pill. Pills may be uncovered or coated with sugar or gelatin. If the pill is fresh and the sugar pure, they are useful. Many pills are fraudulently coated with varnish and are insoluble.

Suppositories are small masses made into a cone shape and having for their basis cacao butter. They are designed to carry into the rectum certain medicines for absorption into the system or for local action.

Tablets. — Under this name manufacturing pharmacists and others prepare compressed pills or lozenges, generally of small size, the mass being made to adhere by means of its being subjected to great pressure by special machinery. Smaller tablets are used for carrying powerful drugs for hypodermic use. These, however, are often only lightly pressed, so as to render them easily soluble.