Principles of therapeutics

Author's Preface

I dedicate this book to young physicians: they will work for a renaissance in Therapeutics which will be the great achievement of twentieth-century medicine.

There is a general impression that Therapeutics is a very imperfect science. It would be more exact to say that it is an encumbered science, which is not studied with the attention it deserves, nor is it practised with sufficient precision. Hence, it often is tainted with fanciful and erroneous views. I shall be happy if I succeed in laying down principles to guide the young physician in the right direction.

This book represents a far more considerable amount of labor than its size would suggest. The principles expounded herein are very numerous. I shall here refer only to the most important.

I have endeavored to demonstrate that Therapeutics may be, and should always be, scientific, viz., an enemy to fanciful theories, hypothetical and hazardous deductions, and incomplete and superficial observations.

I have also shown what therapeutic actions are, distinguished from so-called physiological actions, which are often toxic. I have, therefore, repeatedly combated the principle of physiological therapeutics, which has been a grave error. The latter often leads to the accumulation of medicinal and morbid poisons in the same organism or the same organ.

A chapter is devoted to the differentiation of the various objects which a therapeutist may desire to attain.

Another chapter is devoted to a description of the conditions of medicinal opportunities, including administration of medicines,

v vi AUTHOR'S PREFACE

duration of dosage, interruption, resumption, alternation, and fractional dosage.

No less important is the study of the various ways in which harm can be done by poorly understood therapeutics. Therefore, serious attention is called to a multitude of errors into which the therapeutist may fall.

In treating of the necessity to individualize therapeutics, I have indicated all the reasons which lead to variation in the conditions of medicinal intervention.

In a special chapter I have discussed the considerable resources of non-medicinal therapeutics: hygiene, mineral waters, climatotherapy, psychotherapy, physical agents, and mechanical means.

The new division of therapeutic agents which I have given will throw light upon the conception of a rational Therapeutics.

Finally, I must refer to the chapter on Method in therapeutic studies. I do not flatter myself that I have realized more than an essay which, of course, needs to be perfected.

Such being the material of the book, it might have been called a brief treatise on General Therapeutics; but I was afraid the title would then lead to the supposition that it was a speculative work, whereas every line of it is devoted to practice, with the double object of being useful and doing no harm.

Contents

CHAPTER PAGE

I. — Views of the Various Manners of Conceiving

Therapeutics 12

Chapter I Views Of The Various Manners Of Conceiving

THERAPEUTICS

Definition of therapeutics — Reasoned therapeutics — Answer to some objections — Empiricism and its dangers — Therapeutics of imagination — Of the value of instinct in therapeutics — Definition of the words: medicament, remedy, pharmacology, pharmacodynamics, pharmacotherapy.

What is therapeutics? In the etymological sense of the word (O^paTrelv, to serve, to care), therapeutics is knowing how to take care of the sick. This definition, very comprehensive and very correct, has one defect, however; that of being somewhat vague. Every author treating of therapeutics has therefore sought to give it precision according to his tendencies and personal opinions. Hence the considerable number of definitions proposed.

In the first place, there has been much discussion as to the question whether therapeutics is a science or an art. Such discussions should be banished as idle and barren; they are of no use, as they do not succeed in convincing the contending parties and do not prevent the accumulation of solid information. If I am speaking of it, it is because the word science has of late been the object of widespread discussion, and those who deny to therapeutics the character of a science have asserted that, in order to treat a patient, good sense is sufficient, viz., some kind of divinatory instinct which they

VARIOUS MANNERS OP CONCEIVING THERAPEUTICS 13

call art — a personal practice (how often narrow!) that has taught them everything.

The fact that the laws established by scientists are neither absolute nor complete, and that there has been an abuse of insufficient knowledge by many, does not justify the excessive reaction which leads not a few to distrust the true science and even shun the employment of the word science for fear of arousing anger or laughter. For us the discussion is without interest: we are well aware that therapeutics has no claim for absolutism; when we say that it is a science, we take it in its usual sense, as it is, for instance, defined in the Dictionnaire de Littre: ensemble, system of knowledge on a matter.

The word science thus defined, therapeutics is a science; it is a science after the manner of biology of which it is a branch. Like biology, it adheres to the principle of determinism as this was understood by CI. Bernard; it supposes that the production of a phenomenon is determined by a condition or a set of conditions without which the phenomenon would not be produced and with which it is necessarily produced. If the determining cause, viz., the circumstance which determines the appearance of the phenomenon and constitutes its condition or one of its conditions, eludes, it is because we do not yet know all. When we say that therapeutics is a science, we simply assert that it is composed of a great number of truths that are practically and humanly exact, and that the principle which least misleads is determinism.

Moreover, therapeutics is a science in opposition to the practice of those who pretend that medicine is first of all a matter of good sense, of instinct, of personal observation independent of that of others, thus justifying the criticism of not long ago that medicine is the only profession which can at times be practised by one who knows it not.

Therapeutics is not, however, a simple and independent science like the various branches of mathematics, or like physics or chemistry; it is a composite and complex science. Like hygiene, it is composite, taking in, irrespective of origin, every useful thing it can borrow from other fields of human knowledge. It asserts its independence only when it comes to establish the biological properties of the means it makes use of, and especially in adapting these properties to the requirements of the diseased organism. It is more complex than other sciences owing to the fact that it deals with organisms complicated by malady; that is the highest degree of complexity which can be imagined in biology.

Nevertheless, in order to be logical, we must say that, in its application, therapeutics is an art, since at this point the physician adds to it the value of his own personality: the keenness and development of his sensorial perceptions, his fine diagnostic penetration, his deep understanding of pathological physiology, and finally the experience acquired by himself. But it is a scientific art or an applied science. As a matter of science, therapeutics may easily be learned by all; as an art, it requires special education calculated to develop the aptitudes of the physician from the view-point of exactness in observation and reasoning. Science without art would be a weapon without destination; practice without science would be putting a dangerous weapon into the hand of a blind or demented person.

In order to include both these elements I shall somewhat modify the definition I have once given of therapeutics. 1 It is to be noted, moreover, that therapeutic science comprises two elements: 1. On one hand, a knowledge as exact as possible of all the forces which the organism can utilize in its struggle against a morbid state, whether they affect this organism itself or the cause of the disease, or produce their effect upon both at the same time. 2. On the other hand, a knowledge of the needs of the suffering organism. Scientific therapeutics consists in adapting the modifiers of the organism or of the morbid causes to the needs of the patient.

In the present state of our knowledge, however, scientific therapeutics is not always realizable with absolute precision. In some instances the needs of the organism are not sufficiently understood, in others the mode of action of the measures opposed to the morbid state is not quite clear. It may even happen that we are ignorant of both the essence of the disease and the mode of action of the remedy, as is the case when we deal with gout and its specific remedy, colchicum. In such cases the remedy which has been found serviceable by experience is resorted to without hesitation and without any foreknowledge of the morbid cause or of the mode of action of the therapeutic agent. For this reason a complete definition must take into consideration the empirical treatment of disease, acceptable when its efficacy is made certain by a long series of favorable observations.

Taking into account these various factors, I will define therapeutics: The science of the utilizable modifiers of the organism,

l " Therapeutics is the science from adaptation of the modifying forces of the organism and of the morbid causes to the fulfilment of indications derived from the examination of the sick and from pathogeny" (TraitS elementaire de therapeutique, 5th edition, 1903, Vol. I, p. 6).

of morbid causes and of diseases, and the art of applying their properties to the profitable correction of disturbances of health.

This definition is as comprehensive as possible. It simply asks of the physician not to modify the organism without being well acquainted with the modifier, and to take into intelligent account the action exerted by it on the organism or on the morbid cause. This definition further admits that in certain cases it is permitted to act empirically upon disease; and it supposes that, in the application, the personality of the physician will intervene more or less successfully to take advantage of the sciences; but, at the same time, it requires that the modification of the disorders of health be useful and desirable.

Is this definition satisfactory to all? We do not think so. Indeed, many physicians formulate objections to its principles.

In the first place, some would like to oppose empiricism to scientific therapeutics. It is the place of meeting of the disappointed*, the skeptical, and those who, by an abuse of language, confound therapeutics with observation.

From a triple point of view of history, method, and language, the word empiricism has always had two meanings : a good and a bad one.

At first, empiricism (^Tretpta, experience) pretended to represent science through observation and experience in opposition to rationalism or dogmatism of the School of Alexandria addicted to theoretical discussions as early as three centuries before the Christian era. But precision in observation is probably a matter of great difficulty, because, two centuries later, empiricism had deviated from its original character and the appellation implied very little respect for its adherents who practised the art of healing. The same development has been reached in our times. After the barren doctrinal controversies of the end of the eighteenth and the beginning of the nineteenth century, Trousseau endeavored to rehabilitate empiricism by returning to clinical observation free from the theoretical confusion of his predecessors. But observation is of value only if exact; exact observation remained the lot of some privileged minds and the errors of inexact observers did not fail to give rise to bitter, at times scornful, criticisms against the method.

The word empiricism thus represents two procedures: one, that of observation, exact at least in its intentions, is nothing else than the method employed in sciences, accepted by all; the other, that of superficial impression, insufficient or prejudiced observation, is an obstacle to the progress of therapeutics. Hence, the former finds defenders proclaiming the usefulness of empiricism, while the latter brings the procedure into well-deserved contempt.

But if one is obliged to establish a distinction between "idiotic" (Fonssagrives) and " brutal" (Stokvis) empiricism, which cannot be defended by anyone, and empiricism in its true sense, which consists in scrupulous observation and pure and simple but exact statement of facts whose interpretation is impossible, why should the same name any longer be given to two procedures of such different value? The defensible side of empiricism, namely, observation, is by no means a privilege; it is a scientific procedure common to all the sciences for which we claim a place among the methods of scientific therapeutics.

Even with this understanding which is the most favorable, empiricism represents but one of the means employed by scientific therapeutics, and this means is not the best. One must and often can go further. In many cases it is possible to reason out the intervention to be decided upon, and to know whether it is recovery, a functional correction, the soothing of a symptom, or the reparation of a derangement in the structure or in the chemical constitution that is to be expected. While we conserve for good empiricism some sort of admiration like that aroused at the sight of ancient weapons that have seen much service, we must say it is a method to be exceptionally employed. It easily leads to an exclusive symptomatic therapeutics which restricts itself to relieving each symptom by means of a little remedy, as Henle has well said; it engenders illusion, failing to distinguish what is due to the spontaneous development of the disease from that which is the result of therapeutic intervention. Moreover, it lacks scientific exactness inasmuch as it studies complex facts which seldom admit of precise conclusions.

As to inexact empiricism, it remains the excuse of those who are unwilling to take the trouble to study therapeutics. On the pretext of personal observation and experience the empiricist pretends to judge everything by himself. He does not trouble himself about acquired knowledge. Are not his perspicacity and his experience sufficient to teach him what he does not know? He does not see that he wanders miserably all the time amid the most stupendous errors and the most extravagant theories. It is, therefore, necessary to distrust empiricism and hold it in the comparative contempt it has deserved.

Scientific therapeutics repudiates theories of imagination just as it does in exact empiricism. It is under the cover of so-called scientific, but in reality imaginary, theories that so many inventors of ephemeral remedies sell serums, opotherapic strange products, vegetable juices, alkaloids, antiseptics good for everything, depuratives, panaceas of all sorts which crowd therapeutics without benefit to the sick. The character of such products is readily known: they are in most instances presented as simple deductions from some general theoretical ideas offering no assurance of truth, and unable to resist the most elementary criticism. They are offered either without any previous study, or after a valueless and superficial one.

Scientific therapeutics requires exactness in all. When it does not know } it is aware of it and says so; when it affirms, it proves; when it ventures to lay down a hypothesis, it makes reservations.

There has in all periods of history been found another category of physicians who may well be classified among the empiricists and who pretend to see no more than the aspect of art in therapeutics. According to them the scientific point of view is useless, even harmful. They argue that each organism has a manner of reaction peculiar to itself — a fact no one denies; it is therefore impossible to know n advance the manner in which the one we are dealing with will react. What is then the use of science, result of past observation, which will perhaps be contradicted by the case of to-morrow? The latter will require the physician's intuition, instinct, good sense. Science is the statement of a past which proves nothing for the future.

This argument is a paradox calculated to excuse ignorance and laziness, and to render lawful every irregularity on the ground of individual divination to which all should willingly bow, whether it should come from a charlatan, an empiricist, or a physician in good standing. Sound minds have always repudiated the idea of a medical instinct capable of taking the place of knowledge. As Chomel wrote, as early as 1856, we cannot see "in the so-called occult faculty anything but the result of inadequate observation of facts and of a laziness of mind that does not care enough to scrutinize values.' '

It is not true that a given case cannot be judged by observation and by the study of other cases. While it is true that each organism reacts in a manner peculiar to itself under the influence of a disturbing cause, this manner, however, belongs in a type that possesses a sufficient characteristic. When an organism is infected by a pathogenic germ, for instance, it reacts by a set of symptoms which occur with sufficient constancy to be recognized, in spite of individual variations, as those of a definite infection. Likewise, the effect of a medicine is expressed by a reaction which will almost always be of the same order. Individual susceptibilities capable of modifying this reaction are not generally difficult to foresee for one who makes a careful clinical study of the value and mode of the habitual reaction of organs. Thus we are able to foretell with probability, sufficient for the purposes of practice, the action of digitalis in plain asystole, that of morphin on pain, and that of hypnotics. We are even able to foretell that a certain subject will respond to morphin in a manner different from the one usually observed, and that a certain other subject will ill bear certain hypnotics. In specific therapeutics when we have seen twenty cases of malaria yield to quinin, we would know very well that the same result will be obtained in the twenty-first case, so that when we meet with one failure (which may happen) we begin to doubt the exactness of the diagnosis.

Do we not know equally well, thanks to past observation, that we run the risk of poisoning a patient with a certain dose and that we may practically be altogether safe with a certain other dose? Extraordinary tolerance and idiosyncratic susceptibilities do not at all invalidate the general rule. They do not surprise the conscientious clinician who has familiarized himself with the functions and habitual reactions of all the organs. While we have our minds open to all sorts of individualities, we are in possession of such probabilities as to the effect we are going to obtain that we practically go ahead with sufficient certainty. There should, therefore, be felt no hesitancy to utilize established ideas because of sophisms and paradoxes which tend to minimize their value. The truth is that the better we know the patient as a result of profound mastery of pathology, pathological physiology, and clinics on the one hand, and are in possession of pharmacodynamics and therapeutic ideas derived from precise observations on the other, the more easily will we foresee the action we are to exercise upon a given patient.

Finally, we must also refute the paradox of those who allege the variations of therapeutics as a reason for denying established results. These skeptics say, without reflection, that such and such a medicine has been a favorite at a certain epoch and thrown aside a few years later; similarly, methods of treatment once judged to be excellent have been abandoned by even those who had advocated them. These variations cannot be denied, but what do they prove? When we analyze these variations, we see that they confirm the necessity of thorough therapeutic study. Some of the changes are due to the incessant progress of therapeutics. Take, for instance, a marvelous medicine for acute articular rheumatism, salicylic acid, which does not cure without some inconvenience; should there be any denouncing if some day it undergoes such a modification as to free it from its inconveniences? Is there any proof of error in the fact that quinin is substituted for cinchona, mercurial injections for ingestion of pills or solutions, organic phosphates for mineral ones, and asepsis for antisepsis? Such changes are evidences of progress, not of therapeutic caprice.

Other and more numerous variations are due to the fact that new drugs or therapeutic procedures, inadequately studied, come into undeserved notoriety through influential patronage or shrewd advertising. A physician who is not satisfied with mere assertions for prescribing a medicine, but demands sufficient facts in order to appreciate its real value, will not have the embarrassment of being obliged to change his opinion. With a rigorous method the variations would be greatly lessened.

Let us, therefore, study conscientiously and patiently the ideas which offer the character of certainty and take them as the basis of our practice. When this basis is absent, we shall do our best to soothe our patients, and we shall listen, without high illusions, but also without contempt, to the promises of empiricism, nor shall we deem it forbidden to deduce from what we know that which still eludes us. Thus we shall sometimes have the satisfaction of success and always that of an honest practice.

Scientific therapeutics has two supports: on the one hand, clinics and pathological physiology which enable us to understand the needs of the patient, and on the other, the remedies that are its means of action.

The name remedy is given to all agents, no matter of what nature, employed for the purpose of correcting the disturbances of health. Remedies are very numerous. They are borrowed from objects of chemical study, from natural sciences, physics, psychology, morals, and natural media. The most immediately powerful are the medicaments. Medicaments or medicines are substances employed for the purpose of curing, aiding a cure, soothing, or concurring to the repair of a diseased organism.

It is well, from the very beginning of these studies, to call attention to the important fact that a medicament may become a poison (even though it be an integral part of our organism) under certain conditions of dose, repetition, administration, or retention; such is, for instance, the case with chlorid of sodium. What we mean is that, under certain conditions, a medicinal substance is capable of causing the cellular elements to undergo profound modifications, so as to impair their vitality by chemical, physical, or even mechanical action.

The complete study of medicaments is called pharmacology (<t>dpixaxov, medicament, Aoyos, study). This term is used to designate only the study of forms under which drugs present themselves, of their preparation and mode of administration. Of late, however, its study has also embraced pharmacodynamics, and all that concerns drugs: materia medica, pharmacy, and even pharmacotherapy. This enlargement of the sense is against usage.

Pharmacodynamics (or active force of medicaments) is the study of modifications exercised on the organism by drugs.

Pharmacotheraphy is medicinal therapeutics.

Therapeutics, however, makes use of many other modifiers, for instance hygiene, physical and natural agents, psychic actions, surgical actions. We propose to speak of the manner in which these various forces can, by judicious application, cure or palliate, or favor the reparative efforts of the organism.

Such as it is, and it is very extensive, the intervention of the therapeutist alone would still be incomplete. In the etymological sense of the term, therapeutics does not only include prescription, it also supposes execution. Like the surgeons whose organizing minds reveal themselves in all the details concerning environment and assistants, the physician must organize the minute execution of his medicinal and hygienic prescriptions. To this effect, it is indispensable to include in therapeutics the influence of the pharmacists, the action of nurses, and the realization of all environmental conditions calculated to insure for the sick the optimum of functioning as well as the removal of all causes capable of giving rise to complications or a new morbid state, or of hindering the effects of therapeutic intervention. The genius of Hippocrates could not fail to see that the patient, the attendants, and external things must concur with the physician to combat the disease. The precept is forever true.

Chapter II The Forms Of Therapeutic Action

The objects of therapeutics and the means of realizing them — Their division into four groups which are: 1. Therapeutics of the disease; 2. Organic and functional therapeutics; 3. Symptomatic therapeutics; 4. Reparative therapeutics — Interpretation of the terms empirical, expectant, naturist, pathogenic therapeutics — Is there a nosopoietic therapeutics?

OBJECTS OF THERAPEUTICS

The question has been raised by some whether therapeutics should begin with the patient or with the remedy. In reality the starting-point of all good therapeutics is double; it is simultaneously constituted by the knowledge of the patient and by that of the remedy.

The patient must be thoroughly examined by the concurrence of all the senses (assisted if necessary by laboratory resources) in such a manner as to permit nothing to escape attention, from the form of fingers, the color of the skin, including that of the palm of the hand, and the color of accessible mucosse to the functions of all the organs, and the record divided into two parts, one including everything that is normal and the other all that is abnormal.

The normal features will help the therapeutist to determine the diagnosis and prognosis, as well as the therapeutic aggression which can be endured by the patient. Analysis of the anomalies will often enable him to establish the diagnosis; failing in this, it will in any case reveal the organic and functional deficiencies, their degree and importance; the symptoms whose nature, intensity, and duration may be dangerous and finally, in some instances, lesions or histologic alterations or chemical adulterations. Of these various elements some are accessible to therapeutics, others to the natural defenses of the organism, and still others remain beyond the reach of all our means of action.

CLASSIFICATION OF THERAPEUTIC MEASURES

The needs of the organism, having been clearly established, are to be met by the resources of therapeutics. These may be grouped into four classes as they concern the disease, the organs, the lesions, or the adulterations. Accordingly, there are four different objects and four orders of means constituting as many different modes of treating the sick.

I. Therapeutics of Disease. — This has been qualified in various ways. The most rational qualification is that of nosocratic (vocros, disease, KpaTtiv, to triumph) created by Requin 4o designate the medicaments which attack the cause of disease. This expression is excellent inasmuch as it implies no foreknowledge of the mode of action of remedies; it simply indicates a fact of observation, that the remedies cure the diseases. However, in order to express the most probable mode of action of this category of remedies, Fonssagrives has proposed the word etiocratic which specifies a class of medicines directed against morbid causes.

I would prefer this expression to that of etiological therapeutics which has been adopted by modern authors (Arnozan, Gilbert and Boinet, Roger). In fact, the word etiology designates all of the morbid causes and not the direct cause alone. Thus it is said, regarding the etiology of pneumonia, that one of the causes of this disease is cold (pneumonia a frigore); in speaking of saturnism, the etiological influence of occupation and of water pipes is mentioned. Can therapeutics reach these causes? If not, why speak of etiological therapeutics when the latter is concerned with only one of the morbid causes — the immediate cause, constituted by the pathogenic agent? If we were only sure that the so-called etiological medicines exerted their action on this cause, we would disregard the lack of precision of a word which, after all, would express an exact idea; but this assurance exists only for a few among them.

In order not to go beyond what we know, the expression adopted should be confined to the fact that certain medicines are capable of curing certain diseases. The word nosocratic can therefore quite properly be applied to these medicines; the expression would be above criticism if there were not already simple expressions to designate the therapeutics dealing with the disease, as when we speak, in plain English, of therapeutics of the disease, as opposed to that dealing with an organ, a function, a symptom, a lesion, or a chemical adulteration.

Therapeutics of the disease is that which is concerned more with the disease than with the patient. It has been taught and repeated that there is no treatment of disease, but only of the sick. In its absolutism this formula is inexact; it is simpler and truer to say that it is necessary to individualize therapeutics. This is a most fundamental principle the applications of which will be referred to in almost every page following. When sulphur is prescribed for itch, quinin for malaria, mercury for syphilis, and antidiphtheric serum for diphtheria, it is in reality for treating the disease; there certainly exist, therefore, treatments of disease. But if one should indiscriminately apply the same treatment, that of itch, for instance, to adult men and to children or women with fine skin, or to patients suffering from grave dermitis, one would run the risk of provoking serious accidents in the latter. Individuality intervenes, therefore, in all therapeutic circumstances. It intervenes in order to modify the choice and dose of the remedy, its repetition and mode of administration.

We must conclude that there is a treatment of certain diseases, the number of which is quite limited. This therapeutics of the disease will constitute one manner of dealing with a patient. It is resorted to whenever it is possible to act upon the disease itself; we may place under it five groups of medicaments:

1. Specific medications properly so called.

2. Indifferent anti-infectious medicines (non-specific).

3. Antiseptics.

4. Antiparasitics.

5. Antidotes or chemical neutralizers, and eliminators.

1. The name specific is given to those treatments whose favorable effects are so striking, so immediate, and so constant as to lead to the admission of an action upon the very cause of the disease or the disorders constituting it. As this cause characterizes the morbid species, it is natural to call specific the therapeutic action directed against it. But we do not know exactly whether this action attacks the morbid cause directly or acts through the organism whose means of defense would be specifically aroused, or whether these two means are utilized sometimes separately and at other times concurrently <