THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES ^^3 TREATISE THEEAPEUTICS TKANSLATED BY D. F. LIXCOLX, M.D., FROM FEENCTT OF A. TEOUSSEAU Professor of Therapeutics in the FacitU>/ ofJledi- cijie of Pari" : PInjrsician to the Hotel Dieic ; Member of the Academy of Medicine ; Com- mander of the Leffion of Honor ; Ex-repre- gentatire of the People in the Constituent Assembly, etc. 11. PIDOUX Member of the Academy of Medicine ; Honor- ary Physician to the Huspitals : Inspector of Eaux-Bonnes; Honormu J'resident of the Societe Ue Therapmtlque ; Honorary Member of the Royal Belgian Academy of Medicine, etc. NINTH EDITION REVISED AXD EXLARGED, WITH THE ASSTSTAXCE OF CONSTANTINE PAUL Professeur Agrege in the Faculty of Medicine of Paris ; Physician to the Hopita', Saint-Antoine ; Secretarie General of the Socieli de Therapentique. Volume I. NEW YORK WILLIAM WOOD & COMPANY 27 Geea-t Jones Street 1880 Copyright, 1S60, by WILLIAM WOOD & COMPANY. Trow's painting and bookbinding company, 201-213 Kdst \-2.th Street, NKW YOKK. Bw»edical lArary we CONTENTS CHAPTER I. — Reconstituents. PAGE Iron 1 Tonic treatment in general 29 CHAPTER II.— Astringents. Tannin 73 Oak bark, tan 77 Walnut 78 Uva ursi, comfrey, whortleberry 80 Catechu 81 Kino 81 Rhatany 83 Paulliuia, or guarana 8(5 Creasote , 87 Lead 89 Alum 94 Bismuth 99 Tonic astringent treatment 103 CHAPTER III.— Alteratives. Mercury 115 Iodine .• 137 Iodoform 1 59 Cod-liver oil 101 Arsenic , 169 Gold 185 Platinum 188 Silver 189 Soda 193 706057 IV CONTENTS. PAGE Borax 198 Lime 199 Baryta 203 Lithia 203 Ammonia and comi^ounds 204 Chloride of sodiuiu 210 Alterative treatment in general 213 CHAPTER IV.— Irritants. Potassa 225 Soda 228 Silicate of sodium 229 Lime 229 Ammonia 231 (Jompouuds of ammonia 236 Chlorine 238 Hydrochloric acid 240 Alkaline chlorides 241 Silver 243 Sulphuric acid 246 Zinc 247 Copper 251 Antimony 252 Mustard 253 Cantharides 260 Ranunculaceas 269 Euphorbiacea3 270 Pitch— Turpentine 272 •Resin of thapsia garganica 272 Substitutive irritant treatment 274 Transpositive " " 285 Spoliative " " 296 Excitative " " • 301 THEKAPEUTIOS. CHAPTER I. EECONSTITUENT KEIvIEDIES. Iron. Chlorosis. Tx order to form a just idea of the action of the ferruginous drugs, it is necessary to consider the disturbances produced in the system by modi- fications in the crasis of the blood. A number of disturbances occur after a full bleeding, no doubt owing to the fact that the organs no longer receive an amount sufficient for the discharge of their functions. In proportion as the loss of blood is re- paired, these disturbances cease. But, if the bleedings are repeated so often that the blood cannot be renewed, if the supply of nutriment is not sufficiently rich to furnish materials for such renovation, or if a malady, unknown in its essence but very common, blanches the blood to an extent even greater than the most abundant bleeding will cause, a condition of the system supervenes which is known in women by the name of chlorosis, and in men is termed anaemia. Chlorosis is almost always spontaneous. Anfemia is almost always secondary. It is not easy to say why chlorosis is the almost exclusive property of vFomen; but every one knows that it is extremely rare to find a young man chlorotic. It has been supposed that this fact might be explained by the differ- ence between the composition of the blood in the two sexes. Analysis proves that, in general, the blood of a healthy woman contains a little less of the globules* than that of a man in good health. But, admitting that this difference is not without some influence, it is more rational to suppose that the real cause of this remarkable pathological fact resides in conditions inherent in the sex. The analysis of MM. Andral and Gavarret demonstrate that in 1,000 grammes of normal blood we find, on an average, 137 grammes of blood- Z THERAPEUTICS. globules; while in the case of chlorotic persons the amount may fall to 38, the quantity of fibrin remaining* nearly the same as in women in health. These analyses account for the pallor and the liquidity of the blood of chlorotic patients, and perhaps for the greater part of the singular symp- toms of which they complain. One can see how the blood, robbed of a part of its stimulant principles, ceases to be fit to modify the organs, and that numerous functional troubles are the result. The muscles of animal life lose color, become atrophied and relaxed; hence arises difficulty and slowness of motion. The mviscles of organic life share in the same changes; hence, flaccidity of the heart, difficult circulation, sluggishness of the stomach, constipation, flatulence. Final- ly, the blood which reaches the nervous centres, the glands, and tlie membranes, no longer possessing its natural qualities, these organs can no longer exercise their functions as in their natural state. If, then, we were to restore to the blood the principal elements which it lacked, we should make it again capable of exerting its regular inilu- ence upon the economy. This end is attained by Iron. How does iron act in chlorosis ? Upon this point there are two very distinct opinions. The majority at the present day believe that iron, when absorbed, passes directly into the blood, is there precipitated in the form of oxide, restores to it immediately the principles which are wanting, and makes the blood a reparative fluid at once. Others attribute to this remedy a purely tonic action, in virtue of which the digestive and nervous functions are so influenced as to make innervation and nutrition more perfect — the organic restoration taking place indirectly, by means of this tonic action. In support of this opinion we are able to quote the authority oi Claude Bernard ("Legons faites au College de France," published in the Union medicale, 1854). " The real question," says this eminent physiologist, " is not, whether iron cures chlorosis, but, in the first place, whether chlorosis is due to the absence of iron, and if iron given as a medicine will fill the place of that which is wanting. " Certain authors have claimed that the proportion of iron in the blood of chlorotic jicrsons was lessened, but they have not proved the fact chemically. Those, on the contrary, who have made the analysis, have found that the amount of iron was the same in chlorosis as in other cases. It is true that in this disease the amount of globules is diminished. " Let us suppose — as is probable — tliat there are about 6 grammes of iron in the mass of the blood, and that in chlorosis the blood loses '■) grammes. If all the iron which is given were absorbed, we should soon see the blood regaining this amount; but we know that it requires at least a month, and often much longer, to cure the disease, in spite of the masses of iron which are swallowed." EECONSTITUENT REMEDIES. 3 Another difficulty liere meets us: we cannot positively prove the ab- sorption of iron in the stomach or intestines. Bernard injected iron-fil- ings — the lactate, etc. — into the stomach, but was never able to discover in the blood of the portal vein a larger quantity than is usual. "But," continues Bernard, "since iron exists in the food, a certain combination may be required in order to effect absorption." There is, however, one fact which is positive and perfectly demon- strated: the salts of iron (adds Bernard) exercise a special action upon the gastric mucous membrane. Every portion of the membrane which is touched by them assumes a more active circulation. Iron, therefore, is a direct excitant. In conclusion, Bernard puts this question: " May not chlorosis be due to a faulty digestion ? May not iron re- establish these disturbed functions by the excitation it produces ? " It is possible that Bernard has not said the last word upon this ques- tion. But we see that the data furnished by chemistry are far from satis- fying him; and, if he has not yet solved this grave difficulty, he at least has the merit of placing us on the road to its solution. Two points remain to be settled: on the one hand, the conditions which favor the absorption of a certain quantity of iron by the stomach are to be determined, for such absorption seems to us unquestionable, though it be not fully demonstrated by chemistry; on the other hand, the mysterious combination must be ascertained, which enables the mi- nute and imperceptible absorption to take place. And finally, we must discover the secret of the mechanism by which the atoms of iron, drifting through the circulation, revivify the impoverished and altered globules, and build up the body. The facts, or such as seem best demonstrated at present, are as fol- lows: 1. The blood of chlorotic women contains less of the globules than is the case in well women. 2. Under the use of the chalybeates, the blood usually recovers quickly the cruor and the globules which it had lost. 3. Iron given to chlorotic patients seems to have two methods of action, dis- tinct, but equally necessary. For, firstly, it acts as a tonic and direct ex- citant of the stomach, or (if we prefer the expression) as a special modifier of the peptic sense; and secondly, a part of the iron is very probably dis- solved in the gastric juice and absorbed, coming directly in contact with the inner coats of the vessels; while, by virtue of an action which we call dynamic or vital, without attempting to examine or to define it, the med icine by slow degrees places the impaired functions of h^ematosis* upon a normal footing. It is the combination of these two actions that recon- structs the blood-globules, and finally cures chlorosis. Such, in our opin- * We refer especially to that action of vital chemistry which taken place in the great circulatory system : an important action, too little noticed by our physiologists. which commences in the left cavities of the heart, is continued in the entire circuit of the blood, and is perfected in the capillary extremities. 4 THERAPEUTICS. ion, is the true part played by iron in chlorosis; such, at least, is the in- terpretation which seems to us most rational and acceptable, drawn from the most recent researches in organic chemistry and experimental physiol- ogy, and in harmony with good sense and tradition. Chlorosis, till very lately, was a triumph for the defenders of the chemical theory. " Evidently," said they, " this disease is due to a di- minution of the iron in the blood. By giving iron, we restore the princi- ple which is wanting, and the disease is cured. What is more simple, clear, and decisive ? " Unfortunately, the two bases of their theory, supposed to be unassail- able, have been shaken by experiment. And we may add that, in the recent long discussion in the Academy, the chemists of most authority offered no new argument in support of their theory. The result of this debate and the general tendency of opinion show that chlorosis will soon, like the rest of pathology and therapeutics, be surrendered to the vitalists. Chlorosis, we do not hesitate to say, rules the pathology of woman; and the physician who cannot recognize this affection in its various forms- will often fail in treating this class of diseases. M. Nonat infers from the frequency of abnormal bruits in the neck of children that eight in ten are chlorotic (Acad, de med., 18 Septembre, 1860). This is hardly the place for a pathological dissertation; but, as we entertain certain views upon chlorosis wliich are not generally admitted, we shall have to place the reader at our own point of view by an explanation ; it would other- wise be impossible for him to understand the close connection between affections which seem very distinct, but which, recognizing the same cause, obey the same therapeutical agency — that of iron. In its most marked and unmistakable form, chlorosis is accompanied by the following symptoms: General loss of color of the skin and the mucous membranes; slight emaciation, puffiness of the face and the lower extremities. Nervous condition, hysteria, melancholia, mobility, muscular debility. Neuralgic pains, usually of irregular type. Increase or diminution of the volume of the heart; ventricular impulse sometimes more energetic, sometimes more feeble than in a condition of health ; bruit de souffle, generally soft, with the first sound of the heart; second sound sometimes sharp; various souffles in the great arteries, espe- cially the carotids, subclavians, etc., and in the veins of the neck. Pulse more frequent than in health; febrile heat, dryness of skin, thirst. Panting upon the slightest movement; palpitations. Dyspepsia, pyrosis, depraved appetite, gastralgia, sometimes vomiting, habitual constipation, diarrhoea when the disease has lasted a great while. Menstruation painful, irregular, scanty, wanting in color, absent; leucorrhoea; menorrhagia; sterility. Such is the picture (or the outline) of chlorosis. Under the influence EECONSTITUENT KEJVIEDIES. 5 of ferruginous preparations, this frightful array of symptoms usually dis- appears with rapidity. " How should iron be given in chlorosis, in what dose, and how long ? " These questions have hardly been touched by therapeutists, and few practitioners have taken the trouble to study deeply. We except Syden- ham, who has given the principles of good treatment, but has not suffi- ciently insisted on certain minutiae, of the great importance of which we are convinced by long experience. The slightly soluble preparations ought to be used in general at the beo-inning of treatment. Iron-filings, aperient crocus martis, hydrate of peroxide of iron, occupy the first rank. They are given in powder in a spoonful of broth, or in preserves, morning and evening, at the two chief meals, in doses of from 5 to 15 centigrammes (-8 to 2-d grains). If this dose is easily borne, it is gradually increased, until by degrees the quan- tity of one or two grammes (15 — 31 grains) at each meal is reached. It is essential that the remedy should be taken at the beginning of the meal, for, if taken in the morning fasting, as is sometimes ordered, the patient feels a weight at the stomach, and a great sense of disgust, and loses appetite. There is another reason for giving it at meals, for it is only at those times that the gastric fluids contain a sufficient quantity of acid, while, a little before eating, they are slightly acid or neutral, and sometimes even alkaline. If pyrosis exists, the best time for taking iron would be, for obvious reasons, the interval between meals. If slightly soluble preparations are well borne, and if improvement does not occur, we must give soluble preparations, and in particular the tartrate of iron and potassium, given in pills or in gaseous waters. For certain women, we prescribe the tartarized tincture of iron, ferrated water, chalybeate wine, etc. This treatment is not to be interrupted at the monthly period, and is to be continued till all the symptoms of chlorosis have disappeared. We then cease giving it; a month later we resume it, and continue it for two or three weeks. Then we leave an interval of two months; then we give the iron for a fortnight; and this plan is to be followed up for five or six months, for if it be easy to cure chlorosis, it is hard to cure it in such a way as to be secure against relapses, and relapses are always to be feared if we suspend the use of iron suddenly. Chlorosis is considered by some pathologists as a very slight malady; but we consider it a very serious affection which many women never for- get as long as they live, being either in continual danger of a relapse, or else (as is more common), in continual trouble from some of the functional disturbances which come in the train of chlorosis, although apparently in health. It is also a fact which is observed as one grows older in practice, that iron, after having relieved the worst symptoms, sometimes becomes all at once impotent. The remedy, in such cases, acts with a certainty inversely b THEKAPEUTICS. proportioned to the duration of the complaint and the number of the relapses. Some patients have a singular experience. For a while they bear large doses of iron and improve rapidly, but suddenly they find the remedy disagrees with them, and seem to be in a sort of state of satura- tion. The ph^'^sician should then pause, and begin again according to the method which we have mentioned above. Evident as may be the indication for the use of iron, it is not alwavs easy to fulfil it. The condition of the stomach and intestines — a suscep- tibility which cannot be foreseen — may form a great obstacle. Yet we ought to keep the aim constantly in view, and to persevere for weeks or months in modifyiiig this irritability, or accustoming the system to the effects of iron. Nevertheless, when the signs of chlorosis exist, we must suspect a woman who bears iron badly, for such intolerance is usually the sign of a bad diathesis. When chlorotic patients are disposed to diarrhoea, iron ought not to be given at first, and the soluble forms should never be prescribed. For a time we should give subnitrate of bismuth, Colombo, diascordium, j)lios- phate of lime, in the dose of 25 to 50 centigrammes (3*8 — 7*7 grains) at each meal, nitrate of silver in the dose of 1 to 5 centigrammes {'15 — '77 grain) in a draught taken during the day, to check the diarrhoea. When we have reason to suppose that the gastric irritability is quieted, we give at first, with the above, small doses of iron-filings, or of any other slightly soluble preparation, gradually increasing the propor- tion of iron until it is borne in the amount of 1 or 2 grammes (15 to 31 gr.). When there exists stubl)orn constipation, we add a soluble salt (as the tartrate or citrate) of iron, in pill, to aloes, and a little belladonna ; giv- ing per diem 5 — 10 centigrammes of aloes ("7 to 1'5 gr.), one or two cen- tigrammes of extract of belladonna ("15 to '3 gr.), and 75 centigrammes, 1 gramme, 2 grammes of the iron salt (12, 15, 30 grains). Aloes has here the double advantage of acting as a laxative and as an emmenagogue. It follows that, if menorrhagia exists, as it often does, aloes must not be given, but in its place powdered rhubarb, or (still bet- ter) magnesia, to be taken before bedtime. It is a received opinion among physicians, that chlorosis is confined to young girls„ febris alba virginum. This idea, generally received, is false in every respect, and it daily gives rise to mistakes which have a very fatal effect upon the treatment. Chlorosis is in general a disease of adolescence, but it is also very frequent in adult life; it appears in women at the change of life; and we have seen it twice at a later period — in a woman of fifty-two, and in another of fifty-seven, both of which cases were characteristically marked, and were easily cured by iron. We long regarded iron as a harmless agent, which it was not easy to abuse. Now that we have grown a little old in practice, we declare that KECOISfSTlTUENT REMEDIES. 7 we have repeatedly seen patients whose death seemed to us due to the untimely use of preparations of iron. It is easy to see, a priori, that by increasing- the stimulant properties of the blood in a healthy person, we predispose him to diseases to which he had no previous tendency. It is also easy to understand how a woman, whose blood has lost three-quarters of the normal amount of globules, may, while suliering from the accidents which belong to chlorosis, enjoy a certain immunity from the diseases which attack by preference persons whose blood is rich in these elements. In some instances, women, though strongly predisposed by constitu- tion or inheritance, have escaped all complaints of the chest for several years, while in a chlorotic condition; but when subjected to treatment with iron, acute phthisis has quickly followed the cure of the chlorosis. These are positive facts, and they have been so often repeated in our sight, that we now refuse to give the preparations of iron to chlorotic women, if they have previously had suspicious symptoms of the chest, or have tuberculous parents. In these cases we try to support the strength by neurosthenic tonics, and we are not in haste to use iron, which often is speedily fatal. We desire not to be understood, however, as systematically excluding the preparations of iron from the treatment of pulmonary phthisis. It is important to draw a distinction. We confidently state, as the result of many observations, that iron is usually injurious in the first period of this malady; we mean when the development of the tubercles is accompi;nied by pronounced phenomena of congestion or of irritation of the apparatus of respiration or circulation, as haimoptyses, rough cough, fever with dryness of the skin, sharp pains in the chest, etc. In these conditions, iron, often given as an article of routine treatment, on account of the weakness and the poverty of blood, is formally contra-indicated, as is the ronic and analeptic regimen. But at a later stage the case is changed. If a patient, for instance, has been weakened by repeated or abundant hasmoptyses, and his expec- toration, sweating, diarrhoea, etc., have exhausted him, the iron prepara- tions will then be properly used, to give a little vigor to the languid digestive and assimilative functions. Unhappily, however, in these cases, iron loses a great part of the wonderful virtues which it possesses in chlorosis and in accidental anjemia succeeding sitnple hiemorrhage. But, while it accomplishes nothing against the tuberculous diathesis itself, it is sometimes useful by helping the unhappy patient to struggle for a time with the cachectic state, which is more injurious to him than the local lesion. The greatest circumspection must be used in these cases. Circum- stances may seem imperiously to demand the use of iron, but it will not always be well borne, and in general, it is far from being so harmless as many practitioners imagine. These remarks apply with especial force 8 THERAPEUTICS. to tuberculous phthisis, in which experience has shown that iron gener- ally does more harm than good. Phthisis of scrofulous origin differs from this in the slowness of its course, the slighter intensity of the in- flammatory and reactionary symptoms, and especially in its greater toler- ance of tonics and excitants. Thus, in children who are at the same time lymphatic and strumous, affected with caseous pneumonia and tubercles in the mesenteric glands, it is not uncommon for iron, in moderate doses, to improve the nutrition, sustain the vital resistance, and check the prog- ress of the malady for a time. In general, as we said above, a practitioner ought to distrust a chloro- tic patient who bears iron badly at the outset of the first treatment, or whose condition is not modified by a proper administration of it. He should infer the existence of some latent diathesis, or grave organic dis- ease, or moral affection, holding the chlorosis under obstinate control. The tuberculous diathesis is often masked under the form of chlorosis. The physician vainly attacks the apparent disease; obstinate gastralgia, continued diarrhoea, painful palpitations of the heart, troublesome op- pression, sanguine congestion of the face, especially at evening and after eating, are produced or persist, and the blood is slow to regain the glob- ules which it lacks; happy are they whose blood does not restore itself at the physician's will, for they will pay, by a speedy disorganization of the lungs, for this momentary hope of health. In practice, whenever a young girl has some symptom of chlorosis, or mereh' ana3mia, iron is sent for in haste. A commencing phthisis is thus often spurred into activity. Doctor Millet, of the colony at Mettray, has had more than sixty cases of phthisis in which preparations of iron have been given by nuns or druggists, to the great injury of the patients. A cachexy, which completely resembles chlorosis, is often associated with albuminuria, chronic engorgement of the liver or spleen, or a valvu- lar lesion of the heart. Here, at least, iron does no harm; it is even of unquestionable utility in the treatment of the antemia, which appears to depend on hypertrophy of the spleen or liver, especially when these lesions follow intermittent fevers, and are not accompanied by organic lesion. Component Elements of Chlorosis. The group of symptoms which we have named is not always found combined in chlorosis; most frequently, in fact, some of them are absent. To use the happy expression of Recamier, the symptomatic phrase is in- complete; but it is necessary to recognize it even in its incompleteness, or else we shall fail to attack the root of the malady, and shall be strug- gling with a mere accident, which may be banished for a moment, but will soon return with equal intensity in the same or a different form. Paleness of the blood, and of the skin and mucous membranes, may exist alone without any symptoms besides shortness of breath and disor- RECONSTITUENT REMEDIES. 9 dered circulation. This form is the simplest; it is easily recognized and cured. But quite often the common symptoms of chlorosis, as the nervous symptoms, indigestion, menstrual disturbances, appear together or sin- gly before the pallor has reached its maximum ; and then the common run of doctors — men who require all the elements in order to form a diag- nosis — fail to see chlorosis, which really exists. JVervoics sym2)tot}is. — Women are often attacked by hysteria, by spasms, after great losses of blood, accouchement, lactation; so are young girls at the beginning of chlorosis. Tliese nervous troubles easily yield to preparations of iron, altliough hysterical convulsions are not so easy to conquer as essential spasms. When, however, this spasmodic condition exists in a vigorous, high-colored woman, who exhibits none of the signs of chlorosis, iron increases rather than diminishes the convul- sions. Neuralgias. — These are almost a constant symptom in chlorosis; of twenty chlorotic women, nineteen, perhaps, will have neuralgia. The disease is not always very easy to recognize, and the patient and physician may both be deceived. Women complain of pain in the head or stomach, in the side or legs, etc. A superficial examination shows nothing but a common headache, a stomach-ache analogous to tliat which accompanies difficult digestion, vague pains, attributed to fatigue or ex- haustion; but when they are examined closely their neuralgic nature ap- })ears. The pain in the head occupies the brow, the temples, the region of the jaw, the teeth — in a word, the course of the nerves of the fifth pair and its branches; it scarcely ever attacks both sides at once, but it passes from right to left, or remains fixed in one point. All at once it shifts its place and occupies the region of the stomach, then it leaves the stomach and goes to the intercostal nerves, to the sciatic, or some of its branches, or the various branches of the lumbo-abdominal plexus. Then the ceph- alalgia reappears at the moment when the other pains cease. This inconstancy in the seat of pain is very remarkable and very com- mon ; but sometimes the neuralgia affects a single region, the head, the stomach, or some intercostal nerves. It is rarely fixed obstinately in other parts, but we have observed it in the nerves of the heart, the cli- toris, the superficial cervical plexus, one of the branches of the bracliial plexus, the pharyngeal plexus (Tiirck : Arch, de vied., 18G2); but these cases are rare. These forms of neuralgia, if we attend closely to them, are rarely seen in men, being confined almost wholly to feeble women, with distinct symptoms of chlorosis, past or present. When neuralgia is the leading feature, whether occupying the head or the stomach, it is usually cured by iron, though less easil}^ than simple chlorosis. Temporo-facial neuralgia (called so improperly tic douloureux — a name which should be reserved for spasmodic neuralgia) has been treated 10 TIIEKAPEUTICS. with advantage bv large doses of subcarbonate of iron. Hutchinson, who may be regarded as the author of this method (Benj. Hutchinson: '' Cases of Neuralgia Spasmodica," London, 1812), has observed nearly two hundred cases of cure. He gives from 2 to 4 grammes (30 — 60 grains) of subcarbonate mixed witli honey, three times a day. Wittke has ob- tained the most happy results from it, in the dose of 1^ grammes (22 grains) with |- gramme (4 gr.) of cinnamon, three times a day (Huf eland: Journal, 1828, Vol. 4). The English journals are full of similar observa- tions. M. Caulet reports remarkably rapid cures with the waters of Forges (Caulet: llemarques sur Paction sedative immediate des sources ferrugineuses de Forges-lcs-Jiaux, Seine-Inferieure, 18G7). Having made a great many experiments in the therapeutic use of iron, especially the subcarbonate, and in cases of neuralgia, we can easily see the cause of the differences in opinion which exist. When given to chlorotic women, or in cases of neuralgia in incipient chlorosis, it has usually succeeded ; but if given to men, or to women who were not chlorotic, it has usually failed. These results may be formulated by say- ing that the beneficial effects of preparations of iron in neuralgia are entirely due to the fact that the disease usually depends on chlorosis, which is curable by iron. The cure of neuralgia by iron is not a rapid one, but requires a week, a fortnight, a month, or longer, in order to be complete. If the face is affected we always employ Hutchifison's method to quiet the accesses, and use without delay local applications of stramonium, belladonna, or chloro- form, and hypodermic injections of sulphate or muriate of morphia; when the pain is relieved b}'^ these means, iron becomes of use by curing the general condition upon which the disease depends ; it has thus a powerful effect in preventing relapses. It has not seemed to us that the carbonate of iron has any special utility, but that all the preparations of iron, if given in large doses, possess the same properties. Gastralgias. — In chlorotic women, or women who present some of the .symptoms of chlorosis, gastralgia has certain special features upon which it is necessary to dwell. At the outset it is not continuous, but re- turns at intervals of two, three, or four days; at a later period the inter- vals diminish, and the attacks occur daily, or several times in the twenty- four hours; their return is most apt to be caused by eating something. If the food is of a class which fatigues the patient, the pain may follow directly upon the ingestion ; but in the great majority of cases the time elapsing between eating and the occurrence of pain is at least two or three hours. The sensation is sometimes that of a weight in the epi- gastric region, sometimes it is a pain resembling violent hunger, sometimes cramps or heat referred to the same region; it is usually confined to these ])arts, but may extend to the neighboring regions, and is almost always felt behind the sternum and in the back at the level of the stomach. It is often complicated with intercostal neuralgia, as M. Bassereau has re- marked, and even seems to be an extension of this malady. The pains KECONSTITUENT EEMEDIES. 11 are mostly accompanied by a sense of oppression, revealed by deep in- spirations, yawning-, and a desire to undo the garments which press closely upon the spot. And yet, spite of this frequent and often pro- tracted suffering, digestion is perfect, food is retained, nutrition is elfected suitably, and the freces, b}- their consistency and appearance, in- dicate complete digestion of food. The appetite experiences a more or less distinct alteration, hunger is keen; but as soon as any food is swal- lowed an invincible satiety is felt. Yet some eat much and greedily ; but the meal is hardly ended when they are hungry again, and their hun- ger sometimes comes so suddenly and so frequently that they place food by their bedside to consume in the night. Thirst is commonly increased, though there is neither fever nor excessive secretion; it shares in the de- rangements which all the sensations connected with the digestive canal experience. In a word, sensation is disturbed, and function may be intact. By these marks we recognize distinctly a nervous affection, and we cannot confound these symptoms with those of chronic gastritis, which is commonly accompanied by disgust for food, sharp pain just after eating, difficulty in digestion, and is soon followed by diarrhoea and wasting. We should also remark that the pains dependent on chronic gastritis never disappear, to be replaced by neuralgia of the face or head, and conversely, as is the case in gastralgia. This point is of great import- ance, for when an affection thus shifts its locality, its different manifesta- tions probably have the same seat and nature, as may be seen in the prog- ress of a catarrh or a rheumatism. We have not spoken of heart-burn and vomiting as diagnostic points, for experience has shown us that these symptoms are sometimes found in purely nervous gastric affections, and we think they may be neglected as differential signs. Gastralgia, once established, is accompanied by more or less marked derangement of the intestinal functions; the stools become infrequent, the faecal matters hard, and colics are common. Gastralgia is almost always accompanied by leucorrhoea. This dis- charge gives no indication as to the usefulness of iron, for it is observed equally in certain gastralgias in which iron is far from suitable. The form of gastralgia which is common to men and women who pre- sent no symptom of chlorosis, is of a remarkably fixed character, very differ- ent from that Ave have just described, and often alternating with neural- gic pains which occupy different parts of the body. In women it may coexist with a high complexion, moderate, but bright red menstrual dis- charges, and chronic leucorrhoea; chlorotic gastralgia is also accompanied by leucorrhoea, but the menstrual blood is light-colored, and the complex- ion usually pale. Chlorotic gastralgia is quite readily curable by iron, but the other kind is almost always aggravated by the same remedy. Iron, under whatever form it may be given, is useful in chlorotic gas- tralgia; steel-filings, a'thiops mineral, subcarbonate of iron, hydrate of 1 2 THERAPEUTICS. peroxide of iron, are the forms most commonly used. At the "outset, we should always avoid the soluble preparations, because they often increase the pain. Iron is to be combined at first with a bitter extract and some aromatic. It sometimes happens that a minimum dose of iron increases the gas- tralgia for several days. This will discourage the patient, but not the physician. Let him continue with the same doses until the gastralgia is at the same point as before the treatment was begun; he mav add to the iron some centigrammes of belladonna powder. The dose of iron is then to be increased, and so on until at each meal 2 grammes (30 gr.), or at least 1^ grammes (23 gr.) of filings are taken. Then the soluble prepara- tions may be used, and continued till the close of the treatment. We ought to enjoin the same precautions as are suitable in the treatment of chlorosis, namely: that the iron should be suspended and resumed several times, and even when gastralgia is quite cured. When pyrosis coexists with gastralgia, iron is usually ill borne. We must then begin by giving magnesia in a slightly' laxative dose for several days, and after a little while an infusion of quassia or simaruba. After this preparative treatment, iron will find its opportunity. What we have said of neuralgia of the face is also applicable to gas- tralgia. It sometimes happens — especially in women who have had pains in the stomach for years — that, in spite of the use of iron, and long after the appetite and strength have returned, the gastralgia persists with dis- couraging frequency. In such cases the cure is completed by plasters of theriac, frictions with cerate of stramonium or belladonna, ammoniacal blisters, either simple or dressed with morphine, cauteries, moxas, the in- ternal use of bismuth, magnesia, the poisonous solanacea?, opium. The same list of remedies may be useful in certain cases in combating an in- crease of pain, caused by the use of ii'on at the commencement of treat- ment. It remains to point out certain precepts in regard to regimen. The food which the stomach digests without pain varies with almost every patient; some can endure nothing but milk; some are less tried by meat than by vegetables; others desire meat-pies and similar dishes. These idiosyncrasies must be taken into account in regulating the diet, for we must not imitate those physicians who, considering the diges- tibility of foods as an absolute property, impose the same diet on all their patients; we must have regard to the susceptibilities of individuals, and, however bizarre they may seem, follow the lead which they offer. This is the method which we have followed as constantly as possible, allowing to the patient such articles of food as her daily experience has shown to be the most digestible. We have also striven to limit the quantity to one- quarter or one-half of that which a person in health would take; and when there is no dislike to any article, we order rich broths, white meats, roast meat, etc., avoiding as much as possible the farinaceous vegetables, such as haricots or lentils, the too frequent use of which in hospitals is RECONSTITUENT REMEDIES. 13 certainly one of the causes which render success less frequent in them than in private practice, in which green vegetables and fruits are pre- scribed. Neuralgias occupying other parts than the nerves of the face and stomach must be treated exactly like temporo-facial neuralgia as regards local means; and as regards the chlorosis, by general means. Asthma. — Amaurosis. — W/ioojnng-cough. — There are certain neuroses which have been advantageously treated by iron, among which are the above. Nervous asthma has been cured by M. Battaille of Versailles by mar- tial preparations continued for a long time in large doses. He has treated three cases thus: all were women; the first was evidently chlorotic, while the other two did not seem to be. But even if the asthma were an acci- dent of chlorosis, the therapeutic success of M. Battaille is still of great importance, as serving to confirm the fact which we have so often men- tioned, to wit, that therapeutic indications are more frequently drawn from the general condition of the patient than from local symptoms. M. Blaud of Beaucaire has reported in the Bulletin de therapetttique (t. XVII. Nov., 1839) the case of a chlorotic woman who had suffered from amaurosis for a year. The physician believed that the blood, in its existing state of impoverishment, did not supply a proper stimulus to the organ of sight. He gave iron, and the patient recovered her sight and her health at the same time. M. Bretonneau made the same observation in the case of a man who had become cachectic as a result of prolonged intermittent fevers. In whooping-cough, Drs, Steymann and Chisholme have praised the subcarbonate of iron. This remedy is not employed alone at all stages. The authors strictly prohibit it during the first period, and order that emetics shall always be given previously. Several well-proved facts seem to bear testimony in favor of this treatment. The dose of subcarbonate is from 50 centigrammes to 4 grammes (8 — 60 grains). In a few davs, according to these physicians, the violence of the attacks ceases, and soon nothing remains but a catarrhal cough. We regret that we liave not tried this plan in our own practice. Menorrliarjia. — Amenorrhcea. — Ilcemorrhage. — Ancemia. — Many physicians, good observers, too, think that chlorosis is necessarily char- acterized by a marked diminution or a total suppression of the monthly flow. They regard the menorrhagia, that is, the excessive flow, as so rare an occurrence that they formally exclude it. But they cannot have failed to see often, in their own practice, women who are deeply anaemic and suffer from all the general symptoms of chlorosis, who sifffer abun- dant losses of blood every month. In this case they make a distinction; they call the latter class anaemic, and those whose menses are deficient, chlorotic. And yet, as we just said, these anasmic women have all the symptoms of chlorosis — the extreme pallor, the deficient color of the blood, the 1 4 THERARE UTICS. bellows murmur in the heart and the chief vessels, and the various neu- ralgias; so that, if we should examine all their functions except those of the generative organs, we could not fail to see chlorosis. We shall try, in our turn, to make a distinction between anaemia and chlorosis. Anaemia is an accidental condition, caused directly and without an intermediate stage by a great loss of blood; a person becomes anaemic in a few days or hours. Chlorosis is a permanent malady, usu- ally slow in developing, and slow to leave the patient; always ready to he produced by apparently the most indifferent cause. Anjismia is essen- tially a transitory state; a few weeks are enough to restore the blood and the strength completely, without any other remedies but a good diet. Relapse is never to be feared unless a new loss of blood occurs. M. liurcq has added certain other points of distinction. He says that he has observed that cutaneous sensibility is normal in anaemic patients, and changed in the chlorotic; the antesthesia differs in the different regions of the skin. He adds that muscular force in the anaemic is nearly equally diminislxHl in all the muscles, while in the chlorotic the loss of force differs in the different groups of muscles; in an anannic person, the rela- tive power of the right and left arm, for instance, is as in health, while in the clilorotic, the right side may be more weakened than the left, or in- versely if the person be left-handed {Gazette cles hopitaux, 1864, p. 118). Up to this point the distinction is as clear as possible; but in practice, nature by no means divides the sick into two such separate camps. We may see every day the action of moral causes in producing chlo- rosis in a woman or girl; still oftener, the malady dates from the first application of leeches, which evacuated but a small quantity of blood. If we understand this, we can easily see how an abundant bleeding at the nose, venesection, or repeated leechings, or a large menstrual dis- charge, may bring a patient into such a condition that chlorosis appears. Instead of simple anjiemia, transitory, and curable by nature unaided, there is a special state of the economy in which the blood becomes more pale and fluid every day, although the original losses of blood have not been repeated. Here, then, anaemia has become the starting-point of chlorosis; it has predisposed the economy to chlorosis, has rendered the latter easy, and its development rapid. It is now proper to see what part antemia and chlorosis may play in hitmorrhages. We need not attend to the classic distinction between active and pas- sive hiemorrhage; but we must admit that haemorrhages from the uterus, and othei*s, are sometimes associated with a condition of energetic reac- tion and a superabundance of life, and at other times occur in persons in exactly the opposite state. We will admit tliat in all liiemorrhages (traumatic and hypostatic excepted) there is a previous local action, analo- gous or identical with the first phenomena of inflammation; but we must exclude from present consideration all except general organic conditions. RECONSTITUENT REMEDIES. 15 The general state of the system plays here an extremely important part. When the menstrual molimen is the same, but the condition of the blood is different, it is impossible that the flow should not be consid- erably modified by the degree of plasticity of the blood; and, in fact, it is modified. To take the simplest case first: see what happens in a recent wound in a vigorous, plethoric man, and in one who is profoundly anaimic. In the former, the haemorrhage is slight and quickly stops; though large arterial trunks hav'e to be tied, it is needless to use a haemostatic to arrest capillary bleeding; but in the other, even after the smallest trunks have been tied, a considerable amount of blood or of reddish serum con- tinues to flow, which stains the dressing deeply, and by its abundance may involve danger to life. What is observed in men may be seen in the different species of ani- mals. A dog's legs may be cut off, he may suffer enormous mutilations, without danger to life from htemorrhage, while rabbits die from bleeding after a slight wound. The plasticity of the blood of dogs forms an obsta- cle to haemorrhage, while the liquidity of the blood in rabbits favors it. The tendency of ancemic persons to haemorrhage is marked, from the moment the loss of blood has occurred. If leeches are applied to a child for the first time, the loss of blood will be much less, other things being equal, than that which will follow the second application; and this, still less than at the third; until (as we have, unfortunately, often seen) the bite of one leech may cause a fatal haemorrhage in a child previously ex- hausted by bleeding. But if antemia, considered as a transitory and as it were acute condi- tion, may have such an immense influence on hiemorrhage, how much greater will be this influence if it has lasted for a long time, especially if chlorosis with all its accompaniments has been developed ! Now let us transfer to the mucous membrane of the uterus that which we just said in general. If a woman or a girl has an excessive menstrual discharge, the interval between the periods will doubtless suffice for some months to restore the blood; but the repetition of the same accident will soon bring on antemia, and at last chlorosis. If the molimen remains the same, the flow, as we showed above, will become more abundant, and chlo- rosis, a cause of the increase of haemorrhage, will itself be aggravated by the hiBmorrhage; and the patient, revolving in this circle, will soon be in danger. Let us therefore not lose from sight these leading facts: chlorosis is produced by excessive menstrual discharges; chlorosis may render the discharge still more profuse. In other words — Too copious menses cause thinness and dissolution of the blood; Thinness and dissolution of the blood are a cause of uterine haemor- rhage. There is, then, a form of chlorosis which might be called inenorrliagic. Is this form common in young gii'ls ? It is rare; we estimate from our 1 6 THE K APE UTICS. records that it forms the twelfth part of the cases. In adult women it is more common. Yet we would say that our observations in private and hospital practice do not include a sufficiently large number of facts to fur- nish complete statistics. We have collected a considerable number of cases of menorrhagic chlo- rosis, both in young girls and in married women. Not one of these pa- tients had uterine lesions; this fact we proved by examination of all the married women; but in the case of the girls, where such examinations would have been difficult and unsuitable, we judged from the rapidity of recovery, and the good health which we observed for several years after- wards, that the uterus was exempt from severe lesions. In speaking of treatment, two principal points are obvious: one, men- orrhagia; the other, chlorosis. Menorrhagia is combated by remedies which we usually think contra- indicated in chlorosis; the treatment of chlorosis is supposed to be apt to excite the menstrual flow. It would seem impossible to avoid, striking upon one of these two rocks. Let us consider whether the preparations of iron are really emmena- gogues. It cannot be doubted that iron restores the health and the ute- rine flow in achlorotic woman who has amenorrhoea; but does the iron act as an emmenagogue or as a reconstituent '? Whenever we give ferruginous drugs in cases of chlorosis complicated with amenorrhoea, the first phenomenon observed is a return of color to the tissues, and at the same time, diminution of the depraved appetite, the pains in the stomach, the palpitations of the heart, shortness of breath, bellows murmur in the blood-vessels, thirst, etc., so that, after six or eight weeks of a properly conducted treatment, the appearance of most vigorous health returns; all goes well, but the courses do not yet ap- pear. If we continue the treatment it is not rare to see actual sanguine plethora supervene while the menses are still absent. Health is then re-established, chlorosis is cured — but amenorrhcea persists. Soon, in their turn, the menses appear and take the normal course. In such a case, iron acts at first as a reconstituent; and after the health has been re-established, the functions of health, including men- struation, are re-established in their turn. The patient does not recover health because her menses have returned under the influence of iron, but, on the contrary, the menses return because health has been recovered under the influence of iron. The point is completely proved, for if it were otherwise, we should have seen the return of menstruation give the signal for the return of health; whereas the contrary has occurred It is because they have not followed the evolution and succession of these different phenomena that practitioners have always imagined iron to be an emmenagogue; and this error, accredited for ages, will long continue to prevail against the most manifest facts, against the closest observation, for we are so made as to like to hold to an error, and to resist truth obstinately. KECOlSrSTITrrENT EEMEDIES. 17 To go further, not only is iron not an emmenagogue, but, on the con- trary, it is a haemostatic. Thus, the experiments we have made on a large scale in our hospital show that, in women whose menses are regular, and who are free from chlorosis, the use of iron most frequently retards the menstrual flow and diminishes it. We say most frequently, and not always. • Next, let us see how the indications in menorrhagic chlorosis are sim- plified : Leading indication, to treat the chlorosis. Secondary indication, to treat the menorrhagia. And the latter is so truly secondary that we scarcely ever have time to attend to it. In fact, by giving iron in large doses between two menstrual periods, we easily restore the plasticity of the blood; before twenty-five days are past the complexion has regained almost its normal color, the subcu- taneous veins have recovered their volume and their bluish tint. When, therefore, the menses reappear, the blood is already in such a condition that hemorrhage is less easy, and the discharge is often much less abun- dant, though much more highly colored. We have sometimes, nevertheless, seen menorrhagia increased in spite of the treatment, and perhaps as a consequence of the treatment; but even in this case the debility and pallor which used to follow the menstrual period were much less marked than in the preceding month, and a few days made up for the loss. But observe that in such a case, even when the loss of blood is absolutely greater than before, the relative loss is much less. It follows that the health suffers nothing, or next to nothing, from the bleeding, since the injury is repaired almost at once by the treatment. But if, in spite of the use of iron, menstruation is as abundant as pre- viously, if its amount is even increased, there are other remedies which almost always suffice, in the front rank of which we would place powdered ergot, digitalis, acids, rhatany, plugging, powdered bark of yellow cin- choi,ia given in doses of two or three grammes a day (30 — 45 gr. ), etc., etc. As soon as the menses are over, we must resume the use of iron for eight or ten days, in a dose proportioned to the patient's weakness. If a little anj^mia or chlorosis remains, we should insist on iron during the entire month, and even during the menstrual period, unless the menses are so abundant as to require the use of another remedy. Such, in rapid outline, are the practical rules, to which the physician may add those details which are best taught by having to treat an obsti- nate malady. Nose-bleed, in chlorotic patients, observes the same laws as uterine hemorrhage. We have known a young lady of twenty-one who had ex- tremely abundant nose-bleed every day. Acids, astringents taken in- ternally and by injection into the nasal cavities, had been tried in vain ; 2 18 THERAPEUTICS. powdered cinchona, taken internally, which almost always succeeds in these cases, had likewise failed; the bleeding returned continually. The use of large doses of subcarbonate of iron cured the chlorosis and greatly checked the loss of blood. It would be a mistake to suppose that uterine and nasal hjBmorrhao-e is cured by iron only in the case of chlorotic young girls. We have treated several cases in women at the turn of life, who were exliausted by repeated metrorrhagia. In spite of the apprehensions of the physi- cians who met us we insisted on preparations of iron, and succeeded in easily checking the haemorrhage. This practice is conformable to that of Phil. Frid. Gmelin ("Dissert, de probato tutoque usu interno vitrioli ferri adversus hgemorrhagias spontaneas largiores " (Tiibing., " Thesaur. mat. med.," t. II.). Iron in this case has a double action, as we said above. At first it re- pairs the losses of cruor and fibrin; next, it increases the plasticity of the blood, makes it more coagulable, and thereby lessens its facility of escape. Very unlike the other haemostatics, which for a moment increase the coagulability of the blood without restoring its constitution and relieve only the actual symptom, iron may be of use in certain phases of melaina and hcemorrhoids; not as combating the organic lesion which gives rise to ha3morrhage, but as remedying the consecutive anaemia; by restoring the plasticity of the blood, it may cure, if the htemorrhage depends solely on the licfuefaction of the blood, and may limit, if the liquefaction, though consecutive, is itself a cause of liJEmorrhage. In a word, we must repeat here that which we said before under metrorrhagia. Let us recall the results of the analyses made by MM. Andral and Gavarret. They found that, in cases of sanguineous apoplexy with effusion, the globular portion was more abundant than in most patients. In these haemorrhages, justly called active, iron would very probably be injurious. But if these observ- ers had analyzed the blood of persons exhausted by hemorrhoidal flux, they would have clearl}^ found a diminution of the globules, which would have proved the propriety of using iron. We may then conclude: 1st, that iron is not an emmenagogue; 2d, that in chlorotic patients it seems to provoke the menstrual discharge, because it cures the chlorosis; 3d, that in women in health it usually modifies the uterine flux; 4th, that it restrains uterine haemorrhage, at least, when apparently disconnected with plethora; 5th, that it moder- ates the various haemorrhages which occur in chlorosis. Dysmenorrhoea. — When the menses are painful, and the blood a little discolored, the use of iron in the interval very often suflices to put an end to the symptoms; but when this treatment is inadequate we should add vaginal injections of a strong decoction of stramonium or belladonna, or of a little oil, in which a few drops of chloroform are dissolved. Sterility. — The preparations of iron make women fertile; this fact is as authentic as its emmenagogue properties, and was clearly stated by EECONSTITUENT REMEDIES. 19 Hippocrates (Opera, ed. Foesii, t. I., sect, v., p. 686). The fact is easily- explained. Chlorotic women are usually sterile, and so are those whose menses are excessive or very painful; iron, therefore, which relieves all these troubles, is readily seen to be capable of relieving the sterility which is due to them. M. Blaud, of Beaucaire (^Bulletin de therapeuti- qiie, t. XVII., no\^, 1839), has added facts which confirm this view. Cachexiai. — To say (as did the writers of former centuries) that iron cures the cachexiie, is to use a very vague expression; yet the expression is true in some points. If the serous portions of the blood predominate, in consequence of cancer or scrofula; if hsemorrhage from a cancerous ulceration causes anaemia; if poor and insufficient food impoverishes the blood, there is no doubt that by the use of iron we may get, not a cure, but a beneficial modification of the general health; but the hope of cure which may arise is always destined to disappointment, since the cause remains, and is more mighty to destroy than the remedy to build up. Dropsies. — Visceral engorrjements. — It is certain that in a very ad- vanced stage the heart no longer fulfils its functions normally, and that, besides, the blood has not its natural qualities. The consequent disturb- ances of circulation, both general and capillary, affect the economy in the same way as if there were an organic lesion of the heart. Hence, en- gorgement of the lungs, hypertrophy of the liver, dropsy, anasarca. Iron, by curing chlorosis, cures all these symptoms; but we must not infer that iron can cure them when due to other causes. Intermittent fevers. — In the same way we may speak of the influence of iron, not on the fever, but on the accidents which may retard a cure or provoke a relapse. Bretonneau has shown that the miasms which cause these fevers, before they developed into well-marked paroxysms, often produced anjemia; that intermittent fever developed with a readi- ness proportioned to the amount of blood which the patient had lost, or the degree to which the blood was impoverished; that the fever, after lasting some time, brought about — especially in women — a very pro- nounced state of anaemia, so that antemia was at once a predisposing cause and an effect. Sydenham and Stoll knew from experience that chalybeate wine, and, in general, the preparations of iron, are a useful adjunct to cinchona. Bretonneau, in imitation of these great masters, introduced it into his hospital practice, and found it extremely useful in preventing the access and return of intermittents, and in curing the leuco-phlegmasia and the splenic engorgement which follow prolonged fevers. He was accustomed to give iron in these cases several months at a time, with preparations of cinchona. The direct febrifuge action attributed by Marc to iron {Journ. gen. de tried., 1810), by Martin {Bulletin de la Societe m'ed. d'' emulation^ aotit, 1811), and by d'Autier, in a good many experiments made by Bre- tonneau and M. Barbier, of Amiens, has not been proved. As regards the use of Prussian blue as a substitute for cinchona in 20 THERAPEUTICS. treating intermittents, we will speak further of it under the head of pre- parations of cyanogen. We will state, however, that we have very little faith in its efficacy in the class of cases which we are considering. Scrofula. — Among the many remedies used in this disease, iron occu- pied the first rank before the discovery of iodine. But its action is very equivocal, and the known efficacy of iodide of iron in these diseases is not a sufficient proof. Certain experiments have been made by CI. Bernard upon animals, and have been repeated by M. Quevenne upon himself with much care, which show that iodide of iron, when introduced into the stomach, almost immediately undergoes a sort of resolution into its constituent elements. In a very short time, iodine, having been rapidly absorbed, is found in the saliva, and passes in considerable quantity into the urine. This eli- mination continues, at first in increasing amounts, then decreasing, so that after forty-eight hours three-fourths of the iodine ingested has been rejected by the emunctories, while after the same time the quantity of iron absorbed and carried away by the metalloid is hardly appreciable. From this extreme difference in the results of absorption may we not be justified in inferring that in the very special affections for which iodide of iron is habitually used (that is, in scrofula), the greater part of the action is due to iodine, without claiming that that of iron is absolutely null? Diabetes. — Heine, of Berlin, regards the sulphate of iron, taken inter- nally, as a kind of specific for the diabetes mellitus of children. He quotes from the Journal des maladies des enfants two cases which seem quite convincing; but before pronouncing upon the efficacy of this remedy, we shall see whether our personal experience confirms such rapid results in a disease usually so obstinate. Leucorrhoea. — jBlennorrhagla. — In simple utero-vaginal catarrh con- nected with chlorosis, iron has a manifest utility; but it increases the white discharges in women of high complexions. It has very little influence upon the leucorrhoea which accompanies ulceration of the neck of the womb. Blennorrhagia has been cured by iron in some cases; in the last stage of the disease, after the symptoms of inflammation are gone, workmen often cure themselves by drinking for several days large quantities of the water in which the forge-men quench red-hot iron, which contains a good deal of iron. It would doubtless be better to use large doses of ferrugi- nous preparations, or of the tartrate or chloride of iron. We will add that M. Ricord very often uses a solution of tartrate of iron and potassium (4 — 8 grammes to 100 grammes of water) to dress venereal ulcers, especially when these ulcers threaten to assume a phagedii^nic character. Preservation of water. — For some time, sheet-iron boxes have been used to hold the water for long voyages. The subcarbonate of iron, which forms and dissolves in minute quantities in the water, has the double advantage of preventing the development of plants and infusorial KECONSTITUENT EEMEDIES. 21 animalcules, and consequently preserving it from corruption, while it also acts favorably on the health of the sailors. Poisoning by arsenic. — The hydrated sesquioxide of iron has been recommended in the treatment of poisoning by arsenious acid. In this case an insoluble arsenite of iron is formed; or at least, a salt so far insoluble that purgatives can remove it before it has time to affect the system. But the arsenite of iron is easily dissolved by the hydro- chloric and lactic acids which are naturally formed in the stomach; it is therefore important to neutralize them, which may be done by giving the sesquioxide in excess. This important remedy can only be of use when the physician is very quickly called, for a few moments are enough for arsenic to inflict gen- eral and local injuries which are irremediable. In certain medico-legal cases it may become of extreme importance to know that the hydrated sesquioxide of iron itself is often arsenical, when prepared from commercial sulphate of iron. Poisoning hy salts of copper. — Iron-filings are among the best anti- dotes in cases of poisoning by salts of copper. The filings should have all their metallic lustre. The reaction is as follows : an innocuous salt of iron is formed, and the copper is precipitated in the metallic state. Use of Preparations of Iron in External Maladies. The soluble preparations usually possess more or less astringent power. They drive the blood from the tissues with which they come in contact, they suppress or modify the secretions, they arrest or check haemorrhage, and in general, all kinds of flux; in a word, they exactly satisfy the vari- ous requirements which we commonly try to meet by the substances called astringents. In this respect it is important to establish one distinction. The insoluble preparations are preferable for internal use, and the solu- ble for external ; but the latter may also be used internally. Among the soluble salts most in use for external application, are the sulphate, the muriate, the acetate of the peroxide, and especially the perchloride, which deserves our more special attention. Perchloride of Iron. External Use. — For some years this agent has held an important place in therapeutics, both as a hfemospastic, and as a hasmostatic and astrin- gent. Every one knows that Pravaz was the first to use it by injection in the cure of aneurism. The first trials were far from encouraging; but it seems to have had better luck since: some half-successes in certain aneurisms, more complete 22 THERAPEUTICS. successes in the treatment of varices and hasmorrhoids, both with the perchloride and with the acetate of the peroxide, are the latest results; so that the method seems to have some chance of redeeming the disgrace into wliich its hrst failures cast it. Further careful trials are needed before we can definitely judge of this great question. If the treatment by injection, in diseases of the arteries or veins, tri- umphs over the immense obstacles which arrested it at its birth, the honor will belong first to Pravaz, who took the initial step, and next to the in- telligent perseverance of the surgeons of Lyons. However doubtful may be the value of perchloride of iron as injected into the blood-vessels, there is no doubt as regards its external use. In a memoire presented to the Academie des sciences, in September 1853, M. Putrequin mentioned a large number of cases in which the per- chloride of iron, or of iron and manganese, may be used with advantage externally. Thus, when the bleeding comes in a sheet, from a wounded surface, he states that it suffices to wash the surface with cold water, and then to apply a compress soaked in a mixture of a teaspoonful of the concen- trated solution of perchloride in a glass of water. If the flow is not ar- rested, we shall succeed l^y adding to the mixture a second teaspoonful of the perchloride. If the wound is unequal and irregular, a tampon of charpie moistened in the same liquid is used before the compress. This procedure may suf- fice even when the bleeding comes from a small artery. The charpie might be replaced by amadou, sponge or linen, which will further serve as a compressor of the vessel. A plug of charpie or amadou dipt in pure perchloride and applied with the finger instantly checks the blood from leech-bites. This measure has succeeded in cases of epistaxis where plugging and other haemostatics have failed. We are acquainted with no better means of arresting dental haemor- rhage, which, as we know, is sometimes so refractory. The solution of perchloride has been proposed in sanguineous tumors, haemorrhoids, vascular fungi; and by Dr. Yvonneau {JBulletm de la Soci- ete d^ Indre-et- Loire, 1854) in the treatment of ingrowing nails. This solution has been of good service in various affections of the genital organs, especially in metrorrhagia, leucorrhcea, and laxity of the vaginal walls. The remedy may naturally be used in engorgements of the neck of the uterus, especially those varicose or inflamed states which have been of late commonly treated (perhaps a little abusively) by caustics and heated iron: for where alum or tannin, applied locally, often cures, much may be expected of a remedy possessed of properties so remarkably astringent, resolvent and haemostatic. The trials which have lately been made have entirely justified these hopes. Employed alone, or, still better, associated RECONSTITUEKT REMEDIES. 23 with collodion, the solution has effected in the above-named class of cases cures which promise well for its future career. M. Petrequin says that the perchloride is an excellent antiseptic in gangrenous wounds and fetid suppurations. Washing with a solution of various strength rapidly removes the fetor — a property important in the hygiene of hospitals. For some years past a large number of physicians, including Drs. Bourot and Salleron, have studied the disinfectant and antiputrescent virtues of perchloride of iron; it may be said that the excellent results obtained in purulent and putrid affections, in all ill-conditioned sores, and especially in hospital gangrene, insure to this remedy an important place in surgical practice, especially military surgery. In this respect we may say that the perchloride may rival the most renowned antiputres- cents, such as the iodated preparations. The perchloride has also been used in a great variety of obstinate scrofulous affections of the skin and mucous membranes; and M. Bazin, among others, has found it very useful in certain malignant scrofulidte. It has been used with success in some parasitic diseases, as mentagra, tinea, acne. Finally, there is another instance of external use which deserves special mention: the use as a preservative from syphilis. We owe this new ap- plication to Dr. Rodet, a distinguished physician of Lyons. Its impor- tance may be immense, if the future confirms the results which are an- nounced. Let us say, first, that the perchloride of iron, whatever its deo-ree of concentration, does not of itself suffice to confer this immunitv; but that, in order to insure complete efficiency, a free acid, such as muriatic — or better, nitric — must be added to it. M. Burin de Buisson, who has carefully studied the chemical action of the perchloride, explains the necessity of this addition as follows: When the perchloride is applied over the point of inoculation, the imme- diate effect is the formation of a coagulum in the albuminous portions of the blood, which, acting as a plug, prevents the preservative liquid from penetrating deeply enough to reach and completely destroy the virus. Now, the addition of an acid removes this obstacle by redissolving the coagulum, and by aiding the penetration of the perchloride into all the folds of the mucous membranes and the interior of the tissues to which it is applied. According to the same chemist, the perchloride acts by coagulating, and not at all by cauterizing ; it preserves, by forming an obstacle to the absorption of the virus, by drawing out the albuminous fluids which sur- round the inoculated point, and causing them to coagulate as they ap- proach that point. In this way the virus, seized and imprisoned as it were in the midst of the albuminous coagula, is first neutralized, or de- stroyed, and soon eliminated. Whether the preservative liquid invented by M. Rodet acts as a co- 24 THERAPEUTICS. agulant or as a caustic, is not a question for us to decide. The following formula has been adopted as the best, after long trials: ]^. Pure water 24 grammes (370 grains). Perchloride of iron, liquid, at 30°. . . 12 grammes (185 grains). Hydrochloric, or better, citric acid . . 4 grammes ( 61 grains). M. ^ We cannot now enter into the details of the great number of experi- ments which have been made in the hospitals of Lyons; but we should add, that the results are nearly constant, and seem to show that the Ro- det liquid possesses the power of neutralizing the virus of syphilis in- troduced by inoculation, and of preventing the development of consecutive accidents. We will add that the same effects have been observed with vaccine virus. But will these preservative powers act with equal certainty when the liquid is applied after the sexual act ? Certainly, the results thus far are adapted to give rise to hope; but, on the other hand, it would be a rash thing, in so grave a matter, to utter our judgment before a long and se- vere trial had been made. Besides, in this case, the value of the remedy is not the only point in question, and success must depend on many con- siderations of quite another nature. The method of application, as given by the inventor, is as follows: As quickly as possible, after the suspected coitus, the part is washed in water, to which is added the preservative liquid, in the proportion of one tablespoonful to one or two glasses of water. Charpie, or linen, soaked in the pure liquid, is immediately laid on the part supposed to be contaminated, and allowed to remain for a quarter of an hour, care being taken that the liquid penetrates all the folds of skin and mucous mem- brane. During this application, an injection of the aqueous mixture above mentioned is to be made. Finally, the parts are washed in cold water. Doubtless this proceeding is easier and more certain in men than in women; yet it is applicable to the latter, in the form of injections of the mixture into the vagina, or, of applications of the pure liquor on a piece of linen held between the labia majora and minora. But even if our enthusiastic expectations are not all realized, and the hope of the final suppression of syphilis in a future day be only a beauti- ful dream, M. Rodet will certainly have rendered a signal service to humanitv, if, thanks to the preservative and to the system of precaution which its use requires, even a considerable diminution of the chances of contamination should be attained. We ought to add that M. Rodet proposes his "liquide chloruro-fer- rique " not merely as a prophylactic against syphilis, but as a cure for the same disease. According to his experiments, the liquor modifies simple and even indurated chancres with truly remarkable rapidity, RECONSTITUENT REMEDIES. 25 sometimes arresting in twenty-four hours the power of secreting virulent pus. Assuredly these results are worthy of ail the attention of physicians, and we wish with all our heart for their confirmation. This application in syphilis has naturally been followed by a similar treatment of other virulent diseases. M. Rodet, assisted by his brother, a distinguished veterinarian of Lyons, has made a series of experiments with the object of destroying the virus of rabies and of glanders intro- duced by inoculation, and he seems to have obtained quite conclusive results with his liquid. But as regards hydrophobia, prudence directs a reserve of opinion; until the demonstration is complete, it will be better to first burn the bite with red-hot iron, and afterwards, if there is opportunity, the liquid may be made to penetrate the remoter parts of the wound, which the iron could not reach. We shall further mention the application of the preservative to poi- sons, especially that of the viper; but it is plain that success must depend on a very speedy application, on account of the exceptional rapidity with which absorption occurs. The chances of success will be much greater in the case of bites of gnats, wasps, bees, etc.; it cannot be too highly recommended in the bites of certain flies which so often, in summer, occasion charboii. The preservative liquor is specially recommended by Dr. Pctrequin, in dissection wounds. Internal use. — Great as has been the extension of the external use of perchloride of iron, its internal use has been equally enlarged. Its usefulness as a haemostatic naturally suggested its application to the treatment of internal hiBmorrhages. It has in fact been used from the first, in haemoptysis, gastrorrhagia, and certain intestinal hjemorrhages. The results obtained in these various cases were often good, but they were improved when tlie time for administration was better understood; this should be as distant as possible from the haemorrhagic molimen, es- pecially in active hcemoptysis. By degrees the remedy has been applied in most of the great internal hoemorrhages, and it is now daily given in metrorrhagia, whether essen- tial or symptomatic of various organic lesions. In all these it is very useful. We can say as much for leucorrhcBa, blennorrhagia at the period of decline, and a great many affections of the mucous membranes which are accompanied by bloody or mucous fluxes. We have successfully used perchloride in certain cases of severe dysentery, at an advanced stage, when all ordinary means had entirely failed. The perchloride has particular efficacy in purpura, whether of the variety simplex or hgemorrhagica. A distinction is to be observed in regard to purpura simplex. Accord- 26 THERAPEUTICS. ing' to M. Devergie, if it presents irregular plaques, diffused, always quite large, especially if its progress is continued and progressive, the per- chloride rapidly cures it. If the spots are generally lenticular or petechial, quite circumscribed, and appear in successive crops, the case is otherwise, and the effect may be to shorten each attack a little; but it does not pre- vent relapses or further crops, and in fine exercises but a very slight in- fluence upon the mode of development and the total duration of the disease. In purpura h