V. Therapeutics

The facts which we have reviewed under the four preceding heads are highly encouraging to the practical therapeutist.

In plethora he will reduce the amount of food, increase the excretions, and prescribe increased bodily exertion; five-and-forty years ago he would have bled the patient freely, and repeated the operation at regular intervals.

Anaemia must be treated by the opposite class of measures, which will be discussed immediately under the head of the red corpuscles. Speaking generally, we must sustain and restore the appetite and digestion, spare the body every possible exertion, maintain healthy excretion, and, if the condition be urgent, even transfuse blood into the veins. Deficiency of albumen is met by the same measures. Excess of carbonic acid demands artificial respiration, as we shall find under respiratory diseases.

When the indication is to increase the alkalinity of the plasma in rheumatism, gout, and allied morbid states, we administer salts of Potash, Soda, Ammonia, Lithia, or the Alkaline Earths, the Alkaline Citrates and Tartrates being the most suitable because large quantities can be admitted into the blood without deranging digestion. Acids, which have so little influence in the opposite direction, are fortunately seldom called for. The treatment of poisons in the blood, whether formed in the body or introduced from without, will rationally consist first in removing their cause, e.g. indigestion or renal disorder, or in decomposing or neutralising them chemically. This introduces us to the second use of alkalies in the blood. The acid of rheumatism, whatever it may be, and the uric acid of gout, are converted into soluble salts by the Alkalies and Alkaline Earths, and these salts are fortunately diuretic. In this way excess of acid is not only neutralised, but conveyed out of the system, and the reaction of the urine may be used as a test of the success of our action on the blood. This end is secured in acute cases by the free exhibition of the milder salts of Potash, Soda, Ammonia, and Lithia; in chronic cases by treatment at an alkaline bath, such as Ems, Homburg, Vichy, Carlsbad, Buxton, or Bath. Metallic poisons, such as lead, are removed from the blood and tissues in precisely the same way; lead, for example, by Iodide of Potassium or Sulphur baths.

Poisons may also be removed from the blood by simple increase of the excretions-carbonic acid through the lungs by artificial respiration; urea by diuresis, free purgation, and diaphoresis; and so with the products of indigestion, which is relieved by a cathartic pill and a saline draught.

If the haemoglobin be deficient, we must secure a sufficient supply of digestible and nutritious food, pure air, and direct sunlight; reduce the amount of work, by ordering rest or even confining the patient to bed; and attend to all the functions which are connected with the formation, growth, and purification of the blood. Correction of derangements of the stomach and bowels always demands special attention, and is a sine qua non for success. At the same time, any actual waste of the blood must be arrested, if possible. Passive haemorrhages must be checked. Growth and development may be rendered less trying by directing the blood to parts where it is specially required; for instance, to the uterus by means of emmena-gogues. We must next hasten to restore the red corpuscles by supplying their important chemical elements-Iron, Phosphoric Acid, and Potash. Long before the composition of haemoglobin was understood, it had been empirically discovered that Iron was a certain remedy for "want of blood." This is our daily experience still; science in this instance has confirmed and not suggested practice. Iron has other actions and uses therapeutically, but its chief employment is as a haematinic. The particular form in which the metal may be administered is discussed under its own head, but one or two combinations with iron must be noticed here. The Mistura Ferri Com-posita, an old-established empirical combination of Proto-sulphate of Iron, Carbonate of Potash, Myrrh, and Aromatics; the Pilula Ferri et Aloes; and the non-officinal pill of Blaud, containing Protosulphate of Iron and Carbonate of Potash, are specially successful remedies in anaemia, the rationale of which will now be obvious to the student. The Phosphate of Iron is also indicated, and is highly successful in some instances. Altogether, the medicinal treatment of deficiency of haemoglobin practically resolves itself into the continuous administration of iron in some useful form or combination, without impairing digestion or the action of the bowels.

In urgent cases of want of blood corpuscles, whether acutely developed by haemorrhage, or progressing slowly to an extreme degree, transfusion must be practised.

Reduction of oxyhaemoglobin defies therapeutical measures if it have advanced beyond the very first stage, that is, the treatment of poisoning by carbonic oxide, prussic acid, etc., is rarely successful. It must, however, be attempted. Combined venesection and transfusion would theoretically be the proper treatment-to remove disorganised blood and poison, and to replace them by healthy corpuscles and plasma. But this is manifestly very rarely practicable. All that can be done, as a rule, is to sustain the circulation and respiration, by general stimulants and artificial respiration, and thus preserve vitality by means of the oxygen and haemoglobin that may still remain active. In every case it will be proper to do this until transfusion can be undertaken.