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prehension. He further referred to the statement of Dr. Cartwright, who said that he had given as high as forty-five grains at a dose in the congestive form of malarial fever, and, perhaps, repeated the dose three times a day, and he had no doubt but that Dr. C. gave the doses indicated. For, knowing that, if the patient had a second chill, he would probably die, it was for the prevention of such an occurrence, and he usually succeeded.

He was well convinced that, with regard to the administration of some of the remedies Dr. Clark bad alluded to and many others, he had made a great mistake in not persevering in their use, and had also failed by giving large doses and making the interval too long before the administration of the following dose. This had been the case with him not unfrequently in the administration of ergot for the control of hemorrhage, and he had failed to control it for the simple reason that he had abandoned this remedy much too soon, not having continued the doses in such a manner as to retain the continuous effect of the drug upon the system.

Dr. ULRICH, of Pennsylvania, remarked that he practised some eighteen years in the valley of the Mississippi, and had the pleasure of Dr. Cartwright's acquaintance, and he had kuown of Dr. C.'s administering quinine in forty and forty-five grain doses, and in 1853, in the treatment of yellow fever, his administration of large doses of quinine became quite fashionable. Whether the treatment was original with Dr. Cartwright or not, he was not aware, but it had the approval of as good a man as Dr. Stone, of New Orleans, and also other eminent medical men. In 1855, when yellow fever again appeared, large doses of quinine were again in vogue, but were very soon rejected, and now it need hardly be said that we seldom resort to the use of quinine at all in the treatment of yellow fever. In the treatment of pernicious congestive fever, when he had given large doses, he had not realized any absolute advantage from so doing. When the physician is called in to see a case of pernicious congestive fever in the congestive stage, he will find no benefit from administering quinine then. He must rely upon other means to relieve the paroxysm, but when the patient has once got through the paroxysm, there is no advantage in large doses; for, as a rule, he has ample time to affect the system and thoroughly cinchonize the patient with five or ten grain doses before the recurrence of the paroxysm.

The paper to which we have just listened is just such a paper as we all need. But little attention is paid, by the profession in


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general, to doses in medicine. It is not uncommon to find phys cians disagreeing with regard to the management of doses, but this should not be. It is not a difficult thing to determine the best effect that can be obtained by giving medicines in a certain' manner and with reference to certain periods of time. We give medicines as a rule, however, predicated too much upon experience as given by authors.

Dr. CLARK remarked, lest the Section be led into a misapprehension by the remark of Dr. Johnson, that it was not simply the continuance of doses which he referred to, but the continued presence in the blood of the article which is being administered. A medicine may be given continuously and yet be administered only three times a day, but that is very different from keeping up a steady ratio between absorption and elimination, so that before the article is eliminated, the influence of another dose is felt. A very different effect is produced by a drug when given in this manner than when the blood is not charged with it.

Dr. A. C. McLAUGHLIN, of Ohio, remarked that perhaps the United States Dispensatory is unreliable with regard to the size of the dose of medicine to be given. He was of the opinion that medicine in general is given in too large doses. The use of quinine in large doses is absurd in any case, for experiment will teach anybody that small doses will do just as well. His experience in the use of morphia had been the same; and he could accomplish all he desired with the article, by adding a half grain to part of a teacupful of water, and then giving a teaspoonful every fifteen or twenty minutes. The same was true with regard to the use of cimicifuga and other remedies.

Dr. J. K. BARTLETT, of Wisconsin, remarked that his experience had taught him very much the same thing as Dr. Johnson's had taught him. He had come to the conclusion that Dr. Clark is correct in the position he has taken, and that the administration of medicines continuously is the proper manner for obtaining the best therapeutical effects. For instance, if he wishes to control arterial excitement, he had found that it could be much better done by administering small doses, and repeating them often, than by giving larger ones at longer intervals. The same may be said with regard to the use of ergot for the control of hemorrhage.

Dr. WOODWORTH, of Indiana, inquired of Dr. Clark whether there was not a difference between the continuance of organic and inorganic medicines ? For instance, it has been said mercury re



mains in the system for years, whereas organic substances may pass out of the system in a very short time.

Dr. CLARK replied that there was no doubt upon that point; and that there is a difference. But the point referred to in his paper rests upon absorption and elimination. Mercury has been detected in the system fifteen years after administration, consequently it can be reasonably inferred that such remedies do not require to be administered so frequently as others to maintain a continuous effect. He was well aware that if the law which he had announced is correct, it will necessitate a much larger amount of physiological knowledge upon the part of practitioners than they in general at present possess; for we must possess a knowledge of the time it requires for physiological absorption and elimination of remedies when administered in single doses.

Dr. J. R. BRONSON, of Massachusetts, inquired of Dr. McLaughlin whether he would apply his method of administering morphia in a case of severe pain, such as met with in colic, or peritonitis? He had supposed it was a point of importance to relieve pain, as soon as possible, consistent with safety; and that it hardly would seem that 'th of a grain of morphia would relieve pain as soon as įth of a grain. The proposition, it seems to him, was pernicious in this respect; that it does not give the materia medica the credit it deserves.

Dr. MCLAUGHLIN replied that he would not give morphine at all in peritonitis, and perhaps not in colic, but nux vomica instead. He gives it much oftener in these cases than he does morphine.

Dr. Clark's paper was then referred to the Publishing Committee, and the Section adjourned to meet at 3 P. M. Wednesday.

WEDNESDAY, May 5. Section called to order by the President at 3 P.M.

Dr. MOREAU MORRIS, of New York, read a paper upon Biometry and its Relation to Practical Medicine. It was by vote referred to the Committee of Publication.

Dr. BARTHOLOW, of Obio, presented and read a paper upon Exophthalmic Goitre and its Treatment.

Dr. L. D. BULKLEY, of New York, remarked that he had listened to the paper with much interest, particularly as he had only recently observed other neurotic phenomena closely akin to those mentioned, but which he had not seen mentioned by any observer.

In a somewhat recent case of well-marked exophthalmic goitre


which had fallen under his observation, one marked feature was the presence of an urticaria accompanied with a large amount of erythema; it was an erythema urticarium. This is an important point, especially as illustrating that branch of dermatology which studies the relation which exists between the nervous system and diseases of the skin. These two skin diseases have been placed among the neuroses. In the same patient there was also pigment discoloration upon the face and hands.

Dr. M. H. HENRY, of New York, referred to the same case mentioned by Dr. Bulkley, and stated that, after being under the care of eye doctors, nervous doctors, and skin doctors for a great length of time and without benefit, she finally came under his care. Looking upon the disease as one of nervous origin, he had placed the patient upon bromide of quinine and phosphorus, and the patient at once began to improve, and now is very well indeed. The case was mentioned to show that phosphorus is beneficial in the treatment of affections of the nervous system.

Dr. J. A. OCTERLONY, of Kentucky, remarked that within a few years past he had had several of these cases of exophthalmic goitre to treat, and as he had listened to the paper he had been struck with the absence of some symptoms which he had noticed in his cases. One of these symptoms was change in the color of the hair, but there was no change in the pigmentation of the skin. The hair became very light after having been of a dark brown. Another symptom was very great emaciation and tendency to diarrhoea. With regard to the name he desired to express some dissatisfaction with Dr. Bartholow for finding so much fault with the term exophthalmic goitre. It is well known that some of the symptoms may be absent, but at the same time there is no doubt but that the peculiar grouping of the three symptoms referred to constitute the essential elements of the disease. It seemed that the term exoph. thalmic goitre expresses very concisely, very pointedly the cardinal fact of the disease, consequently is far superior to some names which have been given it by continental observers.

Dr. A. T. KEYT, of Ohio, drew attention to the question of cardiac murmurs in this disease, and if present are they organic or functional, and where located ?

Dr. BARTHOLOW replied that there may be murmurs present, and when present, they are of the same kind met with in anæmia. It is perfectly certain that many cases are complicated with cardiac lesions, but these are not essential to the disease.

Dr. H. D. DIDAMA, of New York, remarked that the Section should not be debarred from the pleasure of listening to remarks from the Chairman, simply by the fact that he is the presiding officer, and regarded it as unfair to the Section and to the Chairman if he was not a participant in the discussion.

Dr. A. Flint, of New York, the Chairman, replied that he will. ingly contributed to the discussion, and was ready to answer any questions which would impart any knowledge to the members of the Section upon this subject. With regard to the question last propounded, namely, the existence of cardiac murmurs, he thought he was correct in the statement that in all cases of the disease which he had seen, cardiac murmurs had been present. In some cases the murmurs have been dependent upon coexisting cardiac lesions, which may coexist with this affection, but these are not essential to it. When no cardiac lesions have been present, the murmurs have been anamic, and are to be explained in the same manner as anæmic murmurs. He further remarked that he had been interested in the paper, particularly with regard to treatment of this disease. He was of the opinion that he bad seen beneficial effects from the long-continued use of aconite given in small doses, just sufficient to keep up a moderate and constant action of the drug upon the heart. It is a disease which resists medication, and he had seen several cases in which this remedy had been tolerated for a long time. He also mentioned a case in which there was a close approximation to recovery.

Dr. Keyt inquired whether there were mitral murmurs present in any of Dr. Flint's cases ?

Dr. Flint answered that there were none, except when mitral lesions were present; and that may give rise to discussion as to whether we have mitral murmur without mitral lesion. The murmurs in general met with in this disease are aortic and pulmo

nary direct.

Dr. Davis, of Illinois, remarked that he had been more interested in learning what he could of the essential pathology of these cases and of the treatment than anything else, and he had listened with attention to the paper, with the hope of catching something upon these two points. Not very many of these cases have fallen under his care, but he would mention the last two. One of these had been treated with electricity, how judiciously he was not aware, but had been treated for a considerable length of time, as well as subjected to considerable other treatment. This patient presented

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