Hypodermic Medication.

BY DR. C. LASEGURE.

TRANSLATED FROM ARCHIVE'S GENERALES, JANUARY, 1866.

Hypodermic Injections have, at the present time, entered into the practice of all physicians. They were first introduced by Wood, in 1855, and imported into France, in 1858, by Prof. Bekier. They have become so familiar by use that it seems almost useless to retrace the history of their progress, only so far as to recall the principal indications which they fill.

We have proposed in this review to signalize-first, some of the latest of their applications, and consequently those not so well determined,

Some have tried lately by observation, and especially by facts, to develop the subject even to a theory, or to give a general formulary of the method. Materials were abundant enough to amply justify a synthetical investigation, and the ideas advanced have appeared to us to merit discussion.

The salts of morphia, and more lately of atropifa, have alone been experimented with by the first observers. After ten years of experience, it is yet to active narcotic preparations that we give the first place in Hypodermic Medication.

One may see by the exposed summary of the essays incited, with other agents, how little the subject of Hypodermic Injections has enriched itself with new remedies.

SULPHATE OF QUININE.

The idea of the administration of the sulphate of quinine by the hypodermic method reverts to several years. As early as 1863, Moore recommended this mode of injection in intermittent fevers, founding his recommendations on his own experience and that of Dr. Chassud, of Syrna, who had cured more than one hundred and fifty patients attacked with poludal fevers, with gastric complications of such a nature as to interdict medication by the stomach.

The solution contained 1 gr. 50 * of the sulphate of quinine to 16 gr. of distilled water, acidulated by 8 to 10 gut. of sulphuric acid. The injection was made by a little stop syringe, containing from 2 to 4 grs. of the

prepared liquid, inserted at various points-the head of the triceps or deltoid, the thigh, the calf of the leg, in the left Hypocondric reagions, when the liver was violently hypertrophied.

The most favorable time, according to this author, was that which preceded the chill. As to the results, they were superior to those which were usually observed with sextuple doses given in the interval (internally).

Since this, these essays have been repeated with such variable results as to be far from reconciling observers as to the relative superiority of this mode of medication. Prof. Winter has given in his excellent review, (Schmidt's Iarh., 1865, t. CXXVI) a resume from which we borrow some indications.

Pzetler and Framuller are of opinion that we only introduce by the subcutaneous puncture an insufficient quantity of the medicine. Sacmann, on the contrary, reports to have cured, by injection of 10 centi-grs. of the sulphate of quinine, a third day fever which had resisted the ordinary use of a gramme of the same salt given internally. Rosenthal (Weir, Med. Holl., 1864) has obtained the most favorable results from the subcutaneous injection of a solution of 1 gr. of sulphate of quinine in 8 grs. of water with out the addition of the acid. Some have injected from 18 to 30 drops of liquid, representing from 15 to 26 centi-grms. of the salt in different regions, and always from three to four hours before a paroxysm.

Drs. Paul and Iarotzky, though they laud the use of the remedy under the hypodermic form, relapses so often return after some weeks, that they think it necessary to recommend the injections only in cases where it is important to affect the system promptly to cut short the attack.

Dr. Gualla, of Brescia, has treated 49 intermittent fevers out of 84, that had been treated, in 1863, at the Island City Hospital, by the subcutaneous method, and he has succeeded in all these cases. He injected, at the internal sides of the thigh, about 1 decigr. of a solution of which he does not give the exact formulary. One single time there followed, as Moore had already observed, some abcesses at the point where the puncture had been practiced; but, as the patient was syphilitic, there succeeded to the abcess some ulcerations which only yielded to a long usage of iodide of potash.

From a communication made to the Medical Chirurgical Society of London, (Dec. 1864) Dr. Desvignes has equally cured some hundreds of the laborers occupied in the labor of excavation of a railroad, and afflicted by different symptoms of malaria, by the injection of 7 to 8 centigrms. of the sulphate of quinine, dissolved in 15 drops of water. Finally we will mention the recent researches of Dr. Pihan Dufeillay.

The hypodermic administration of the sulphate of quinine has the advantage of exercising the least doses of the remedy, to fatigue less the stomach; but these advantages will be almost compensated by the yet doubtful persistence of the cure.

This will be an operative procedure to add to all the others and nothing

more.

It is not thus in very young children; we know how difficult it is to employ in them the sulphate of quinine, on account of the intolerable taste of the remedy, notwithstanding the many precautions we have recourse to to dissimulate it. The injections per anum are not retained, and leave the physician in uncertainty of the doses absorbed or even retained by the intestine. Frictions are yet more uncertain.

Dr. Rosenthal has had the happy idea to try this method in very young children, and success has responded to all his hopes. It is to-day a procedure which, making all allowance for objections, ought to hold an important place in infantile therapeutics.

The physician of Vienna has not stopped at this; he has extended the use of hypodermic injections of the sulphate of quinine to other infantile diseases besides intermittent fevers. Neuralgias with periodicity more or less regular, but returning with indisputable paroxysms, have no more efficient remedy than the sulphate of quinine. Children are so rebellious to this means that we have been oblidged very often to give it up.

On the other side, narcotic substances are badly tolerated, and their employment is not without danger in early life. Subcutaneous injections will be called to render important services. It has not only resolved a critical problem, but has opened a newer way to researches than that limited to the use of sulphate of quinine in intermittent fevers by injection. No one has, however, engaged himself in this direction, for we cannot so construe the memoir of Zuelzer, who is an old man afflicted of the stenocordia with forty degenerations of the heart, compliments himself on having injection of the sulphate of quinine.

Dr. Bourdon has been the first in these last times to advise the use of hypodermic injections against rheumatism of a medicament, so frequently and heroically employed internally. One of the students of our honorable college, M. Doduil, has published a conscientious investigation upon this mode of anti-rheumatismal therapeutics, of which we here resume the principles given.

M. Bourdon gives the preference to the following formulary: Distilled water, 10 gr.; bi-sulphate of quinine, 1 gr. ; tartaric acid, 50 centigrms. The tartaric acid replaces, as we know, the sulphuric used by the major part of experimentors. This substitute, already advised by Dr. Gualla, has been equally indicated by Prof. C. Bernard as having the advantage of introducing into the orgasm a vegetable acid, always more acceptable than the mineral acids.

We have nothing to note in the operative procedure, the punctures have been made upon the lateral parts of the verterbral column, upon the thighs, and upon the arms.

We have difficulty in estimating the results of a medication, whether it be in acute or subacute articular rheumatism. The metnods the most contradictory are given, both of admitted and disputed success-as vividly attacked, as warmly defended-the comparison wants force because the cases are without parity.

Out of the individual variations, it is still necessary to estimate the influences of climate, season, upon the medical constitution, &c. The means being numerous, it is necessary to represent them by a single hypothetical conjecture, the effects which have been produced, to equal conditions the other remedies, where rheumatism has not, as intermittent fever, pneumonia, or pleurisy, of manifest conclusion. It is languid in its convalescence; acidity gives space to a subacute state which prolongs itself indefinately, and which lasts for months after the observer has failed to notice its exit.

We have not found the elements of a subordination in the work of M. Dodeuil, and consequently have not assigned the hypodermic use of sulphate of quinine any way whatever upon the scale of anti-rheumatismatic remedies. The observations, resumed as it appears in a memoir of this kind, has some inevitable omissions.

The first patient observed, age 42 years, had been attacked for twelve days of rheumatic fever without cardiac complications. The injections are used each day in doses at first increasing from 0,25 centigr. to 90 centigr. of the sulphate of quinine, and afterwards gradually decreasing the doses even to the minimum limit of 30 centigr. The treatment lasted from the 25th of March to the 7th of April; from this date the patient is put upon the use of the wine of quinine. As the digestive ways are good, the appetite improved, the convalescence was rapid. In this patient, where the fever was always so moderate that the pulse did not exceed 88, it is not sufficient to know that the convalescence was uninterrupted, without stating in what time and under what incidents it passed to a cure. In the other observations we find almost invariably the same formula: convalescence was rapid, except one time the patient left even before convalescence had set in.

The duration of treatment had been of two days in observation two, but the patient was free from fever; the rheumatism dates from two months, the pains moderate, occupied only two articulations. The patient aged 56 years, had been submitted to treatment by the sulphate of quinine, and by morphine internally with little success.

In observation six, the injections had been continued from the 27th of April to the 18th of May. The rheumatism developed in a woman of 36 years, had a vivid intensity, and was accompanied in its course by grave complications, cerebral accidents, periodic expression, and pleurisy.

Some have said that the medication has been exempt from inconveniences, except some abcesses supervened at the points where the punctures had been made, and rapidly healed. M. Deuil has not contented himself by observ

ing the therapeutic results. He has sought to profit by the experiences instituted at the Maison de Sante, to study the physiological process of absorption of the medicament.

The injection of a strong dose has appeared to him to have a double advantage, a more fixed action, and absorption more prompt. In injecting 10 centigrs. at a single time, it has produced a falling of the pulse in threequarters of an hour, and appearance of the sulphate of quinine in the urine in less than twenty minutes. The effects upon the eyes and the ears are more slow than the effects produced on the pulse. The roaring in the ear and the trouble in the sight has not appeared in a precise manner in less than two hours and a half. Their duration was variable and they returned by intervals, two or three times in the day.

The duration of the elimination of a dose of 40 centigrs. is generally of 24 hours; that of a dose of 20 centigrs. appeared after to terminate in 9 hours.

DIGITALINE.--Amongst the substances besides the narcotics, to which Wood had at first entirely limited the method, there are scarcely any that deserves to be mentioned, such as, for example, digitaline, which Frenmuller advises after having employed it, said he, with success in diseases of the heart not well defined. Digitaline gives to its name a favor which should not last-an uncertain medicine, of a composition almost unknown, it is far from representing the therapeutic principle of digatalis, and it seems rather to concentrate its toxic element. Difficult of administration on account of the small amount that makes a dose, it does not respond to any of the indications which the digitalis is so apt to fill. It not only has not added anything to our resources, but has placed the medicine in a false view in habituating us to treat the diseases of the heart by insignificant doses, contrary to that which experience teaches, which shows the utility of large doses. Subcutaneous injections have no reason to be adopted in diseases of every elimination, progressive where it is important above every thing to oppose a remedy equally durable and continued in its effects.

Some essays reported without force, with short observations, as those upon which some have retired, unhappily, too willingly, the therapeutic recommendations call forth neither discussion nor examination.

STRYCHNINE. The same is not the case with strychnine which, on the contrary, ought to be given in an intermittent manner, and to thus say by intermissions. One has not the possibility, with strychnine, to maintain a continued action, and the end to which we propose-the only one to which we could pretend without grave dangers-is to avert momentarily the nervous irritability. Prof. Courty, of Montpellier, has presented to the Academy of Medicine, in 1863, a note upon the good effects to be obtained through the use of injections of strychnine in cases of paralysis of the face and the inferior extremities.