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ABSENIO

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Gentlemen, — A.rsenic, next to iron, is our
most valuable hsematinic, but it is much more
than a simple blood restorer. It possesses
actions of a marked degree, which in the present
state of our knowledge it is impossible ade-
quately to explain. There is no medicinal
agent, whose actions on the body are more
difficult to explain than thosQ of arsenic.

Absorption and Elimination. — Arsenious
acid in all its combinations, and by whatever
method it is introduced, whether by the mouth,
or by the rectum, by the lungs, or by the skin,
wounds or excoriations is readily absorbed and
can be detected in the blood a few minutes
after its administration.

It is eliminated by the skin and mucous
membranes, through the bile, lungs and various
glands, but mainly through the kidneys. The
rapidity of its elimination varies considerably.
It commences a few hours after its introduction,
but it is seldom complete for a number of days.
Occasionally small quantities may remain for
an almost indefinite length of time, and it may

be made to reappear by the administration of
iodide of potassium. It is in all probability
deposited in greatest abundance in the nervous
tissues. It resembles lead in this respect, but
it differs from the latter that it is deposited
principally in the central nervous structures,
while the lead deposition is more pronounced in
the peripheral nervous system.

It is supposed that arsenic displaces phos-
phorus in the nervous system.

I^ARMACOLOOT.

1. Its Action on Micro-organisms. — The
power that arsenic has of preventing decom-
position from going on in animal tissue is well
known^ being made use of in the dissecting
room for this purpose. Its antiseptic action,
however, when brought to bear on the organ-
isms of ordinary putrefactive material is of a
very low order, being very much inferior to the
more commonly used antiseptics. In ordinary
medicinal doses it exerts no influence on pep-
sine and other non-organized ferments. After
death from acute arsenical poisoning the signs
of putrefaction set in about the usual time, but
they speedily become arrested and the body
passes into a peculiar mummified condition, in
which condition it may remain for a lengthened
period.

2. When Applied Externally. — The prepara-
tions of arsenic when applied to the &kin cause

redness, iDflammaticn or destraction of tissue
according to their strength and character.

It is an irritant when applied in a mild form,
and an esuijarotic when ustd in a concentrated
form.

Its action as an escharotic is not brought
about by any chemical influence that it exerts
on tlie tissues. It does not, like the caustic
acid and alkalies, coagulate the albuminous
tissues. It acts more by direct interference
with the nutrition of the tissues, causing rather
a condensation and "mummifying" than an
actual destruction of tissue. The escharotic
action of arsenic is characterized by a high
degree of inflammation, great swelling, and
quick destruction of the part. It is a very
panful escharotic. It should be always re-
membered that when weak applications of
arsenic are used to destroy tissue, the arsenic
may be absorbed in such quantities as to bring
about fatal poisoning, while if a strong pre-
I'aratiou is employed such a destruction oi'
tissue takes place that absorption is prevented.

A case has come under my observation where
a medical man applied a weak arsenical paste,
for the re.noval of a malignant tumor, to the
b.easc of a woman. It was followed by the
prominent symptoms of acute arsenical poison-
ing, from which the woman recovered. Some -
days afterwards a weaker arsenical paste was
Uhed, and it was kept applied for some time.

Subacute poisoning developed, lehich, not being
recognized, persisted, and from the effects of
which the patient died some days afterwards.

The lesson to be learned from this is that in
applying arsenic for its caustic action it should
be used in a sufficiently concentrated foim to
ensure the entire destruction of the paits.

3. The Action of Arsenic when "taken Inter-
nally. — In very small doses (0.002 to 0.004, one-
thirtieth to one-fifteenth of a grain) its action is
that of a gentle tonic to the gastric mucous
membrane. It increases the appetite and pro-
motes digestion. When it is given in larger
doses, and yet short of quantities sufficient- to
produce poisonous effects, it brings about a train
of marked symptoms, which will be more appro-
priately described under the untoward effects of
the drug.

Arsenic given in small, medicinal doses has
the effects of increasing the intestinal secretions
and of keeping the bowels regular when there is
constipation. A part of this action is prob:ibly
due to the fact that it causes a transudation
from the intestinal vessels.

Action on the Blood. — Arsenic enters the
blooi with rapidity, and, like iron, enters into
combination with the red corpuscles, and not
with the serum. It exists in the blood as an
albuminate. Whether it has any power, like
iron, of directly increasing the red cells has not
been definitely determined. In all likelihood it

has no such action. The principal action of
arsenic on^the blood is the power it has of in
creasing the amount of hsemoglobin in the cor-
puscles. It is, in the true sense of the term, a
hfematinic. When speaking of the action of
i'on on impoverished blood, I mentioned that
ihere were two distinct influences manifested
by this agent — the first being an increase in the
number of the red cells, the second and more
important being the increase in the amount of
hsemoglobin in the individual corpuscles.

The difference between the hsematinic poweis *
of iron and arsenic is that the former has a
dou>>le, while the latter has only a single, action.
Iron increases the quantity and quality of the
red cells, while arsenic only*" increases their
quality. Ho^ arsenic increases the quality of
the red corpuscles is not known. It does not,
like iron, suoply a deficiency.

Arnenic in overdoses diminishes both the
number and quality of the red cell». In this
connection I will make mention of a remarkable
action possessed by urseniuretted hydrogen on
the red blood disks. It has the power of dis-
placing their haemoglobin into the blood plasma.
When inhaled in excess, a sufficient number of
corpuscles aie destroyed so as to give rise to a
condition of hsemoglobineemia. If the coloring «
matter discharged is sufficient to color the urine,
then we have, in addition, the condition which
is now called hsemoglobinuria. Pyrogallic acid^

potassie chloride, and the different ansesthetio
agents have all, when given in excess, similar
actions on the coloring matter of the blood.
In slight excess they cause htemoglobineenua ;
in great excess they give rise to both 1 semo-
globinsemia and heemoglobinuria.

Although arsenic in overdoses interferes
with the oxygen-carrying powers of t. < red
cells, it does not destroy them.

Action on Metabolism. — Next in importance
to th<^ hsematinic action of arsenic, and in >ome
respects before it, is its influence on meta* oliAm*
It has a marked power in increasing metabolism.
This constitutes its so-called " alterative " action.
Iti enters into combination with living proto-
plasm and exercises some obscure chang>^ in it,
which rests in an increase of its nutrition.
The above is the action of ordinary medicinal
doses of arsenic. When it is given in overdoses
we find that it very seriously intei feres with
the complete elaboration of the changes that
takes place in the albuminous tissues. It pre-
vents the fats from undergoing their transform-
ation into carbonic acid and water. This action
is due to the oxygen carrying power of the
corpuscles being interfered with. As a result,
we find fatty degeneration of the muscular and
epithelial structures.

In poisonous doses, arsenic, like phosphorus,
diminishes the amount of glycogen ; and in these
doses it acts as a direct protoplasmic poison.

The influence of arsenic on nutrition is well
seen in those who take it habitually, like the
peasants in the Styrian Alps. These people
are in the habit cf taking it daily in very con-
siderable quantities. They begin with very
small doses, and gradually increase the quantity
until they are able to take with impunity
quantities sufficient to bring about fatal poison-
ing in those unaccustomed to its use. An
average dose for an adult Styrian peasant is
I'OO (15 grains) of aisenious acid in the week.
The arsenic-eating is commenced at an early
age, and continued usually during the whole
lifetime. It is claimed by these people that the
arsenic makes them longswinded, and that it
enables them to do an amount of work which,
without ifc, they could not do. They increase
in weight and vigour generally. They became
more pugnacious and salacious.

Action on the Circulation. — When arsenic is
given for some time in small dones it acts as a
weak cardiac stimulant, while large doses have
a depressant action on the heart. In small
doses it dilates the abdominal arterioles slightly,
thus causing a transudation into the intestinal
canal. It is in all probability owing to this
action that arsenic tends to relieve constipation.
In poisonous doses it causes great dilatatibn of
these vessels, the result being a copious serous
transudation, strikingly resembling the copious
rice- water stools of Asiatic cholera. It was at

one time thought that the serous diarrhcea
present in arsenical poisoning was owing to the
gastro-enteritis set up by its irritating action,
but now we know that it is due to the par-
alyzing influence that it exercises on the vaso-
motor fibres of the abdominal arterioles.

In poisonous doses, death is not usually
caused by the depressant action on the heart,
but more commonly through a paralyzing in-
fluence on the respiratory centre in the medulla.
This is almost constantly the case in warm-
blooded animalfi, while in cold-blood* d animals
the contrary is the rule.

Action on the Respiration. — The power that
arsenic possesses of making tho^e who take it
for a lengthened period " long winded " is pro-
bably explaiiiable as much through its influence
in increasing the haemoglobin as through any
direct stimulating influence on the respiratory
centre. That the latter is a factor, however,
in the production of this long-windedness is
rendered probable from the experiments of
Lesser.

When arsenic is given in overdoses it induces
a form of dyspnoea, and in positively poisonous
doses it completely paralyzes the respiratory
centre.

Action on the Temperature. — When given in
full medicinal doses a trifling rise in the temper-
ature is observable. The opposite eflect is con-
stantly present from poisonous doses. This-

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action on the body temperature is explainable
through its influence on metabolism.

Action on thb Nervous System. — The action
of small doses of arsenic on the nervous system
is that of a tonic. This is in all probability
secondary to the hsematising influence of the
drug. In larger doses, and especially in poison-
ous doses, it brings about a train of symptoms
due to the direct deposition of the metal in the
nervous tissues. It is especially apt to attack
the multipolar cells of the anterior horns when
given in overdoses for a long time. It produces
paralysis, especially of the extensors. It re-
sembles lead in this respect. They differ, how-
ever, in this particular, that the latter is more
prone to affect the peripheral nerves, while the
former is more likely to affect the central
*-ervous system.

Remote Local Action. — During its elimination
through the kidneys, arsenic does not exercise
any constant effect on the quantity of urine, or
of its individual ingredients. It, as already
mentioned, increases, when given in small doses,
the nitrogeneous waste, but it has no direct power
over its elimination.

In its elimination through the skin, arsenic
induces changes of a nature which are far from
being perfectly understood.

TOXICOLOGy.

1. Acute Arsenical Poisoning. — The symp-
toms of this vari 'ty of poisoning are simply

those of a severe toxic gastro-enteritis. Tbey
come on usually half an hour after the injection
of the poison, and if the dose has been large the
case is almost invariably fatal. No matter how
arsenic is introduced, it commonly induces a
gastroenteritis, showing that its intestinal action
is for the most part not confined to the mucous
membrane. After death the usual signs of
violent inflammatory action in the intestinal
canal are commonly discernible; but case's do
occur where during life severe intestinal symp-
toms were present, together with marked symp-
toms of a nervous character, such as giddiness,
delirium, pain in the limbs, paralysis and coma,
and where not the slightest trace of any inflam-
matory action was discernible in the mucous
membrane of the intestinal canal. This is the
so-called "Arsenicismus Cerebro-Spinalis."

Parenchymatous and fatty degeneration of
the liver, kidneys, of the epithelium of the
urinary tubules, of the heart muscles and of the
voluntary muscles, are constantly to be observed
if the patient has lived twenty-four hours or
more. Cases of chronic poisoning are not un-
common as the rrsult of arsenical emanations
from wall paper, paints, hangings, dresses, orna-
ments, and not only from green colors contain-
ing arsenite of copper, but also red, drab, blue,
gray, and enamel papers generally, and from
aniline colors fixed by arsenical mordants in
carpets, curtains, etc.

The more common symptoms that result from
arsenical emanations are similar to those which
we find when overdoses of an arsenical prepara-
tion are given internally. They are conjunc-
tivitis, swelling of the eyelids, sore throat,
nasal catarrh, nausea, and serous diarrhoea. At
times the prominent symptoms are headache,
mental irritability, and restlessness. If a per-
son has been exposed for a lorg time to the in-
jurious influence of arsenic, we find, in addition
to the above, paralysis of both upper and lower
extremities. Arsenical paralysis is very slowly
recovered from. Neuiitis of the terminal
branches of the radials I have observed several
times in students who were engaged in dissecting.
Erythematous pustules are f i equently present,
owing to the irritating action of the agent on
the skin during its elimination. The ulcers
which appear at the root of the nails are due to
interference with the so-called trophic functions
of the nerves. From one to two grains of ar*
senious acid may be looked upon as a fatal dose.
In the treatment of a case of acute arsenical
poisoning, after the stomach is emptied by means
of the stoitiach pump or apomorphia, large quan-
tities of dialyzed iron should be given repeat-
edly — a tablespoonful every few minutes. The
freshly-prepared sesqui-oxide of iron may also
be used. Neither of these antidotes are trust-
worthy except where the arsenical preparation
has been taken in a state of solution. Your

principal aim should be to see that the stomach
is thoroughly cleaned, and afterwards treat the
symptomatic indications on general physiological
principles. In the treatment of chronic arseni-
cal poisoning, the.bource of the poisoning should
be discovered and removed, and the iodide of
potassium should be given internally, but not
in doses of over five grains, as otherwise a suffi-
cient quantity of the arsenic may be reintro-
duced into the blood to bring about acute ar-
senicismus.

Therapeutics. — The external us(s of arsenic
are unimportant. Its internal uses are, how-
ever, of very great importance. Its action for
good in a number of diseases is very sti iking,
but as to the way in which it acts in many
cases, we have no positive knowledge.

I will first take up its use in the so-called
blood diseases. In ordinary ansemia it is a
useful agent, but much inferior to iron. It is,
however, curative in some cases where iron
fails to bring about more than a slight and
temporary improvement. It is more efficacious
in the simple anaemia of advanced adult life,
than in the form that is so commoh in young
women. Sometimes a combination of iron and
arsenic is followed by better results than when
either is given singly. In symptomatic
anaemia arsenic is* probably as powerful as a
blood restorer as is iron. It is in the disease
known as pernicious or idiopathic anaemia, where

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th'e hsematinic action of arsenic far transcends
that of iron. At the present time we charac-
terize as idiopathic or pernicious all those cases
of ansemia which run a fatal course, azid whe e
d uring life or after death no definite cause can
be found for the profound destruction of the
cellular elements of the blood. Many dis-
tinguished physicians go so far as to maintain
that it is not possible for a patient to recover
from what is called true idiopathic anaemia, and
that the fact of a case of ihis form of anaemia
being diagnosed and cured with arsenic or any
other remedy, is proof that the diagnosis was
ii correct. If these views aie correct there
must; be a form of severe ansemid, clinically
indistinguishable from the " pernicious " form,
and over which arsenic has tt times a curative
influence.

Several cases have been reco. ded by the most
competent observers where the use of arsenic
has been i'oUowed by a complete and permanent
cure where true pernicious anaemia was diag-
nosed.

Bran well, of Edinburgh, gives an account of
a case under his care, which was treated for a
period of three weeks in hospital with full doses
of quinine and iton and later With phosporized
cod-liver oil. During all this time there was a
steady advance in the severity of the case, and
it was not checked until two minims of Fowler's
solution were given thrice daily. The dose

was gradually increased until filteen minims
thrioe daily were taken. The after progress of
the case may be described a^ oue of slow but
uninterrupted improvement. In a month's
time he was able to attend as an outpatient*
Shortly afterwards he was able to go to vvork,
and expressed himself as feeling well again.
The blood from presenting the characteristic
alterations of pernicious anaemia became normal.
Dr. Finney, of Dublin, reports three cases of
this disease, two of which made complete and
permanent recoveries while taking arsenic. Dr.
Campbell, of Seafortb, and Dr. Graham^ of
Brussels, have each had cases of pernicious
anaemia under their care, where the use of
arsenic was followed by complete recoveries,
and where the previous use of iron had no efFect
whatever in staying the downward progress.

Dr. R. P. Howard, who was about the first,
if not the first, on this continent to describe
this disease, has had a very exti nsive experience
of its treatment with arsenic. At the present
time he has a case under observation where this
agent has brought about apparently a complete
recovery. The blood from presenting the
characteristic alterations has assumed a normal
appearance, and there is no evidence to indicate
but what the recovery is a permanent one.

There is no necessity for laying before you
any more proof of the value of arsenic in this
disease. It is true the vast majority of cases

of this form of anxmia proceed to their fatal
ending in spite of arsenic or anything else, but
evea in the severest forms the progress is some-
what stayed by its timely and judicious use.
It should always be the first agent to receive a
fair trial.

It is not known how arsenic acts in idiopathic
ansemia. It is more than probable that its
influence is deeper than its haematinic action.
There in another diseased condition bearing
some analogy to pernicious ansemia, where the
lengthened continuous use of arsenic does good,
often great und permanent good. I refer to
lymphomatous formations of the lymphatic and
blood glands. These formations are of a semi-
malignant nature. They generally occur in
young adults, and as a rule gradually progress
to a fatal termination. There are a number
of these cases no^ recorded where. the internal
use of arsenic and its injection inio the diseased
glands has brought about a permanent improve-
mont.

Billroth has recorded a remarkable case —
that of a woman, aged 40, in whom the cervical,
axillary and other glands, as well as the spleen,
were affected, and where the internal adminis-
tration of Fowler's solution brought about a
permanent cure.

Winni water and Israel have each had cases
where permanent cures have resulted. No
later than a few weeks ago, a case of this

disease w^s shown at one of the B.^rlin Mr^dical
Societies, where the use of arsenic was attended
by great and gradually progressive benefit.

In this connection I will mention the use o£
arsenic in malarial fevers. It is a well-known
fact that, next to quinine and cinchonine, it i»
the most powerful agent we have for averting
an attack of fever and ague. It appears to be
especially use^'ul in cases of long standing,
where there is considerable loss of the red cor-
puscles of the blood, together with enlargement
of the spleen.

In Diseases of the Nervous S}fstem. — Some of
the most important uses of this drug are in
diseases of the nervous system.

It is a valuable agent in many cases of
chronic neuralgia, especially those cases depend-
ing on a depraved general state. It is said
that it is of more value in facial and ovarian
neuralgia than in the other more common
varieties of this trouble. In gastralgia, which
essentially is a neuralgic affection of the nerves
of the stomach, arsenic is an agent of the
greatest value.

There is one neurotic disorder whrre the
use of arsenic accomplishes wonders, and that
is in the condition called angina pectoris^ in-
cluding both the " true '' and " false " varieties
of this trouble.

When considering the actions and uses of
the nitrites, I mentioned that they had a great

influence in relieving these attacks and also
in preventing them when given in the form of
a slow acting nitrite, such as the sodium nitrite.
I then mentioned that these agents acted
symptomatically, — that they counteracted the
active pathological state present during the
anginal paroxysm — the contraction of the cor-
onary arterioles.

Arsenic, however, does not act in this man-
ner ; it appears rather to combat or prevent the
actual cause of the attacks, whatever this may
be. It is supposed to be nerve degeneration, but
on this subject we need much light. It is not
only in anginal attacks that arsenic does good,
but in fact in every painful intrinsic cardiac
affection. Speaking of the use of this agent in
cardiac disease attended with pain, Dr. G. W.
Balfour, of Edinburgh, says that "next to digi-
talis, arsenic is probably our most important
agent in the treatment of cardiac disease; its
neurotic action is undoubtedly its most remark-
able one, and its effect in removing cardiac pain
of an anginous character is really something
marvellous." Another important use of arsenic
is in the treatment of chorea. This disease is
undoubtedly due to an instability of certain
nervous motor centres, and it is likely that the
arsenic acts here as it does in angina and in
neuralgia in general. There is a general con-
sensus of opinion that arsenic is by far the most
useful agent that we have in the treatment of

chorea. In a self-limited disease like this it is
necessary that great care should be exerciHed in
drawing conclusions as to the positive value of
any agent The value of arsenic, however, is
unquestionable when we find that its admim'H-
tration to patients who have had chorea for
months and even years is followed by recovery.
Numerous instances are recorded of cure from
its use in cases of chorea of over two year&'
standing. Failure to obtain satisfactory results
in the treatment of chorea with arsenic is fre-
quently owing to a too small dose. Children of
five years and upwards bear adult doses well.
Girls, as a rule, require ]arg<^r doses than boys.
It is necessary to induce the milder physiologi-
cal effects of the drugs usually before any marked
difference is noticeable in the patient's condition.
If these effects are brought about by small doses,
the remedy should be employed hypodermically.
When given in this way, doses of fifteen or
twenty minims three times daily can be tolerated
without the production of any of its untoward
effects. In neuritis the internal use of arsenic
is of much benefit. It is of especial benefit in
the cases of neuritis as seen in the intercostal
nerves, in the condition called herpes zoster.
The pain preceding and following the eruption
in these cases is very severe. There is no agent
that can compare with arsenic in relieving this
painful state. A great deal has been written
about the beneficial action of arsenic in cases of

asthma of a neurotic '"haracter. I am confident
that its use in this disease has heen very much
overrated.

In bH these cases it is impossible, in the
present state of pharmacology, to say how ar-
senic acts. In some mysterious way it exerts
an influence over nervous protoplasm.

The InJitLence of Arsenic in Tuberculosis.-^
Recently renewed attention has been directed
to the '* anti-tubercn!ous " properties of arsenic
by the great German surgeon, Langenheck, who
has published an account of several cases of
tuberculous diseased joints where the internal
administration of Fowler's solution was followed
by very marked improvement both in the local
conditions and general states. There is much
evidence to show that arsenic has at least con-
siderable influence in retarding the progress of
the more chronic forms of pulmonary consump-
tion. The acutely progressive cases are unin-
fluenced by it. The whole subject of tuber-
culosis, general and local, is at the present time
in such a state of obscurity that it is idle work
even speculating as to the possible ways that
the alleged action of arsenic is brought about.
Whether it is through an influence exerted on
foreign protoplasmic agents in the blood, or
through an influence on the metabolism of the
tissues, is very far from being known.

Finally, I will refer to the use of arsenic in
certain skin diseases. Not long ago, it was the

almost universal custom lo prescribe this drug
in nearly all cases of chronic disease of the skin.
Aft long as cases were chronic thoy were considered
to be fit for the arsenical treatment. Th^re
is much less of this practice since we know that
the greit majority of chronic diseases of the
skiti are curable by local means. Since the
humoral element in the pathology of diseases of
the skin ha? been practically thrown aside^
arsenic is less seldom used. It is not so very
long ago that physicians talked about a
" herpetic diathesis," just as they talked then
and now about a scrofulous diathesis, a tuber-
culous diathesis, an arthritic diathesio, and as
alkalies, etc., are given in the latter, and iodine-
in the scrofulous, so arsenic was prescribed for
the *' herpetic diathesis." Undoubtedly arsenic
has a modifying influence on a number of
chronic diseases of the skin, such as psoriasia
and eczema, but this influence is r ot due to any
obscure antidotal action on the so-called di ithcsis,
but to the fact that the arsenic influences
directly the morbid changes in the skin, during
its elimination. A Httle known but im-
portant use of arsenic is the power it possesses
of prevent" ng bromide acne, and of curing it
when it is piesent. We are often compelled to
diminish the dose of the potassium bromide, or
even to stop it altogether in the treatment of
epilepsy on account of the production of acne.
By combining arsenic with the bromide^ acne ia

preventecl, and much larger dosfs of the latter
can in consequence be ^'ven. At the presfnt
time there is an epileptic attending the Univer-
sity clinic for diseases of the nervous system,
who is enabled to take two drams of the bromide
daily without its producing any rash, because
with eacH dose of his bromide he takes five
minims of Fowler's solution. Previous to the
administration of the latt«r, half the present
dose of bromide caused a disfiguring acne. A
rare un'owar 1 efiect of arsenic is noticeable in
this case. The patient's skin has assumedsinoe
he commenced the arsenic a brownish tint.
The skin of the hands and face are more deeply
stained than that of any other part of the
body.

This staining is of no significance. It is not
caused, like the staining produced by silver, by
the deposition of the metal in the tii^sues. It
will disappear shortly after the discontinuance
of the drug.

A much more common accidental efifecb than
the staining is a general erythema (" Erythema
Multiforme, "or Le win's ''Dermatitis Exsudativa
Erythematosa.")

This arsenical rash is well exemplified in the
patient before you now, and as his case is an
example of where we nntutally look to the
arsenic doinp; much good, I will give you a short
account of it. He is. as you see, a power-
fully-built man. He is 51 years of age. He

first consulted me five days ago, at the Montreal
Dispensary, coiiplainiDg of great weakness of
three months' standing. His mucous mem-
branes and face are decidedly anaemic, but owing
to thiB diffused redness of the other parts of the
body his previous general paleness is not dis-
cernible. There is a marked diminution in the
numb r of his red cells. They do nob exceed
3,000,000 in each c.m.m. They have not
suffered much in form or in individual value,
the amount of hajraoglobin being not below
80 per cent. I cannot find any gross lesion to
account for this anaemia, and am therefore
obliged to look upon his case as one either
simple anaemia or commencing pernicious an-
aemia It is probably tne former. When he'
came under observation five days ago, he was
ordiered 5 minims of Fowler's solution after
each meal. After the sixth dose he felt
feverish, and he noticed that his hands and
arms were red, swollen, and very hot. The
redness of the skin spread rapidly until now it
involves the entire surface, except the face.
On examin ng it closely you will find the skin
covered with < ountless papules about the size
of millet seeds. You will notice also the great
oedematous infiltratioii there is of the forearms,
the integumeiit of which has a darker tint
than that of the ether parts. This is due to
the venous return being hindered by the copious
transudation into the subcutaneous cellular
tissue.

i«»

It is verv unusual to find that such a small
quantity of arsenic as half a drachm, in divided
doses, give rise to such an extensive and intense
efflorescence as we have here. It requires no
special treatment.

It would serve no useful purpose were I
to simply enumerate the score of other troubles
where arsenic has been or is recommended. I
have given an account of its great uses; and
although it is impossible to give a scientific
bans for all these, I would not have you to
think leas of it as a power for good on this
account.

It is not so many years since digitalis was
given in a purely empirical manner, and we
may confidently look forward to a time in the
near future when we can prescribe arsenic on
the same sound physiological grounds that
we prescribe digitalis to-day.

Dose and Mode of Administration. — In pre-
scribing arsenic internally, the acid itself or
Fowler's solution may be employed. The latter
is the favourite method of giving it ; but,
as a rule, it is better to prescribe it without the
lavender, as the latter frequently disgusts
patients. The dose varies from 3 drops up
to 30 drops. In commencing the arsenical
treatment of any case it is not well to give
more than the minimum dose until the patient's
susceptibility to its action has been determined.
The uose can then, if there is no special contra-

indication, be gradually increased until 20 or
more minims are taken three times daily.
When it is considered advisable to give more
than 20 minims three times in the day (in
case of severe chorea it is sometimes necessary),
it had better be given hypodermically, because
this method of introduction is less liable to
cause the usual untoward effects. In cases of
profound anaemia, where there is irritability of
the stomach. Dr. R. P. Howard has resorted
to the method of giving small doses frequently
and with great success. He orders a minim of
Fowler's solution every hour.

When arsenious aoid is prescribed, it should
be given in the form of pills. The following
formula, which is known as Hebra's Asiatic
pills, is much employed in Germany, especially
in the treatment of chronic diseases of the
skin : —

R Acidi arseniosi 0*25 (4 J gr.)

Piperis nigri 2*50 (40 gr.)

Mucilaginis gi. Arabici . . (4-S-)

V(\^. et fiat pil., No. 50.

Each pill contains 005 (^ gr.) of arsenious
acid.