Class. Book.. -58 Copyright^?. 1909 COPYRIGHT DEPOSIT. BOOKS BY ARTHUR A. STEVENS, M.D. Modern Materia Medica and Therapeutics Octavo of 675 pages. Cloth, #3.50 net. Fifth Edition Practice of Medicine 121110 of 556 pages, illustrated. Flexible leather, $2. 50 net. Eighth Edition MODERN MATERIA MEDICA AND THERAPEUTICS BY A. A. STEVENS, A.M., M.D. |1 Professor of Therapeutics and Clinical Medicine, Woman's Medical College of Pennsylvania ; Lecturer on Physical Diagnosis in the University of Penn- sylvania ; Physician to the Episcopal Hospital and to St. Agnes's Hospital ; Assistant Physician to the Philadelphia General Hos- pital ; Fellow of the College of Physicians of Philadelphia, etc. ffittb Bfcitfon, Uborou0bl£ IRexnsefc In Conformity witb tbe EiQbtb "Revision (1905) of tbe THniteo States pbarmacopoeia PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1909 id 4 (SEP ^ I90b> 3 1909 Set up, electrotyped, printed, and copyrighted March, 1894. Revised, reprinted and recopyrighted June, 1895. Revised, entirely reset, reprinted, and recopyrighted May, 1903. Reprinted July, 1904. Revised, reprinted, and recopyrighted November, 1905. Re- printed June, 1906, and April, 1907. Revised, reprinted, and recopyrighted August, 1909. Copyright, 1909, by W. B. Saunders Company. AUTHORITY TO USE FOR COMMENT THE PHARMA" COPOEIA OF THE UNITED STATES OF AMERICA, EIGHTH DECENNIAL REVISION, IN THIS VOLUME. HAS BEEN GRANTED BY THE BOARD OF TRUSTEES OF THE UNITED STATES P H A R M A C O PO E I A L CONVENTION, WHICH BOARD OF TRUSTEES IS IN NO WAY RESPONSIBLE FOR THE ACCURACY OF ANY TRANSLATIONS OF THE OFFICIAL WEIGHTS AND M EASU RES, OR FOR ANY STATE- MENTS AS TO STRENGTH OF OFFICIAL PREPARATIONS PRINTED IN AMERICA PRESS OF SAUNDERS COMPANY PHILADELPHIA PREFACE TO THE FIFTH EDITION. This edition has been thoroughly revised, and contains many important modifications and considerable additions. The section dealing with the Action and Uses of Drugs has been in large part rewritten. Articles dealing with a number of new remedies have been incorporated, and new formulae have been added where it was thought they would make more clear the therapeutic application of the drugs under consideration. The author ventures to hope that the work in its present form may be found equal to existing requirements, and that it may prove as acceptable to students of medicine as former editions. 314 S. Sixteenth Street, Philadelphia, August, 1909. PREFACE TO THE FOURTH EDITION. The fourth edition of this work has been thoroughly revised and adapted to the Eighth Decennial Revision of the United- States Pharmacopeia. Such corrections and additions have been made as seemed necessary to make it a more complete guide to the study of Materia Medica and Therapeutics. New articles, dealing with Scopolamin, Ethyl-chlorid, Theocin, Ver- onal, and Radium have been introduced, and in the section on Radiotherapy much new matter has been incorporated. Among the many changes to be found in the new Pharma- copoeia, attention is especially called to the following : The tincture of aconite has been reduced in strength from 35 per cent, to 10 per cent., and the tincture of veratrum from 40 per cent, to 10 per cent. The tinctures of strophanthus and can- tharides have each been increased in strength from 5 per cent. to 10 per cent. The tincture of nux vomica now contains 0.1 per cent, instead of 0.3 per cent, of strychnin. Blue ointment and mercurial ointment are no longer synony- mous. The former (Unguentum Hydrargyri Dilutum) now contains about 33.5 per cent, of metallic mercury, while mer- curial ointment contains about 50 per cent. — which was for- merly the strength of blue ointment. The most noteworthy additions to the Pharmacopoeia are Acetphenetidum (phenacetin), ^Ethylis Carbamas (urethane), ^Ethylis Chloridum (ethyl-chlorid), Antipyrina (antipyrin), Bromoformum (bromoform), Cresol, Gelatinum (gelatin), Glan- dulae Suprarenales Siccae (desiccated suprarenal glands), Glan- dulae Thyroidese Siccae (desiccated thyroid glands), Guaiacol, Guaiacolis Carbonas (guaiacol carbonate), Hexamethylenamina (hexamethylenamin or urotropin), Iodolum (iodol), Liquor Formaldehydi (solution of formaldehyde), Methylthioninae 10 PREFACE TO THE FOURTH EDITION. Hydrochloridum (methylene blue), Pelletierinae Tannas (pel- letierin tannate), Scopolamine Hydrobromidum (scopolamin hydrobromid), Serum Antidiphthericum (diphtheria antitoxin), Strontii Salicylas (strontium salicylate), Sulphonethylmethanum (trional), Sulphonmethanum (sulphonal), and Thymolis Iodi- dum (thymol iodide or aristol). A number of compound preparations have been introduced as substitutes for commercial articles of a similar, but less defi- nite, composition. The chief of these are Cataplasma Kaolini (cataplasm of kaolin, or white clay), Fluidextractum Rhamni Purshianae Aromaticum (aromatic fluidextract of cascara sagrada), Liquor Antisepticus (antiseptic solution), Liquor Cresolis Compositus (compound solution of cresol), Pulvis Acetanilidi Compositus (compound acetanilid powder), and Vinum Cocae (wine of coca). The titles of a number of official articles have been changed. Thus, all Extracta Fluida have been changed to Fluidextracta. Instead of writing, for example, Extracti Ergotae Fluidi, one now writes Fluidextracti Ergotae. Hydrochloridum has been substituted for Hydrochloras, Hydrobromidum for Hydro- bromas, Valeras for Valerianas, Arseni Trioxidum for Acidum Arsenosum, Phenol for Acidum Carbolicum, Chloralum Hy- dratum for Chloral, Betanaphthol for Naphtol, Potassii Hy- droxidum for Potassa, Resorcinol for Resorcinum, Spiritus Glycerylis Nitratis for Spiritus Glonoini, and Veratrum for Veratrum Viride. CONTENTS MATERIA MEDICA. PAOK General Considerations . 17 Composition of Drugs 18 Preparations of Drugs 19 Incompatibility in Prescriptions 30 Methods of Administering Drugs 35 By the Mouth 35 Hypodermic Method 35 Intravenous Injection 36 By the Rectum 36 Inunction 36 Endermic Method 37 Fumigation 37 Inhalation 37 Circumstances Modifying the Effect of Drugs 37 Circumstances Modifying the Effect of Dosage 38 Drugs , 39 Circulatory Stimulants 39 Increase of Blood Pressure 39 Acceleration of the Heart-heat , 40 Circulatory Depressants „ 59 Reduction of Blood Pressure 59 Reduction of Pulse-rate „ . " . 60 Vasoconstrictors and Vasodilators . ' . . . ^ 66 Respiratory Stimulants , 73 Respiratory Depressants 74 Cerebral Excitants . » 74 Cerebral Depressants 89 Somnifacients 90 General Anesthetics 118 General Analgesics or Anodynes 130 Anticonvulsants 130 Antispasmodics 131 Spinal Cord Excitants 140 Spinal Cord Depressants 145 Motor Nerve Depressants 150 Sensory Nerve Depressants 153 Mydriatics 161 Myotics . « 165 Emetics 166 11 1 2 CONTENTS. PAGE Anti-emetics x 5g Gastric Antacids j« Stomachics I7 . Digestants l8o Carminatives !3^ Cathartics jq. Diuretics 220 Stimulants to the Genito-urinary Tract 233 Sedatives to the Genito-urinary Tract 242 Uric-acid Solvents 2 ^-> Aphrodisiacs and Anaphrodisiacs 244 Emmenagogues 247 Oxytocics, or Ecbolics 252 Diaphoretics, or Sudorifics 257 Antihydrotics 262 Expectorants 266 Sedative Expectorants 269 Stimulant Expectorants 275 Tonics 289 Alteratives 305 Desiccated Thyroid Glands 341 Thymus Gland 344 Pituitary Body 345 Testis and Ovarium 34c Antipyretics or Febrifuges 346 Astringents 353 Hemostatics 377 Germicides, Antiseptics, and Deodorizers 383 Antimalarials 414 Anthelmintics 422 Antitoxins and Vaccines 428 Irritants and Counterirritants 438 Escharotics or Caustics 447 Protectives . x 458 Flavoring Agents , 469 Remedial Measures Other than Drugs 475 Electricity 475 Massage 4^4 Movement Therapy for Locomotor Ataxia 4^6 The Schott or Nauheim Treatment 4^8 Application of Cold 49° Application of Heat 493 Hypodermoclysis and Infusion 49^ Enteroclysis 49^ Lavage of the Stomach 5°° CONTENTS. 1 3 PAGE Bloodletting 501 Cupping 5 QI Leeching 5 02 Venesection or Phlebotomy 503 Actinotherapy 504 Rontgen Ravs 505 Radium 506 Lumbar Puncture 507 APPLIED THERAPEUTICS- Acute Infectious Diseases 5°9 Typhoid Fever, 509 — Typhus Fever, 514 — Relapsing Fever, 514 — Cere- brospinal Fever, 515 — Malarial Fever, 516 — Influenza, 517 — Croup- ous Pneumonia, 519 — Diphtheria, 523 — Scarlet Fever, 525 — Measles and Rubella, 527 — Small-pox, 528 — Yellow Fever, 530 — Cholera, 531 — Whooping-cough, 532 — Erysipelas, 534 — Tetanus, 535 — Rheu- matic Fever, 536 — Mumps, 538. Constitutional Diseases 539 Diabetes Mellitus, 539 — Diabetes Insipidus, 542 — Gout, 542 — Chronic Rheumatism, 544 — Muscular Rheumatism, 545 — Rheumatoid Arthri- tis, 545 — Rachitis, 546. Diseases of the Blood and Ductless Glands . . . 547 Chlorosis, 547 — Pernicious Anemia, 547 — Leukemia, Pseudoleukemia, and Splenic Anemia, 548 — Scurvy, 548 — Purpura Haemorrhagica, 549 — Hemophilia, 549 — Addison's Disease, 549 — Myxedema, 550 — Ex- ophthalmic Goiter, 550. Diseases of the Digestive Tract 55 1 Stomatitis, 551 — Acute Pharyngitis, 552 — Chronic Pharyngitis, 553 — Acute Tonsillitis, 553 — Acute Catarrhal Gastritis, 554 — Indigestion, 555— Gastralgia, 558 — Gastric Ulcer, 559 — Gastric Cancer, 561 — Dilatation of the Stomach, 562 — Chronic Constipation, 563 — Acute Diarrhea, 565 — Chronic Diarrhea, 568 — Dysentery, 569 — Appendi- citis, 571 — Catarrhal Hepatitis, 572 — Cholelithiasis, 573 — Cirrhosis of the Liver, 575. Diseases of the Respiratory System 577 Acute Rhinitis, 577 — Chronic Rhinitis, 578 — Atrophic Rhinitis, 579 — Acute Laryngitis, 580 — Spasmodic Croup, 580 — Chronic Laryngitis, 581 — Tuberculous Laryngitis, 582 — Syphilitic Laryngitis, 583 — Acute Bronchitis, 584 — Chronic Bronchitis, 585 — Asthma, 587 — Emphysema, 590 — Catarrhal Pneumonia, 591 — Pulmonary Tubercu- losis, 592 — Pleurisy, 601 — Empyema, 604. 14 CONTENTS. PAGE Diseases of the Circulatory System 604 Pericarditis, 604 — Acute Endocarditis, 606 — Chronic Endocarditis, 607 — Chronic Myocardial Disease, 613 — Angina Pectoris, 615. Diseases of the Kidneys 616 Acute Nephritis, 616 — Chronic Nephritis, 618 — Nephrolithiasis, 622. Diseases of the Nervous System 624 Acute Cerebral Leptomeningitis, 624 — Cerebral Hemorrhage, 624 — Loco- motor Ataxia, 625 — Myelitis, 627 — Poliomyelitis, 628 — Neuritis, 629 — Sciatica, 630 — Neuralgia, 631 — Chorea, 634 — Epilepsy, 635 — Neurasthenia, 639 — Hysteria, 642. Weights and Measures 644 Index ....... 647 MODERN MATERIA MEDICA AND THERAPEUTICS Modern MATERIA MEDICA AND THERAPEUTICS. GENERAL CONSIDERATIONS. Materia medica is that branch of medical science which treats of the remedies used in medicine. It deals with their sources, physical characters, composition, preparations, and doses. Pharmacy is the art of preparing, compounding, and dis- pensing medicines. Pharmacodynamics is the study of the action of drugs upon living organisms. Our knowledge of the action of drugs upon human beings is obtained in two ways : First, by clinical experience, and secondly, by comparative study of their action on the lower animals. Therapeutics is that branch of medicine which deals with the application of remedies to disease. In its broadest sense, it has to do not onlv with dru^s, but with all other agents which are of service in restoring health, prolonging life, or affording comfort to the sick. Treatment based solely on clinical experience, and instituted without reference to the physiologic action of the remedies employed, constitutes empirical therapeutics. Thus, the giv- ing of opium in diabetes and of salicylic acid in rheumatism, simply because experience has taught that these drugs often do good, are illustrations of empirical therapeutics. The treatment of disease by drugs which are expected, from a knowledge of their physiologic actions, to antagonize cer- tain known pathologic conditions, constitutes rational thera- peutics. The employment of chloral in the convulsions of tetanus maybe cited as an illustration of rational therapeutics, since it is expected that chloral, through its sedative effect, will counteract the spinal irritation which is manifesting itself in convulsions. COMPOSITION OF DRUGS. The composition of the inorganic drugs is indicated by their names and formulas. The composition of the organic drugs is often exceedingly complex. They may contain fixed oils, 2 17 1 8 GENERAL CONSIDERATIONS. volatile or essential oils, resins, oleoresins, balsams, gums, gum-resins, alkaloids, glucosids, saponins, neutral principles, and organic acids. Stereoptenes are the solid oxidized products which certain volatile oils yield when they are cooled sufficiently or are al- lowed to stand. Camphor, thymol, and menthol are examples. Fixed oils are oils obtained by simple pressure, and are not readily volatilized. Croton oil, cod-liver oil, castor oil, and olive oil are examples of fixed oils. Volatile or essential oils are obtained chiefly by dis- tillation. They give the peculiar odor and taste to plants. Oils of cinnamon, turpentine, mint, eucalyptus, juniper, cloves, copaiba, and lemon are volatile oils. Resins are exudations allied to and probably derived from volatile oils. They are oxidized hydrocarbons, amorphous, brittle, insoluble in water, but freely soluble in alcohol. They unite with alkalies to form soaps. They melt at a low heat, and solidify again on cooling. The chief official resins are those of copaiba, jalap, podophyllum, scammony, and guai- acum-wood. Oleoresins are stable mixtures of a volatile oil and a resin. Their two constituents can be separated by distillation. The oleoresins used in medicine are those of aspidium, capsi- cum, cubeb, lupulin, ginger, and black pepper. Balsams are resins or oleoresins containing benzoic acid or cinnamic acid. The chief balsams are those of peru, tolu, and storax. Gums are desiccated exudations obtained by incising the limbs and branches of certain plants. They form a mucilage or jelly with water, and are insoluble in alcohol. The most important gums are those of acacia and tragacanth. Gum-resins are mixtures of gum with resins or oleo- resins. Asafetida, ammoniac, myrrh, gamboge, and scammony are examples of gum-resins. Alkaloids are nitrogenous compounds occurring in plants, resembling ammonia in being basic and capable of forming salts with acids. In many instances, as in the case of atropin, morphin, aconitin, and quinin, the alkaloid represents to a great extent the active properties of the drug. Glucosids are compounds which, treated with mineral acids or certain ferments, are resolved into two or more sub- stances, one of which is glucose. They may be either neutral or acid in reaction, and nearly all are soluble in alcohol. The chief glucosids are arbutin, amygdalin, glycyrrhizin, convalla- marin, adonidin, digitalin, digitoxin, and strophanthin. PREPARATIONS OF DRUGS. 1 9 Saponins are non-nitrogenous bodies, generally glucosids, which possess the property of foaming with water, emulsifying fats, and laking the red blood-cells. They are found in a number of plants, especially soap-bark, sarsaparilla, and senega. They are not absorbed from the intact alimentary canal, but have an intensely irritant local action. Neutral principles are neutral or feebly acid constituents of plants, differing from glucosids in not being resolvable into glucose, and from alkaloids in not being precipitated by tannic acid or mercuric potassium iodid. Aloin, elaterin, santonin, picrotoxin, salicin, and chrysarobin belong to this class of compounds. Organic Acids. — Many vegetable drugs contain organic acids, either free or combined with alkaloids or inorganic bases. The organic vegetable acids of most value in medicine are gallic, tannic, salicylic, benzoic, citric, acetic, and tartaric acids. PREPARATIONS OF DRUGS. Vinegars (aceta) are liquid preparations made by treating vegetable drugs with diluted acetic acid. Only two are official : Acetum Opii (vinegar of opium). Acetum Scillae (vinegar of squill). Waters (aquae) are aqueous solutions of volatile sub- stances. The waters most commonly used are : Aqua Ammonise (water of ammonia). Aqua Ammoniae Fortior (stronger water of ammonia). Aqua Anisi (anise-water). Aqua Aurantii Florum (orange-flower water). Aqua Camphorae (camphor-water). Aqua Chloroformi (chloroform-water). Aqua Cinnamomi (cinnamon-water). Aqua Fceniculi (fennel-water). Aqua Hamamelidis (hamamelis-water). Aqua Hydrogenii Dioxidi (solution of hydrogen dioxid). Aqua Menthae Piperita^ (peppermint-water). Aqua Rosae (rose-water). Solutions (liquores) are solutions of non-volatile substances in water. The official solutions contain only inorganic salts. Among the most important of this class of preparations are : Liquor Acidi Arsenosi (solution of arsenous acid). Liquor Ammonii Acetatis (solution of ammonium acetate, spirit of Mindererus). Liquor Arseni et Hydrargyri Iodidi (solution of arsenous and mercuric iodids, Donovan's solution). 20 GENERAL CONSIDERATIONS. Liquor Calcis (solution of calcium hydroxid, lime-water). Liquor Chlori Compositus (compound solution of chlorin). Liquor Ferri et Ammonii Acetatis (solution of iron and ammonium acetate, Basham's mixture). Liquor Ferri Subsulphatis (solution of ferric subsulphate, Monsel's solution). Liquor Formaldehydi (solution of formaldehyde). Liquor Iodi Compositus (compound solution of iodin, Lugol's solution). Liquor Magnesii Citratis (solution ot magnesium citrate). Liquor Plumbi Subacetatis Dilutus (diluted solution of lead subacetate, lead-water). Liquor Potassii Arsenitis (solution of potassium arsenite, Fowler's solution). Liquor Potassii Citratis (solution of potassium citrate, neu- tral mixture). Liquor Potassii Hydroxidi (solution of potassium hydroxid). Liquor Sodii Hydroxidi (solution of sodium hydroxid). Decoctions (decocta) are liquid preparations made by boil- ing vegetable drugs for fifteen minutes in a closely covered vessel, allowing to cool, and then straining. They should be freshly prepared, since they readily decompose. There are no official decoctions. Infusions (infusa) are liquid preparations made by adding to vegetable substances hot or cold water, allowing the mix- ture to stand for a certain period, and then straining it. The large dose and the tendency to decompose are disadvantages. The official infusions are : Infusum Digitalis (infusion of digitalis). Infusum Pruni Virginians (infusion of wild cherry). Infusum Sennae Compositum (compound infusion of senna, black draught). Mixtures (misturae) are liquid preparations holding in sus- pension medicinal substances. In some mixtures mucilage or syrup is used to prevent rapid precipitation of the insoluble substance. Mixtures should be well shaken before being ad- ministered. The official mixtures are : Mistura Cretae (chalk mixture). Mistura Ferri Composita (compound iron mixture, Griffith's mixture). Mistura Glycyrrhizae Composita (compound mixture of glycyrrhiza, brown mixture). Mistura Rhei et Sodae (mixture of rhubarb and soda). Mucilages (mucilagines) are aqueous solutions of gums or other mucilaginous substances. They are used as emollients, PREPARATIONS OF DRUGS. 21 as excipients for pills, and for suspending insoluble substances in liquids. The official mucilages are : Mucilago Acacias (mucilage of acacia). Mucilago Sassafras Medullas (mucilage of sassafras pith). Mucilago Tragacanthae (mucilage of tragacanth). Mucilago Ulmi (mucilage of elm). SyrupS (syrupi) are concentrated aqueous solutions of sugar containing medicinal or flavoring agents. The official syrups in most common use are : Syrupus Acacias (syrup of acacia). Syrupus Acidi Citrici (syrup of citric acid). Syrupus Acidi Hydriodici (syrup of hydriodic acid). Syrupus Aurantii (syrup of orange). Syrupus Calcii Lactophosphatis (syrup of calcium lacto- phosphate). Syrupus Ferri Iodidi (syrup of ferrous iodid). Syrupus Ferri, Quininae, et Strychninae Phosphatum (syrup of the phosphates of iron, quinin, and strychnin). Syrupus Hypophosphitum (syrup of hypophosphites). Syrupus Hypophosphitum Compositus (compound syrup of hypophosphites). Syrupus Ipecacuanhae (syrup of ipecac). Syrupus Lactucarii (syrup of lactucarium). Syrupus Pruni Virginianae (syrup of wild cherry). Syrupus Rhei (syrup of rhubarb). Syrupus Rhei Aromaticus (aromatic syrup of rhubarb). Syrupus Sarsaparillae Compositus (compound syrup of sar- saparilla). Syrupus Scillae (syrup of squill). Syrupus Scillae Compositus (compound syrup of squill, Coxe's hive syrup). Syrupus Senegas (syrup of senega). Syrupus Tolutanus (syrup of tolu). Syrupus Zingiberis (syrup of ginger). Simple syrup (Syrupus) consists of water and 85 per cent, (by volume) of sugar. Elixirs (elixiria) are sweetened aromatic alcoholic prepara- tions. The official elixirs are : Elixir Adjuvans (adjuvant elixir). Elixir Aromaticum (aromatic elixir). Elixir Ferri, Quininae et Strychninae Phosphatum (elixir of iron, quinin, and strychnin phosphates). Spirits (spiritus) are alcoholic solutions of volatile sub- stances. The most important spirits are : 22 GENERAL CONSIDERATIONS. Spiritus ^Etheris Compositus (compound spirit of ether, Hoffmann's anodyne). Spiritus Athens Nitrosi (spirit of nitrous ether). Spiritus Ammoniae (spirit of ammonia). Spiritus Ammoniae Aromaticus (aromatic spirit of ammonia). Spiritus Camphorae (spirit of camphor). Spiritus Chloroformi (spirit of chloroform). Spiritus Cinnamomi (spirit of cinnamon). Spiritus Frumenti (whisky). Spiritus Glycerylis Nitratis (spirit of glyceryl trinitrate, spirit of glonoin, spirit of nitroglycerin). Spiritus Juniperi Compositus (compound spirit of juniper). Spiritus Lavandulae (spirit of lavender). Spiritus Menthae Piperitae (spirit of peppermint). Spiritus Vini Gallici (brandy). Tinctures are alcoholic or hydro-alcoholic solutions of non-volatile (except iodin) substances. They are made by simple solution, maceration, percolation, or maceration and percolation. They are not so strong as the fluid extracts, and, unlike the latter, they are not all of the same definite strength. Most of the tinctures are made with water and alcohol, but some are made with undiluted alcohol. The following are among the most important tinctures that are made with alcohol and water : Tinctura Aconiti (tincture of aconite). Tinctura Aurantii Amari (tincture of bitter orange peel). Tinctura Belladonnas Foliorum (tincture of belladonna leaves). Tinctura Calumbae (tincture of calumba). Tinctura Capsici (tincture of capsicum). Tinctura Cardamomi Composita (compound tincture of cardamom). Tinctura Cinchonae (tincture of cinchona). Tinctura Cinchonae Composita (compound tincture of cin- chona, Huxham's tincture). Tinctura Colchici Seminis (tincture of colchicum seed). Tinctura Digitalis (tincture of digitalis). Tinctura Gambir Composita (compound tincture of gambir). Tinctura Gelsemii (Tincture of gelsemium). Tinctura Gentianae Composita (compound tincture of gentian). Tinctura Guaiaci Ammoniata (ammoniated tincture of guaiac). Tinctura Hyoscyami (tincture of hyoscyamus). Tinctura Kino (tincture of kino). PREPARATIONS OF DRUGS. 23 Tinctura Krameriae (tincture of krameria). Tinctura Lavandulae Composita (compound tincture of lavender). Tinctura Lobeliae (tincture of lobelia). Tinctura Nucis Vomicae (tincture of nux vomica). Tinctura Opii (tincture of opium, laudanum). Tinctura Opii Camphorata (camphorated tincture of opium, paregoric). Tinctura Opii Deodorati (tincture of deodorized opium). Tinctura Quassiae (tincture of quassia). Tinctura Rhei (tincture of rhubarb). Tinctura Stramonii Seminis (tincture of stramonium seed). Tinctura Strophanthi (tincture of strophanthus). Tinctura Valerianae Ammoniata (ammoniated tincture of valerian). The following official tinctures are made with undiluted alcohol : Tinctura Asafcetidae (tincture of asafetida). Tinctura Aurantii Dulcis (tincture of sweet orange-peel). Tinctura Benzoini (tincture of benzoin). Tinctura Benzoini Composita (compound tincture of benzoin). Tinctura Cannabis Indicae (tincture of Indian cannabis). Tinctura Cantharidis (tincture of cantharides). Tinctura Cimicifugae (tincture of cimicifuga). Tinctura Guaiaci (tincture of guaiac). Tinctura Iodi (tincture of iodin). Tinctura Physostigmatis (tincture of physostigma). Tinctura Veratri (tincture of veratrum, tincture of veratrum viride). Fluid Extracts (fluidextracta) are liquid preparations (alcoholic or hydro-alcoholic) of organic drugs, so made that one cubic centimeter represents the active properties of one gram of the crude drug. The most important fluid extracts are: Fluidextractum Belladonnae Radicis (fluid extract of bella- donna root). Fluidextractum Buchu (fluid extract of buchu). Fluidextractum Cannabis Indicae (fluid extract of cannabis indica). Fluidextractum Cimicifugae (fluid extract of cimicifuga). Fluidextractum Cinchonae (fluid extract of cinchona). Fluidextractum Cocae (fluid extract of coca). Fluidextractum Conii (fluid extract of conium). Fluidextractum Ergotae (fluid extract of ergot). 24 GENERAL CONSIDERATIONS. Fluidextractum Gelsemii (fluid extract of gelsemium). Fluidextractum Glycyrrhizae (fluid extract of glycyrrhiza). Fluidextractum Hydrastis (fluid extract of Hydrastis). Fluidextractum Hyoscyami (fluid extract of hyoscyamus). Fluidextractum Nucis Vomicae (fluid extract of nux vomica). Fluidextractum Pilocarpi (fluid extract of pilocarpus). Fluidextractum Rhamni Purshianae (fluid extract of cascara sagrada). Fluidextractum Rhois Glabra (fluid extract of rhus glabra). Fluidextractum Sarsaparillae (fluid extract of sarsaparilla). Fluidextractum Sarsaparillae Compositum (compound fluid extract of sarsaparilla). Fluidextractum Sennae (fluid extract of senna). Fluidextractum Spigelian (fluid extract of spigelia). Fluidextractum Uvae Ursi (fluid extract of uva ursi). Fluidextractum Veratri (fluid extract of veratrum, fluid ex- tract of veratrum viride). Fluidextractum Viburni Opuli (fluid extract of viburnum opulus). Fluidextractum Viburni Prunifolii (fluid extract of viburni prunifolium). Wines (vina) are alcoholic liquids made by fermenting the juice of fresh grapes. Medicated wi?ies are alcoholic prepara- tions in which white wine is used as a menstruum. The offi- cial wines are : Vinum Album (white wine). Vinum Antimonii (wine of antimony). Vinum Cocae (wine of coca). Vinum Colchici Seminis (wine of colchicum seed). Vinum Ergotae (wine of ergot). Vinum Ferri (wine of iron, wine of ferric citrate). Vinum Ferri Amarum (bitter wine of iron). Vinum Ipecacuanhas (wine of ipecac). Vinum Opii (wine of opium). Vinum Rubrum (red wine). Emulsions (emulsa) are aqueous preparations in which, by the aid of some mucilaginous material, insoluble, oily, or resinous substances are suspended in the form of minute particles or globules. The chief excipients used for making emulsions are acacia, tragacanth, and yelk of egg. Alcoholic preparations in large quantity are incompatible with emulsions, since they precipitate the excipient, the gum, or egg. The official emulsions are : PREPARATIONS OF DRUGS. 2$ Emulsum Amygdalae (emulsion of almond). Emulsum Asafcetidae (emulsion of asafetida). Emulsum Chloroformi (emulsion of chloroform). Emulsum Olei Morrhuae (emulsion of cod-liver oil). Emulsum Olei Morrhuse cum Hypophosphitibus (emulsion of cod-liver oil with hypophosphites). Emulsum Olei Terebinthinae (emulsion of oil of turpen- tine). Honeys (mellita) are Hquid preparations in which honey is used as a menstruum. The official honeys are : Mel (honey). Mel Despumatum (clarified honey). Mel Rosae (honey of rose). I/iniments (linimenta) are liquid preparations containing oleaginous substances, and intended for external application. With the exception of belladonna liniment and lime liniment, which are used as sedative applications, all the official lini- ments are of a stimulating character, and are to be applied with friction. The official liniments are : Linimentum Ammoniac (ammonia liniment). Linimentum Belladonnae (belladonna liniment). Linimentum Calcis (lime liniment, carron oil). Linimentum Camphorse (camphor liniment). Linimentum Chloroformi (chloroform liniment). Linimentum Saponis (soap liniment). Linimentum Saponis Mollis (liniment of soft soap, tincture of green soap). Linimentum Terebinthinae (turpentine liniment). I/Otions (lotiones) are weak medicated solutions or mix- tures for external use. When intended for the eyes, they are known as collyria. Collyria are usually applied by means of a pipet with a rubber bulb. There are no official lotions, but the following are in common use : Lotio Plumbi et Opii (lead-water and laudanum : lead acetate, 120 gr. (8.0 gm.); tincture of opium, \ fl. oz. (15 c.c.) ; water, 16 fl. oz. (475 c.c.)). Lotio Hydrargyri Flava (yellow wash : corrosive sublimate, 24 gr. (1.5 gm.); lime-water, 16 fl. oz. (475 c.c.)). Lotio Hydrargyri Nigra (black wash : calomel, 64 gr. (4.0 gm.) ; lime-water, 16 fl. oz. (475 c.c.)). Collodions (collodia) are liquid preparations having for a menstruum a solution of pyroxylin (gun-cotton) in ether and alcohol. They are used externally, and are applied by means of a brush. With the exception of cantharidal collodion, which is used for blistering the skin, they are chiefly employed as protectants. The official collodia are : 26 GENERAL CONSIDERATIONS. Collodium (collodion). Collodium Canthari datum (cantharidal collodion, blistering collodion). Collodium Flexile (flexile collodion). Collodium Stypticum (styptic collodion). Glycerites (glycerita) are solutions of drugs in glycerin. The following are official : Glyceritum Acidi Tannici (glycerite of tannic acid). Glyceritum Amyli (glycerite of starch). Glyceritum Boroglycerini (glycerite of boroglycerin). Glyceritum Ferri, Quininae et Strychninae Phosphatum (glyc- erite of the phosphates of iron, quinin, and strychnin). Glyceritum Hydrastis (glycerite of hydrastis). Glyceritum Phenolis (glycerite of phenol, glycerite of car- bolic acid). Enemas or Clysters (enemata) are liquid preparations intended for injection into the rectum. There are no official enemas. Extracts (extracta) are solid or semisolid preparations made by evaporating solutions of vegetable drugs. The menstrua are alcohol, diluted alcohol, water, water and ammonia-water, diluted acetic acid, or acetic acid and diluted alcohol. Being concentrated and solid or semisolid, they are well adapted for administering in the form of pills. The most important extracts are : Extractum Aloes (extract of aloes). Extractum Belladonnas Foliorum (extract of belladonna leaves). Extractum Cannabis Indicae (extract of cannabis indica). Extractum Cimicifugae (extract of cimicifuga). Extractum Colchici Cormi (extract of colchicum corm). Extractum Colocynthidis (extract of colocynth). Extractum Colocynthidis Compositum (compound extract of colocynth). Extractum Digitalis (extract of digitalis). Extractum Ergotae (extract of ergot). Extractum Euonymi (extract of euonymus). Extractum Gentianae (extract of gentian). Extractum Glycyrrhizae (extract of glycyrrhiza). Extractum Glycyrrhizae Purum (pure extract of glycyr- rhiza). Extractum Haematoxyli (extract of hematoxylon). Extractum Hyoscyami (extract of hyoscyamus). Extractum Jalapae (extract of jalap). Extractum Malti (extract of malt). PREPARATIONS OF DRUGS, 2J Extractum Nucis Vomicae (extract of nux vomica). Extractum Opii (extract of opium). Extractum Physostigmatis (extract of physostigma). Extractum Quassiae (extract of quassia). Extractum Rhamni Purshianae (extract of cascara sagrada). Extractum Rhei (extract of rhubarb). Extractum Stramonii (extract of stramonium). Extractum Sumbul (extract of sumbul). Extractum Uvae Ursi (extract of uva ursi). Masses (massae) are soft-solid preparations preserved in bulk and intended for forming into pills. The official masses are : Massa Ferri Carbonatis (mass of ferrous carbonate, Vallet's mass). Massa Hydrargyri (mass of mercury, blue mass, blue pill). Pills (pilulae) are small rounded^ masses containing one or more medicinal substances held together by some adhesive material, known as an excipient. The usual excipients are water, glycerin, tragacanth, acacia, honey, bread-crumbs, soap, confection of rose, extract of glycyrrhiza, and extract of gen- tian. Ordinarily, pills should not exceed in weight 5 grains, unless made of very heavy drugs of small bulk. The official pills are : Pilulae Aloes (pills of aloes). Pilulae Aloes et Ferri (pills of aloes and iron). Pilulae Aloes et Mastiches (pills of aloes and mastich). Pilulae Aloes et Myrrhae (pills of aloes and myrrh). Pilulae Asafcetidae (pills of asafetida). Pilulae Catharticae Compositae (compound cathartic pills). Pilulae Cartharticae Vegetabiles (vegetable cathartic pills). Pilulae Ferri Carbonatis (pills of carbonate of iron*; Blaud's pills). Pilulae Ferri Iodidi (pills of ferrous iodid). Pilulae Laxativae Compositae (compound laxative pills). Pilulae Opii (pills of opium). Pilulae Phosphori (pills of phosphorus). Pilulae Podophylli Belladonnae et Capsici (pills of podo- phyllum, belladonna, and capsicum). Pilulae Rhei Compositae (compound pills of rhubarb). Confections (confectiones) are soft masses made by mixing drugs with sugar and water or honey. Only two are official : Confectio Rosae (confection of rose). Confectio Sennae (confection of senna). Powders (pulveres) are drugs in the form of fine, loose, uncompacted particles. They are commonly dispensed in 28 GENERAL CONSIDERATIONS. small paper packages, known as chartulce. But the latter are not suitable for highly volatile, hygroscopic, efflorescent, or deliquescent substances, or drugs with a disagreeable taste. When not suitable for papers, powders may be dispensed in capsules or cachets. Capsules are small gelatin cases or envel- opes (hard or soft) in which liquid or solid medicines are enclosed to be swallowed. Cachets are round concave wafers made of flour and water. The drug is contained in the cavity formed by bringing together the concave surfaces of two wafers. Their edges are fastened by being moistened and then pressed together. They are well adapted for enclosing powders having a disagreeable taste. They should be taken floated on a small quantity of water. Triturates (triturationes) are fine powders of medicinal substances intimately mixed with sugar of milk. There is only one official triturate : Trituratio Elaterini (triturate of elaterin). Tablets (tabellae) are small disks containing medicinal sub- stances mixed with sugar, and pressed into shape by metallic moulds. They are a convenient form in which to administer concentrated remedies, such as calomel, morphin, and strych- nin. There are no official tablets. Troches or lozenges (trochisci) are small, cylindrical or flat, solid masses, containing medicinal agents mixed with sugar and mucilage. Most of them are intended to influence the mucous membrane of the throat. The official troches are : Trochisci Acidi Tannici (troches of tannic acid). Trochisci Ammonii Chloridi (troches of ammonium chlorid). Trochisci Cubebae (troches of cubeb). Trochisci Gambir (troches of gambir). Trochisci Glycyrrhizae et Opii (troches of glycyrrhiza and opium). Trochisci Krameriae (troches of krameria). Trochisci Potassii Chloratis (troches of potassium chlorate). Trochisci Santonini (troches of santonin). Trochisci Sodii Bicarbonatis (troches of sodium bicarbonate). Suppositories (suppositoria) are solid bodies, of various shapes, intended to be inserted into the rectum, vagina, urethra, or nostril. The usual base is oil of theobroma. They are poured while in liquid form into suitable moulds and are so- lidified by cooling on ice. The only official suppositories are : Suppositoria Glycerini (suppositories of glycerin). Ointments (unguenta) are soft fatty preparations, melting at the temperature of the body, and containing medicinal sub- stances incorporated with a base of lard, a fixed oil, petrolatum, wax, or spermaceti. The official ointments are : PREPARATIONS OF DRUGS. 29 Unguentum Acidi Borici (ointment of boric acid). Unguentum Acidi Tannici (ointment of tannic acid). Unguentum Aquas Rosae (ointment of rose-water, cold cream). Unguentum Belladonnas (belladonna ointment). Unguentum Chrysarobini (chrysarobin ointment). Unguentum Diachylon (diachylon ointment). Unguentum Gallae (nutgall ointment). Unguentum Hydrargyri (mercurial ointment). Unguentum Hydrargyri Ammoniati (ointment of ammoni- ated mercury). Unguentum Hydrargyri Dilutum (blue ointment). Unguentum Hydrargyri Nitratis (ointment of mercuric nitrate, citrine ointment). Unguentum Hydrargyri Oxidi Flavi (ointment of yellow mercuric oxid). Unguentum Hydrargyri Oxidi Rubri (ointment of red mer- curic oxid). Unguentum Iodi (iodin ointment). Unguentum Iodoformi (iodoform ointment). Unguentum Phenolis (ointment of phenol, ointment of car- bolic acid). Unguentum Picis Liquidae (tar ointment). Unguentum Potassii Iodidi (ointment of potassium iodid). Unguentum Stramonii (stramonium ointment). Unguentum Sulphuris (sulphur ointment). Unguentum Veratrinae (veratrin ointment). Unguentum Zinci Oxidi (ointment of zinc oxid). Unguentum Zinci Stearatis (ointment of zinc stearate). Oleates (oleata) are solutions of metallic oxids or alkaloids in oleic acid. There are five official oleates : Oleatum Atropinae (oleate of atropin). Oleatum Cocainae (oleate of cocain). Oleatum Hydrargyri (oleate of mercury). Oleatum Quininae (oleate of quinin). Oleatum Veratrinae (oleate of veratrin). Cerates (cerata) are solid fatty preparations resembling ointments, but made firmer by the addition of wax. They are of such consistence that they soften but do not melt at the body-temperature. The official cerates are : Ceratum (cerate). Ceratum Camphorae (camphor cerate). Ceratum Cantharidis (cantharides cerate). Ceratum Plumbi Subacetatis (cerate of lead subacetate, Goulard's cerate). 30 GENERAL CONSIDERATIONS. Ceratum Resinse (rosin cerate, basilicon ointment). Ceratum Resinae Compositum (compound rosin cerate). Plasters (emplastra) are solids having a fatty or resinous base, and of such consistence that they do not melt but become adhesive when applied to the surface of the body. The official plasters are : Emplastrum Adhaesivum (adhesive plaster). Emplastrum Belladonnae (belladonna plaster). Emplastrum Capsici (capsicum plaster). Emplastrum Hydrargyri (mercurial plaster). Emplastrum Opii (opium plaster). Emplastrum Plumbi (lead plaster, diachylon plaster). Emplastrum Saponis (soap plaster). Papers (chartae) are strips of paper impregnated or coated with some medicinal substances. They are intended to be moistened and applied as a plaster, or else to be burned and the fumes inhaled. One paper is official : Charta Sinapis (mustard paper). Poultices (cataplasmata) are soft semiliquid preparations made of some cohesive substance, mixed with water, to be used for applying heat and moisture to the tissues, or for securing a local stimulant effect. They are usually made of flaxseed meal, slippery elm, or bread and milk. Charcoal may be added as an absorbent, mustard as a stimulant, and laudanum as an anodyne. Only one cataplasm is official : Cataplasma kaolini (cataplasm of kaolin). INCOMPATIBILITY IN PRESCRIPTIONS- 1 Incompatibility in a prescription has been defined as that condition in which there exists either " a chemical decomposi- tion, a pharmaceutic dissociation, or a therapeutic opposition " of its constituents. The term is thus susceptible of three meanings. A prescription is chemically incompatible where chemical change results ; it is pharmaceutical^ incompatible where there is violation of correct pharmaceutic procedure; and there is therapeutic incompatibility where there is antago- nism in physiologic action. Now, accepting these definitions, a prescription may be chemically incompatible, and yet be just what the physician wants. It may be pharmaceutical^ incom- patible, and yet be desirable for the same reason. But it is never desirable when a change of chemical composition or 1 This article has been written by Joseph W. England, Ph.G. INCOMPATIBILITY IN PRESCRIPTIONS. 3 1 pharmaceutic character results in the formation of new prod- ucts having totally different therapeutic effects than those obviously intended. And this view — the intended therapeutic action of the prescription — the pharmacist should ever bear in mind. Every new prescription is largely a law unto itself until tried. Expertness in pharmaceutic manipulation, of which prescription- work is the highest type, is a matter of individual ability, which can be acquired only in the largest and best measures by per- sonal experience. The subject of incompatibility is not a for- midable one if there primarily exists a clear knowledge of the chemical or pharmaceutic properties of the substances used, so that any deviation from the right standard may be detected ; but here is the puzzling question, How are we to know but that, in the event of some chemical or pharmaceutic change, the phys- ician does not mean just such a change, and nothing else ? At first glance it seems strange, but there are some most successful physicians who, every now and then, write pharma- ceutically and chemically, the most incompatible prescriptions. Yet they have success ; and their happy results can only be due to the certain formation of new products or an alteration in pharmaceutic character of old ones. It does not follow that all prescriptions thus written are of the highest thera- peutic value. Far from it. The tendency of the times is steadily in the direction of greater simplicity in prescription- writing. It is to be regretted that the physician often depends in large measure upon the pharmacist for detecting any chemical or pharmaceutic incompatibility, and that the pharmacist depends solely and alone upon the physician for recognizing any therapeutic incompatibility. A physician, with his many duties, cannot be expected to have at his command the vast detail of pharmaceutic facts, nor can the pharmacist be con- sidered negligent in not possessing an extended acquaintance with the application of drugs in medicine; but it is clear that some elementary knowledge as to how drugs act and for what purposes they may be employed would be of great practical value to the pharmacist in affording him a clear idea of the therapeutic intent of the prescriber, and the ability to detect any deviation through a chemical or pharmaceutic error. An argument for therapeutic knowledge is not a step in the direc- tion of counter-prescribing. It is only a plea for broader edu- cation — for elementary therapeutics on distinctly pharmaceutic lines. With therapeutics pure and simple the pharmacist has nothing whatever to do. That is solely the province of the 32 GENERAL CONSIDERATIONS. physician. Medicine and pharmacy are making rapid scien- tific progress — not in the same way, but upon certain definite lines of work and study, yearly becoming more distinct and widely separated, rendering each the more dependent on the other. To render a knowledge of the solubilities and insolubilities of inorganic compounds readily accessible, the following table is presented, based almost wholly upon Professor Attfield's "Statement of the Solubilities and Insolubilities of Salts," which expresses, directly or by inference, nearly five hundred soluble and insoluble compounds of the following inorganic basylous radicals : aluminum, ammonium, antimony, barium, bismuth, cadmium, calcium, chromium, cobalt, copper, ferric, ferrous, gold, lead, lithium, magnesium, manganese, mercuric, mercurous, nickel, potassium, silver, sodium, stannic, stannous, strontium, and zinc. In using this table it is only needful to remember the well- known chemical law that when a solution of a compound is brought in contact with a solution of another compound, and, by an interchange of radicals, an insoluble compound is ren- dered possible, that compound will be precipitated. Acetates are soluble. Arsenates are insoluble, except those of the alkali metals. Arsenites are insoluble, except those of the alkali metals. Bromids are soluble, except mercurous and silver ; those of antimony and bismuth are decomposed by water to form oxysalts. Carbonates are insoluble, except those of the alkali metals. Chlorids are soluble, except those of lead (s), 1 mercurous, and silver. Citrates are soluble, except those of manganese, mercurous, silver, and strontium, aluminum (s), barium (s), bismuth (s), cadmium (s), calcium (s), lead (s), zinc (s). Cyanids are insoluble, except the mercuric and those of the alkaline metals and earths. Hydrates are insoluble, except those of barium, strontium, calcium (s) f lead (s), and the alkali metals. Iodids are soluble, except those of antimony, bismuth, gold, lead (s), mercuric, mercurous, platinum (s), and silver. Nitrates are soluble. Oxalates are insoluble, except those of antimony (Y), chro- mium, ferric (s), ferrous (s), stannic, and the alka'i metals. ' Oxids are insoluble, except those of barium, strontium, cal- cium (s), and the alkaline metals. 1 (s) means sparingly soluble. INCOMPATIBILITY IN PRESCRIPTIONS. 33 Phosphates (ortho) are insoluble, except those of the alkali metals. Sulphates are soluble, except those of barium, strontium, calcium (s), antimony, lead, mercurous (s), and silver (s). Sulphids are insoluble, except those of barium, calcium (s), strontium, and the alkali metals. Sulphites are soluble, except those of aluminum, antimony, barium, bismuth, calcium (s), cobalt (s), copper, ferrous (s), lead, manganese (s), nickel (s), silver, stannous, strontium, and zinc (s). Tartrates are soluble, except those of antimony, barium, bis- muth, cadmium (s), calcium (j), copper (s) t ferrous (s), lead, manganese (s), mercuric, mercurous, nickel (s), silver, stron- tium (s) f and zinc (s). Acids decompose hydrates, carbonates, and acid carbonates to form salts ; the stronger acids, which are largely inorganic, set free the weaker acids, which are largely organic ; or, brought in contact with alcohol or alcoholic solutions, form ethers ; alkaline hydrates, carbonates, and acid carbonates neutralize free acids, decompose some glucosids, and precipitate all alka- loids, some of which precipitates are soluble in excess of the precipitant, or in alcohol, if that liquid be present in sufficient amount to dissolve them. Oxidizing agents, such as nitric, hydrochloric, nitrohydro- chloric, picric, and chromic acids, and potassium bichromate and permanganate, with readily oxidizable substances, such as carbohydrates, alcohols, ethers, sulphur, phosphorus, sulphids, and organic matter in general, form explosive compounds. Potassium permanganate, if ordered in pill form, can best be made with cacao butter and cosmolin in very small quantity, and enclosed in gelatin capsules. Silver nitrate is reduced by organic matter to oxid, with the exception, it is said, of opium and extract of hyoscyamus. A very good way of making pills of it is with cacao butter and cosmolin, etc., as mentioned above under potassium permanganate ; syrup of ferrous iodid and potassium chlorate form a poisonous compound, and potassium iodid and potassium chlorate form a mixture which yields the poisonous iodate on being taken internally. 1 Iodin and iodids yield precipitates with the alkaloids; bro- mids precipitate morphin and strychnin salts on standing, but a few drops of dilute hydrochloric acid added, after the addi- tion of the alkaloid, prevents the change. Sodium biborate precipitates morphin and cocain salts, but on the addition of a small quantity of boric acid, or with boric acid alone, precipi- 1 Am. Jour. Phar., p. 277, 1876. 34 GENERAL CONSIDERATIONS. tation does not take place. Mercuric chlorid with acidulated solutions of the alkaloids forms crystalline double salts ; potas- sium-mercuric iodid precipitates alkaloidal solutions. Solu- tions of quinin salts with those of the alkaline acetates, or with Basham's mixture, precipitate the sparingly soluble qui- nin acetate. Morphin solutions give the phenol reaction if mixed with tincture of ferric chlorid. Glucosids are decomposed by free acids and precipitated by tannin ; tannic and gallic acids precipitate alkaloids, albumin, gelatin, and the majority of metallic salts, and yield inks with iron solutions. Resinous tinctures and fluid extracts prescribed with aque- ous solutions should always be emulsified with acacia ; tinct- ures and fluid extracts made of stronger alcohol, mixed with those made of diluted alcohol, become turbid and precipitate, since the special solvent power of alcohol or of water for a substance diminishes in proportion to the quantity of the other liquid present. A " shake " label should always be used. When for internal use, fixed and volatile oils and oleoresins and aqueous solutions should always be emulsified, whether ordered or not, and to better emulsify the volatile oils they should have mixed with them, prior to emulsification, an equal volume of olive, almond, or cotton-seed oil. Tincture of ferric chlorid gelatinizes mucilage of acacia; free acids separate insoluble carminic acids from compound tincture of cardamom ; free acids precipitate glycyrrhizin from fluid extract of licorice. Commercial spirit of nitrous ether liberates iodin from solu- tions of iodids, decomposes antipyrin solutions to form a green nitroderivative, and precipitates mucilage of acacia, but if it be well diluted with water it can usually be added last without precipitating. Tincture of guaiac and spirit of nitrous ether are stated to be pharmaceutically incompatible by Potter, although they are often prescribed together ; likewise infusion of wild cherry with compound infusion of gentian, infusion of cinchona with compound infusion of gentian, and infusions with metallic salts generally. Sodium salicylate in solution precipitates the sparingly soluble salicylic acid if mixed with acids, and yields, if dis- pensed in powders with potassium acetate, the very deliques- cent potassium salicylate. Sodium salicylate in strong solu- tion is decomposed by tincture of ferric chlorid, but if well diluted first changes only into ferric salicylate. Sodium- benzoate solution is decomposed by acids to yield the spar- ingly soluble benzoic acid. METHODS OF ADMINISTERING DRUGS. 35 Mercuric chlorid is decomposed by solution of potassium arsenite, but if the alkaline solution has first added to it, in slight excess, diluted hydrochloric acid, no precipitation will take place on the addition of the mercurial salt. Pyrophos- phate and phosphate of iron solutions precipitate with dilute phosphoric acid. The National Formulary recommends the usage of dilute metaphosphoric acid in place of the official " ortho" variety, as yielding a permanently clear solution. In conclusion, the writer would say that in this brief article he has endeavored to present, not an exhaustive list of special incompatibles, but simply a general expression of those liable to occur in the every-day routine of prescription-work. METHODS OF ADMINISTERING DRUGS* By the Mouth. — This is the most common method. Drugs may be administered by the mouth for their local action on the mouth, throat, stomach, or intestines, or for the purpose of being absorbed. When it is desired to influence the mouth or throat, the remedy is generally given in the form of a lozenge, and the patient advised not to take food or water for at least an hour afterward. Remedies intended to act directly on the mucous membrane of the stomach should be given when the stomach is empty, that is, half an hour or an hour before meals. Drugs intended to exert a direct influence on the intestine should be given two or three hours after meals, and preferably in firm pills. Sometimes such pills are coated with a substance, like keratin, that will resist the action of the gastric juice. Absorption may take place from any part of the alimentary canal. Powerful remedies, as nitroglycerin and tincture of aconite, are readily absorbed from the tongue. Absorption from the stomach is effected most quickly, as a rule, when the drug is given in solution on an empty stomach. However, in the case of remedies that have a local irritant action, it is far better to give them immediately after meals, so that by becoming mixed with the food their local effect is more or less avoided. A few remedies, such as calomel and salol, are digested almost entirely in the intestine. Hypodermic Method. — This consists in injecting medici- nal solutions into the subcutaneous tissue by means of the hypodermic needle and syringe. The advantages of this method are the great rapidity with which absorption is effected, and the certainty of securing the action of the entire $6 GENERAL CONSIDERATIONS. dose, since partial destruction of the remedy by the digestive organs is avoided. The disadvantages of this method are the pain inflicted, the liability of causing abscess, and the risk of throwing the solution directly into a vein. The alkaloidal salts, on account of their small bulk, are especially adapted for hypodermic use. Some remedies, such as toxins and antitoxins, are effective only when administered subcu- taneously. The best places to select for the injections are the extensor surface of the arm, the calf of the leg, the abdom- inal wall, and the buttock. Both the needle and the solution should be sterile. All the air should be expelled from the syringe before the injection is given, and great care should be exercised to avoid entering a vein. The dose of a drug administered hypodermically is ordinarily about one-half of that given by the mouth. Intravenous Injection. — This method is employed only in great emergency. Saline solution may be given intraven- ously in copious hemorrhage, uremia, diabetic coma, and in the algid stage of cholera. In the collapse of acute poison- ing, diffusible stimulants — ammonia-water, ether, whiskey — may be introduced into the system through the veins. By the Rectum. — Absorption through the rectum is not effected near so rapidly as through the stomach. To accom- plish the same result it is generally necessary to give twice the dose by the rectum that would be required by the mouth. This method is convenient when the stomach is unretentive. It also affords a means of acting directly on the bowel with drugs, and of removing hardened feces, flatus, and parasites. When the enema is to be retained in the bowel for its local effect, the fluid should be warm, the quantity should not exceed two ounces, and the injection should be made very slowly. When the enema is intended to bring about defeca- tion, one or two pints of fluid may be employed. When flatus is to be removed, an enema consisting of from 4 to 6 ounces of the emulsion of asafetida is effective. Both local and constitutional effects may also be secured by means of suppositories containing medicinal agents. Inunction. — Many medicinal substances, if dissolved in fats, are fairly well absorbed through the unbroken skin, espe- cially if friction be used in their application. When this method of administration is employed systematically to secure a constitutional effect, different surfaces should be selected each day. The best surfaces for inunction are those having a thin skin, such as the axillae, popliteal spaces, the groins, and the inner sides of the thighs. The drugs that are most fre- CIRCUMSTANCES MODIFYING THE EFFECT OF DRUGS. 37 quently introduced by inunction are mercury and iodin. A convenient method of treating syphilis in infants is by smear- ing mercurial ointment on a flannel binder worn around the abdomen. Bndermic Method.— This method consists in raising a blister, removing the epidermis, and sprinkling on the raw derm the drug that is to be absorbed. It is very painful, and it is far less satisfactory than the hypodermic method. Flttnigation. — This method is sometimes employed in syphilis instead of inunction. A mercurial salt, preferably calomel, is volatized from a tin plate suspended over a spirit- lamp. The latter is placed under a cane-seated chair, upon which is seated the patient, disrobed and surrounded by a blanket fastened to the neck. Inhalation. — Volatile drugs are rapidly absorbed from the respiratory tract, and this method is especially employed for the administration of drugs which induce general anes- thesia, such as ether, chloroform, and nitrous oxid. The effect of other volatile substances, like amyl nitrite, is also secured by inhalation. Medicated vapors and sprays are employed to influence directly the mucous membrane of the respiratory tract. ORCUMSTANCES MODIFYING THE EFFECT OF DRUGS. The effect of drugs is modified by many circumstances, chief of which are the age of the patient, sex, race, body- weight, temperament, disease, temperature, habit, idiosyncrasy, method of administration, time of administration, preparation of the drug, and dose. Habit. — With many drugs continuous use induces tolera- tion. This is particularly true of opium. Increased elimina- tion and diminished absorption may play a part in the development of this condition, but it is probably due very largely to a change in the tissues themselves, whereby they are rendered less susceptible to the influence of the drug. Idiosyncrasy. — This is a peculiar susceptibility or insus- ceptibility of one or more of the tissues to the influence of certain drugs. Less than % of a grain of calomel has been known to induce salivation. The smallest dose of quinin will in some individuals cause a diffuse erythematous rash. Cumulative Action. — This is the property which some drugs have, after they have been given for a certain length of time, of producing a severe and more or less sudden effect. 38 GENERAL CONSIDERATIONS. It is probably due in most instances to an accumulation of the drug in the tissues, excretion, for one reason or another, being less rapid than absorption. In some cases, however, it may depend upon irregular absorption, a large quantity of the drug suddenly entering the circulation from the alimentary canal, where, owing to some accidental condition, there has been an undue accumulation. DOSAGE. The circumstances which modify the effect of drugs must also necessarily influence dosage. The most important con- ditions to be considered are the age, sex, weight, and disease. Age. — Children require smaller doses than adults. Two rules are in common use for determining the proper dose for children of different ages : Young's rule is as follows : Add 1 2 to the age and divide by the age, and the quotient will be the denominator of a fraction the numerator of which is 1. Thus, for a child of four years, = 4, and the dose is j£ that for an adult. 4 Cowling's rule is to divide the age of the child at its next birthday by 24. Thus, for a child 3 years old, the dose would be -£% = •§■ of the adult dose. These rules, of course, are only approximately correct, and each drug must be considered by itself in reference to dose. Thus, children are very susceptible to opium, and, therefore, the dose of this drug must be smaller than the age would apparently indicate. On the other hand, arsenic and bella- donna are well borne by children, and, therefore, relatively larger doses of these drugs can be prescribed. Sex. — Women generally require smaller doses than men. The dose for a woman is about four-fifths of that for a man. Weight. — Weight has less influence on dosage than either age or sex, but a very heavy muscular individual will generally require a larger dose than one of slight frame. DRUGS CIRCULATORY STIMULANTS. Circulatory stimulants are drugs which increase the effi- ciency of the heart. They may increase the force of the beat and lessen its rate, or they may increase both the force and the rate of the beat. Among those which strengthen the heart- beat, but decrease its frequency, are the following : Digitalis. Squill. Strophanthus. Canadian hemp (apocynum). Convallaria. Adrenalin. Adonis vernalis. Strychnin. Among those which increase both the force and frequency of the beat may be mentioned the following : CafTein. Atropin. A number of drugs quicken the heart-beat and slightly in- crease the output of the heart per unit of time, not so much by acting on the heart directly as by causing peripheral irrita- tion and a reflex stimulation of the organ. The effect of these drugs on the circulation is necessarily transitory. The import- ant members of this group are : Ammonia. Ether. Alcohol. Camphor. Increase of Blood-pressure. — A drug may increase the blood-pressure (i) by stimulating the heart directly (digitalis, strophanthus, partly in this way) ; (2) by constricting the ves- sels directly (adrenalin) ; (3) by constricting the vessels through a central action (digitalis, strychnin, atropin). The blood- 39 40 CIRCULATORY STIMULANTS. pressure may also be increased by compression of the peripheral vessels, as in the pneumatic rubber suit devised by Crile ; and by increasing the amount of fluid in the vessels (salt solution intravenously or subcutaneously). Acceleration of the Heart-beat. — This can be brought about (i) by excitement or peripheral irritation (alcohol, ether) ; (2) by stimulation of the heart itself (caffein) ; (3) by direct de- pression of the inhibitory nerves, centrally or peripherally (belladonna) ; (4) by reduction of the blood-pressure and in- direct depression of the inhibitory centers in the medulla (nitrites, partly in this way) ; and (5) theoretically, by stimula- tion of the accelerator mechanism of the heart. Circulatory stimulants are indicated in heart-failure and vaso- motor paresis from various causes. In collapse, quickly acting stimulants, such as ammonia, alcohol, and camphor, are often effective, especially when their administration is combined with the external application of heat and the injection of salt solu- tion intravenously, subcutaneously, or into the rectum. In shock (exhaustion of the vasomotor centers) the same meas- ures also may be used, but they are not likely to prove so effi- cacious as intravenous injections of adrenalin, which directly constricts the peripheral vessels, and thus serves to increase the tonus in the medulla oblongata. Circulatory stimulants with a constricting effect upon the peripheral arteries, like digitalis, are often exceedingly useful in valvular disease of the heart with simple dilatation, especially when there is dropsy. For a certain degree of tension in the arteries it is necessary (1) to equalize the two circulations, (2) to keep the coronary arteries well filled and so secure for the heart-muscle the requisite amount of nourishment, (3) to pro- mote diuresis. When, however, the myocardium is the seat of advanced degenerative changes, drugs like digitalis must be used with considerable caution, since their constricting influence upon the vessels may be much more pronounced than their stimulating effect upon the heart. In such cases a vasodilator, as one of the nitrites, should also be given, or a heart stimulant selected that will cause less contraction of the muscular fibers of the vessels. Drugs with the digitalis action also act favorably in cases of cardiac incompetence by diminishing the number of the heart's contractions (prolonging the diastolic phase), and thus giving more rest to the crippled organ. In heart-weakness resulting from asthenic fevers, drugs of the digitalis group are generally less beneficial than alcohol, strychnin, and caffein. AMMONIA. 41 AMMONIA. (NH,) Ammonia is a colorless gas having an intensely pungent odor and acrid taste, and obtained as a by-product in the manufacture of coal-gas. It acts as a base in uniting with acids to form salts. Preparations. Dose. Aqua Ammonias, U. S. P. (io per cent, of the gas) 10-30 min. (0.6-2.0 c.c). Aqua Ammoniae Fortior, U. S. P. (28 per cent, of the gas). Spiritus Ammoniae, U. S. P. (10 per cent, of the gas) 20-60 min. (1.0-4.0 c.c.) Spiritus Ammoniae Aromaticus, U. S. P. (ammonium carbonate, 34; ammonia- water, 90 ; aromatic oils ; water to make iooo parts) 20-60 min. (1.0-4.0 c.c). Linimentum Ammoniae, U. S. P. Physiologic Action. — Circulatory System. — Both the inhalation of ammonia and the administration of its preparations by the mouth produce a transient elevation of the blood-pres- sure. This effect is due not to the direct action of the drug on the heart, but to the reflex stimulation of the organ and also of vasomotor center in the medulla from irritation of the nasal or gastric mucous membrane. Sometimes temporary slowing of the pulse is observed as the result of reflex stimulation of the inhibitory center. Elevation of blood-pressure also occurs when ammonia is injected subcutaneously or intravenously if the dose be moderate, but in this case the vasomotor center is, probably, stimulated directly as well as reflexly. Very large doses of ammonia, administered intravenously, lower the blood- pressure by directly depressing the vasomotor center and the heart. Respiratory System. — Moderate doses increase the depth and volume of the respirations by stimulating reflexly the respiratory center in the medulla. This effect is especially pronounced when the drug is administered by inhalation. Alimentary Canal. — In the stomach, ammonia, like other alkalis, serves to neutralize any free acid that may be present, and in dilute solution is sufficiently stimulating to act as a carminative. Local Action. — Locally, it is a powerful irritant, though its action is not corrosive like that of the fixed alkalis. Even in concentrated solution it does not dissolve the epidermis, but passes through it and produces a blister. 42 CIRCULATORY STIMULANTS. Elimination. — As ammonia undergoes rapid decomposition in the body, its action is very evanescent. Unlike the fixed alkalis, it does not add to the alkalinity of the urine, for after absorption it is transformed into urea, in which form it is excreted. Toxicology. — Ammonia-poisoning is characterized by severe burning pain in the fauces, esophagus, and stomach, dyspnea, persistent vomiting and purging, a rapid, thready pulse, and the symptoms of collapse. The mind may remain clear until the end, but coma often precedes death. The intense irritation of the throat sometimes causes edema of the larynx, in consequence of which death may result in a few minutes from asphyxia. Treatment. — The ammonia should be neutralized by the administration of some weak acid, such as vinegar. Subse- quently the inflammation should be allayed by demulcents and opium. Asphyxia from laryngeal edema will demand tracheotomy. Therapeutics. — Ammonia is employed chiefly as a quickly acting cardiac and respiratory stimulant, as an antacid in gas- tric acidity, and as a counter-irritant. In syncope, collapse, and other forms of sudden heart-failure, ammonia is an invaluable stimulant. In gastralgia and heart- burn dependent upon unnatural acidity of the stomach-con- tents, it is a useful antacid. As an antacid it is employed also externally to neutralize the poison in the bites of certain insects. As a rubefacient, ammonia liniment is a useful remedy in chilblains, chronic rheumatism, and myalgia. Administration. — The spirits of ammonia are usually selected for internal administration. They should be given well diluted. For subcutaneous or intravenous injection am- monia-water is the most suitable preparation. The latter is also used in various rubefacient liniments. Stronger ammonia- water, applied on a pledget of cotton, covered with a watch- crystal, has been used as a vesicant, but the process is very painful and the blister is slow in healing. Incompatibles. — Ammonia is incompatible with mineral and vegetable acids, chloral, and alkaloids. With solutions of corrosive sublimate it forms the insoluble ammoniated mer- cury. With solutions of ferric salts it forms the sesquioxid of iron, which is the antidote to arsenic. With tincture of iodin it yields a black precipitate of nitrogen iodid, which when dry is very explosive. With solutions of formaldehyd it forms uro tropin. ALCOHOL. 43 AMMONII CARBONAS, U. S. P. (Ammonium Carbonate, NH 4 HC0 3 .NH 4 NH 2 C02.) Carbonate of ammonium occurs in the form of white, trans- lucent, crystalline masses having an extremely pungent odor and acrid taste. When exposed to the air it breaks up into a white powder — bicarbonate of ammonium. It is soluble in 4 parts of water. Its dose is 5-10 gr. (0.3-0.6 gm.). Physiologic Action and Therapeutics.— Ammonium carbonate acts like ammonia, and is used for the same purpose, that is, to stimulate reflexly the medullary centers. It also shares with other ammonium compounds the property of ren- dering the bronchial secretion less viscid, hence it is frequently employed as an expectorant. It is particularly efficacious in acute pulmonary diseases associated with cardiac and respiratory weakness, such as severe bronchitis, bronchopneumonia, and croupous pneumonia. Administration. — To guard against excessive gastric irri- tation, it is usually prescribed in mucilage or syrup of acacia, as in the following formula : 5k Ammonii carbonatis, sjij (8.0 gm.); Pulveris acacise et sacchari, aa q. s ; Tincturae lavandulse composite, f^ij (8.0 c.c); Aquae, q. s. ad f^iij (90.0 c.c). — M. Sig. A teaspoonful in water every two or three hours. Incompatibles. — The same as the preparations of am- monia. Ammonium carbonate cannot be prescribed with syrup of squill, syrup of citric acid, or syrup of ipecac, or other syrups of acid reaction. ALCOHOL, U. S. P. (Ethyl Alcohol, C 2 H 6 HO.) Ethyl alcohol is obtained from the distillation of fermented saccharine material. The official preparation contains 92.3 per cent, by weight of absolute ethyl alcohol, and appears as a colorless, inflammable liquid, having a pungent odor and a burning taste. Preparations. Alcohol Absolutum, U. S. P. (99 per cent, alcohol). Alcohol Dilutum, U. S. P. (41.5 per cent, absolute alcohol). Spirits : Spiritus Frumenti, U. S. P., or whisky (37 to 47.5 per cent, alcohol), distilled from fermented grain. Spiritus Juniperi Compositus, U. S. P., equivalent to gin (about 60 per cent. alcohol). Spiritus Vini Gallici, U. S. P., or brandy (39 to 47 per cent, alcohol), distilled from fermented grapes. 44 CIRCULATORY STIMULANTS. Malt Liquors : ^ ' 1 obtained from the fermentation of malted grain, and contain from 3 to p C rt ' I ^ P 61 cent * alco ^°^ Wines : Vinum Album, U. S. P., or white wine (7 to 12 per cent, alcohol). Vinum Rubrum, U. S. P., or red wine (7 to 12 per cent, alcohol). Vinum Portense, or port wine (15 to 20 per cent, alcohol). Vinum Xericum, or sherry wine (15 to 20 per cent, alcohol). The official wines are made by fermenting the unmodified juice of the grape. Physiologic Action. — Circulatory System. — The exact action of alcohol on the circulation is still obscure. Moderate doses cause acceleration of the pulse and flushing of the sur- face, without materially augmenting the blood-pressure. The acceleration of the pulse is due (1) in part to mental and physi- cal excitement, (2) in part to reflex stimulation from gastric irritation, and probably also (3) in part to a direct action, slight and transitory, on the nervous or muscular mechanism of the heart itself. The flushing of the surface is caused by dilatation of the peripheral vessels from depression of the vasomotor centers. The vessels of the splanchnic area apparently do not share in the dilatation ; indeed, there is some reason for believing that they are slightly constricted. While alcohol increases the amount of blood pumped by the heart in a given length of time (Wood and Hoyt), it does not cause under ordinary conditions any material change in the blood- pressure, probably because the actions of the drug in increasing the heart power and in widening the peripheral vessels are about equally balanced. It is generally admitted, however, that very large amounts of alcohol produce a notable fall in the arterial pressure through depression of the vasoconstrictor centers and the heart muscle. Nervous System. — The first effect of alcohol upon the nervous system is one of apparent stimulation, with indications of increased mental and motor activity. As a matter of fact, however, attention, self-control, judgment, and the higher mental processes generally, as well as the capacity of the individual for physical work, are distinctly impaired at once by even small quantities of the drug, and, therefore, the vivacity of speech and excess of motor energy often displayed in the early stage of alcoholic intoxication must be attributed rather to a depression of the inhibitory or controlling functions than to a true stimu- lation of the higher cerebral centers. With a very large dose of alcohol the stage of excitement is soon followed by one of paralysis, which is characterized by loss of memory, thick speech, ataxia, lessened reflex irritability, and somnolence, gradually deepening into coma. ALCOHOL. 45 Respiration. — Moderate amounts of alcohol slightly quicken the respiration and increase the amount of air inhaled. These effects are probably produced reflexly by irritation of the stomach, as there is no evidence to show that the drug is a direct respiratory stimulant. Failure of respiration is the usual cause of death in fatal alcoholic poisoning. Alimentary Canal. — Alcohol augments the flow of saliva and gastric juice, quickens peristaltic movements, and accele- rates absorption. Very small amounts (less than 2 per cent.) favor peptic digestion, while large amounts (more than 10 per cent.) distinctly retard it. Large doses of concentrated alcohol produce acute gastritis. Effect on Metabolism. — Moderate amounts of alcohol undergo combustion in the body, spare to a certain extent the oxidation of fats and proteids, supply energy to the tissues, and serve to maintain the body-weight, when, for any reason, the diet is insufficient. To this extent alcohol is a food. Temperature. — Alcohol lowers the body temperature to a slight extent by dilating the skin-vessels, and so allowing an undue loss of heat. Accompanying the fall of temperature a sensation of warmth is experienced, which is also due to the increased amount of blood in the skin. Elimination. — In moderate doses alcohol undergoes com- plete oxidation in the body, only a small amount (1 or 2 per cent.) being eliminated unchanged by the kidneys and lungs. The products of its decomposition are carbon dioxid and water. Local Action. — Concentrated solutions withdraw water from the cells and precipitate albumins, and thus produce decided irritation. When applied to skin in dilute form and allowed to evaporate, it abstracts heat and produces a sensation of coldness. Action on Lower Organisms. — Alcohol possesses moderate germicidal properties. According to the researches of Har- rington and others the best results are obtained with alcohol of 60 per cent, strength, its germicidal power diminishing with departures in both directions from this dilution. Toxicology. — The ingestion of large quantities of alcohol produces the following symptoms : Flushing of the face, men- tal excitement, quickening of the pulse and respiration ; then incoherent speech, delirium, dilated pupils, loss of co-ordina- tion, subnormal temperature, vomiting, and, finally, stupor and coma. Not infrequently the coma is interrupted by convul- sive seizures. In most cases, if the dose has not been too large, recovery follows in a day or two. Care must be taken to distinguish acute alcoholism from fti CIRCULATORY STIMULANTS. uremia, opium-rxMsoning, and apoplexy. The urinous odor of the breath, the accentuation of second aortic sound, the small pupils, and the presence of albumin in the urine will serve to distinguish uremia. The small pupils, slow respira- tion, and slow pulse will indicate opium-poisoning. The unequal pupils, hemiplegia, and elevated temperature will serve to separate apoplexy from alcoholism. Treatment. — The stomach should be emptied by the stomach-pump, a stimulating emetic, or the hypodermic in- jection of apomorphin (gr. ^ — 0.007 g 111 - - If th e pulse -:ens, stimulants like strychnin, ammonia, or digitalis should be administered hypodermically. Chronic alcoholism is characterized by disturbed sleep, fine tremors, mental impairment, injection of the eyes, redness of the nose, and the symptoms of gastro-intestmal catarrh. When the habit is long-continued, degenerative and cirrhotic changes in the heart, blood-vessels, liver, and kidneys are apt to develop. A common complication of chronic alcoholism is delirium, tremens, which is generally excited by temporary excess, an injury, or some acute intercurrent disease, especially pneu- monia. It is manifested by great mental excitement, insom- incoherent speech, tremors, disordered intellect, and terri- fying hallucinations of sight or hearing. The pulse is rapid and feeble, the appetite is lost, the bowels are constipated, and the temperature slightly elevated. In favorable cases con- valescence follows in a few days, but not infrequently typhoid symptoms develop and the attack ends in death. Among other sequels of dipsomania may be mentioned pneumonia, chronic meningitis, multiple neuritis, amblyopia, epilepsy, and dementia. Treatment of Delirium Tremens — As there has usually been a complete abstinence from food during the debauch leading to the delirium, nutritious foods are always necessary, and the best are milk with lime-water and highly seasoned beef-tea. Sleep must be secured by chloral (gr. xx — 1.3 gm.), hyoscin (gr. yl^ — .00065 gm.), potassium bromid (sj — 4-0 gm.), or paraldehyd (fsss-fej — 2.0-4.0 c.c). Sir William Broadbent has found cold affusions, followed by vigorous rubbing, of great service in promoting sleep. Active catharsis should be encouraged. When the pulse is weak, strychnin and digitalis will be found useful stimulants. Subcutaneous injections of normal salt solution are sometir effective. In many cases physical restraint will be required ; it may be secured by strapping the patient to the bed with sheets. Should profound DIGITALIS. stupor develop, the application of a blister to the back of the neck or a few light touches of the actual cautery will serve to arouse the patient. Therapeutics. — Alcohol is employed internally as a dif- fusible circulator}- stimulant, a _ ; t:machic, a food, and a chemical antidote. Externally it is used as an antiseptic a stimulant, a hemostatic, and an antihydrotic. In all forms of sudden heart-failure, as in syncope, shock, snake-bite, and acute febrile disease, alcohol is an invaluable stimulant In the continued fevers, lik -'..'.:", it fills a triple role : it serves as a food, as a general stimulant, and as a promoter of digestion. In these cases, however, it is well to withhold it until the pulse flags or the heart-sounds indi- cate a weakening of the circulation. Brunton's rule for administering alcohol is a good one: Sit by the si tie :: your patient for a while and watch him after the adrriiriistration of a dose of alcohol, and if you find that the alcohol brings back the various functions nearer to the normal, then it is doing good ; if the functions of the organs diverge further from the normal after the administration of alcohol, then it is doing harm." In chronic diseases, like phthisis, obstinate atari: sia. and valvular affections of the heart, it often does good, but it should be administered tentatively, with due regard for the danger of producing chronic alcoholism. The power which alcohol possesses of counteracting tfa : escharotic action of carbolic acid was first pointed out Phelps and Powell in 1 899. Since then sufficient evidence has accumulated to warrant die belief that alcohol, when admin- istered promptly, is a valuable antidote in carbolic-acid poison- ing. From 1 to 3 ounces of diluted alcohol should be poured into the stomach through a tube, and lavage immediately prac- tised with water containing a soluble sulphate External Uses. — Bathmg with send ad u to other measures in disinfecting the skin. A mixture of alcohol and water makes a useful evaporating lotion in the treatment of contusions with ecchymosis. Applied to wounded surfac es it is effective in controlling capil.t.r : zing. Sponging the body with alcohol and water is often s erw g the night- sv/eats ::" z '.:-.'::: ; : ; . DIGITALIS. U. S. P. (Faxglore.) Digitalis is the dried leaves of Digitalis biennial herb growing in Central and Southern Europe. It : tains several principles, all of which are probably of the 48 CIRCULATORY STIMULANTS. glucosids, the most important being digitoxin, digitophyllin, digitalin, digit alein, digitonin, and digitin. The first four are cardiac stimulants and vasoconstrictors, and represent more or less imperfectly the virtues of the crude drug. Digitonin is a member of the saponin group and is not absorbed from the alimentary canal. By its presence, however, the other glu- cosids, which are insoluble in water, are held in suspension when an infusion is made of the leaves. Digitin is inert. Preparations. Dose. Tinctura Digitalis, U. S. P 5-20 min. (0.3-1.2 ex.). Fluidextractum Digitalis, U. S. P. . . . 1-2 min. (0.06-0. 12 c.c). Infusum Digitalis, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). Extractum Digitalis, U. S. P i-igr. (0.010-1.016 gm.). Pulvis Digitalis |— 2 gr. (0.032-0.13 gm. ). Digitalin (an amorphous powder, ex- tremely variable in composition) - . . -50-jft gr. (0.001-0.002 gm.). Digitaline Cristallisee, or Nativelle's digi- taline (impure digitoxin) -zhnh S r - (0.00025-0.001 gm.). Digitalinum Germanicum (a mixture of glucosids, soluble in water and alcohol ; suitable for hypodermic use) .... -£$- ^ gr. (o.ooi-c.003 gm.). Physiologic Action. — Circulatory System. — The domi- nant action of digitalis is on the circulation. In tJierapentic doses it slows the pulse and raises the blood-pressure. The slowing of the pulse is due mainly to stimulation of the vagi (prolonged diastole), but partly to the action of the drug on the cardiac muscle (prolonged systole). The increased blood- pressure is due (1) to more complete and forcible contractions of the ventricle and (2) to constriction of the peripheral vessels. The vasoconstriction is mainly the result of the direct action of the drug on the muscle of the arterioles, but it is partly in- duced by stimulation of the vasomotor center. The action of digitalis on the vagi is antagonistic to its action on the cardiac muscle. The tendency of the inhibitory action is to cause disastolic slowing and less complete systole, while that of the muscular action is to cause more complete and pro- longed systolic contraction (systolic slowing) and less complete diastole. Nevertheless, the sum of these effects is an increase in the total output of the heart per unit of time ; for, although the slowing of the heart tends to decrease the output, the de- crease is more than compensated for by the increased amount of blood that enters the ventricle because of the longer diastole, and leaves it because of the stronger systole. In the first stage of the poisoning the pulse becomes slow and irregular, and the output of the heart per minute less than it was before the administration of the drug. This effect is to be DIGITALIS. 49 ascribed to excessive inhibitory stimulation. In the second stage of poisoni?ig the pulse becomes rapid and still more irregular. The output of the heart per minute varies. For a time it may be increased in consequence of the greater number of ventricular contractions, but soon it falls off, owing to the imperfect relaxation of the ventricle. Finally, the heart passes in fibrillary contractions and stops in diastole. The phenomena of the second stage of poisoning by digitalis are to be ascribed to increased irritability of the heart muscle. It has been shown that decided hypertrophy of the heart can be induced in animals by giving them digitalis in small doses for a prolonged period. Local Action. — Digitalis is intensely irritant, and when applied to mucous membranes causes smarting, redness, and swelling. Of the glucosids, digitoxin is the most irritant and digitalin the least. Alimentary Canal. — Large doses of the drug frequently excite nausea, vomiting, and diarrhea. Nervous System. — The medulla appears to be the only part of the central nervous system influenced by digitalis. Even in therapeutic doses the drug stimulates the inhibitory cardiac and the vasoconstrictor centers. Toxic doses increase the depth and rate of the respirations and sometimes cause con- vulsions. It is possible that the vomiting, which follows the exhibition of large doses of the remedy, is partly of central origin. Kidneys. — In health digitalis has but little diuretic action, but when the urine is scanty from low arterial tension, it induces free diuresis. It may, therefore, be assumed that the drug has little or no direct influence on the renal epithelium, but that it indirectly increases the quantity of urine through its action on the heart and blood-vessels. The elimination of digitalis is effected very slowly. Toxicology. — Digitalis-poisoning is characterized by ob- stinate vomiting, diarrhea, headache, disordered vision, and a very slow full pulse. The pulse, however, often becomes sud- denly rapid and feeble when the patient sits up. Later, even in recumbency, the pulse becomes rapid, irregular, and thready, the urine scanty or suppressed, the surface cold, and the mind cloudy. Intelligence, however, is not lost until shortly before death. Occasionally convulsions develop during the last stage. The uninterrupted use of digitalis in full doses is sometimes followed by the sudden appearance of toxic symptoms ; this untoward effect seems to be due to the cumulative action of the drug, and is especially liable to occur when there is no 4 50 CIRCULATORY STIMULANTS. diuretic effect, and after the removal of serous effusions by paracentesis. In the first instance elimination is interfered with, and in the second, absorption is effected with undue rapidity. The earliest manifestations of this accident are usually irregularity of pulse, precordial distress, and the appearance of the heart-beats in couples, the first of which only can be detected at the wrist. When a prolonged use of the remedy is required, it should be suspended at intervals for a definite period, so as to allow of complete elimination. Treatment of Poisoning'. — The patient must be kept in the recumbent position. Emetics or purges may be necessary for the removal of any part of the poison that is still unabsorbed. Tannic acid should be administered as a chemical antidote. It is important to maintain the body-temperature by the applica- tion of external heat. Alcoholic stimulants may prove useful. Aconite has been recommended on theoretic grounds as a physiologic antidote, but it should be used with considerable caution. Therapeutics. — Digitalis fills three important offices : It serves as a powerful cardiac stimulant ; it slows the heart and regulates its rhythm, and it acts as a diuretic. As a Cardiac Stimulant. — Digitalis is especially indicated when there is simple dilatation of the heart. By prolonging diastole it rests the heart and allows the ventricles to become more completely filled; and by strengthening the systole it aids in the more thorough emptying of these chambers, this combined action tending to readjust the inequality in the arterial and venous circulations. Moreover, by forcing more blood into the coronary arteries, digitalis may permanently in- fluence for good the tone of the heart muscle. Hypodermic injections of digitalin are often useful in syncope, in collapse from various causes, and in poisoning by cardiac depressants. In chronic valvular disease with symptoms of failing compen- sation digitalis is often of the utmost value, but it must not be used indiscriminately. The chief indications for its use are dropsy, deficient urination, and a rapid, weak, and irregular pulse. When cardiac hypertrophy overbalances dilatation and the symptoms of arterial hyperemia exist, its administration will be productive of harm. The best results are seen in mitral regurgitation. In this disease digitalis secures a more perfect closure of the mitral valves by causing a more vigorous contraction of the muscles surrounding the orifice ; moreover, it supports the right ven- tricle, which is subjected to a severe strain on account of the DIGITALIS. 51 increased resistance in the pulmonary circuit. In some cases of mitral regurgitation, digitalis, although apparently indi- cated, fails to afford relief because of the existence of peri- cardial adhesions or of advanced degeneration of the myocar- dium. When the right ventricle is much distended and the evidences of venous stasis are marked, the drug may fail to act until the tension in the veins has been lessened by the abstraction of a few ounces of blood. In mitral stenosis digitalis is far less serviceable than it is in mitral regurgitation. It should be used only when, as the result of a failing right ventricle, dropsy and anuria are present. Theoretically, by strengthening the contractions of the right ventricle, and by lengthening diastole, so allowing a longer time for blood to enter the left ventricle through the constricted orifice, it should be effective in lessening venous stasis, but unfortunately, in many cases of mitral stenosis, there is extensive disease of the myocardium, and in the presence of the latter — which in all forms of endocarditis is more important than the mere mechanical defect in the valve — digitalis is often useless or harmful. In aortic stenosis digitalis is rarely indicated, and used inju- diciously it may provoke serious injury. When, however, there are symptoms of back-pressure in the lungs, with dropsy, it may be employed with advantage. The existence of aortic regurgitation is not necessarily a con- traindication to the employment of digitalis. It is true that by prolonging diastole regurgitation is favored, but under certain conditions the drug more than compensates for this draw- back by strengthening the contractions of the ventricle, and by improving the tone of the myocardium. It should be with- held when the pulse is slow, full, and regular, but when the pulse becomes rapid, weak, and irregular, and symptoms of venous stasis appear, it may be administered tentatively. In tricuspid regurgitation not dependent upon disease of the valves, but due to simple dilatation of the right ventricle, digitalis is sometimes effective, but when used too freely it may excite, as Potain has observed, pulmonary hemorrhage. In advanced fatty degeneration digitalis often entirely fails or acts unfavorably, but in the early stages of the disorder the exhibition of minute doses, as recommended by Balfour, is often followed by gratifying results. In these cases it is nearly always necessary to counteract the constricting effect of the drug on the arterioles by giving with it some vasodilator, like nitroglycerin, sodium nitrite, or potassium iodid. When symptoms of angina pectoris are present, digitalis must be used with extreme caution, but even here small doses are some- 52 CIRCULATORY STIMULANTS. times of value in the intervals between the attacks, and espe- cially after severe attacks, when symptoms of cardiac failure present themselves. In pneumonia, when there is failure of the right ventricle in its efforts to drive blood into the partially consolidated lung, and in consequence the pulse becomes rapid and feeble, digi- talis often causes a decided improvement in the symptoms. In such cases it has seemed to us to be more effective when given hypodermically. As a Vagus Stimulant. — In Graves's disease digitalis some- times quiets the heart and lessens the pulse-rate, but generally its action is disappointing, and in not a few cases it is badly borne. In the irritable heart resulting from overwork, and in arhythmia dependent upon simple dilatation, it is often of great service, but in nervous palpitation and paroxysmal tachycardia it rarely affords relief. As a Diuretic. — We regard digitalis as the most valuable remedy we possess in cardiac and renal dropsy. The best results are obtained when the pulse is soft and rapid. In hepatic dropsy, in common with other diuretics, it often proves useless. In pleural effusion and in other inflammatory transu- dations it is rarely of value. Contraindications. — Digitalis is contraindicated in aneu- rysm, advanced degeneration of the myocardium, and well- developed atheroma. Administration. — For general use the tincture is the most reliable preparation ; as a diuretic, however, some prefer the infusion. When digitalis is not well borne by the stomach, or when a prompt action is desired, digitalin may be given hypo- dermically. When it is desirable to give the drug in pill form the powdered leaves or the extract will be found convenient. In cardiac or hepatic dropsy it may be advantageously com- bined with mercury, as in the well-known Niemeyer's pill : R Pulveris digitalis, Pulveris scillse, Massse hydrargyri, aa gr. xx (1.3 gm. ). — M. Fiant pilulae, No. xx. Sig. One thrice daily after meals. In renal dropsy the following combination of digitalis with juniper and potassium acetate is well thought of: JJ Junip. contus., ^x (40.0 gm.) ; Pulv. scillse, 3J (30.0 gm. ) ; Pulv. digitalis, £j (4.0 gm. ) ; Vin. xerici, Oj (J liter). Macerate for four days and add : Potass, acetatis, giij (12.0 gm.). — M. Express and filter. Sig. Tablespoonful three times a day. ST£ OPHANTHUS. 5 3 Patients taking digitalis should be seen at frequent inter- vals, on account of the suddenness with which untoward symp- toms may develop during its administration. When large doses are being used it is essential that the patient should be confined to bed. While some patients can take small doses of digitalis with advantage for long periods without inter- rupting the treatment, it nevertheless is advisable in most cases to suspend the administration every six or seven days for a like period, employing in the interval some alternate, such as cafTein, strophanthus, or convallaria. Incompatibles. — Digitalis is incompatible with prepara- tions containing tannic acid. With iron salts it forms an inky mixture. STROPHANTHUS, U. S. P. Strophanthus is the seed of Strophanthus Kombe, a native of Africa. It contains a glucosid, strophanthine which represents, in a measure, the therapeutic properties of the drug. This principle appears as a white, amorphous, or crystalline powder, of an intensely bitter taste, and soluble in water and alcohol. Preparations. Dose. Tinctura Strophanti, U. S. P 3-10 min. (0.18-0.65 c.c). Strophanthinum, U. S. P TF0~F& S 1 *- (0.0006-0.0013 gm.). Physiologic Action. — Strophanthus has an action very similar to that of digitalis ; like the latter, it slows the pulse, stimulates the heart, raises the blood-pressure, and increases the flow of urine. There are, however, certain points of differ- ence in the action of the two drugs : (1) Strophanthus con- stricts the vessels of the splanchnic area, but has little or no action on the peripheral vessels ; (2) it is diuretic even in nor- mal animals, probably because it is without influence on the renal arteries ; (3) it is a more powerful muscle poison than digitalis ; (4) it is absorbed more rapidly than digitalis, and, in consequence, is less irritant to the stomach; (5) it is eliminated more rapidly than digitalis, and, therefore, its action is less likely than that of the latter to become cumulative. Therapeutics. — Strophanthus is a valuable cardiac tonic, and may be employed in the class of cases in which digitalis is indicated ; it is more prompt in its action, but, as a rule, it is less reliable than the latter. It may be recommended when- ever the older remedy fails, or is not well borne, or when an alternate is desired. Contraindications. — The contraindications to the use of strophanthus are the same as those referred to in connection with digitalis. 54 CIRCULATORY STIMULANTS. CAFFEINA, U. S. P. (Caffein.) Caffein is an approximate principle obtained from the leaves of Thea sinensis, or from the seeds of Coffea arabica. It ap- pears in the form of colorless, fine, silky crystals, having a bitter taste and a neutral reaction, and soluble in about 46 parts of cold water. The drug is freely soluble in solution of sodium benzoate and sodium salicylate. Preparations. Dose. Caffeina Citrata, U. S. P 2-5 gr. (o. 1 3 -0.3 gm.). Caiieina Citrata Effervescens, U. S. P 1-2 dr. (4.0-8.0 gm.). Caffeinae Sodio-benzoas (45 percent, of caffein), 5-10 gr. (0.3-0.6 gm.). Physiologic Action. — Circulatory System. — The actions of caffein on the circulation are more or less antagonistic to one another. The drug tends to increase the rate of the heart by acting directly on the heart-muscle, and to decrease it by stimulating the inhibitory center in the medulla oblongata. Again, it tends to raise the arterial pressure (1) by increasing the efficiency of the heart itself, and (2) by stimulating the vaso- motor center (vasoconstriction) ; on the other hand, it tends to lower the arterial pressure by directly dilating, to some extent, the peripheral vessels. The total effect of therapeutic doses is generally to increase the rate of the heart and, also, slightly the output of blood per unit of time. After very large doses the contractions follow each other so rapidly that the ventricle has not time to fill, the blood-pressure falls, delirium cordis ensues, and the heart stops in diastole. Nervous System. — Caffein is a powerful cerebrospinal stim- ulant. In man the cerebrum is first affected, then the medulla, and, lastly, the spinal cord. Even small doses increase mental activity, quicken perception, induce wakefulness, and lessen fatigue. In the medulla the drug stimulates not only the vaso- motor and cardio-inhibitory centers but also the respiratory center. Its effects on the spinal cord are seen in mammals only after the administration of relatively large doses. They are indicated by an increase in the reflex excitability and the occurrence of tetanic convulsions. Muscles. — Small amounts of caffein increase both the irrita- bility and working power of all forms of muscle. Large amounts bring about a condition of rigor, which is shown by the fibers becoming contracted, hard, and opaque. Respiratory System. — Caffein is a powerful stimulant to CAFFEINA. 55 the respiratory center. Under its influence both the number and depth of the respirations are increased. Kidneys. — Under favorable conditions caffein increases very decidedly the secretion of urine. The increase involves the output of water to a much greater extent than that of the solids, hence the specific gravity of the urine falls. Caffein diuresis is, probably, due to a direct stimulation of the renal epithelium, though some pharmacologists ascribe it to a dilata- tion of the renal arterioles of peripheral origin. It is certainly not the result of any changes in the general circulation. Alimentary Canal. — Caffein is rapidly absorbed, and, except in very large doses, is without action on the alimentary canal. Elimination. — Only a small quantity of the caffein ingested is secreted in the urine unchanged. To a great extent the drug is eliminated as di- and mono-methylxanthins. A very small amount is oxidized to urea. Toxicology. — The characteristic symptoms of caffein-poi- soning are mental excitement followed by delirium, palpitation, rapid breathing, frequent urination, intestinal colic, numbness of the extremities, tremors, convulsions, and, finally, collapse. Therapeutics. — Generally speaking, caffein is a far less useful remedy in valvular lieart disease than digitalis. When there is marked dropsy, however, a combination of caffein and digitalis often acts more favorably than either drug alone. In combating cardiac insufficiency in pneumonia and other infec- tive processes, it is usually more effective than digitalis. Being a direct diuretic, it often affords relief in chronic par- enchymatous nephritis with dropsy \ when digitalis fails. In chronic interstitial nephritis, when the left ventricle dilates and, in con- sequence, the secretion of urine falls off, dyspnea develops, and dropsy appears, it is sometimes serviceable. In acute pulmonary edema a combination of caffein and atropin may have a very happy effect, especially if administered hypodermically. As a respiratory stimulant it is valuable in poisoning by opium and other drugs which depress the respiratory center. In combination with phenacetin or one of the bromids it will often afford relief in migraine and headache from nervous strain. Contraindications. — It is contraindicated in all conditions associated with troublesome insomnia. In some persons even small doses, when administered late in the day, cause wake- fulness at night. Administration. — Since caffein and citrated caffein are readily decomposed in the presence of water, they are gen- erally prescribed for internal use in pills, powders, or capsules. When a prompt action is desired the drug should be given 5 6 CIRCULA TOR Y STIMULANTS. hypodermically, and for this purpose the sodiobenzoate of caffein, as it is freely soluble and quite stable in solution, will be found a suitable preparation. The following formulae will illustrate the method of prescribing caffein : R Cafifeinse citratse, gr. xxiv (1.6 gm.); Acetanilidi, £j (4.0 gm. ). — M. Fiant chartulse, No. xii. Sig. One every two hours. (In nervous headache.) R Caffeinae, gr. xlviii (3.0 gm.) ; Sodii benzoatis, gij (8.0 gm.). — M. Fiant chartulae, No. xii. Sig. One every four hours. (In chronic nephritis with dropsy.) R Caffeinae sodio-benzoatis, gr. xij (0.8 gm.) ; Aquae destillatae, gj (4 c.c.). — M. Sig. 20 minims = 4 grains, or I c.c. =0.2 gm. CONVALLARIA, U. S. P. (Lily of the Valley.) Convallaria is the rhizome and roots of Convallaria majalis. It contains two glucosids, convallarin and convallamarin. Convallarin, being a saponin (see p. 19), is not absorbed from the alimentary canal, and, therefore, the value of the drug as a cardiac stimulant depends chiefly upon the convallamarin. Preparations. Dose. Fluidextractum Convallariae, U. S. P. . . 5-20 min. (0.3-1.2 c.c). Convallamarin \-\ gr. (0.03-0.065 gm.). Physiologic Action and Therapeutics. — The results obtained from the study of the physiologic action of conval- laria are somewhat conflicting, but clinical experience indicates that it acts much like digitalis in stimulating the heart and increasing the flow of urine. It has the advantages of not having any cumulative effect, and of not disturbing the stom- ach. Most authorities, however, agree that, as a rule, its action is inferior to that of digitalis, but that it sometimes gives excellent results in cases in which the latter remedy has failed. Its best effects are seen in the dropsy of heart-disease. Administration. — Convallaria should be prescribed only in the form of the fluid extract, since the convallamarin of commerce is a variable product. ADONIDIN. Adonidin is a glucosid obtained from the Adonis vernalis, a perennial plant indigenous to Central Europe and Asia. It is an amorphous, yellow or brown, odorless powder, having an OTHER CIRCULATORY STIMULANTS. 57 intensely bitter taste. It is soluble in water and alcohol. The dose is from -jV" i S r - (0.005-0.01 gm.). Physiologic Action. — Adonidin affects the circulation somewhat like digitalis. It slows the pulse, probably by stim- ulating the vagi, and increases the arterial pressure probably by stimulating both the heart and the vasomotor center. Its action is more prompt than that of digitalis, but not so pow- erful. It does not seem to have any cumulative action. When the arterial pressure is low, adonidin causes some increase in the quantity of urine, but the drug apparently exerts very little influence on the kidney itself. Overdoses may cause nausea, vomiting, and diarrhea. Therapeutics. — Adonidin is used in about the same class of cases as digitalis. While generally less reliable than digi- talis, it may be employed as a substitute when the older remedy is badly borne or is ineffective. Oliver speaks favor- ably of its action in aortic regurgitation. OTHER CIRCULATORY STIMULANTS* 1 lather (see p. 118). — In ordinary doses ether by the mouth or skin has little direct action on the heart, but through its local irritant effects it reflexly quickens the pulse and slightly raises the blood-pressure. On account of the promptness of its action it is a useful remedy in sudden heart-failure , as in shock, poisoning, and collapse of cholera, and other infections. In these cases it may be. given hypodermically in doses of from 15-30 min. (1.0-2.0 c.c.). Nitrites. — Nitroglycerin, amyl nitrite, sodium nitrite (see p. 69) affect the circulation in a similar manner, but differ in the rapidity and duration of their action, that of nitrite of amyl being the most rapid, but the least persistent, and that of sodium nitrite being the least rapid, but the most persistent. They quicken the pulse by stimulating the vagus center in the medulla oblon- gata and lower the blood-pressure by depressing the muscle of the arteries and thus causing vasodilation. The value of these drugs in diseases of the circulatory system is not due to their action on the heart itself, but to the relief they afford to the heart in diminishing the resistance in the peripheral vessels. They are especially useful in valvular diseases, when there is precordial distress and increased pulse-tension. When there is myocardial degeneration they may be combined advanta- geously with small doses of digitalis, in order to counteract the constricting effect of the latter on the blood-vessels. The 1 The properties of these drugs are more fully considered under other headings. 58 OTHER CIRCULATORY STIMULANTS. dyspnea, headache, and precordial discomfort attendant upon chronic nephritis with arteriosclerosis are often relieved by a nitrite. Inhalations of amyl nitrite are exceedingly efficacious in the paroxysms of angina pectoris. When a very prompt action is desired, nitrite of amyl (3- 5 drops) may be given by inhalation. Nitroglycerin may be given in the form of the official 1 per cent, alcoholic solution, the dose of which is 1-2 min. (0.06-0.1 c.c), cautiously increased, or in the form of tablets containing a dose of from 2< U 5*0 S r - (0.0003-0.001 gm.). On account of the marked variation in individual suscepti- bility small doses should be administered at first, and these gradually increased until the limit of tolerance is reached. Camphor (see p. 132). — Camphor is a useful diffusible car- diac stimulant in adynamic fevers. It not only serves to strengthen the pulse, but it also acts favorably in lessening the restlessness and delirium. It is best given hypodermically in doses of J— 2 gr. (0.03-0.13 gm.), dissolved in sterilized olive oil. Squill (see p. 224). — Squill closely resembles digitalis in its action on the circulation. It is also an efficient diuretic, acting partly by increasing the quantity of blood flowing through the kidneys and partly by directly stimulating the renal epithelium. Its irritant effect on the stomach, however, is especially pronounced, and for this reason it was at one time used in large doses as an emetic. In smaller doses it is a favorite expectorant. In valvular heart disease it is chiefly employed as an adju- vant to digitalis when there is persistent dropsy. In such cases the combination of blue mass, powdered squill, and digitalis, known as Niemeyer's Pill (see p. 52), is commonly prescribed. Owing to its expectorant properties, squill is frequently effica- cious also in clironis bronchitis with emphysema and dilated right heart. Apocynum (see p. 225). — This drug has the same qualitative action as digitalis, but as it is more irritant to the stomach and intestines than the latter, it is less serviceable as a cardiac stimulant. The fluidextract is sometimes given in doses of from 5 to 10 min. (0.3-0.6 c.c.) in valvular disease when there is much dropsy. Cactus Grandiflorus. — This drug has been employed for a number of years as a substitute for digitalis in various func- tional and organic diseases of the heart. The experimental evidence, however, does not support the view that it has a digitalic action, nor are clinicians in accord as to its therapeutic value. It is usually prescribed in the form of a fluidextract CIRCULATORY DEPRESSAXTS. 59 made of the fresh plant, the dose of which is from 10 to 30 minims (p.60-2.0 c.c). Adrenalin (see p. 66). — When injected directly into a vein, adrenalin slows the pulse and causes a marked increase in the blood-pressure. The first of these effects is due chiefly to stimulation of the cardio-inhibitory center in the medulla, and the second, partly to the direct action of the drug on the heart itself and partly to its powerful constricting effect on the pe- ripheral vessels. These effects of adrenalin on the circulation are prompt but evanescent, and are pronounced only when the drug is given intravenously. Administered in this way (i part of adrenalin chlorid to 50,000 parts of normal salt solu- tion) it is sometimes useful in maintaining the arterial pressure in shock and collapse, the result of severe injury or operation. Strychnin (see p. 141) in full medicinal doses raises the arterial pressure by stimulating the vasomotor center in the medulla. This action, together with its influence on the respiration, digestion, and muscle tonus, renders it a valuable remedy in combating certain forms of circulatory depression. Administered hypodermically, it is of considerable benefit in surgical shock. In simple dilatation of the heart, with or with- out valvular disease, it is often of the greatest service as an adjuvant to digitalis. In pneumonia and other infective proc- esses it may prove more useful than digitalis. In the weak heart of the old, also, it is generally a better remedy than digitalis. In chro?iic bronchitis with emphysema it is indispens- able in supporting the circulation and respiration. CIRCULATORY DEPRESSANTS. Circulatory- depressants are drugs which lessen the activity of the heart. They decrease the output of the heart per unit of time. Some of them act by directly depressing the cardiac muscle. As samples of this group may be mentioned : Chloral. Chloroform. Potassium salts. Others act by stimulating the inhibitory mechanism of the heart. The most important members of this group are : Aconite. Yeratrum. Reduction of Blood-pressure. — A drug may lower the blood-pressure (1 ) by decreasing the output of the heart per 60 CIRCULATORY DEPRESSANTS. unit of time (cardiac depressants and vagal stimulants), (2) by- decreasing the quantity of fluid in the vessels (venesection), (3) by decreasing the resistance in the peripheral vessels (vaso- dilators and purgatives). Reduction of the Pulse-rate. — The action of the heart may be slowed (1) by directly stimulating the inhibitory mechan- ism in the medulla (digitalis, aconite, veratrum) ; (2) by raising the blood-pressure and thus indirectly stimulating the inhibitory- mechanism in the medulla (adrenalin, in part through vaso- constriction). Depression of the excitomotor apparatus would also tend to lessen the frequency of the heart's contractions, but no drug is known which in therapeutic doses has this effect. The only drugs employed as circulatory depressants are those which act by stimulating the vagal mechanism, namely, aconite and veratrum. These are indicated when the action of the heart is unduly forcible. Thus they may be of service in sthenic fevers, in acute local inflammation, in valvular disease when there is excessive hypertrophy of the heart, and in aneurism when the tension in the arteries is very high. ACONITUM, U. S. P. (Monkshood.) Official aconite is the root of Aconitwn Napellus, a perennial herb growing in Europe, Asia, and North America. The root is conical in shape, 2 or 3 inches long, brownish in color, and closely resembles horse-radish ; from this, however, it may be distinguished by its lack of pungent odor when scraped. When slowly chewed, it produces in the mouth a sense of warmth and tingling, soon followed by numbness. Active Principle. — The most important principle of aco- nite is aconitin (aconitina, U. S. P.), a crystalline alkaloid,, very sparingly soluble in water, but more freely so in dilute acids and alcohol. The amorphous aconitin of commerce is a mixture of alkaloids of variable strength, but much weaker than the official variety. The dose of crystalline aconitin is 600 250 g r - (O.OOOI 1-0.00025 g m -)« Preparations. Dose. Tinctura Aconiti, U. S. P 5 _I 5 m i n > (0.3-1.0 c.c. ). Fluidextractum Aconiti, U. S. P. . . . 1-2 min. (0.06-0.12 c.c). Linimentum Aconiti. Physiologic Action. — Local Action. — Aconitin in aque- ous solution is not absorbed from the unbroken skin, but if rubbed in with fat, alcohol, or chloroform it produces first a ACONITUM. 6 1 tingling sensation, then numbness, and, finally, anesthesia. From all mucous membranes it is readily taken up, so that the merest trace applied to the tongue induces almost immediately the characteristic tingling and numbness. Even when the drug is admininistered by the mouth or subcutaneously the same phenomena occur after absorption, chiefly, however, in the tongue, lips, throat, and finger-tips. This peculiar effect of aconitin on the skin and mucous membranes is the result of its selective action on the sensory nerve-endings. These are first stimulated and then paralyzed. Even in concentrated form the drug does not induce redness or other signs of inflam- mation. Circulatory System. — From a therapeutic standpoint the dominant circulatory action of aconite is on the vagus. Mod- erate doses in mammals slow the pulse, lower the blood- pressure, and decrease the output of the heart per unit of time. These effects are the result of powerful stimulation of the inhibitory centers in the medulla. They can be prevented by section of the vagi and even by the application of atropin. Toxic doses accelerate the heart's action, cause extreme auriculoventricular arhythmia, and finally bring on delirium cordis. These phenomena seem to be due to the direct action of the drug on the heart-muscle, since they occur after division of the vagi and also in the isolated heart. It is probable that aconite first stimulates and then depresses the vasomotor center. This action, however, is entirely overshadowed by that on the inhibitory cardiac mechanism. Effects of Aconite and Digitalis on the Circulation Compared. — Both drugs in medicinal doses slow the heart by stimulating the vagus, but digitalis, owing to its very pro- nounced action on the vasomotor center, blood-vessel walls, and heart, raises the arterial pressure and increases the output of the heart per unit of time. Respiration. — After large doses of aconite the breathing becomes slower, more labored, and sometimes dyspneic. These phenomena have been ascribed to broncho-constriction from stimulation of the vagal endings in the lungs, but in addition to this there appears some depression of the respira- tory center, for ultimately death results from asphyxia. Nervous System. — Apart from its action on the medullary centers, aconite does not seem to have any important influence on the central nervous system. The convulsions sometimes seen after toxic doses are probably the result of asphyxia. In poisoning the mind generally remains clear until near the end, though occasionally unconsciousness occurs early from col- 62 CIRCULATORY DEPRESSANTS. lapse. Certain other endings besides those of the sensory nerves, notably the motor endings in striped muscle, appear to be excited by the drug. Secretions. — It is doubtful whether aconite has any direct action on the nerve-endings of the secretory glands. The excessive flow of mucus following the introduction of the drug into the nostrils or mouth is excited reflexly by irritation of the sensory nerve-endings, and the free perspiration observed in poisoning is probably the result of collapse. Digestive Tract. — Toxic doses of aconite not rarely cause nausea, vomiting, or purging. These are, no doubt, reflex effects. Minute doses may allay vomiting by benumbing the sensory nerve-endings of the stomach. Temperature. — Aconite lowers temperature to a certain extent, both in health and in febrile states, but the manner of antipyretic action is not definitely known. It is believed, how- ever, that the drug has some influence on the heat-regulating centers. Toxicology. — The symptoms develop very rapidly after the injection of the poison. Among the first to appear is the characteristic tingling, which, beginning in the lips, tongue, and throat, soon spreads to the fingers and toes, and at last involves the whole surface. This is accompanied by excessive saliva- tion, and sometimes by nausea, vomiting, and purging. The pulse, at first infrequent and soft, later becomes extremely fre- quent, weak, and irregular. The breathing is slow and labored. The skin is cool, livid, and covered with sweat. The mind is usually clear until near the end, but sometimes unconscious- ness occurs rather early in consequence of the profound col- lapse. Death, which is generally the result of respiratoiy failure, is not rarely preceded by convulsions. Treatment. — This consists in keeping the patient in the recumbent posture, with the feet somewhat higher than the head; in washing out the stomach, if necessary; in the main- tenance of the bodily temperature by external application of heat; and the administration hypodermically of ammonia, brandy, and atropin, especially of the latter, which in several respects is antagonistic to aconitin. Therapeutics. — In the early stages of acute inflamma- tions, such as tonsillitis, pharyngitis, laryngitis, and bronchitis, and in the beginning of the acute infectious diseases of child- hood, aconite is often very useful in quieting the circulation and lowering the temperature. In excessive hypertrophy of the heart it sometimes acts favorably. In acute cerebral congestion, with high arterial tension, it may be given in full doses. In VERATRUM. 63 tachycardia and palpitation it is of little value unless these symptoms be associated with hypertrophy of the heart. Small doses (J- drop), at frequent intervals, are sometimes efficacious in hyperemesis. An ointment of aconitin (5-10 gr. to the ounce — 0.3-0.6 to 30.0 gm.) was formerly much used as a local remedy in neuralgia. The liniment of aconite, official in the British Pharmacopoeia, is often beneficial in muscular rheumatism. Administration. — The tincture is the preparation most commonly selected for internal use; small doses should be given in water, frequently repeated, and the effect watched. Aconitin, on account of its pronounced toxicity, is rarely given internally. If used externally, care should be taken to avoid the eye, as the drug is highly irritating. On cutaneous sur- faces, provided there are no abrasions, it may be applied with safety. The following time-honored combination is efficient in the mild febrile diseases of childhood : $t Tincturse aconiti, Tltxv (1.0 c.c.); Spiritus setheris nitrosi, i%\) (23.0 c.c.) ; Liquoris ammonii acetatis, q. s. ad f^iij (90.0 c.c). — M. Sig. A teaspoonful every two or three hours for a child of two years. VERATRUM, U. S. P. (Green Hellebore or White Hellebore.) Under one title, veratrum, the United States Pharmacopoeia of 1906 recognizes the rhizome and roots of Veratrum viride and of Veratrum album. The former is a native of North America and the latter of Europe. While the action of the two plants is very similar, it is not known to be identical. White hellebore, the European variety, is apparently the more toxic of the two. Both plants contain a number of alkaloids. Veratrin appears to be the most active of those present in veratrum viride, and protoveratrin of those present in Veratrum album, though this is not certainly established. The official veratrin is obtained from the seed of Asagrcea officinalis, a bulbous herb growing in Mexico and Central Amer- ica. It is a mixture of pure veratrin and a number of other less active alkaloids. Preparations. Dose. Tinctura Veratri, U. S. P 5-15 min. (0.3-1.0 c.c. ). Fluidextractum Veratri, U. S. P. . . . 1-3 min. (0.06-0.2 c.c). Unguentum Veratrinoe, U. S. P. (4 per cent.). Oleatum Veratrinae, U. S. P. (2 per cent.). 64 CIRCULATORY DEPRESSANTS. Physiologic Action. — Veratrum very closely resembles aconite in most of its actions. In moderate doses it produces a distinct slowing of the pulse, with some lowering of the blood-pressure. These phenomena are mainly attributable to stimulation of the cardiac inhibitory center. Very large doses, after first slowing the pulse, suddenly accelerate it and at the same time induce extreme arhythmia, with an enormous fall of blood-pressure. The acceleration of the pulse appears to be due in part to paralysis of the peripheral vagi and in part to stimulation of the cardiac muscle. The progressive fall of the arterial pressure observed in late poisoning is caused by de- pression of the vasomotor center and of the myocardium itself. Like aconite, veratrum also depresses the respiration and lowers the temperature. Special Action of the Alkaloids. — Of the alkaloids, veratrin has a characteristic effect on muscle, both striated and unstriated. Under its influence, the muscle, when stimu- lated, contracts as rapidly as usual, but more vigorously, and, once contracted, requires from twenty to thirty times the normal time to relax again. Further, the drug increases the irritability of muscle and restores to some extent its contractility, when this has been lost through fatigue. These effects are thought to be due to increased catabolism. Like aconitin, veratrin first irritates and then depresses the sensory nerve-endings, hence local applications of the drug give rise in turn to tingling, numbness, and anesthesia. Inhaled, it causes violent sneezing, coughing, and increased secretion of mucus. Large quantities also paralyze the motor nerve-endings, but without stimulating them first. The vomiting and purging constantly observed in veratrin-poisoning are probably produced reflexly by irritation of the sensory nerve-endings. Pj'otoveratrin, while it increases the strength of muscular contractions, does not prolong the contractions, but rather shortens them. It is even more depressant to sensory nerve- endings than veratrin, but it has no paralyzant effect on motor nerve-endings. Toxicology. — Veratrum-poisoning resembles aconite- poisoning, but is generally marked by more severe gastro- intestinal symptoms. Therapeutics. — In excessive hypertrophy of the heart, with or without valvular lesions, veratrum is a useful circulatory sedative. In aneurism, when there is much pain and the pulse is full and strong, veratrum, in conjunction with potassium iodid and rest, often affords relief. In the beginning of acute inflammatory diseases it may replace aconite as a cardiac seda- tive and febrifuge. OTHER CIRCULATORY DEPRESSANTS. 65 In the first stage of croupous pneumonia of a sthenic type it may affect favorably the pulse and temperature, but it has no power of aborting the disease. In puerperal eclampsia, by lowering arterial tension, it often proves a valuable addition to other remedies. Veratrin, in the form of the official ointment or oleate, is occasionally used as a local remedy in neuralgia. It should never be applied over large surfaces or where there are any abrasions, and in employing it about the face great care must be exercised to keep it out of the eye. Contraindications. — Cardiac and systemic weakness and irritability of the stomach are the chief contraindications to its use. Administration. — The tincture is the best preparation ; it should be given at frequent intervals, the dose being cautiously increased until the physiologic effect is produced. OTHER CIRCULATORY DEPRESSANTS. Stavesacre. — This drug (Staphisagria, U. S. P.) is the seed of Delphinium Staphisagria, an annual herb growing in South- ern Europe. It contains several alkaloids, the chief of which is delphinin. The action of stavesacre is very like that of aconite, but the drug is rarely used at present except exter- nally for the destruction of pediculi. For this purpose the oil diluted with 8 parts of olive oil or an ointment of the crushed seed (20 per cent.) may be prescribed. The United States Pharmacopoeia recognizes a fluidextract of stavesacre, the dose of which is 1-2 min. (0.06-0.12 c.c). Pulsatilla. — This drug is the herb of Anemone Pulsatilla and Anemone prcetensis. It contains a colorless, crystalline, acrid principle, known as anemonin. The dose of the latter is from \-\ gr. (0.008-0.03 g m 0- The drug may be used also in the form of the tincture, the dose of which is 10-20 min. (0.6-1.2 c.c). Locally, pulsatilla acts as an irritant. Internally, large doses may cause vomiting and even purging. On the circulation its action is said to resemble that of aconite. Pulsatilla has been used as a circulatory sedative in acute inflammatory diseases, as a respiratory sedative in asthma, and as an emmenagogue, but as a therapeutic agent it is of little value. 66 VASOCONSTRICTORS AND VASODILATORS. VASOCONSTRICTORS AND VASODILATORS. Vasoconstrictors are drugs that constrict the peripheral arterioles. They may act (i) by stimulating the vasomotor center in the medulla or (2) by contracting the vascular walls directly. A number of them act in both ways. Among those having a central action may be mentioned: Atropin. CafTein. Strychnin. The following act both centrally and peripherally: Digitalis. Ergot. Cocain. The best example of a peripheral vasoconstrictor is : Adrenalin. Vasoconstrictors raise the general blood-pressure, and, by increasing the tonus in the medulla, tend to lessen the fre- quency of the heart's action and to stimulate the respiration. As internal remedies they are especially indicated in conditions of low arterial tension, such as shock and collapse. Only adrenalin, which is chiefly used as a vasoconstrictor, will be considered in this chapter. Vasodilators are drugs that dilate the peripheral arterioles. They may act (1) by depressing the vasomotor center in the medulla or (2) by relaxing directly the vascular walls. The most important are : The nitrites. The organic nitrates (nitroglycerin, erythrol tetranitrate). These drugs act peripherally, and are employed to facilitate the passage of the blood through the vessels and to lower the arterial tension. ADRENALIN. The remarkable action of suprarenal extract on the circula- tion, which was first pointed out by Oliver and Schaefer, in 1894, depends upon the alkaloid isolated by Abel, in 1896, and variously known as epinephrin, suprarenin, and adrenalin. With acids the alkaloid forms salts, of which the hydrochlorid is freely soluble in water. This salt may be obtained in crys- ADRENALIN. 67 tals and in the form of a 1 : 1000 solution, preserved with some antiseptic. Physiologic Action. — When injected into a vein, even in small doses, adrenalin causes marked elevation of the blood- pressure and slowing of the heart-beat. The first of these effects is due mainly to constriction of the arterioles, especially those of the splanchnic area, and in part to stimulation of the cardiac muscle. The retardation of the heart-beat is due to stimulation of the vagus center in the medulla oblongata, directly by the drug itself and indirectly by the rise of blood- pressure. The vasoconstriction is chiefly, probably entirely, of peripheral origin, and the result of a stimulant action exerted either on the muscle of the arterioles or the sympa- thetic nerve-endings in the muscle. As perfusion of adrenalin through vessels which are not innervated by the sympathetic, as those of the lungs and brain, does not cause constriction, it is probable that the drug acts on the nerve-endings rather than on the muscle-fibers themselves. These effects of adrenalin on the general circulation are pronounced only after intra- venous injections ; after subcutaneous injections they are very slight, even with large doses, and after administration by the mouth they are not noticeable. Even after intravenous injec- tions they are very fugitive. The great variation in the action of the drug with these different methods of administration is to be ascribed to the slow absorption, on the one hand, and its rapid oxidation on the other. Locally, applied to mucous membranes or raw surfaces, it causes intense ischemia by directly constricting the peripheral vessels. Upon the un- broken skin it has no effect. Josue and others have shown that repeated intravenous injections of adrenalin in rabbits sometimes lead to degenerative changes in the aorta and larger arteries, resembling atheroma. Whether these changes are the result of a direct toxic action, increase of blood-pressure, or constriction of the vaso vasorum, has not been definitely determined. Upon plain muscle other than that of the vessels the action of adrenalin is not uniform. Thus, while it contracts the ureter, vas deferens, and seminal vesicles, and in the female, the uterus and vagina, it inhibits the movements of the stomach, bowel, and bladder. In the eye, the drug produces the effect of sympathetic excitation; namely, dilatation of the pupil, separation of the eyelids, and exophthalmos. It also promotes the secretion of certain glands, probably by stimu- lating the nerve-endings in their cells. Thus, it increases the tears, saliva, bronchial mucus, and bile. Injected intraven- 68 VASOCONSTRICTORS AND VASODILATORS. ously or intraperitoneally, and particularly when applied directly to the surface of the pancreas, adrenalin produces temporary glycosuria. This is apparently the result of some obscure toxic action exerted directly on the cells of the pancreas. Therapeutics. — As the characteristic effects of adrenalin on the general circulation occur only with its intravenous administration, and even then are extremely fugitive, it follows that its field of usefulness as a circulatory stimulant must be a very limited one. It appears to be chiefly indicated in marked vasodilation with good heart muscle. Thus, in shock and col- lapse during anesthesia, it may prove life-saving. In these conditions 10 minims (0.6 c.c.) of the solution (1 : 1000) may be given intravenously, drop by drop ; or better, especially in shock, intravenous transfusion may be practised, using one part of the drug to 50,000 parts of normal salt solution. As a local vasoconstrictor adrenalin is of great value in relieving co7igestion and in checking hemorrhage. In operations on the eye, nose, and throat, solutions of 1 : 5000 to 1 : 1000 not only prevent bleeding, but render anesthesia with cocain more complete, and at the same time lessen the danger from absorption of the anesthetic. In severe epistaxis prompt relief is usually afforded by plugging the nostrils with cotton soaked in a 1 : 1000 solution. In hematemesis benefit may be derived from the administration of to to 30 minims (0.6-2.0 c.c.) of a 1 : 1000 solution in a tablespoonful of water every hour or half-hour. In distant hemorrhages, however, adrenalin is use- less. Solutions 1 : 10,000 to 1 : 5000 are sometimes efficacious in acute coryza and hay fever. Suppositories containing 1 part of adrenalin to 1000 of cocoa butter are recommended in bleeding hemorrhoids. The drug is said to relieve pain in vari- ous inflammatory diseases of the eye, but Lemare urges against its use when there is a tendency to iritis, contending that it may prove harmful by driving the blood from the surface to the deeper anastomosing vessels of the iris and ciliary body. Desiccated suprarenal glands (Glandulse Suprarenales Siccse, U. S. P.), in doses of 3-5 grains (0.2-0.3 gm.), thrice daily, have been shown to be of some value in Addison's disease. In most cases, however, the good effects have been only tempo- rary, and this is what we should have expected, knowing the incurable nature of the local lesions. One of Osier's patients gained nineteen pounds, the asthenia disappeared, and he was alive two years subsequently, but was still pigmented. Kinni- cutt has collected 48 cases treated with the extract. Of these, 6 were reported cured and 22 as improved. In estimating the AMYLIS NJTRIS. 69 value of these and similar statistics, due allowance should be made for the fact that favorable results are more likely to be published than those which are unfavorable. AMYLIS NITRIS, U. S. P. (Amyl Nitrite, C 5 H n N0 2 .) Amyl nitrite is prepared by distilling equal volumes of pure amylic alcohol and nitric acid. It appears as a yellowish, highly volatile liquid having a strong ethereal odor. Physiologic Action. — The inhalation of nitrite of amyl is speedily followed by flushing of the face, a sense of fulness in the head, quickening of the pulse, and a pronounced fall of blood-pressure. The flushing of the face and fall of blood-pressure are due to dilatation of the arterioles, which in turn is the result of the direct depressant action of the drug upon the vessel walls. The vasodilation is especially marked in the brain, abdominal organs, and u blush area " of the skin. The quickening of the pulse appears to be chiefly brought about by direct depression of the vagus center in the medulla oblongata, though it may be in part the result of the lowered blood-pressure, which tends to diminish the tonus in the medulla. Small doses do not affect the heart directly, but large doses depress it, exactly as they depress other forms of involuntary muscle. It is evident, therefore, that it is only by lessening resistance in the peripheral vessels that the nitrites can favorably influence the heart. Blood. — When mixed with a nitrite blood acquires a choc- olate color, owing to the transformation of oxyhemoglobin into methemoglobin. This compound is more stable than oxyhemoglobin!, and cannot act as an oxygen carrier. In man the amount produced by medicinal doses, however, is so small that no harmful effects are seen. The blood-cells them- selves are not injured, as with many other methemoglobin formers (coal-tar derivatives, potassium chlorate, pyrogallol), and in a short time the methemoglobin is reduced by the tis- sues and replaced by oxyhemoglobin. When present in the blood in large quantities methemoglobin gives rise to cyanosis and intense dyspnea. Respiratory System. — Moderate doses slightly increase the rate and depth of the respirations, probably by acting directly on the respiratory center. Very large doses decrease the fre- quency and depth of the respirations by depressing the center. Nervous System. — In man the nitrites have no direct action on the central nervous system. In frogs, however, JO VASOCONSTRICTORS AND VASODILATORS. they depress the spinal cord and lessen reflex excitability. The ringing in the ears, throbbing, and headache which follow the inhalation of amyl nitrite are the result of cerebral con- gestion. Convulsions are sometimes observed in poisoning, but they are probably due to asphyxia. Muscles. — Other forms of plain muscle, as that of the ureters, bronchioles, and intestines, are also relaxed by the nitrites, though not to the same extent as that of the blood- vessels. Striated muscle is only slightly effected. Temperature. — Some fall in temperature occurs after mod- erate doses, as a result of the dilatation of the cutaneous ves- sels and increased radiation Elimination. — Amyl nitrite undergoes oxidation in the body part being completely broken up and part being ex- creted in the urine as metallic nitrates and nitrites. Therapeutics. — Nitrite of amyl is employed chiefly for two purposes: To relax spasm and to lower arterial tension. Owing to the rapidity with which it is absorbed and eliminated, it is of service only when a very prompt but transitory effect is required. As an Antispasmodic. — Inhalations of amyl nitrite often prove servicable in arresting the convulsions of epilepsy, teta- nus, uremia, and strychnin-poisoning, though the manner of the drug's action is not apparent. When the seizures of epilepsy are preceded by an aura the patient may carry the remedy in a small bottle containing the exact dose, or in glass " pearls " made especially for the purpose. Amyl nitrite sometimes does good also in asthma and ivhooping-cough. As a Vasodilator. — On account of the fugaciousness of its action amyl nitrite is not so useful as nitroglycerin or erythrol tetranitrate in circulatory diseases associated with persistent high arterial tension. In attacks of angina pectoris, however, it often acts most happily. Curiously enough, the drug is just as likely to do good in this disease when the pulse is soft as when it is hard. Brunton explains this fact in the following way : The excessive work to be done, which is the cause of the pain, may be due either to the resistance in the vessels being increased above the normal, or to the power of the heart to overcome the resistance being lessened below the normal. In either case the resistance becomes too great for the heart. The vasodilator action of the drug has led to its use in malaria, to cut short the first stage of the paroxysms. It is said to be of service in migraine, when the pain is associated with constriction of the peripheral vessels. By lowering the general arterial pressure, it may also have a salutary effect in hemoptysis. AMYLIS NITRIS. ?l Administration. — Amyl nitrite is almost always given by inhalation : 2-5 min. (0.1-0.3 c.c.) maybe dropped upon a handkerchief, or one of the small glass capsules containing the requisite dose may be crushed in a handkerchief, and the vapor inhaled. According to Osier it sometimes acts better in angina pectoris when given by the mouth, combined with the tincture of capsicum and peppermint-water. As a rule, however, nitroglycerin is better suited for internal administra- tion. GLYCERYLIS NITRAS. (Nitroglycerin, Glonoin, Glyceryl Trinitrate, Trinitrin, C 3 H 6 (N0 3 ) 3 .) Nitroglycerin is prepared by gradually adding dehydrated glycerin to nitric acid, or a mixture of nitric and sulphuric acids. It is official in the form of a I per cent, (by weight) alcoholic solution (Spiritus Glycerylis Nitratis, U. S. P.), the dose of which is from 1-3 min. (0.06-0.2 c.c), cautiously in- creased until effects are manifested. The spirit should be kept in well-stoppered tin cans, and should be stored in a cool place, remote from lights or fire. Care must be exercised in handling it, since a dangerous explosion may occur if any considerable quantity be spilled. Physiologic Action. — The action of nitroglycerin is simi- lar to that of amyl nitrite, except that it is not quite so prompt, and is more persistent. Its effects are recognizable within a few minutes, and last, according to the dose, from one to two hours. Therapeutics. — In fatty and fibroid degeneration of the myocardium nitroglycerin is often a useful remedy, especially when there is precordial pain or oppression. In angina pectoris it is often of value when given between the paroxysms, alone or in conjunction with potassium iodid. In chronic valvular disease it is sometimes advantageous to give nitroglycerin along with digitalis in order to counteract the tendency of the latter to constrict the peripheral vessels. In such cases, how- ever, the two drugs should not be combined, since the action of the one is very prompt, but fugacious, while that of the other is slow, but persistent. No remedy equals nitroglycerin in relieving the high arterial tension, dyspnea, palpitation, head- ache, vertigo, and insomnia of chronic nephritis. On the other hand, in acute heart failure the drug may do harm by lowering still further the pressure in the coronary arteries, and in shock it is, of course, absolutely contraindicated. In small, frequently repeated doses nitroglycerin sometimes proves effective in controlling persistent hiccough. Wade rec- ommends it in the abdominal palpitations frequently seen in 72 VASOCONSTRICTORS AND VASODILATORS. nervous women. He believes that it acts by lowering the blood- pressure in the splanchnic area. Good results occasionally follow its use in migraine and sciatica. Temporary relief is sometimes obtained from its use in the asphyxial stage of Raynaud's disease. It has also been highly recommended in hemoptysis. Untoward Effects. — In certain individuals the smallest dose of nitroglycerin induces flushing of the face, headache, tinnitus aurium, and vertigo. Administration. — It may be given by the mouth or sub- cutaneously. For internal use, the available preparations are the official spirit and the tablets, which are commonly found in the market, and which contain from ^^ gr. (o.oooi- 0.0012 gm.). For subcutaneous injection either the spirit or soluble hypodermic tablets may be employed. It is very im- portant that the preparation should be fresh, as both solutions and tablets deteriorate with age. On account of the extreme variation in individual susceptibility to the drug, very small doses should be administered at first, and these gradually in- creased until the therapeutic or physiologic effect (flushing, etc.) is secured. According to Wood, a single drop has caused insensibility ; on the other hand, Whittaker has given as much as 8f gr. (0.56 gm.) in twenty-four hours without untoward effects. Toleration of the drug is rapidly acquired, and this is another reason for making the initial doses the smallest that will prove effective. ERYTHROL TETRANITRATE. (Tetranitrol, (CH 2 .ON0 2 ) 2 (CH.ON0 2 ) 2 .) Erythrol tetranitrate occurs in the form of large scales, which are soluble in alcohol, insoluble in water, and which readily explode on percussion. In the form of chocolate or cocoa-butter tablets, however, it may be handled with perfect safety. The dose is from \-2 gr. (0.03-0. 1 3 gm.). Physiologic Action and Therapeutics. — The action of erythrol tetranitrate closely resembles that of nitroglycerin, but it is milder and decidedly more prolonged. As in the case of the nitrites, patients vary considerably in their sus- ceptibility to the drug : \ gr. (0.03 gm.) has caused intense headache and great malaise lasting thirty-six hours ; on the other hand, so much as J dr. (2.0 gm.) in twenty-four hours has been given with good results. Erythrol tetranitrate is indicated in the same class of cases as nitroglycerin. On account of its prolonged action it is especially useful in arteriosclerosis, angina pectoris, chronic interstitial nephritis, and Raynaud's disease. RESPIRATORY STIMULANTS. 73 SODII NITRIS, U. S. P. (Sodium Nitrite, NaN0 2 .) Sodium nitrite occurs in the form of white, opaque, fused masses, or colorless, transparent crystals, odorless, and of a mild saline taste. It is soluble in 1.4 parts of water, and sparingly soluble in alcohol. The dose is from 2-3 gr. (0.13- 0.2 gm.). Therapeutics. — The action of sodium nitrite is identical with that of amy! nitrite, except that it is less rapid and more lasting. As a vasodilator it is not so reliable as erythrol tetranitrate, although it resembles that drug in the perma- nency of its effects. It is indicated in the same class of cases as erythrol tetranitrate and nitroglycerin. RESPIRATORY STIMULANTS. The following drugs stimulate the respiratory center in the medulla oblongata: Ammonia. Cocain. Strychnin. Atropin. Caffein. Aspidospermin. In addition to these drugs, external heat increases the depth of the respirations. The expiratory and inspiratory fibers of the vagus are stimulated by the rhythmic expansion and collapse of the lung, which takes place in the practice of artificial res- piration by Sylvester's method. In pursuing this method the patient is placed in a supine position ; his arms are drawn upward and outward so as to fully expand the chest ; after a pause of a few seconds the arms are brought down forcibly to the sides of the chest and pressed against them for a second. These movements are repeated about sixteen or eighteen times in a minute. The respiratory center may be stimulated also reflexly by irritating certain peripheral sensory nerves. Thus, in Laborde's method of treating asphyxia by rhythmic traction of the tongue, the center is affected through the sen- sory nerves of the tongue. This method consists in drawing the tongue outward and upward by means of forceps for from twelve to fourteen times a minute. The vapor of ammonia when inhaled stimulates the nasal branches of the fifth nerve, and thus reflexly excites the respiratory center. The use of the cold douche, the pouring 74 CEREBRAL EXCITANTS. of ether on the bare chest, and the application of an electric current to the skin are also means of arousing the respiratory center through peripheral irritation. Drugs which stimulate the respiratory center are indicated in pulmonary affections associated with marked dyspnea, such as pneumonia , severe bronchitis, and emphysema ; and in poi- soning by drugs which cause asphyxia, such as opium and ether. The various measures by which the respiratory center is stimulated reflexly are especially indicated in poisoning. RESPIRATORY DEPRESSANTS. The following drugs depress the respiratory center : Opium (morphin, codein). Bromids. Chloral. Hyoscin. In addition to these drugs there are many others (aconite, veratrum, gelsemium, physostigma, belladonna, hydrocyanic acid, alcohol, ether, phenol, salicylic acid) that cause asphyxia in toxic doses. Certain of the respiratory depressants, notably opium and its alkaloids and the bromids, are employed in pulmonary diseases to allay coitgli. CEREBRAL EXCITANTS. Our knowledge concerning the action of drugs on the brain is very imperfect. We know, however, that certain of them stimulate the motor area, and in large doses cause an increase in movement and even epileptiform convulsions, while others affect chiefly the psychic centers and increase the capacity for intellectual work. To the first class belong : Atropin. Cocain. Cafifein. Heavy metals (lead, copper, silver) and certain volatile oils, especially camphor, oil of wormwood (absinth), oil of tansy, and oil of nutmeg, in toxic doses also cause epileptiform seizures by exciting the cerebral cortex. Cornutin (see Ergot) and picrotoxin in large doses induce BELLADONNA. 75 convulsions, which are apparently due to intense excitation of the medulla oblongata, since they cease after removal of the latter, but persist after removal of the cerebrum. The chief representative of the second class of cerebral stim- lulants, or of those which act on the psychic centers of the brain is caffein. Cocain also stimulates the higher functions, but much less powerfully those of the lower centers, such as the motor. A number of drugs (alcohol, ether, atropin) cause more or less mental excitement, but at no time exert any real stim- ulant effect on the highest intellectual functions — attention, perception, judgment. The excitement is probably due to depression of the inhibitory or controlling centers of the brain. In large doses these drugs cause confusion of thought and delirium. A few of the cerebral excitants, particularly atropin, caffein, and cocain, are useful in arousing the cerebral centers when they have been profoundly depressed by poisons, such as opium. BELLADONNA. (Deadly Nightshade.) Belladonna is official as the leaves {belladonna folia) and as the root {belladonna radix) of Atropa Belladonna, a bushy perennial, a native of Europe, but largely cultivated in North America. The chief active constituents are the two alkaloids atropin and hyoscyamin, though a third alkaloid, hyoscin, is also present in minute quantities. Hyoscyamin is isomeric with atropin and is readily changed to it. Indeed, the preparations of belladonna apparently owe their activity very largely to atropin, which is official as Atrophia and Atropines sulphas. Both the alkaloids and its salts appear in the form of a white crystalline powder, having an acrid, bitter taste. The former is sparingly soluble in water, the latter in 0.4 part of water and 3.7 parts of alcohol. The dose of atropin is 2W-T5 gr. (0.00032-0.00086 gm.); of atropin sulphate, yj-g-^ gr. (0.00043-0.0013 gm.). Preparations. Dose. Tinctura Belladonnse Foliorum, U. S. P. . . 5~ 2 ° min - (0.3-I.2 c.c). Extractum Belladonnas Foliorum, U. S. P. . . \-\ gr. (0.008-0.016 gm.). Fluidextractum Belladonnas Radicis, U. S. P., 1-3 min. (0.06-0.2 c.c). Emplastrum Belladonnas, U. S. P. Unguentum Belladonnas, U. S. P. (10 per cent.). 76 CEREBRAL EXCITANTS. Physiologic Action. — When taken internally in large doses belladonna produces dryness of the throat, dilatation of the pupils, quickening of the pulse, elevation of tempera- ture, and sometimes talkative delirium and an erythematous rash. The rash generally appears on the face and neck and resembles that of scarlatina, but it lacks the characteristic punctations of the latter. Circulatory System. — In moderate doses atropin quickens the pulse, raises the arterial pressure, and increases the output of the heart per unit of time. The acceleration of the pulse is due to depression of the peripheral fibers of the vagus in the heart. Prior to the acceleration there is occasionally some slow- ing from stimulation of the inhibitory center in the medulla, but this effect is always transient. Because of the low tonus of the vagal fibers in the extremes of life little or no change in the pulse-rate follows the use of the drug in infants and old persons. The elevation of the blood-pressure is due in part to marked constriction of the splanchnic vessels from stimulation of the vasoconstrictor center in the medulla, and in part to accelera- tion of the heart-beat. While the abdominal vessels are con- stricted, however, those of the skin are dilated from excitation of the vasodilator center, hence the tendency to an erythema- tous rash in belladonna-poisoning. Large doses of atropin ultimately lower the blood-pressure by depressing the heart muscle. Respiratory System. — Moderate doses of the drug stimu- late the respiratory center and render the respirations quicker and deeper. Large doses paralyze the respiration. In fatal poisoning the breathing ceases before the heart-beat. Nervous System. — The action of atropin on the central nervous system is a complex one. In man, large doses cause restlessness and excitement, then talkative delirium, and, finally, stupor and coma. The first of these effects is probably due to stimulation of the brain, especially of the motor area, and the later ones to depression of the brain, first of the controlling centers and then of the psychic centers. In frogs, because of the poor development of the brain, the action of the drug is chiefly on the spinal cord and motor nerves. Thus, after toxic doses, there is a loss of reflex excitability with cessation of vol- untary movements lasting a day or two, then recovery with exaggerated reflexes and clonic convulsions. The primary effect is apparently due to paralysis of the motor nerve-endings, and the secondary effect to stimulation of the spinal cord. Under atropin the peripheral endings of the nerves in the unstriped muscle of the bronchioles, stomach, intestines, uterus, BELLADONNA. *]>] and bladder are all depressed. The motor nerve-endings in the voluntary muscles are depressed in frogs, but not perceptibly in man. The terminations of the sensory nerves are depressed by local applications of the drug, but not when it is given internally. Secretory Glands. — By depressing the nerve-endings in the secretory glands, atropin lessens nearly all the secretions — saliva, mucus, sweat, gastric juice, and milk. The pancreatic secretion and urine are not much affected, as the pancreas and kidneys are only partially controlled by the nerves. Alimentary Canal. — Atropin diminishes the total quantity of gastric juice and also the percentage of hydrochloric acid. Large doses decrease intestinal peristalsis, while small doses apparently increase it. Given with purgatives it prevents griping, but the manner of its action is not known. Temperature. — Large doses often cause a marked rise of tem- perature, probably by acting directly on the thermogenic centers. Eye. — Atropin dilates the pupil by paralyzing the oculo- motor nerve-endings in the sphincter muscle of the iris, and destroys the power of accommodation by paralyzing the nerve- endings in the ciliary muscle. Like other mydriatics, it also raises the intra-ocular pressure. These effects of the drug in the eye are best seen after its local application. Elimination. — Atropin is excreted chiefly by the kidneys, though much of it undergoes oxidation in the tissues. Toxicology. — The characteristic phenomena of belladonna- poisoning are dryness of the throat, dilated pupils, rapid pulse, hurried respiration, restlessness, talkative delirium, an erythe- matous rash, and, finally, stupor, paralysis, and collapse. The urine of patients suffering from belladonna-poisoning when dropped into the eye of an animal (except birds) causes dilatation of the pupil. Treatment of Poisoning". — After evacuating the stomach, tannic acid should be administered as a chemical antidote. Respiratory and circulatory stimulants are frequently required. Opium, physostigma, and jaborandi are somewhat antagonistic to belladonna, and, therefore, have been recommended as physiologic antidotes. Considerable caution should be exer- cised in their employment. Therapeutics. — Belladonna is employed chiefly to relax spasm, to check excessive secretion, to stimulate the vaso- motor center, to dilate the pupil, and paralyze accommodation, to allay peripheral irritation, to stimulate intestinal peristalsis, to impress the nervous mechanism of the heart, and to antag- onize certain poisons. 7S CEREBRAL EXCITANTS. To Relax Spasm. — It is of little value in general convul- sions of cerebral or spinal origin, but it is of great service in local spasms excited by peripheral irritation. Thus, it is useful in whooping-cough and laryngismus stridulus. In the various forms of colic — renal, biliary, and intestinal — atropin is a valuable adjuvant to morphin, and should be given freely to guard the latter and to relax spasm. In asthma it may be given internally, but inhalation of the smoke made by burning the leaves often gives better results. When in- continence of urine is due to vesical hyperesthesia and spasm of the sphincter, as it frequently is in children, belladonna is a very reliable remedy. To be effective, however, the remedy must be pushed to the point of intolerance, that is, until it causes dryness of the throat and dilatation of the pupils. In obstinate torticollis or wry-neck intramuscular injections of atropin are often followed promptly by relief. In spasm of the anal sphincter and in dysmenorrhea suppositories of bella- donna are often efficacious. To Check Excessive Secretion. — Atropin is one of the best remedies we possess for controlling the night sweats of phthisis. A dose of 2 ^ Q 1 ^ gr. (0.0003 2-0.00065 gm.) at bedtime is sufficient. Unfortunately, untoward effects — dry- ness of the throat, thirst, and dimness of vision — often militate against its use. In salivation from mercury it is also useful. In hyperidrosis of the hands and feet belladonna is used both as an internal remedy and as a local application. When the mother is unable to suckle her child and the breast becomes swollen and tender, the thorough application of an ointment of belladonna will often serve to arrest the secretion of milk and to prevent suppuration, even though the latter seems imminent. In leucorrhea with ulceration of the os uteri, Trous- seau's suppositories containing 1 gr. (0.06 gm.) of the extract and 8 gr. (0.5 gm.) of tannin will be found beneficial. In the bronchopneumonia of childhood belladonna in large doses (2 drops of the tincture every hour) is often of the utmost value in lessening secretion and in relieving dyspnea. In pneumonia with edema it is also useful. To Stimulate the Vasomotor Center. — In shock and col- lapse atropin hypodermically is useful, though much less effective than adrenalin intravenously. It has also been recommended as a vasomotor stimulant in the algid stage of cholera. To Dilate the Pupil and Paralyze Accommodation. — If a drop or two of a solution of atropin, having the strength of 4 gr. (0.26 gm.) to the ounce (30.0 c.c), be dropped into the con- junctival sac, dilatation of the pupil begins in a few minutes, and BELLADONNA. 79 attains its maximum in about half an hour. Accommodation is not affected quite so quickly, paralysis not being complete within an hour and a half. On the other hand, mydriasis per- sists somewhat longer than the suspension of accommodation. The effect of a 4-grain solution usually lasts from ten days to two weeks. Atropin may be employed as a mydriatic to facilitate ophthal- moscopic examination, but euphthalmin, cocain, or homatropin should be given the preference, since the action of these drugs is much less persistent. In estimating errors of refraction it is necessary to select a mydriatic that will suspend the accom- modation, and for this purpose atropin may be used, although there are cycloplegics equally efficient and less persistent in their effects. In iritis it is indispensable in preventing and in breaking up adhesions between the iris and the capsule of the lens. In acute keratitis it is also very useful in allaying the ciliary irritation. The sulphate, on account of its ready solubility, is the salt usually selected. As a simple mydriatic \ gr. (0.016 gm.) to the ounce (30.0 c.c.) is sufficient, and the mydriasis from this solution will not last more than four or five days. As a cycloplegic in refraction work a strength of 4 gr. (0.26 gm.) to the ounce (30.0 c.c.) should be employed. A like solution is generally used in iritis. In keratitis a solution containing 1-2 gr. (0.065-0.13 gm.) to the ounce (30.0 c.c.) will be effec- tive. To Allay Peripheral Irritation. — In the form of an oint- ment or plaster belladonna makes a very useful sedative appli- cation in muscular rheumatism (pleurodynia, wry-neck, lum- bago), in inflammatory affections of the joints, orchitis, and chronic heart-disease. Suppositories containing the extract are much used in pain- ful hemorrhoids, and for the relief of painfid defecation due to inflammation of the pelvic organs. To Stimulate Intestinal Peristalsis. — Belladonna is a use- ful adjuvant to other drugs in chronic constipation. By allay- ing spasm of the intestinal muscles it also prevents griping. To Impress the Nervous Mechanism of the Heart. — Although the manner of its action is obscure, belladonna is often efficacious in nervous palpitation and tachycardia. It may be applied over the region of the heart in the form of a large plaster, or given internally, alone or in combination with sodium bromid. In some cases of exophthalmic goiter, when given in doses large enough to cause some dryness of the throat, it is more useful than any other drug. For the purpose 80 CEREBRAL EXCITANTS. of blocking inhibitory influences on the heart, Allbutt strongly advises the use of atropin hypodermically at the beginning of attacks of angina pectoris. To Antagonize Certain Poisons. — It is a useful antidote in poisoning by opium, physostigma, muscarin (poisonous prin- ciple of toadstools), hydrocyanic acid, aconite, jaborandi, and chloroform. Administration. — The root and leaves are not used inter- nally. The tincture is the most reliable of the liquid prepara- tions. For subcutaneous administration the sulphate of atropin should be employed, since atropin is only sparingly soluble in water. Children are relatively less susceptible to belladonna than adults, and, therefore, often tolerate much larger doses than their age would naturally indicate. The following for- mulae will serve to illustrate the manner of prescribing the drug: R Atropinae sulphatis, gr. j (0.065 g m -) > Acidi borici, gr. x (0.65 gm.); Aquae destillatae, f!|j (30.0 c.c). — M. Sig. A drop or two to be instilled into the conjunctivae twice a day. [Acute keratitis.) R Tincturae belladonnae, f^iss (5.5 c.c); Glycerini, f£ij (7.4 c.c.) ; Aquae menthae piperitae, q. s. ad f^ij (60.0 c.c). — M. Sig. Thirty minims three times a day for a child of three years. The dose to be gradually increased until slight flushing of the face is induced. ( Whooping-cough.) R Extracti belladonnae, gr. x (0.65 gm.' Acidi tannici, gr. vj (0.4 gm. Hydrargyri chloridi mitis, gr. xxx (2.0 gm.) ; Cocainae gr. vj (0.4 gm.); Unguenti petrolati, ^j (31.0 gm.). — M- Sig. Apply night and morning after washing the parts. [Hemorrhoids.) Ineompatibles. — Atropin should not be prescribed in solutions containing caustic alkalies or tannic acid. STRAMONIUM. (Jamestown Weed; Thorn-apple.) The drug is official as the leaves of Datura Stramonium, 2l weed growing in waste places in Europe, Asia, and America. It contains atropin, hyoscyamin, and a minute quantity of hyoscin. Preparations. Dose. Tinctura Stramonii, U. S. P 10-20 min. (0.6-1. c.c). Fluidextractum Stramonii, U. S. P 1-3 min. (0.06-0.2 c.c). Ex tractum Stramonii, U. S. P *-| gr. (0.015-0.03 gm.). Unguentum Stramonii, U. S. P., contains 10 per cent, of the extract. HYOSCYAMUS, 8 1 Therapeutics. — Stramonium is a therapeutic equivalent of belladonna, and may be employed in the same class of diseases in which the latter is prescribed. It has a special reputation in asthma, in which disease it may be used in the form of cigarettes made of the dried leaves. Ointment of stramonium with an equal amount of ointment of galls makes a useful application for hemorrhoids. HYOSCYAMUS, U. S. P. (Henbane.) The leaves and flowering tops of Hyoscyamus niger, a plant growing in Europe, Asia, and North America. They contain hyoscyamin and hyoscin, and a small quantity of atropin. Preparations. Dose. Tinctura Hyoscyami, U. S. P 20-60 min. ( 1. 2-3.7 c.c). Fluidextractum Hyoscyami, U. S. P. . . . 5-20 min. (0.3-1.2 c.c). Extraction Hyoscyami, U. S. P ^-3 gr. (0.03-0.2 gm.). Physiologic Action. — In full doses hyoscyamus act£ like belladonna, causing dilatation of the pupils, dryness of the throat, and quickening of the pulse and respiration. On the brain its action is somewhat more sedative than that of belladonna. Therapeutics. — Like belladonna, it is used to relax spasm and to allay peripheral irritation. It may be employed in whooping-cough, m bronchitis with harassing cough, when opium is contraindicated, and in incontinence of urine due to vesical irri- tation. It is also a useful vesical sedative in acute cystitis. SCOPOLA, U. S. P. Scopola is the dried rhizome of Scopola carniolica, a peren- nial plant growing in southern Europe. It is closely related to belladonna and hyoscyamus. It contains several alkaloids, the chief of which are hyoscyamin and scopolamin. Scopolamin appears to be identical with hyoscin, and is official in the form of the hydrobromid {Scopolamines hydrobromidum). Preparations. Dose. Fluidextractum Scopolae, U. S. P 1-3 min. (0.06-0.2 c.c). Extractum Scopolse, U. S. P \-\ gr. (0.008-0.016 gm.). Physiologic Action and Therapeutics.— Scopola close- ly resembles hyoscyamus in its action, and may be used for the same purposes. Injections of scopolamin and morphin have been used to 82 CEREBRAL EXCITANTS. some extent as a means of inducing general anesthesia. Korff, an ardent advocate of the method, makes three injections — the first 2 J hours, the second I \ hours, and the third \ hour before the operation, using in all -^ gr. (o.ooi gm.) of sco- polamin and \ gr. (0.02 gm.) of morphin. The advantages of the method are said to be the absence of mental excitement, bronchial irritation, and vomiting. As scopolamin and mor- phin, however, are not, as was formerly supposed, antagonistic in their action on respiration, considerable caution should be exercised in using them thus conjointly in such large doses. HYOSCYAMINA. Hyoscyamin is official in the form of the sulphate (Hyos- cy amines sulphas) and the hydrobromid (Hyoscyaminee hydro- bromidum), both of which are freely soluble in water. The dose of either salt is from j^-q— ^5 g r - (0.0004-0.0008 gm.). Hyoscyamin has an action almost identical in kind with that of atropin, though it depresses more powerfully than the latter the nerve-endings in the secretory glands, eye, etc. In pain- ful facial spasm and torticollis it is sometimes very useful. Dana has recommended it in the chorea of childhood. It may afford relief in the tremors of paralysis agitans, disseminated sclerosis, and chronic mercurial poisoning. HYOSCINA. Hyoscin itself is a colorless syrupy liquid, but its salts are solid and crystalline. Of the latter the hydrobromid (Hyos- cincE hydrobromidmn) is official, and may be given in doses of 1 5 ■ ■ 7^ gr. (0.0004-0.0008 gm.). Hyoscin depresses the ter- minations of the same nerves as atropin. Its action in this respect, however, is more prompt and powerful than that of atropin, and its effect less persistent. Unlike atropin, it depresses the cerebrum almost from the beginning, a dose of y^ gr. (0.0005 gm.) usually being sufficient to induce sleep without causing a preliminary stage of excitement. It also differs from atropin in not stimulating, but rather depressing, the respiratory and vasomotor centers in the medulla. In large doses it has a tendency to produce paresis of the throat muscles, and for this reason is contraindicated in affections involving the throat, like diphtheria and scarlet fever. Toxic doses induce dryness of the throat, dilatation of the pupils, stupor, coma, extreme slow- ing of the respirations and pulse, and muscular relaxation. In animals death results from asphyxia. On account of the very pronounced susceptibility of certain persons to the action of hyoscin, the initial dose should always be small. COCA. 83 Therapeutics. — Hyoscin hydrobromid is used as a somni- facient, a depressomotor, and an anaphrodisiac. It is a very efficient somnifacient in insomnia, associated with great mental or emotional excitement ; thus it often acts admirably in mania, delirium tremens, melancholia agitata, and typhoid fever with active delirium. As it has little effect upon the circulation, it sometimes acts favorably as a somnifacient in chronic heart disease, but usually it is inferior to morphin. Given hypo- dermically in doses of -jJo" S r - (0.0003 §" m twice daily, gradu- ally increased, it is sometimes useful in quieting the violent movements of acute chorea. It is the best remedy that we have in diminishing the severity of the tremors and in allaying the restlessnes of paralysis agitans. A dose of y-l-g- gr. (0.OOO4 gm.), gradually increased to -^ gr. (0.0008 gm.), may be given in chloroform-water two or three times a day. It is an excel- lent remedy in spermatorrhea, erotomania, and allied sexual disorders. Administration. — It may be given hypodermically, or by the mouth in pills, granules, or aqueous solution. COCA, U. S. P. The leaves of Erythroxylon Coca, a native of Peru and other South American States. It contains several alkaloids, the most important being cocain, which is official as Cocai?ia, and Cocaines hydrochloridum. Both the free alkaloid and the salt appear in the form of colorless prismatic crystals, having a slightly bitter taste, and producing on the tongue a tempo- rary numbness. Cocain is sparingly soluble in water ( 1 : 600 parts), much more so in alcohol (1 15), in ether (1 : 3.8), and olive oil (1 : 12) ; cocain hydrochlorid is freely soluble in water (1 : 0.4 parts), somewhat less so in alcohol (1 : 2.6), and insol- uble in ether and oils. The dose of either cocain or its salt is from J— 1 gr. (0.015-0.06 gm.). Cocain to the amount of 5 per cent, is contained in the newly introduced oleate of coca {Oleatum cocaines). Preparations. Dose. Fluidextractum Cocae, U. S. P. ..... £-2 fl. dr. (2.0-8.0 c.c). Vinum Cocae, U. S. P 2-8 fl. dr. (8.0-30.0 c.c). Physiologic Action. — In full doses cocain raises the arte- rial pressure and increases the rate of the pulse. The rise of arterial pressure is due to stimulation of the vasomotor center and acceleration of the heart, and, perhaps, also, to constric- tion of the vessels from a peripheral action. The increased 84 CEREBRAL EXCITANTS. pulse-rate is probably due to stimulation of the accelerator mechanism and depression of the vagal endings. After very large doses there is a pronounced fall of the arterial pressure from paralysis of the heart and vasomotor center. Locally, it is a powerful vasoconstrictor; the ischemia, how- ever, is finally replaced by congestion. Central Nervous System. — Cocain first stimulates and then depresses the central nervous system — brain, medulla, and spinal cord. Both the psychic and motor areas of the brain are affected, large doses first inducing wakefulness, mental exhilaration, physical unrest, and then more or less depression. Toxic doses not rarely cause clonic convulsions of cerebral origin. The injection of a small quantity into the spinal canal is followed in a few minutes by complete anesthesia of the entire lower half of the body, without any disturbance of consciousness. Respiratory System. — In small doses it increases both the depth and the rate of the respirations by stimulating the res- piratory center. Toxic doses render the respiratory move- ments irregular in rhythm and shallow, and finally kill through asphyxia. Muscles. — It appears first to stimulate and then to paralyze striated muscles. Kidneys. — Cocain has very little influence on the excretion of urine. The nitrogenous elimination is probably slightly decreased. Alimentary Canal. — Small doses increase and large doses diminish peristaltic movement. Temperature. — Therapeutic doses are without effect, but toxic doses cause a rise of temperature, probably by increas- ing heat production. Local Action. — A very important physiologic property of cocain is its power, when applied directly to a mucous mem- brane or an abraded surface, or when injected under the skin, of inducing temporary anesthesia of the part by paralyzing the sensory nerve-filaments. The anesthesia begins in from five to ten minutes, and generally lasts from twenty to thirty minutes. The application of cocain solutions directly to cuta- neous surfaces is without effect, since absorption through the epidermis is very slight. In addition to anesthesia, cocain causes a blanching of the part, which is subsequently followed by congestion. Applied in sufficient concentration, it is a general protoplasmic poison, nerve-tissue being especially sensi- tive to its influence. Bye. — The instillation into the eye of a few drops of a 4 COCA. 85 per cent, solution of cocain hydrochlorid causes in from ten to fifteen minutes, in addition to anesthesia, contraction of the conjunctival vessels and moderate dilatation of the pupil. The mydriasis attains its maximum in about an hour, and persists for from twelve to fifteen hours. It is of peripheral origin, and is probably caused by stimulation of the sympathetic nerve- endings. Cocain has but little effect on accommodation. Strong solutions have an injurious effect upon the corneal epithelium. Toxicology. — The symptoms of acute cocain-poisoning are somewhat variable ; the usual phenomena, however, are nerv- ous excitement, followed by delirium, and ultimately by stupor ; nausea, vomiting, a very rapid pulse, hurried respira- tions, elevation of temperature, dilatation of the pupils, and convulsive seizures. The treatment is purely symptomatic. When there are- symptoms of circulatory and respiratory failure, ammonia, atropin, and strychnin are indicated. When cerebral excite- ment and convulsions are prominent features, inhalations of chloroform may be employed, and bromids and chloral may be administered tentatively. Untoward Effects of Medicinal Doses. — There is a very wide variation in individual susceptibility to cocain. In some subjects the local application of the drug to the nose or throat, even in solutions of moderate strength, is followed by nausea, vomiting, blindness, syncope, or convulsions. Chronic Poisoning" {Cocainism). — A potent cause of the cocain-habit has been the frequent use of the drug in diseases of the nose and throat. Tyson states that he has known three successive chiefs of clinic in nose and throat dispensary service to acquire the habit. The habit is also common among those addicted to other narcotics, such as opium, alcohol, and chloral. The chief symptoms are emotional excitement, physical unrest, mental impairment, moral turpitude, halluci- nations, mild epileptiform attacks, dilatation of the pupils, a rapid, feeble pulse, severe gastric disturbance, wasting, and anemia. When cocainism is uncomplicated the prognosis is guardedly favorable. The drug should be withdrawn rapidly but not suddenly. Treatment in a sanatorium is always advisable. Stimulants like strychnin are often useful. Hygienic and dietetic measures calculated to improve general nutrition are indicated. Therapeutics. — Cocain is employed as a local anesthetic, mydriatic, and respiratory and circulatory stimulant. As a Local Anesthetic. — As a local anesthetic cocain has a 86 CEREBRAL EXCITANTS. very wide range of usefulness. In the various operations on the eye, nose, throat, urethra, and rectum it is indispensable. In minor surgical operations — like amputation of the fingers, removal of small neoplasms, opening of small abscesses — it may also be employed with advantage. In these cases care must be taken to prevent undue absorption of the drug, and this is best accomplished by the application of a tight rubber band to the proximal side of the part to be operated on, thus controlling the circulation. A 2 per cent, solution may be injected to the extent of a dram with safety. The capillary oozing should not be checked immediately, as it serves to carry off the cocain. The same quantity of cocain in weak solution is distinctly less toxic than it is when in strong solution (Custer). In operations in which the circulation cannot be controlled, and in which much of the solution must be allowed to remain in the tissues, the method employed by Schleich, known as infiltration anesthesia, is of very great value. Schleich employs solutions of three strengths. The one of medium strength con- sisting of — Cocain hydrochloric!, I gr. (0.065 gm.) ; Morphin hydrochloric!, \ gr. (0.013 gm.) ; Sodium chlorid, 2 gr. (0.13 gm.) ; Sterilized, distilled water, 2 fl. oz. (60.0 c.c). The stronger solution contains 2 gr. (0.13 gm.) of cocain, and the weaker solution, -^ gr. (0.0065 gm.). The important factors in the induction of anesthesia by this method are the ischemia of the tissues caused by the pressure of the injected fluid, the compression of the terminal nerve- filaments from the same cause, and the direct paralysis of the sensory nerves by the cocain. The effect of the morphin is not local, but general. Physiologic salt-solution is employed as the vehicle, because it is unirritating to the tissues. The field of operation may be infiltrated en masse, or it may be surrounded by an anesthetic edematous zone. In addition, the nerves leading to the part may also be cocainized either some distance from the prospective incision, or directly as they are exposed in the wound. An ordinary antitoxin syringe capable of holding at least 10 c.c. may be employed. The derm should be infiltrated before the deeper tissues are injected. The needle having been introduced obliquely, a few drops of the solution are forced out ; the needle is then thrust deeper and deeper, while more of the fluid is injected in various directions until the field is thoroughly edematized. The subsequent application of an ice-bag to the part will intensify the analgesic effect of the COCA. 8? injection. At least five minutes should elapse after the infil- tration before the incision is made. The period of analgesia generally lasts from twenty to thirty minutes. The strength of the solution and the amount employed will depend upon the sensitiveness of the part, the extent of the operation, and the amount of cocain that is likely to be retained in the tissues. It is not safe to allow more than I grain of cocain to remain in the part. Of the strong solution, i ounce (30.0 c.c.) ; of the solution of medium strength, 2 ounces (60.0 c.c.) ; and of the weak solution, 10 ounces (300.0 c.c.) or more may be em- ployed without risk. Medullary Cocainization. — The employment of spinal sub- arachnoid injections for the purpose of inducing analgesia was suggested by Corning in 1885, and made practical by the researches of Bier, published in 1899. The technic of medullary cocainization is as follows : The entire lumbar and sacral region is prepared with antiseptic care as for operation ; the patient is placed in a sitting posture, and the injection is made at the level of the crest of the ilium, that is, just above or below the fourth lumbar vertebra, and 1 cm. Q- in.) external to its spinous process. The solution is injected through a fine iridoplatinum needle, about 9 cm. (3-4 in.) long, attached to an ordinary hypodermic syringe capable of holding 2 c.c. (30 min.). As the injection should not be made before a flow of cerebrospinal fluid is observed, the needle should be introduced into the subarachnoid space before the syringe is attached. The injection is made very slowly, and to insure the retention of the solution the needle is held in situ for about a minute, then carefully withdrawn, and the puncture sealed with collodion. A 2 per cent, solu- tion (9 gr.-i oz. — 0.6 gm-30.0 c.c.) of cocain hydrochlorid is usually employed ; it should be freshly prepared and sterile. From 15-20 min. (1.0-1.2 cc.) are injected. The amount of cocain should not exceed f gr. (0.025 gm.). Analgesia extend- ing downward from about the level of the diaphragm follows in from five to ten minutes, and usually persists about an hour and a half. The relative value of this method of inducing analgesia has not yet been determined; it is certainly not altogether free from danger. Unpleasant after-effects — fever, headache, ver- tigo, nausea, and vomiting — are of frequent occurrence. Co- cain analgesia is not suitable for prolonged, complicated opera- tions, especially when they are intra-abdominal ; and since it does not induce unconsciousness, it should not be employed in young children nor in insane or hysteric adults. 88 CEREBRAL EXCITANTS. In inflammations and ulcerations of the nose, pharynx, and larynx cocain may be employed alone or in combination with antiseptic sprays or powders. In acute coryza and hay-fever it gives great relief by lessening the sensibility and constricting the turgid tissues. In laryngeal tuberculosis it is invaluable for the relief of the intense pain and dysphagia. It may be given in insufflation in combination with iodoform, iodol, or morphin. As a local anesthetic it is also used internally to relieve the pain of gas- tric ulcer and to check excessive vomiting. The application of a 10 per cent, solution of cocain hydro- chlorid on a cotton pledget has been found useful in rigidity of the os uteri. As a Mydriatic. — As a mydriatic, cocain is not so gen- erally useful as atropin. Since, however, it only slightly impairs accommodation, and its effects pass off in a few hours, it is a convenient mydriatic for retinal examinations. In iritis atropin is distinctly preferable on account of its forcible action and lasting effect. The mydriatic effect of cocain is readily neutralized by the instillation into the eye of a few drops of a \ per cent, solution of eserin. As a Respiratory Stimulant. — Cocain is an active respira- tory stimulant, and for this reason, and also on account of its general excitant influence, it is a useful physiologic antidote in opium- poisoning. As a Circulatory Stimulant. — In adynamic pneumonia, cocain, administered hypodermically, is an efficient adjuvant to strychnin. Administration. — As a local anesthetic to mucous mem- branes the hydrochlorid is employed in solutions varying in strength from 2 to 20 per cent. The mucous membrane of the larynx is less susceptible than that of the nose or throat. On the latter, from 4 to 6 per cent, solutions are usually suffi- cient. A solution stronger than 4 per cent, should not be used in the eye on account of the danger of inducing degenerative changes in the corneal epithelium. Aqueous solutions of cocain lose in efficacy on boiling, methyl alcohol and benzoic acid being split off from the alkaloid. The drug is not well borne by children and women of a neurotic temperament. The danger of causing the habit from the frequent use of cocain in chronic diseases of the nose and throat must never be lost sight of, and under no circumstances should the remedy be placed in the patient's own hands. In tuberculous laryngitis with dysphagia small CEREBRAL DEPRESSANTS. 89 tablets containing from -^o-jj g r - (0.003-0.005 gm.) of cocain may be allowed to dissolve slowly in the mouth, or the drug may be used in the form of a powder or spray : R Cocainse hydrochloride gr. xx (1.3 gm.) ; Resorcinol, gr. x (0.65 gm. ); Aquae, f^j (30.0 c.c.) — M. Sig. To be used as a spray. ( Tuberculous laryngitis.) The fluidextract and the wine of coca are used as mild stimulants. Incompatibles. — Cocain is incompatible with tannic acid, alkaline carbonates, iodids, borax, and zinc sulphate. It cannot be added to Dobell's solution, since the latter contains borax. CEREBRAL DEPRESSANTS. The cerebral depressants may be classed as somnifacients, general anesthetics, general analgesics, and anticonvulsants. Somnifacients or hypnotics are remedies which induce sleep. The factors favoring natural sleep are the withdrawal of afferent stimuli, decreased responsiveness of the brain-cells as the result of fatigue, the accumulation in the blood of products evolved by the cells in the exercise of their functions, and, finally, lessening of the blood-supply to the brain. Pure som- nifacients inhibit the functional activity of the brain-cells, but they do not completely suspend the power of the cells to recuperate (the main object of sleep) nor to react to stimuli which reach them from without. General anesthetics are drugs which induce unconscious- ness and insensibility. Their effect upon the brain-cells is much more profound than that of the hypnotics, in that they temporarily inhibit the responsiveness of the cells to external stimuli, and suspend more or less completely recuperative changes. General a7ialgesics or anodynes are remedies which relieve pain. They may act either by directly influencing the receptive centers in the brain or by preventing the transmission of painful impressions through the sensory nerves and spinal cord to the brain. Anticonvulsants are remedies which check excessive motor activity. In the case of cerebral convulsions they may act by directly depressing the cells in the cortex of the brain, by go SOMNIFACIENTS. lessening the power of the sensory tract in the peripheral nerves and spinal cord to transmit to the brain-cells stimuli from without, or by lessening the power of the motor tract in the spinal cord and peripheral nerves to transmit to the mus- cles the excessive discharges emanating from the brain-cells. SOMNIFACIENTS. The most important element in the treatment of insomnia is the removal of the cause. A potent factor in many cases of persistent insomnia is the circulation in the blood of the prod- ucts of faulty metabolism, as seen in dyspeptic and gouty subjects. In such affections a careful regulation of the diet is of the utmost importance. The evening meal especially should be simple and light. Systematic exercise, coupled with the use of mild mercurial or saline aperients, often proves more effective in promoting sleep than the exhibition of hypnotics. In the aged insomnia is very often associated with lowered vas- cular tone, and when such is the case, small doses of strychnin are beneficial. In chronic valvular disease stimulants like digitalis, strophanthus, and nux vomica are indicated. In chronic Bright's disease insomnia is a common symptom, and it may depend upon the retention in the blood of excrementi- tious materials or it may be due to high arterial tension. In the former case a milk-diet and the use of eliminants will be most helpful, and in the latter case the administration of some vasodilator, such as nitroglycerin or erythrol tetranitrate, will often afford marked relief. Tea, coffee, and tobacco are some- times preventives of sleep, and if so they must be used sparingly or perhaps altogether avoided. When anemia is a causal factor, iron and arsenic will be needed. Insomnia from overwork, mental anxiety, or grief will demand mental rest, diversion, or change of scene. When the habit of sleeplessness has become well established it may require more than the removal of the cause to effect a complete cure. Simple measures, however, should always be tried first before resorting to hypnotics. The bedroom should be quiet, well ventilated, and of moderate temperature. When the feet are cold the blood should be diverted from the head by hot foot-baths, which may be made more effective by the addition of mustard. Vigorous rubbing of the limbs is also useful. A glass of hot milk, a cup of bouillon, or a toddy just before retiring often acts favorably as a derivative. In some persons light reading for half an hour, in others a brisk walk, will invite sleep. In neurasthenia, massage and the systematic use of the wet-pack are invaluable aids. OPIUM. , 91 Hypnotic drugs must be used with caution. Their con- tinued exhibition predisposes to invalidism and favors the development of vicious habits. In simple habitual insomnia they should not be prescribed until general measures have been tried and found wanting. The chief somnifacients are : Opium. Sulphonal. Cannabis indica. Trional. Hyoscin. Paraldehyd. Hydrated chloral. Urethan. Chloralformamid (chloralamid). Hedonal. Chloralose. Veronal. Chloretone. Bromids. OPIUM, U.S. P. Opium is the inspissated juice obtained by incising the unripe capsules of Papaver somniferum, a poppy indigenous in West- ern Asia. To be up to the official standard, it should contain not less than 9 per cent, of crystallized morphin. It appears in the form of irregular lumps, having a dark-brown color, a gummy consistence, a peculiar narcotic odor, and a bitter taste. In addition to meconic acid and a neutral principle, mecojiin, it contains a number of alkaloids, the most important of which are morphin, codein, thebain, papavetin, narcotin, and narcein. Preparations. Dose. Opium, U. S. P. (9 per cent, of morphin) . . \-2. gr. (0.03-0.13 gm.). Opii Pulvis, U. S. P. (1 2-1 2. 5 per cent, of morphin) \-z gr. (0.03-0.13 gm.). Opium Deodoratum, U. S. P. (denarcotized opium, 12-12. 5 per cent, of morphin) . . . i-2 gr (0.03-0.13 gm.). Opium Granulatum, U. S. P. (12-12.5 per cent, of morphin) ^-2 gr. (0.03-0.13 gm.). Pilulse Opii, U. S. P. (1 gr. — 0.06 gm. of pow- dered opium in each) 1-2 pills. Extractum Opii, U. S. P. (20 per cent, of morphin) ^-1 gr. (0.016-0.65 gm.). Tinctura Opii, U. S. P. (laudanum ; 10 per cent, of granulated opium ; 100 c.c, contain 1.2 to 1.25 gm. of morphin) 5-20 min. (0.3-1.2 c.c). Tinctura Opii Deodorati, U. S. P. (10 per cent, of granulated opium ; 100 c.c, contain 1.2 to I.25 gm. of morphin) 5-20 min. (0.3-1.2 c.c). Tinctura Opii Camphorata, U. S. P. (pare- goric ; contains camphor, benzoic acid, oil of anise, and about 2 gr. — 0.12 gm. of pow- dered opium per ounce) \-\ fl. dr. ( 1. 8-1 5.0 c.c). Tinctura Ipecacuanhas et Opii, U. S. P. . . . 5-15 min. (0.3-1.0 c.c.) Acetum Opii, U. S. P. (black drop; 10 per cent, of powdered opium) 5-20 min. (0.3-1.2 c.c). 92 SOMNIFACIENTS. Preparations. Dose. Vinum Opii, U. S. P. (io per cent, of granu- lated opium) 5-20 min. (0.3-1.2 c.c). Pulvis Ipecacuanhse et Opii, U. S. P. (Do- ver's powder; contains 10 per cent, of powdered opium ; 10 per cent, of ipecac ; and 80 per cent, of sugar of milk) . . . 5-10 gr. (0.3-0.6 gm.). Trochisci Glycyrrhizge et Opii, U. S. P. (each contains ^ gr. — 0.005 S m - °f powdered opium). Emplastrum Opii, U. S. P. (6 per cent, of extract of opium). Morphin is the chief alkaloid of opium and represents its physiologic activity. It occurs in white prismatic crystals, or fine needles, of a bitter taste, and very slightly soluble in water. The salts of morphin, being much more soluble than the alkaloid itself, are generally prescribed. The following alkaloids of opium and their preparations are used medicinally : Preparations. Dose. Morphina, U. S. P $-£ gr. (0.008-0.032 gm.). Morphinse Acetas, U. S. P Hg r ' (0.008-0.032 gm.). Morphinse Hydrochloridum, U. S. P |-| gr. (0.008-0.032 gm.). Morphinse Sulphas, U. S. P l~ J gr. (0.008-0.032 gm.). Pulvis Morphinae Compositus, U. S. P, (Tul- ly's powder; contains licorice, camphor, calcium carbonate, and morphin sulphate) 5-10 gr. (0.3-0.6 gm.). Codeina, U. S. P £-2 gr. (0.03-0.13 gm. V Codeinse Sulphas, U. S. P £-2 gr. (0.03-0.13 gm. J. Codienae Phosphas, U. S. P £-2 gr. (0.03-0.13 gm.). The following compounds are derived from the alkaloids of opium. From morphin : apomorphin (see p. 273), heroin, dionin, and peronin ; from codein : apocodein (see p. 274); and from narcotin : cotarnin hydrochlorid (see p. 380). Physiologic Action. — Nervous System. — In man the dominant action of opium is on the cerebrum. Even in small doses the drug diminishes all sensations, especially those of pain, and causes drowsiness. In full therapeutic doses it pro- duces natural sleep, from which the patient usually awakes refreshed, but not rarely complaining of dull headache and nausea. Toxic doses are followed by profound coma. In some instances the narcotic effect is preceded by a short period of exaltation or exhilaration, with increased play of the imagi- nation. This excitement, as in the case of alcohol, depends rather upon depression of the controlling centers than upon any direct stimulation of the psychic functions. Unlike chloral, opium has little action, except in large doses, on the motor cells of the brain cortex. opium. 93 Opium increases to some extent the reflex irritability of the spinal cord. In human beings this action is rarely apparent, owing to the much greater sensitiveness of the brain to the influence of the drug, but in animals, like the frog, in which the cerebral hemispheres are poorly developed, large doses give rise to tetanic convulsions. In some of the opium alka- loids, particularly thebain and laudanin, the convulsant action is predominant. On the peripheral sensory and motor nerve-endings opium has little or no effect. Respiratory System. — Opium is a powerful depressant of the respiratory center in the medulla. In poisoning, the respi- rations become progressively weaker and fewer, and if the dose has been sufficiently large, finally cease entirely. Bye. — Applied to the conjunctiva, morphin has no effect upon the pupil, but when administered internally in toxic doses it causes extreme myosis through a central action. In fatal poisoning, dilatation of the pupil is observed just before death as a result of the asphyxia. Circulatory System. — Opium dilates the peripheral cuta- neous vessels and causes flushing, sweating, and occasionally itching; otherwise it has little effect on the circulation. In poisoning, the pulse at first is full and somewhat infrequent, and later it is feeble and frequent, but these changes are chiefly the result of the asphyxia. Secretions. — All the secretions, except the sweat, are dimin- ished by opium. Alimentary Ganal. — In man medicinal doses of opium lessen peristaltic movements, probably by depressing some part of the nervous mechanism in the bowel wall. To this action and the diminished intestinal secretion the well-known constipating effect of the drug is to be attributed. Very large amounts of morphin, especially if introduced directly into the blood, sometimes increase peristaltic movements and induce purgation, probably by depressing the inhibitory nerve of the bowel. Metabolism. — Morphin decreases to some extent the ab- sorption of oxygen and the excretion of carbonic acid. By interfering with respiration and oxidation it sometimes causes slight glycosuria. Elimination. — Morphin escapes from the body chiefly through the stomach and bowel, only minute quantities appear- ing in the urine. Elimination is rapid, and even after hypo- dermic injection the drug may be found in the stomach within a few minutes. Ordinarily only a small amount of the mor- 94 SOMNIFACIENTS. phin injected is oxidized in the tissues, but under increasing doses the proportion is gradually increased, so that in habitues only traces appear in the excreta. Conditions Modifying the Action of Opium. — Cer- tain symptoms and diseases counteract the narcotic effect of opium, and when these are present the drug may be used in much larger doses than are generally prescribed; thus, patients suffering from diabetes or affections attended with severe pain, such as acute peritonitis, renal or biliary colic, can frequently take with advantage doses that under other circumstances would produce profound narcosis. On the other hand, when there are evidences of nephritis the drug must be used with great caution, since small doses not infrequently produce lethal effects. Age and sex modify its action. Children, on account of the sensitiveness of their nervous systems, are peculiarly sus- ceptible to opium, so that it must be given in smaller doses than the age would naturally indicate. A drop of laudanum has produced a fatal result in a child less than six months old. Its action is more pronounced on women than on men, and in the former it is more apt to cause disagreeable after- effects. Patients rapidly acquire a tolerance of the drug through frequent repetition of the dose, so that habitues can often take enormous amounts without experiencing the usual effects. The Action of Opium and Morphin Compared. — Apart from being more powerful than opium, morphin differs from the latter in having a less constipating, less nauseating, and less diaphoretic effect. Toxicology. — Acute Opium-poisoning-. — Unless the dose is very large, there may be at first a stage of excitement, in which the imagination is stimulated and the feelings are ex- alted. This stage is soon followed by one of depression, in which the patient becomes listless and drowsy, and finally falls into a deep sleep. The pulse is slow and full, the pupils are contracted to a pin-point size, the respirations are slow and labored, the muscles are relaxed, and the face is pale. In this stage it is still possible to arouse the patient by loud noises, flagellation, or shaking. In the third stage coma is absolute, the pulse is rapid and irregular, the skin is clammy, and the breathing is shallow and irregular. Finally, death results from paralytic asphyxia. Treatment of Acute Opium-poisoning. — The stomach should be emptied by means of the stomach-pump or a stimulating emetic, such as zinc sulphate or mustard flour. Since mor- opium. 95 phin is eliminated by the stomach and then reabsorbed, lavage should be repeated at short intervals. Black coffee may be given by the mouth or by the rectum ; it promotes wakeful- ness and also stimulates respiration. The best chemical anti- dote is potassium permanganate ; 3 to 5 grains (0.2-0.3 g m of this drug, dissolved in a glassful of water, should be given at once and repeated in thirty minutes. Tannic acid is also recommended as a chemical antidote. The best physiologic antidotes are the powerful respiratory stimulants, such as atropin, strychnin, and caffein ; one or all of these may be given hypodermically in full doses. Artificial respiration is of the greatest value, and should be maintained so long as the beating of the heart continues. It is necessary that the patient should be aroused and kept awake, so that he himself can aid in keeping up respiration. Flicking with a wet towel, the use alternately of hot and cold water, and the application of the faradic current are among the meas- ures that may be employed in staving off sleep. In carrying out the treatment it is important to avoid chilling or exhausting the patient. Chronic Poisoning" (Morphinomania, Morphinism). — The symptoms resulting from the habitual use of opium are an irresistable craving for the drug, loss of flesh and strength, tremors, anemia, a peculiar sallow complexion, anorexia, deranged digestion, a tendency to diarrhea, disturbed sleep, mental depression, irritability, and a characteristic propensity for lying and deceiving. Treatment of Chronic Opium-poisoning . — Isolation in a spe- cial institution or asylum is almost imperative. As a rule, the drug should be withdrawn rapidly, but in aggravated cases not too abruptly for fear of collapse. The diet should consist of nutritious, easily digested food. Strychnin, while it is with- out specific action, is often extremely valuable for its stimulating effect. Bromids and cannabis indica are sometimes useful in ameliorating the distress which follows the withdrawal of opium. Sulphonal, paraldehyd, and veronal are the best somnifacients. Massage, graduated exercise, and the Turkish bath are useful roborant measures in the convalescent stage. Therapeutics. — Opium is used to relieve pain and dis- tress ; to induce sleep ; to allay peripheral irritation ; to check excessive secretion ; to promote diaphoresis ; to eontrol con- vulsions ; and to check hemorrhage. To Relieve Pain and Distress. — Opium is by far the best analgesic that we possess. In allaying the severe pain of gross lesions — -fractures, malignant growths, and acute inflam- 96 SOMNIFACIENTS. mation of serous membranes — it has no rival. In neuralgia and other forms of recurrent pain it should be used only after all other measures have failed, and then with extreme caution, since the danger of forming the opium-habit in these cases is very great. In the painful crises of locomotor ataxia its use may become imperative. Osier regards morphin, hypodermically, as the most useful drug in those attacks of angina pectoris in which amyl nitrite proves ineffective. In various forms of colic — renal, biliary, and intestinal — it is well to combine atropin with morphin, since the former aids the latter in relaxing the spasm. Acute inflammation of the brain and its membranes cannot be considered, as was formerly the case, a contraindication to the use of opium ; indeed, in cerebrospinal fever and other forms of acute meningitis it may be the only remedy that will afford relief from the intense suffering. In most cases of acute appendicitis morphin should be withheld, since it masks the symptoms and thus interferes with an accurate study of the local conditions. In acute melancholia and other psychoses associated with profound mental anxiety, opium often exerts an excellent calmative effect. In many cases of chronic heart-disease it is invaluable in relieving the general discomfort and in pro- moting sleep. To obtain the best results, however, it should be given hypodermically. To Induce Sleep. — While opium will relieve insomnia from almost any cause, it is especially suitable when the cause of the sleeplessness is pain. It is also useful as a somnifacient in continued fevers, like typhoid fever, in delirium tremens, and in chorea, when the movements prevent sleep, . Occasionally, owing to some peculiar idiosyncrasy, opium causes excitement and wakefulness instead of sleep. In states of extreme nervous excitement chloral is generally superior to opium, but not infrequently better results are obtained from a combination of opium with chloral than from either drug singly. To Allay Peripheral Irritation. — No remedy is so useful as opium or one of its derivatives in relieving the irritative cough of bronchitis and phthisis. It should not be employed, however, in pulmonary affections when the expectoration is copious, and in pulmonary edema it is a dangerous drug. In asthma morphin hypodermically, with or without atropin, is a reliable remedy. In some cases of acute vomiting injections of the drug act happily, but in the pernicious vomiting of preg- nancy its effects are not good. In chordee and in threatened opium. 97 abortion is frequently employed in the form of suppositories, but it acts just as well when given by the mouth or hypo- dermically. To Check Excessive Secretion. — In acute inflammatory affections of the bowel, after irritating matters have been re- moved, opium is often serviceable in checking the excessive secretion. In cholera infantum hypodermic injections of mor- phin (j-J^ gr. — 0.00065 gm.) are sometimes of benefit. In diabetes mellitus it does mare good than any other remedy, and as the disease establishes a tolerance for the drug, it should be given in ascending doses until it induces favorable or untoward results. The manner in which it acts in this dis- ease is unknown. Codein is preferred by some practitioners to morphin and opium, since it causes less disagreeable after- effects. In diabetes insipidus the drug is of far less value. To Promote Diaphoresis. — In the beginning of " colds," and in so-called muscular rheumatism, it is useful for its sudo- rific effect. In these cases Dover's powder is the best prepa- ration, since the ipecac which it contains assists the opium in promoting diaphoresis. To Control Convulsions. — Morphin hypodermically is of service in controlling the painful spasmodic seizures of tetanus. Mackenzie, Loomis, and Osier speak favorably of its action in the convulsions and other nervous manifestations of uremia, and unquestionably it may be given with great benefit in many cases, but it should always be employed with considerable caution, especially when there are evidences of chronic inter- stitial nephritis. Flechsig's method of using opium in the treatment of epilepsy is occasionally of service in old and obstinate cases. This method consists in giving opium in large doses for a period of six weeks (beginning with 1 grain of the extract the dose is rapidly increased until 1 5 grains a day are taken at the end of the first week, this amount being kept up for six weeks). The opium is abruptly withdrawn and potassium bromid is substituted. Large closes of the latter drug (30 grains three times a day) are given for about two months, and are then gradually reduced until less than 40 grains a day are being taken. To Check Hemorrhage. — It is a common practice to com- bine opium with hemostatics in the various hemorrhages, such as hemoptysis, hematemesis, and enter orrhagia. The good which it accomplishes is probably the result of its calmative influence on the nervous system. External Use. — In the form of a lotion it is extensively em- 7 98 SOMNIFACIENTS. ployed as a sedative application in sprains, bruises, articular rheumatism, and erysipelas, but any other weak alcoholic preparation would probably be quite as efficient, since opium itself has no effect on the sensory nerve-endings. In these cases, notwithstanding the chemical incompatibility of the two drugs, it is generally combined with lead subacetate, as in the following formula : }£ Tincturse opii, Liquoris plumbi subacetatis, aa ^ij ; Aquae, q. s. ad Oj. — M. Untoward Effects. — In some persons the use of opium, even in moderate doses, is followed by headache, depression, anorexia, nausea, and vomiting. In others, on account of a peculiar idiosyncrasy, it causes excitement and wakefulness instead of sleep. In rare instances it occasions general pru- ritus or an erythematous rash. Contraindications. — Opium should not be used in pulmo- nary affections associated with embarrassed respiration, such as edema, and pneumonia during the stage of consolidation. For reasons already mentioned it is best to withhold it in ap- pendicitis. When chronic nephritis exists it must be used with the utmost circumspection. Administration. — When a prompt analgesic effect is de- sired, one of the salts of morphin should be selected in prefer- ence to opium, and should be administered hypodermically. When large doses are required it is well to add a small dose of atropin ( T j^ gr. — 0.0004 gm.) to each injection. Pulverized opium, deodorized opium, and the extract are suitable prepa- rations for use in pills. Dover's powder is the best preparation for promoting diaphoresis. The most agreeable liquid prepa- rations are the deodorized tincture and paregoric. Paregoric, on account of its weakness and pleasant taste, is especially suitable for children. The disagreeable after-effects of opium are often prevented by combining with it potassium bromid. Children are extremely intolerant to the drug in all forms, and, in consequence, the dose must be considerably less than the age would apparently justify. Incompatibles. — Ammonia, alkaline carbonates, prepara- tions containing tannic acid, or salts of the metals should not be prescribed in solution with morphin. Chlorids, bromids, iodids, and borates, when present in large amount, precipitate morphin from solutions. Even dilute hydrocyanic acid may slowly precipitate from solutions of morphin an insoluble cyanid of the alkaloid. opium. 99 codeina, u. s. p. Among the alkaloids of opium codein ranks next in im- portance to morphin. It occurs in the form of colorless crys- tals, of a bitter taste, and soluble in %% parts of water and in 1.6 parts of alcohol. The sulphate and phosphate are to be preferred to the alkaloid itself, on account of their greater solubility. The phosphate, being soluble in 2.25 parts of water, is adapted to hypodermic use. Codein resembles morphin in its action, but it is far less powerful as a hypnotic and analgesic. It is less liable, how- ever, than morphin to induce nausea and constipation. It is an excellent remedy for allaying irritative cough in bro?ichitis and phthisis. It is preferred by some clinicians to opium in the treatment of diabetes, but, as a rule, the crude drug or morphin will be found more efficacious. HEROIN. Heroin is the diacetyl ester of morphin. It appears as a white crystalline powder, of slightly bitter taste. It is insolu- ble in water, but freely soluble in acidulated solutions. It has a more depressant action on the respiratory center than mor- phin, but is less powerful than the latter as an analgesic and a somnifacient. The dose is from ^ 2 ~ \ S r - (0.005-0.008 gm.). Large doses are frequently followed by nausea, headache, dry- ness of the throat, vertigo, diplopia, and numbness of the limbs. Heroin is useful in allaying the cough of bronchitis and phthisis, although it is not so generally efficacious as codein. In emphysema and asthma it is an excellent sedative. It may be given in pill, powder, or in water to which a little acid has been added. The hydrochlorid of heroin is freely soluble, and may be given in aqueous solution by the mouth or hypo- dermically. Heroin is incompatible with alcoholics, acids, and apomorphin. DIONIN. Dionin is the ethyl ester of morphin hydrochlorid. It is freely soluble in water. According to Winternitz, it does not depress the respiration, and it has no unpleasant effect upon the stomach. As an analgesic and a somnifacient it is far less powerful than morphin ; as a sedative it stands probably midway in efficiency between codein and morphin. It may be prescribed in the same dose as codein. As a local remedy dionin has been well recommended as an analgesic and absorbent in certain diseases of the eye, such as iritis, interstitial keratitis, and corneal opacities. As it does not IOO SOMNIFACIENTS. affect sensibility, it is not suited for use in operations on the eye. It is usually employed in the form of a 5 or 10 per cent, solution or a 10 per cent, ointment. The eye rapidly acquires tolerance for the drug, hence little effect is to be secured from its use for a longer period than a week or ten days. Patients should be warned that the first instillation often causes marked swelling of the conjunctiva and eyelids. This soon subsides, and is of no serious import. PERONIN. Peronin is the hydrochlorid of the benzyl ester of morphin. It was first studied by von Mering, who found it less active than morphin, but freer from disagreeable after-effects. Later researches indicate that, while it is a somewhat more powerful sedative than codein, it is also more toxic. A sufficient num- ber of clinical observations have not yet been made to determine the exact rank of peronin as a therapeutic agent, but, in view of its slight solubility, unpleasant taste, and relatively high toxicity, it would seem to have few, if any, advantages over codein. The dose is from \-\ gr. (0.02-0.06 gm.). CANNABIS INDICA, U. S. P. ( Indian Hemp ; Hashish.) The flowering tops of an East Indian plant, Cannabis sativa. It contains a resinous principle known as cannabinol. Preparations. Dose. Tinctura Cannabis Indicse, U. S. P. . . . 10-30 min. (0.6-2.0 c.c. ). Fluidextractum Cannabis Indicae, U. S. P. 1-5 min. (0.06-0.3 c.c). Extractum Cannabis Indicae, U. S. P. . . ^-1 gr. (0.008-0.06 gm. ). Physiologic Action. — In large doses it produces a condi- tion of mental exhilaration associated with hallucinations and disordered consciousness of time, locality, and personality. This stage of excitement finally gives way to sleep, which may last several hours. Sensation is perverted and benumbed, and before sleep is induced there is often more or less general anes- thesia. Upon the circulatory and respiratory systems the drug has little influence unless given in very large doses. Although alarming symptoms sometimes follow overdoses of cannabis indica, no death from its use has been recorded. Therapeutics. — Cannabis indica is used chiefly as a mild analgesic, sedative, and hypnotic. Although much inferior to opium, it may replace the latter when, for any reason, the more active drug is unavailable. It is often efficient in the CHLORAL. IOI persistent cough of chronic bronchitis and phthisis, in the dysp- nea of asthma, and in the restlessness and insomnia of chronic nephritis. As an analgesic it is very valuable in certain forms of netiralgia, especially migraine, in which affection it is not only useful between, but also during, the paroxysms. It is occasionally effective in relieving the violent pains of locomotor ataxia. It may be employed as an adjuvant to chloral in tetanus. In some forms of dysmenorrhea and menorrhagia it proves serviceable. In combination with the bromid of potas- sium it is sometimes useful in mania and delirium tremens. See and Suckling have strongly recommended it in gas- tralgia. Administration. — As the preparations of cannabis indica vary considerably in strength, and as some individuals are far more susceptible to the action of the drug than others, it is always advisable to begin with small doses and to increase them gradually. A dose of 10 drops of the tincture, repeated in four hours, has caused in an adult intense excitement, dila- tation of the pupils, and disordered sensation. As the addition of water or of an aqueous liquid to the fluid extract or tincture precipitates the resinous principle, an alcoholic menstruum should be selected for these preparations, or, in case water is used, enough mucilage should be added to hold the resin in suspension. CHLORALUM HYDRATUM, U. S. P. (Hydrated Chloral; Chloral, C 2 HCl s O + H 2 0.) Hydrated chloral is obtained from the union of a molecule of water with trichloraldehyd (chloral), the latter being a product of the action of chlorin on alcohol. It occurs in the form of colorless, transparent crystals, having a bitterish, caustic taste, a pungent odor, and a neutral reaction. It is freely soluble in water, alcohol, ether, and chloroform. The dose is from 10-20 gr. (0.65-1.3 gm.). Physiologic Action. — Nervous System. — The dominant action of chloral is on the central nervous system. In moderate doses (i5-20gr. — 1.0-1.3 gm.)it depresses the cerebrum with- out sensibly disturbing the circulation and respiration, and pro- duces a natural sleep lasting from four to eight hours. Unlike morphin, it has but little effect on the algesic centers of the braim and, therefore, pain antagonizes its soporific action. Larger doses of chloral (30-40 gr. — 2.0-2.6 gm.) depress all the cerebral centers, including the motor, and cause profound sleep. Doses of this size also diminish the reflex excitability of the spina/ 102 SOMNIFACIENTS. cord and depress the respiratory and vasomotor centers in the medulla. Toxic doses produce all the phenomena observed in chloroform-poisoning. On the peripheral nerves chloral has little or no action. Circulatory System. — Moderate doses of chloral do not affect the circulation, but large doses lower the blood-pressure by depressing the vasomotor center and the cardiac muscle. Respiratory System. — The respiration is not affected by ordinary doses of chloral, but after large doses it becomes in- frequent and shallow, and, finally, ceases from paralysis of the respiratory center. Temperature. — Toxic doses lower the temperature by di- lating the cutaneous vessels, by decreasing muscular move- ments, and probably also by depressing the heat centers in the brain. Metabolism. — The prolonged use of chloral is followed by increased destruction of proteids and fatty degeneration of the viscera. Local Action. — Locally, chloral is an active irritant, es- pecially to mucous membranes. Unless taken in dilute solu- tion it is very likely to cause nausea and vomiting. Action on Lower Org-anisms. — Chloral prevents the move- ments of protozoa and retards the putrefaction of proteid solutions. Elimination. — Chloral circulates in the blood as chloral, and is eliminated by the kidneys as urochloric acid. When taken in excess it escapes in part unchanged. Urine contain- ing urochloric acid responds to Fehling's test for sugar. Toxicology. — The characteristic features of acute chloral- poisoning are sleep, deepening into coma, a rapid feeble pulse, slow breathing, followed by rapid shallow breathing, contracted pupils, followed by dilated pupils, muscular relax- ation, and collapse. Death usually results from respiratory paralysis. Treatment of Poisoning-. — The temperature must be maintained by external heat. Brunton and Strieker found that an animal would stand a very much larger dose of chloral when the body-temperature was kept up artificially than when it was allowed to fall. The patient should be aroused by friction, flagellation, douches, etc., but should not be shaken or forcibly made to walk, as in opium-poisoning, on account of the danger of heart-failure. Cardiac and respira- tory stimulants like strychnin, atropin, ammonia, and digitalis should be given freely. Artificial respiration should be re- sorted to early, before the development of asphyxia. CHLORAL. IO3 Chronic Poisoning" (Chloralism). — The chief symptoms of chronic chloral-poisoning- are nervousness, dyspnea, palpita- tion, insomnia, mental impairment, and a group of phenomena apparently due to vasomotor disturbance, such as temporary lividity, erythematous rashes, ecchymoses, and edema. Therapeutics. — Chloral is used chiefly to induce sleep and to allay spasm. Somnifacient. — It is a valuable somnifacient, inducing quiet and refreshing sleep. It is especially indicated for occa- sional use in the insomnia of overwork, excitement, sthenic fevers, delirium tremens, mania, and chronic nephritis. In sleeplessness resulting from pain it is much inferior to opium. In persistent insomnia it should be avoided, owing to the dan- ger of habituation. Antispasmodic. — It may be employed with advantage to arrest uremic and puerperal convulsions. In conjunction with the bromid of potassium it is perhaps the best sedative we possess in the convulsions of tetanus and strychnin-poisoning. In grave cases of epilepsy, in whooping-cough attended with violent paroxysms, and in chorea insaniens chloral is often useful, but in the milder manifestations of these diseases it should not be selected, on account of the depressing effect which follows its continued use. When equal parts of chloral and camphor are rubbed together a clear syrupy liquid is formed, which is termed chloral camphor. It is used as a local anesthetic in neuralgia and toothache. In the form of an ointment, 30-60 gr. to the ounce (2.0-4.0 gm. to 30.0 gm.), it is useful in pruritus. Contraindications. — Marked cardiac and respiratory weakness are contraindications to the use of chloral. In the chronic neuroses it must be given with considerable caution, on account of the danger of inducing the chloral habit Administration. — It is best given dissolved in some agreeable vehicle, as in the following formula : R Chlorali hydrati, gr. lxxx (5.2 gm.) ; Tincturse aurantii dulcis, fzss (2.0 c.c.) ; Syrupi aurantii, f:fj (30.0 c.c.) ; Aquae, q. s. f^ij (60.0 c.c). — M. Sig. A tablespoonful at bedtime. [Insomnia.) Morphin and the bromids may be given with chloral to enhance its effect : Ijt Chlorali hydrati, gr. xvj ( 1 .0 gm.) ; Sodii bromidi, gr. xl (2.5 gm.) ; Syrupi aurantii, ^3 v i ( 22 -5 c.c); Aquae, q. s. fglj (60.0 c.c). — M. Sig. A dessertspoonful every four hours for a child of three years. ( Whooping- cough.) 104 SOMNIFACIENTS. To lessen its irritant effect when given by the bowel, chloral should be mixed with some demulcent, such as milk. Incompatibles. — Alkalies and strong solutions of anti- pyrin. BUTYL-CHLORAL HYDRAS. (Butyl-chloral Hydrate, Croton-chloral Hydrate, C^ClgO^O.) Butyl-chloral is an oily liquid formed by the action of chlorin on acetic aldehyd. It is converted into the solid butyl-chloral hydrate by the addition of water. Butyl-chloral hydrate occurs in the form of white pearly scales having a pungent odor and an acid, disagreeable taste. It is sparingly soluble in water, but freely so in glycerin and alcohol. The dose is from 5-20 gr. (0.3-1.3 gm.). Therapeutics. — The action of butyl-chloral hydrate is much the same as that of chloral hydrate, except that it is less powerful and more irritant to the stomach. It is generally supposed that the fifth nerve is especially sensitive to its seda- tive influence, and therefore it has been extensively employed in the treatment of trifacial neuralgia and migraine. On account of its nauseous taste, it is best given in capsules or in pills or dissolved in some aromatic mixture. Solutions should be freshly made when wanted, as the drug gradually decomposes when dissolved. It is incompatible with alkalies. CHLORALFORMAMIDUM, U. S. P. (Chloralformamid, Chloral amid, CCl 2 CH(OH).CONH 2 .) Chloralformamid, or chloralamid, is a synthetic compound formed by the union of chloral with formamid. It occurs in the form of colorless crystals, having a bitter taste, and soluble in 18 parts of water and \\ parts of alcohol. The dose is from 10-30 gr. (0.65-2.0 gm.). Physiologic Action. — The dominant action of chloral- formamid is upon the cerebrum, which it depresses, causing profound sleep. Unlike chloral, it has little effect on the cir- culation, and is only a feeble depressant to the spinal cord. The experiments of Wood and Cerna indicate that it rather stimulates than depresses the respiratory center. It is slowly broken up in the organism into chloral and formamid, the latter, owing to its stimulant properties, counteracting to some extent the depressant action of chloral on the circulation. It is excreted as urochloralic acid. Therapeutics. — Chloralformamid is a pure hypnotic, less depressing and less irritating to the stomach than chloral, but at the same time less powerful and less prompt in its action. CHLORAL. I05 It is not so slow in its action as sulphonal, and it is less liable than that drug to cause languor and drowsiness next day. Headache, giddiness, exhilaration, nausea, and inco-ordination are occasionally observed after its use. It has no cumulative effect, and patients do not readily become addicted to its use. It is an excellent somnifacient in chronic heart, lung, and kidney disease, in hysteria, neurasthenia, delirium tremens, senility, and acute fevers. When wakefulness is due to pain, opium is a better remedy, although chloralformamid seems to possess some analgesic properties. It has been highly recommended as a sedative in cardiac asthma, and, in combination with potas- sium bromid, as a superior remedy in seasickness. Administration. — Chloralformamid should be given about half an hour before bedtime. On account of its bitter taste and imperfect solubility it is better not to prescribe it in the form of powders. It may be conveniently given in some aromatic aqueous vehicle, to which a little alcohol or weak acid has been added to facilitate solution. It is decomposed by hot water. R Chloralformamidi, gr. lxxx (5.2 gm.) ; Elixiris aromatici, f^j (30.0 c.c.) ; Aquse, q. s. ad fgij (60.0 c.c). — M. Sig. A tablespoonful in water half an hour before bedtime. Incompatibles. — Alkalies convert it into chloral. CHLORALOSE. (Anhydroglucochloral, CgH^ClgOg.) Chloralose is a compound prepared by subjecting a mixture of equal parts of anhydrous chloral and glucose to a tem- perature of 212 F. for one hour. It appears in the form of fine colorless crystals having a bitter, disagreeable taste. It is freely soluble in hot water and in alcohol, and slightly so in cold water. The dose is from 5-8 gr. (0.32-0.5 gm.). Physiologic Action. — Chloralose, like chloral, induces sleep by directly depressing the brain. During sleep the reflex excitability is not diminished, but rather exaggerated, indicating that in ordinary doses the drug does not depress the spinal cord. Its somnifacient effect cannot be due to chloral set free in the alimentary canal, since chloralose is active in less than half the dose of the older hypnotic. It has little effect on the sensory nervous system, and is, therefore, only a feeble analgesic. Small doses do not generally affect the circulation, but large doses depress the heart. 1 06 SOMNIFA CIEXTS. The great drawback to the general use of chloralose is the irregularity of its action: it often acts very promptly, inducing a refreshing sleep, lasting from six to eight hours, but not infrequently alarming symptoms follow its exhibition, even in small doses. The untoward effects are retardation of the pulse, dilatation of the pupils, deafness, tremors, extreme prostration, cyanosis, incoherent speech, convulsive seizures, nausea, profuse sweating, and incontinence of urine and feces. In neurotic subjects it may induce delirious excitement instead of sleep. Therapeutics. — Chloralose has been used with some suc- cess in functional insomnia. Tyson has found it effective in the sleeplessness of chronic heart-disease and Bright s disi Balfour also speaks favorably of its action in the insomnia associated with heart-disease. The drug should be avoided when there is great debility-. Administration. — Chloralose is best administered in cachets or capsules, followed by a draught of hot milk or tea. CHLORETONE. (Aneson, Trichlortertiary Butyl Alcohol, CCl 3 C(CH 3 ) 2 OH. ..loretone is a compound formed by the addition of caustic potash to equal weights of chloroform and acetone. It is a white crystalline powder, with a camphoraceous odor and taste. It is sparingly soluble in cold water, but freely so in ether and strong alcohol. The dose is from 5-20 gr. (0.3-1.3 g: Physiologic Action. — Chloretone has two important actions: it is a somr j a local anesthetic. In ani- mals large doses reduce the temperature and also lower the blood-pressure, probably by depressing the heart and the vaso- motor center. Impens considers the drug to be more toxic n chloral. It probably undergoes decomposition in the body, since after its ingestion neither chloretone itself nor its components (chloroform and acetone | are found in the urine. It has pronounced germicidal properties. Therapeutics. — Chloretone may be regarded as a reason- ably onotic of moderate power. It is prompt in its action, sleep usually following in from half an hour to an hour after its administration. Beyond causing slight drowsi- ness on the day following its exhibition, it rarely gives rise to unpleasant after-effects. Toleration of the drug is rather rapidly acquired by continuous use. It is especially adapted for use in cases of insomnia unattended with severe pain, iiigh -. ox pronounced nervous excitement. It has been used with some success as a sedative in sea-sickness and noctu epsy. Sl'LPHOXAL. 107 As a local anesthetic and antiseptic it has proved service- able in minor surgery. It may be applied in the form of a dusting-powder to wounds y burns, and painful ulcers. hloietone (5 per cent, serves as a preservative of solutions of organic compounds (adrenalin, homatropin). Administration. — It may be given in tablets, cachets, or powders, followed by a draught of water. SULPHONMETHANUM. U. 3. P. (Sulphonmethan, Sulphonal, (CH 3 ) 2 C(S0 2 C 2 H 3 ) 2 .) Sulphonal is a synthetic compound obtained by oxidizing a mixture of ethyl hydrosulphid and acetone. It occurs as a colorless, crystalline powder, free from odor and taste. It is soluble in 360 parts of cold water, 1 5 parts of boiling water, and 47 parts of alcohol. The dose is from 15-30 gr. (1.0- 2.0 gi Physiologic Action. — In moderate doses sulphonal is a pure hypnotic, inducing sleep by a direct action on the cere- brum. Owing to its insolubility- in gastric juice it is very slowly absorbed from the stomach, and when given in the form of a powder its soporific effect may not be manifest for several hours or, after a late dose, not until the following day. In ordinary amounts it does not influence the circulation or respiration, and rarely the digestion. Drowsiness, headache, vertigo, mental confusion, and cutaneous rashes are sometimes noted after its use. When exhibited in single doses, or in short courses not exceeding a week or two, sulphonal may be regarded as a safe hypnotic, rarely producing unpleasant symp- toms. It has no analgesic properties. Toxicology. — Acute sulphonal-poisoning does not com- monly prove fatal, probably because much of the drug escar es from the stomach before absorbtion takes place. r re- | : r:5 the case of a person who took a tablespoonful of drug, and slept in consequence four days and nights, and then rapidly convalesced ; and another patient, aged fifteen ye who took nearly 3 ounces and was unconscious for five c rec ivering entirely in eight c. : Death, he wever, has followed the ingestion of comparatively small amounts. Murrell has cited two instances of death from 30 and 40 grains respectively. The symptoms of acute poisoning are headache, vertigo, tinnitus aurium, marked cyanosis, vomiting, diarrhea, shallow breathing, feeble pulse, dilated pupils, unconsciousness, and collapse. The treatment consists in administering saline ca- Ib8 SOMNIFACIENTS. thartics and quickly acting stimulants (strychnin, ammonia), and in maintaining the body-temperature. Chronic sulphonal-poisoning has frequently followed the continuous use of the drug for weeks or months. Seven- teen out of 20 cases collected by H. C. Wood, Jr., terminated fatally. Probably from the gradual accumulation of the drug in the body the symptoms often appear abruptly, sometimes even after the habit has been suspended for several days. The chief phenomena of chronic poisoning are a peculiar red coloration of the urine, languor, ataxia, progressive weakness, paralysis, paresthesia, nausea, vomiting, colicky pains, serous diarrhea or obstinate constipation, insomnia, and mental con- fusion. In unfavorable cases the urine becomes scanty and albuminous, and the exhaustion deepens into collapse. In a fatal case reported by Taylor and Sailer well-marked degen- erative changes were found in the liver, kidneys, and heart. The discoloration of the urine, which is of considerable diag- nostic import, is due to the presence of hematoporphyrin, a compound thought to be derived from hematin. The treatment of chronic poisoning consists in withdrawing the drug at once, and in freely administering alkaline carbon- ates (sodium carbonate) with saline cathartics. Hypodermo- clysis and enteroclysis are also recommended by Wood. Therapeutics. — It is an excellent hypnotic in the insomnia of nervous excitement, overwork, and mental disease. When sleeplessness is due to pain, it is ineffective. In chronic dis- ease of the heart, lungs, or kidneys, sulphonal is not, as a rule, to be chosen. Administration. — Sulphonal is best administered in some hot liquid, and, as its action is slow, it is well to give it an hour or two before bedtime. Compressed tablets should be avoided. On account of its tendency to accumulate in the body, it should not be given continuously for more than a week. Even after its exhibition for several successive days, it is advisable to order a saline cathartic for the purpose of removing from the bowel any portion of the drug remaining unabsorbed. SULPHONETHYLMETHANUM, U. S. P. (Sulphonethylmethan, Trional, (C 2 H 5 .CH 3 .C(S0 2 C 2 H 6 ) 2 .) Trional, like sulphonal, belongs to the group of " sul- phones," i. e., combinations of So 2 with organic radicles. Sul- phonal, trional, and tetronal contain respectively two, three, and four molecules of ethyl. It occurs in the form of color- less, flat crystals, free from odor, and almost tasteless. It is PARALDEHYDUM. IO9 soluble in 195 parts of cold water, and freely soluble in hot water, ether, and alcohol. The dose is from 15-30 gr. (1.0- 2.0 gm.). Physiologic Action and Therapeutics. — The action of trional is almost identical with that of sulphonal. Owing to its greater solubility, however, it is more prompt in its effect, and has less tendency to accumulate in the body. When not used too continuously, it is a safe and reliable hypnotic, suit- able for the same class of cases in which sulphonal is most effective. It is best given in some warm vehicle — milk, tea, or whisky — an hour or two before retiring. Occasionally it gives rise to headache, drowsiness, and nausea on the day following its administration. When used continuously for several weeks, it causes the following toxic symptoms : head- ache, vertigo, impairment of memory, disordered speech, tremors, nausea, constipation or diarrhea, colicky pains, hema- toporphyrinuria, oliguria, and even strangury. These symp- toms, however, do not, as a rule, develop so abruptly as they do after the prolonged use of sulphonal. The treatment does not differ from that of sulphonal-poisoning. TETRONAL. ((C 2 H 5 ) 2 .C.(S0 2 C 2 H 5 ) 2 .) Tetronal is an analogue of trional and sulphonal, containing four ethyl groups. It is used in the same doses and for the same purposes as trional. It has no advantages over the latter; on the contrary, it is less soluble and much more costly. PARALDEHYDUM, U. S. P. (Paraldehyd, C 6 H 12 3 .) Paraldehyd is a product obtained by treating aldehyd with dilute sulphuric or nitric acid. It appears as a colorless liquid, having a strong ethereal odor and a disagreeable, pun- gent taste. It is soluble in 8.5 parts of water, and is miscible in all proportions with alcohol, ether, chloroform, and oils. The dose is |— 1 fl. dr. (2.0-4.0 c.c). Physiologic Action. — The action of paraldehyd some- what resembles that of chloral. Like the latter, it depresses the brain and spinal cord. Although it causes a sensible fall in the arterial pressure, it is not so depressing to the heart itself as chloral. Large doses are prone to disturb the stomach. It is eliminated by the lungs and kidneys. Toxic doses produce coma, feeble breathing, great muscular relaxation, abolition of 1 1 SOMNIFA C 'IE NTS. reflex activity, and, finally, death from paralysis of the respira- tory center. Its long-continued use is sometimes followed by cutaneous eruptions. It has no analgesic properties. Therapeutics.— Paraldehyd is a safe and reliable hyp- notic. The great drawbacks to its use are its unpleasant taste and the disagreeable odor which it imparts to the breath for twenty-four hours after its ingestion. Toleration is some- what rapidly acquired. It may be employed with advantage in the insomnia of mania, delirium tremens, hysteria, and heart- disease. It is sometimes efficient as an antispasmodic in asthma. It has also been used with some success in control- ling the convulsions of tetanus. Administration. — It may be prescribed in capsules or in some aromatic vehicle. A few drops of alcohol render it freely miscible with water. The dose should be well diluted. R Paraldehyde Glycerin i, Spiritus aurantii compositi, aa f^iv ; Aquse, q. s. ad f^ij. — M. Sig. A dessertspoonful in water, repeated in an hour if necessary. iETHYLIS CARBAMAS, U. S. P. (Ethyl Carbamate, Urethane, NH 2 .CO.OC 2 H 5 .) Ethyl carbamate, or urethane, is made by the interaction of ethyl alcohol and nitrate of urea. It occurs as colorless tabular crystals, odorless, and having a cooling saline taste. It is readily soluble in water, alcohol, ether, and chloroform. The dose is from 15-45 gr. (1.0-3.0 gm.). Physiologic Action and Therapeutics. — Urethane is a comparatively safe hypnotic, without influence in ordinary doses upon the respiration and circulation, but mild and some- what uncertain in action. It has no analgesic effect. Toxic doses are followed by coma, a fall of temperature, weakness of the pulse, abolition of reflex activity, and death from respi- ratory paralysis. It is excreted as urea. It may be successfully employed in insomnia from nervous excitement or insanity. It is not without value as an anticonvulsant. Dana and Jacobi have spoken very favorably of its action in some cases of epilepsy. Urethane is incompatible with acids and alkalies. Rubbed with chloretone it produces a liquid compound. POTASSII BROMIDUM. Ill HEDONAL. (Methylpropylcarbinolurethane, C 6 H 13 2 N.) Hedonal is a synthetic compound closely allied to urethane. It occurs as a white crystalline powder, of a menthol-like taste, almost insoluble in water, but soluble in alcohol and ether. As a somnifacient it is more prompt and effective than urethane, but distinctly less powerful than chloral, trional, or sulphonal. It usually produces, within from J to I hour, quiet sleep, lasting from 4 to 8 hours, without unpleasant after-effects. It is an agreeable and safe somnifacient, only suitable, however, for very mild forms of insomnia, unaccom- panied by pain or excitement. It is most effective in doses of from 20-30 gr. (1.3-2.0 gm.), in dry powder or in capsules. VERONAL. ( Diethylmalonylurea, Diethylbarbituric acid, C 8 H, 2 N 2 3 .) Like urethane and hedonal, veronal also belongs to the urea group of somnifacients. It is a white crystalline powder, of a faintly bitter taste, soluble in 145 parts of cold water and in 1 2 parts of boiling water. It appears to be a comparatively safe, prompt, and reliable somnifacient, producing, in from \ to 1 hour a quiet sleep, lasting from 5 to 10 hours. Occa- sionally, its use is followed by lassitude, dulness, and anorexia. In a few cases toxic symptoms, such as somnolence, dryness of the throat, elevation of temperature, an erythematous rash, and prostration, have resulted from the repeated administration of the drug. It may be employed with advantage in cases of simple insomnia, unaccompanied by pain or marked excitement. The dose is from 8-15 gr. (0.5-1.0 gm.). It is best given in hot tea or milk, or in capsules followed by some warm liquid. POTASSII BROMIDUM, U. S. P. (Potassium Bromid, KBr.) Potassium bromid occurs in colorless or white cubical crystals, odorless, and having a pungent saline taste. It is soluble in 1.6 parts of water and in 200 parts of alcohol. The dose is from 10-60 gr. (0.65-4 gm.). Physiologic Action. — Circulatory System. — Small doses have no influence, but large doses, owing to the presence of the potassium base, exert a depressant action on the heart. Nervous System. — The bromid ion, irrespective of the base with which it is combined, depresses the entire central nervous system — cerebrum, spinal cord, and medulla — psychic, motor, 1 1 2 SOMNIFA C IE NTS. and sensory functions all being involved. By depressing the psychic centers it causes apathy, lapse of memory, and con- fusion of thought ; by depressing the motor area of the brain it lessens the power of irritants to excite epileptiform convul- sions ; and by depressing the spinal cord and medulla it diminishes reflex activity, blunts the sensibility of the mucous membranes, and impairs muscular coordination. Large doses of a bromid promote sleep by lessening the sensitiveness of the cerebrum to all centripetal stimuli. They also reduce or abolish sexual feeling by a similar central action. Wright and Crisafulli have found after poisonous doses marked degenerative changes (vacuolation and atrophy) of the cortical nerve-cells. Respiratory System. — The respiratory centers share with other parts of the nervous system in the depression caused by large doses of bromids, and in fatal poisoning respiration may fail before the heart ceases to beat. Alimentary Canal. — In concentrated form potassium bro- mid acts as an irritant to the stomach, and may occasion nausea and vomiting. Absorption and Elimination. — Potassium bromid is rapidly absorbed, and may appear unchanged in the urine within fifteen minutes after its ingestion. Elimination is not effected as rapidly as absorption, hence there is a tendency for the drug to accumulate in the body. Small quantities of bromid are also excreted by the skin, respiratory tract, and bowel. Bromism. — The continuous use of bromids is usually fol- lowed by a group of symptoms to which the term bromism has been applied. This condition is characterized by anemia, a general eruption of acne, fetor of the breath, gastric disturb- ance, mental depression, somnolence, failure of memory, aboli- tion of the sexual appetite, diminution of the reflexes, impair- ment of tactile sensibility, unsteady gait, and muscular weakness. Exceptional Effects of Bromids. — The continued exhi- bition of bromids in large doses is occasionally followed by one of the following symptoms : Paresis of the limbs, ptosis, depression of the heart, intense irritability of temper, depres- sion of spirits, and suicidal or homicidal impulses. Acute Poisoning". — The chief symptoms resulting from the ingestion of a single toxic dose of potassium bromid are severe headache, inco-ordination, somnolence, dilatation of the pupils, burning in the stomach, and collapse. No fatal case of bromid-poisoning has been reported. Action of Potassium Bromid Compared with Other Bromids. — On account of the relatively large amount of po- POTASS II BROMIDUM. 1 1 3 tassium (44 per cent.), this salt is the most powerful depressant of all the bromids. Therapeutics. — Potassium bromid is used to control con- vulsions, to allay nervous excitement, to promote sleep, and to relieve certain forms of headache and neuralgia. To Control Convulsions. — The bromids are by far the most useful drugs we possess in the treatment of epilepsy. They not only exert a direct sedative influence on the cerebral cortex, but through their action on the sensory neurons of the spinal cord they protect the brain from the disturbing influ- ence of external stimuli. While they rarely effect a cure, they very often lessen materially the frequency of the paroxysms. The amount required varies with the severity of the case and the susceptibility of the individual, and must be deter- mined experimentally in each case. Saturation is indicated by a loss of the palatal reflex, mental hebetude, and gastric disturbance. The daily dose usually ranges between 1 and 2 dr. (4.0-8 o gm.). When larger doses than these are required, it is better to try a combination of other remedies with the bromid than to depend upon the latter alone. Sometimes small doses of potassium iodid, or moderate doses of antipyrin or acetanilid, will serve to lessen the amount of bromid re- quired. A combination of several bromids often acts more satis- factorily than a single bromid. In nocturnal epilepsy the occa- sional exhibition of chloretone or sulphonal with the bromid often proves very efficacious. When the circulation is weak a combination of a bromid with digitalis or of adonis venalis, as recommended by Bechterew, will be found useful. It has been shown by Richet and Toulouse that the deprivation of salt from food very decidedly increases the efficacy of the bromid treatment. The addition of a drop or two of Fowler's solution to each dose of the bromid often prevents the out- break of acne. In some cases of epilepsy it is necessary to withhold the bromids entirely, since the general disturbance which they occasion more than counterbalances the good they accom- plish in diminishing the number of seizures. The bromids are of considerable value also in other con- vulsive disorders besides epilepsy, such as puerperal eclampsia, uremia, infantile convulsions, strychnin-poisoning, and tetanus. In severe cases of chorea with incessant movements the bromids may be employed, but they are less efficient than chloral. In local spasmodic affections — whooping-cough, laryngismus st?id- ulus, and essential asthma — bromids are sometimes of service. To Allay Nervous Excitement. — In nervous irritability of all kinds potassium bromid is useful. It is an excellent seda- 1 14 SOMNIFACIENTS. tive in the excitement of overwork, worry \ and anxiety, and also in that which attends hysteria. In the varied nervous disturbances which attend the menopause it is our most reliable remedy. In fully developed delirium tremens it is of little value, but in the stage of excitement which precedes the latter it is very efficient. Potassium bromid is a powerful anaphrodisiac ; by dimin- ishing the irritability of the sexual centers in the spinal cord it renders excellent service in priapism, spermatorrhea, and nymphomania. Given for several days before the expected voyage, in doses of from 10-20 gr. (0.65-1.3 gm.), three times a day, it often prevents sea-sickness. It may also be tried in the vomiting of pregnancy. Da Costa found that from 30-60 gr. (2.0-4.0 gm.) of potassium bromid, administered an hour before a dose of opium, would prevent the disagreeable after-effects of the latter. To Promote Sleep. — As pure hypnotics the bromids are feeble compared with opium and chloral, but in insomnia due to nervous excitement they frequently produce refreshing sleep. To Relieve Headache and Neuralgia. — Potassium bromid is often useful in attacks of migraine, trifacial neuralgia, and the headache of cerebral congestion. In these affections it may be given alone or in combination with antipyrin, phenacetin, caffein, or a salicylic compound. Administration. — Potassium bromid should be given in solution, well diluted, after meals. In epilepsy it is best to divide the daily dose according to the time at which the seiz- ures are likely to occur. Thus in nocturnal epilepsy compara- tively small doses may be given early in the day, and a very large dose (J— I dr. — 2.0-4.0 gm.) at supper-time. The bromid may be combined with antipyrin and Fowler's solution, as in the following formula suggested by Wood : R Potassii bromidi, Ammonii bromidi, aa sjiij (12.0 gm.) ; Liquoris potassii arsenitis, f^j (4.0 c.c.) ; Antipyrinae, %] (4.0 gm.) ; Aquae menthae piperitae, q. s. ad f^vj (180.0 c.c). — M. Sig. Tablespoonful in water night and morning. In insomnia from nervous excitement potassium bromid may be combined with chloral, as in the following formula : R Chlorali hydrati, gr. xl (2.6 gm.) ; Potassii bromidi, ^iss (6.0 gm.) ; Aquae et syrupi aurantii, aaq.s. ad f^ij (60.0 c.c). — M. Sig. Tablespoonful in water at bedtime. P OTA SSI I BROMIDUM. I.15 Incompatibles. — Potassium bromid is incompatible with acids and acid salts. It also precipitates certain alkaloids — morphin, quinin, and strychnin — from neutral solutions. AMMONII BROMIDUM, U. S. P. (Ammonium Bromid, NH 4 Br.) Bromid of ammonium occurs in the form of white crystals or as a yellowish-white powder having a disagreeable salty taste. It dissolves in 1.2 parts of water and in 12.5 of alcohol. Its dose is from 20-60 gr. (1.3-4.0 gm.), well diluted. Physiologic Action. — The dominant action of ammonium bromid, like the corresponding potassium salt, is on the nervous system. It depresses the cortical brain-cells, and both the sen- sory and motor neurons of the spinal cord, especially the for- mer. It differs in its action from potassium bromid in being less depressing to the heart, muscles, and peripheral nerves. Therapeutics. — It may be substituted with advantage for the potassium salt in all the conditions in which a bromid is indicated. Incompatibles. — The same as in the case of potassium bromid, and, in addition, spirit of nitrous ether. SODII BROMIDUM, U. S. P. (Sodium Bromid, NaBr.) Sodium bromid occurs in colorless or white cubical crystals, or as a white granular powder, odorless, and of a saline, bitter taste. It is soluble in 1.7 parts of water and in 12.5 of alcohol. It contains 78 per cent, of bromin. The dose is from 20-60 gr. (1.3-4.0 gm.), well diluted. Physiologic Action and Therapeutics. — Its action closely resembles that of potassium bromid, but it is less irritating to the stomach and somewhat less depressing. It may be used as a substitute for the potassium salt in the vari- ous conditions in which a bromid is indicated. STRONTII BROMIDUM, U. S. P. (Strontium Bromid, SrBr 2 .6H 2 0.) Strontium bromid occurs in colorless, very deliquescent, hexagonal crystals, odorless, and of a bitter, saline taste. It is readily soluble in water and in alcohol. The dose is from 30-60 gr. (2.0-4.0 gm.). Therapeutics. — Strontium bromid has an action on the nervous system similar to that of the other bromids, but it is Il6 SOMNIFACIENTS. less powerful. At the same time it is less depressing - , less prone to cause acne, and, instead of disturbing the stomach, it tends rather to allay gastric irritation. It may be used as a succedaneum for other bromids when only a mild effect is required or when there is irritability of the stomach. In other cases it may be combined with potassium or ammonium bromid to mitigate their unpleasant by-effects. Germain See and others have spoken favorably of its action in gaslralgia and acid dyspepsia. LITHII BROMIDUM, U. S. P. (Lithium Bromid, LiBr.) Lithium bromid is a white, granular, deliquescent salt, odor- less, of a sharp, bitter taste. It is freely soluble in water and in alcohol. The dose is from 20-60 gr. (1.3-4.0 gm.). Therapeutics. — Lithium bromid has a therapeutic value about equal to that of sodium bromid. ACIDUM HYDROBROMICUM DILUTUM, U. S. P. (Diluted Hydrobromic Acid, HBr.) Diluted hydrobromic acid is an odorless, colorless liquid, of acid properties, composed of 10 per cent, by weight of abso- lute hydrobromic acid and 90 per cent, of water. The dose is from 1-4 fl. dr. (4.0-15.0 c.c), well diluted. Therapeutics. — Hydrobromic acid has very much the same action as the bromids. It differs from potassium bromid in being less powerful, less likely to cause acne and general depression, and in being more irritating to the stomach. It may be given alone or in combination with bromids in epilepsy and other convulsive disorders. It is especially valu- able in tinnitus aurium resulting from aural disease or following the administration of quinin or salicylic compounds. It has been employed as a sedative in febrile excitement, whooping- cough, and nervous headache. The following combination of dilute hydrobromic acid and horse-nettle is sometimes effica- cious in the milder forms of epilepsy : I£ Acidi hydrobromici diluti, Fluidextracti solani carolinensis aa f§iss (45.0 c.c.) ; Syrupi aurantii, ffj (30.0 c.c.) ; Aquae, q. s. ad fijvj (180.0 c.c). — M. Sig. A tablespoonful in water after meals. BROMOFORM, U. S. P. (Bromoform; Tribrommethane, CHB 3 .) Bromoform is made by the action of hypobromite of sodium on acetone, or of bromine on a mixture of methyl alcohol and BROMOFORM. 1 1 J milk of lime. It appears as a clear, colorless liquid having a pleasant odor and a sweetish taste. It is sparingly soluble in water, but freely so in alcohol and glycerin. The dose is from 1-6 min. (0.06-0.4 c.c). To be fit for use it should be free from color and acidity. Therapeutics. — Bromoform has anesthetic properties iomewhat analogous to those of chloroform, but as a thera- peutic agent it is of interest chiefly as an internal remedy in zv hooping-cough. While it has a definite value in lessening the severity of the paroxysms, it has no power to shorten the duration of the disease. Toxicology. — Many cases of poisoning by bromoform have been reported since its first introduction as a remedy for whooping-cough. Very often the accident has resulted from a lack of familiarity with the physical properties of the drug. As bromoform is heavier than mucilage, its suspension in the latter can only be temporary ; it naturally tends to fall to the bottom of the bottle, and unless this is prevented by frequent and thorough shaking, a much larger dose may be taken on emptying the bottle than w T as intended. The chief phenomenon of bromoform-poisoning is a kind of intoxication, followed by coma, marked cyanosis, difficult breathing, a rapid, feeble pulse, muscular relaxation, and collapse. In some cases the coma has been interrupted by general convulsions. Death usually results from asphyxia. Treatment consists in the evacuation of the stomach, the practice of artificial respiration, and the administration of cardiac and respiratory stimulants. Administration. — It may be administered by simply dropping it on sugar or into a little peppermint-water. On account of its high specific gravity a minim is equal to about 6 drops. If suspended in mucilaginous liquids, the bottle must be well shaken before each administration. As it is soluble in alcohol and glycerin, a mixture of these liquids may be made the vehicle, as in the following formula: R Bromoformi, tT[xx-xxx (1.2-1.8 c.c.) ; Alcoholis, f^ij (8.0 c.c.) ; Spiritus menthse piperitse, tTi xx ( I -3 c.c). ; Glycerini, fgij (60.0 c.c). — M. Sig. — A teaspoonful four times a day for a child of two years. HYOSCIN^ HYDROBROMIDUM, U. S. P. (Hyoscin Hydrobromid. ) Hyoscin (see p. 83) is a useful somnifacient when sleepless- ness is attended by great mental and motor excitement. Thus Il8 GENERAL ANESTHETICS. it often acts favorably in mania, melancholia agitata, delirium tremens, and chorea insaniens. In chronic heart disease, while it is sometimes efficacious, it is not so generally useful as mor- phin. The dose is from T | 7 \ gr. (0.0004-0.0008 gm.). GENERAL ANESTHETICS. General anesthetics are volatile drugs which when absorbed by the lungs induce unconsciousness and insensibility. They are employed to abolish or lessen pain and to relax spasm. They are used for both of these purposes in surgical opera- tions, in labor, and in biliary and renal colic. They are of service in subduing the convulsive seizures of tetanus, strych- nin-poisoning, and uremia. By suspending muscular irritabil- ity they also render valuable aid in the reduction of luxations, fractures, and strangulated hernias, and in the recognition of deep-seated abdominal lesions. The most important general anesthetics are: Ether. Nitrous oxid. Chloroform. Ethyl bromid. Ethy 1 chlorid. ^THER, U. S. P. (Ether, Ethyl Oxid, C 4 H, O.) Ether is obtained by the action of sulphuric acid on alcohol, and appears as a colorless, volatile, highly inflammable liquid, having a strong characteristic odor. It is soluble in alcohol, chloroform, oils, and water. The official preparation contains about 4 per cent, of alcohol. Preparations. Dosy. Spiritus Athens, U. S. P. ...... . 1-3 fl. dr. (3.5-1 1.0 c.c). Spiritus yEtheris Compositus, U. S. P. . . . \-\ fl. dr. (2.0-3.5 c - c -)- Physiologic Action. — When freely inhaled ether first causes coughing, choking, and a sense of strangulation from its irritant effect on the mucous membrane of the respiratory tract. Soon it induces flushing of the face, injection of the eyes, dilatation of the pupils, irregularity in breathing, and an increase in the rate and strength of the pulse. Frequently marked emotional excitement develops, characterized by shout- ing, crying, laughing, or violent struggling. These phenomena gradually subside, and are followed by complete unconscious- ness, muscular relaxation, moderate contraction of the pupils, jEther. 119 abolition of the reflexes, slight cyanosis, regular but shallow breathing, a decrease in the rate and strength of the pulse, and some lowering of the body temperature. If the anesthetic be pushed still further, the face becomes pale or deeply cyanosed, the pulse grows feeble, the respirations become slow and very shallow, the sphincters relax, the pupils dilate, and finally death ensues, usually from failure of respiration. Circulatory System. — The increase in the rate and strength of the pulse observed at the beginning of anesthesia is due in part to general excitement and partly to reflex stimu- lation of the heart from irritation of the air passages. Hypo- dermic injections of ether, as of alcohol, may also cause transient stimulation of the heart by inducing local irritation. The drug probably never directly stimulates the heart. In advanced anesthesia the blood-pressure falls, owing to depres- sion of the heart and vasomotor center. Respiratory System. — The irregular breathing often noted at the commencement of anesthesia is due partly to excitement and partly to irritation of the nasal mucous membrane. The failure of respiration occurring from overdoses of ether is the result of direct depression of the respiratory center, though in the majority of cases low blood-pressure in the medulla is an important contributing factor. Unless the cardiac weakness is too pronounced, respiratory failure can nearly always be over- come by artificial respiration. It should be borne in mind that the ill effects of ether on both the respiration and circulation are much more closely related to the degree of concentration in which it is administered than to the actual amount of it inhaled. Nervous System. — Ether directly depresses the entire cen- tral nervous system, the cerebrum being first affected, then the spinal cord, and last of all the medulla. The sensory neurons are probably acted upon before the motor. From 5 to 6 per cent, of ether must be present in the inspired air to produce complete anesthesia in human beings. Pupils. — The pupils are dilated at first as the result of excitement. During the period of anesthesia they are con- tracted as in sleep. Dilatation again occurs when conscious- ness is returning or when death is imminent from bulbar paralysis. Temperature. — Etherization always lowers the body tem- perature and, therefore, it is important that the operating room should be well heated and the patient should be guarded against exposure. The fall of temperature is due partly to increased loss of heat from dilatation of the cutaneous vessels. 120 GENERAL ANESTHETICS. and partly to decreased production of heat from the absence of muscular movements. Blood. — The studies of Da Costa and Kalteyer and others indicate that anesthetics increase hemolysis, and thus reduce the percentage of hemoglobin. A slight polycythemia, how- ever, is often observed at the close of anesthesia, probably from concentration of the blood. Local Action. — When applied to the skin, ether evaporates quickly, produces intense cold, and thus benumbs the periph- eral nerves. Local irritation, sometimes sufficient to cause inflammation and even vesication, may follow if the evapora- tion is prevented. Inhaled, it causes considerable irritation of the mucous membrane of the respiratory tract, and thus leads to a profuse secretion of saliva and mucus. During anesthesia a certain amount of ether is swallowed with the mucus and causes nausea and vomiting. Elimination. — Ether leaves the body mainly by the lungs, though a small amount is excreted by the kidneys. On the latter the drug has a decidedly irritant effect, and, therefore, considerable caution must be exercised in its employment as a general anesthetic when there are evidences of serious nephri- tis. After prolonged anesthesia the urine may contain not only albumin and casts but also certain bodies the result of disturbed metabolism, such as glucose, acetone, and diacetic acid. Therapeutics. — Ether was first employed as an anesthetic in general surgery by William T. G. Morton, at the Massa- chusetts General Hospital in 1846; since that time it has been, in this country, the most extensively used anesthetic in all operations excepting the most trivial. The Administration of Ether as an Anesthetic. — When administered as an anesthetic the following precautions should be observed : No solid food should be taken for several hours before the operation. If there has been nausea or if the patient is very weak, a little brandy may be given prior to the anesthetic. When given to a female, a third person should always be present. Before its administration the teeth should be examined, and, if false, they should be removed. The throat and waist should be freed from tight clothing, but the patient should not be exposed, as inflammation of the lungs is liable to follow when this precaution is unheeded. The anesthetizer must guard against placing the head and arms of the patient in positions likely to cause pressure on nerve-trunks. The eyes should be covered with a pad of moistened gauze and the lips and nostrils anointed with petro- JZTHER. 121 latum to protect them from the irritant action of the ether. As the vapor of ether is highly inflammable, and since it is heavier than air, it is necessary when operating by gas-light to have the jet above the operator. In using the actual cautery special care is necessary to prevent ignition. No more ether should be used than is absolutely necessary to induce and maintain the desired degree of anesthesia. The anesthetizer should be continually on the lookout for any irregularities in the respira- tion or pulse and for changes in the facial appearance. Ether may be administered from a towel loosely folded in the form of a cone, surrounded by stiff paper, and enclosing at its tip a small sponge, or, better, from an open inhaler made especially for the purpose. At first the inhaler should be held some distance from the nose, to accustom the patient to the irritant effects of the ether, but soon it should be brought close to the nose, so that the anesthetic may be inhaled in a more concentrated form. Regular snoring respiration, muscu- lar relaxation, and insensibility of the conjunctivae are the indi- cations that the patient is prepared for the operation. Admin- istration by the " drop method " or " open method," which is now adopted in many hospitals, has much to recommend it. It consists in pouring ether, drop by drop, slowly but continuously upon several layers of gauze (six or eight), supported by a wire- framed mask. Complete narcosis is produced in from eight to ten minutes. With this method there is much less tendency to coughing, struggling, and retching, the secretion of mucus is not nearly so profuse, and the frequency of after-sickness is notably reduced. The quantity of ether required for an ordinary operation, lasting about an hour, is usually from 6 to 10 ounces (180- 300 c.c), more being necessary with the open method than the older one. Accidents During Anesthesia. — The most common accident during etherization is failure of respiration. When this occurs after the first few inhalations, it is generally the result of a reflex spasm of the laryngeal muscles excited by the ether. The admixture of a little more air with the vapor will serve to relax the spasm, when respiration will be resumed. Embarrassed respiration is often due to the accumulation of mucus in the upper air-passages or to the tongue falling back into the throat. In the event of the former accident the head should be turned to one side, when much of the fluid will run out or will collect in the dependent cheek, from which it may be removed by means of a sponge held by forceps. In the event of the latter accident, it will be necessary to press the 122 GENERAL ANESTHETICS. lower jaw forward and to draw the tongue outward with forceps or the fingers. Finally, respiratory failure may result from the direct action of the a?iesthetic on the respiratory center. Should such an accident occur, the method of treatment to pursue is as follows : Withdraw the ether ; lower the head and elevate the legs ; push the jaw forward and draw the tongue outward ; and practice artificial respiration, persisting in it, if necessary, for at least half an hour. If the pulse is also weak, atropin and strychnin should be given hypodermically, but not alcohol, as its action closely resembles that of ether. Sudden heart-failure is a much less common accident under ether than asphyxia. It calls for lowering of the head, hypo- dermic injections of strychnin, caffein, and atropin, rhythmic compression of the precordium, and artificial respiration. The last serves to remove the ether from the chest, favors the en- trance of fresh air, and stimulates the circulation. After-effects. — The most common after-effects are nausea and vomiting. The administration of oxygen with the anes- thetic will often prevent their occurrence. The inhalation of vinegar immediately after the withdrawal of the ether is also efficacious. Should the nausea persist, a hypodermic injection of morphin and the administration of cracked ice with a little brandy, or of bismuth subnitrate with cerium oxalate, will usually suffice to allay it. Pneumonia is an occasional sequel. It has been ascribed to exposure of the patient, to chilling of the lungs by the rapid evaporation of the anesthetic, to the irritant action of the ether, to the accumulation of secretion in the bronchi, and, finally, to the lowered vitality of the tissues induced by pro- longed etherization. Paralysis. — Central paralysis from hemorrhage or embolism is rare. Peripheral palsies are not infrequent, and are due to compression of nerve-trunks. The anesthetic contributes only indirectly to the latter by rendering the patient oblivious to pain. Contraindications. — The contraindications to the employ- ment of ether as an anesthetic are advanced arteriosclerosis, acute inflammatory infections of the respiratory tract, severe nephritis, especially when associated with cardiovascular lesions, and anemia when the hemoglobin is less than 30 per cent. The presence of valvular disease is not in itself a contraindication, provided compensation is well maintained. Diabetes, especially when well established and associated with acetonuria, should be considered a contraindication, since it has been shown that the anesthetic increases the acetone and renders the patient more liable to coma. CHL OR O FOR MUM. 1 2 3 Other Uses of Ether. — Ether may be employed in the form of a spray to induce local anesthesia preliminary to opening small abscesses or performing paracentesis. Administered hypodermically (15-30 min. — 1.0-2.0 c.c), it has long enjoyed a reputation as a diffusible stimulant in collapse resulting from poisoning, acute infections, and diseases of the heart itself. It has been used internally as an anthelmintic against tape- worms and as a carminative in various forms of colic. To allay its irritant effect on the fauces it is best given in capsules or in ice-water. CHLOROFORMUM, U. S. P. (Chloroform, Chloroformum Purificatum, CHC1 3 .) Chloroform is a heavy, colorless, non-inflammable liquid, obtained by the action of chlorin on alcohol. It is soluble in two hundred times its volume of water, and in all propor- tions in alcohol, oils, and ether. The dose is 5-30 min. (0.3- 2.0 c.c). Preparations. Dose. Aqua Chloroformi, U. S. P $-1 fl. oz. (15.0-30.0 c.c). Emulsum Chloroformi, U. S. P. (4 parts of chloroform in 100) ........ 1-4 fl. dr. (4.0-15.0 c.c. ). Linimentum Chloroformi, U. S. P., Spiritus Chloroformi, U. S. P 20-60 min. (1.0-4.0 c.c). Physiologic Action. — Chloroform has much the same action as ether. Like the latter, it produces, when freely in- haled, a set of phenomena which may be divided into three stages : The first stage is characterized by excitement, reflex effects (coughing, salivation, etc.), mydriasis, irregular breathing, acceleration of the pulse, loss of self-control, muscular rigidity, and imperfect consciousness ; the second, by complete uncon- sciousness, muscular relaxation, loss of reflexes, moderate con- traction of the pupils, regular shallow breathing, fall of blood- pressure, and fall of temperature ; and the third y by symptoms of cardiac and bulbar paralysis — pallor, dilatation of the pupils, feeble irregular breathing, extreme weakness of the pulse, and very low temperature. Circulatory System. — Anesthesia induced by chloroform is always accompanied by a distinct lowering of the blood- pressure. This effect is mainly due to depression of the heart muscle, but partly also to dilatation of the blood-vessels from depression of the vasomotor center. Death from chloroform may occur at the very beginning of the anesthesia from in- 124 GENERAL ANESTHETICS. tense reflex stimulation of the inhibitory cardiac center, aided, no doubt, by the weakening effect of the drug on the heart muscle itself. Such sudden arrest of the organ is more likely to occur when the vapor is administered in too concentrated form. Respiratory System. — In large amounts chloroform acts as a respiratory paralyzant. It depresses the respiratory center not only directly but also indirectly by lowering the blood- pressure in the medulla. Nervous System. — The action of chloroform on the central nervous system is marked by a progressive paralysis involving successively the cerebrum, the spinal cord, and the medulla. As in the case of ether, the sensory neurons appear to be affected before the motor. To produce complete anesthesia the inspired air must contain not less than 1.5 to 2 volumes per cent, of the vapor. Temperature. — In prolonged anesthesia there is a very pro- nounced fall in the body temperature, due in part to increased loss of heat from dilatation of the cutaneous vessels and in part to decreased production of heat from the absence of muscular movements. Nutrition. — Prolonged chloroform administration increases the output of nitrogen, phosphates, and sulphates in the urine, and produces fatty degeneration of the various organs, especially of the liver, heart, and kidneys. Degenerative changes in the cardiac ganglia have also been described. Alimentary Canal. — Taken internally in small quantities, chloroform produces a sense of warmth in the stomach, in- creases peristaltic movements, and aids in the expulsion of flatus. Local Action. — When applied to the skin, it evaporates rapidly and produces a sense of coldness. When evaporation is prevented, it causes redness of the surface and even vesication. Lower Organisms. — Even in dilute solution chloroform is destructive to many of the lower forms of animal and vegetable life. Cause of Death Under Chloroform. — When the vapor is administered in too concentrated form death may occur sud- denly at the very beginning of the anesthesia from reflex arrest of the heart. Even with comparatively dilute vapor death may occur late in the anesthesia from failure of the heart or failure of the respiration, largely aided by the marked fall of blood- pressure. Again, death may occur in from twelve hours to three or four days after the operation (delayed chloroform- poisoning) from a toxemia induced by degenerative changes in the liver. In some of these cases the symptoms closely re- CJIL OR O FOR MUM. 1 2 5 semble those of acute yellow atrophy of the liver, and in others the condition appears to be one of acidemia, with acetonuria, vomiting, restlessness, delirium, Cheyne-Stokes breathing, and coma as its chief manifestations. The Actions of Chloroform and Ether Compared. — Chloroform is a much more powerful anesthetic than ether. Quantity for quantity, it is more irritating than ether, but being administered in less concentrated form than the latter, it is more agreeable to the patient and is less productive of cough- ing and choking. The toxic effect of chloroform on the circu- lation is much greater than that of ether, and the margin of safety between the amount required to induce anesthesia and that which causes death is much narrower with chloroform than with ether. Sudden death from intense vagal stimulation, which is not very rare under chloroform, is never observed under ether. Unpleasant sequelae (nausea, vomiting, hyper- secretion of saliva and bronchial mucus) are more pronounced after ether than chloroform anesthesia ; on the other hand, serious metabolic changes (fatty degeneration of the liver, heart, etc.) are far more likely to result from the administration of chloroform than of ether. Finally, the mortality from chlo- roformization appears to be at least three times that from ether- ization. Therapeutics. — Chloroform is employed as a general an- esthetic, as a nerve sedative, a carminative, an anthelmintic, and a counterirritant. General Anesthetic. — The precautions to be observed in administering chloroform as an anesthetic are much the same as those already described in dealing with ether. The vapor, however, must never be concentrated, but' well mixed with air. A number of special devices for regulating the strength of the vapor have been recommended, but it is doubtful whether any of these offers any great advantage over the ordinary mask or folded towel in the hands of a skilled anesthetist. If the mask or towel be employed it should not be brought closer to the face than two inches, even after the patient has become accus- tomed to the anesthetic. If struggling occurs or the breath be held the distance should be increased, as the following inspi- rations will of necessity be unusually deep. The drug is best delivered drop by drop, at a rate never exceeding 60 drops per minute. Regular snoring breathing, muscular relaxation, and loss of the eye reflexes indicate complete anesthesia. An ordinary operation will not usually require more than an ounce or two of chloroform. The anesthetist should not rely upon any one sign as a warning of danger, but should keep careful watch 126 GENERAL ANESTHETICS. on the face, the respiration, and the pulse. Lividity of the face, irregular gasping respiration, feebleness of the pulse, or sudden pupillary dilatation (unless accompanied by signs of returning consciousness) call for immediate withdrawal of the anesthetic, lowering of the head, practice of artificial respira- tion, and the hypodermic administration of cardiac stimulants, such as ammonia, strychnin, caffein, and digitalis, or the injec- tion of adrenalin (1-2 c.c. of 1 : 1000 solution) in salt solution into an artery (radial), toward the heart (Crile). Massage of the heart through the diaphragm, when operating on the abdomen, has also been recommended. In sudden arrest of the heart from excessive inhibition at the beginning of anes- thesia, the injection of atropin in large dose should be included among the restorative measures. When chloroform is administered in the presence of lighted gas-jets, the room should be well ventilated, since the burnt vapor of the anesthetic yields irritant products (especially car- bonyl chloride) capable of inducing pneumonia when inhaled in concentrated form. Conditions Favoring- the Use of Chloroform as an Anesthetic. — While chloroform is ordinarily more dangerous than ether, it is to be preferred to the latter when the patient is suffering from an acute inflammation of the respiratory tract or advanced nephritis ; when it is desired merely to lessen the excitability of the nervous system, as in checking convulsions or to dull intense pain, as in labor or biliary colic ; when very complete muscular relaxation is required, as in the reduction of certain luxations ; and when the actual cautery is to be applied. In very hot climates chloroform is generally preferred to ether, because the latter is so very volatile that there is diffi- culty in maintaining complete anesthesia with it. In military practice also chloroform is preferable on account of the rapidity of its action and the small quantity required to induce insen- sibility. Contraindications to Chloroform Anesthesia. — Chloro- form is particularly to be avoided in all conditions of heart weakness ; in all operations likely to be attended by profuse hemorrhage ; in operations requiring the sitting posture, and in very prolonged operations. Nerve-sedative. — A few whiffs of chloroform may be employed to allay motor excitation in puerperal eclampsia, tetanus, and chorea insaniens, and to allay local spasm in asthma, whooping-cough, aud severe attacks of renal and biliary colic. NITROUS OXID. 127 In attacks of angina pectoris of great intensity Balfour and Osier recommend inhalations of chloroform. It may be dropped upon a handkerchief, or, as Balfour recommends, poured on a sponge in a smelling-bottle, and the patient told to breathe it through the nose as deeply as possible. In a minute or two relief is obtained. In the obstinate cough 0$ phthisis the addition of chloroform to the usual cough-mixture is often advantageous. U Codeinse sulphatis, gr. iv. (0.26 gm.); Acidi hydrocyanici diluti, TT^ xl (2.5 c.c.) ; Spiritus chloroformi, f^ij (8.0 c.c.) ; Glycerini, fjfss (15.0 c.c.) ; Elixiris aurantii, q. s. ad f^iij (90.0 c.c). — M. Dose. One teaspoonful. Carminative. — It is a useful carminative and sedative in gastralgia and intestinal colic. The following combination will be found useful in gastralgia: R Chloroformi, %iss-ij (5.5-8.0 c.c.) ; Spiritus ammoniae aromatici, Spiritus vini gallici, Tincturae cardamomi composite, aa fgv (18.0 c.c.).— M. Sig. A teaspoonful in hot water every fifteen or thirty minutes until relief is obtained. Anthelmintic. — It has been used in large doses .(fgss-j — 2.0-4.0 c.c.) as an anthelmintic against tapeworms, but it is an unreliable remedy. In nineteen cases reported by Whyte and Leichtenstern it proved successful in only two instances. Counterirritant. — In the form of a liniment chloroform is extensively used as a stimulating application in muscular rheu- matism, sprains, and contusions. NITROUS OXID. (Nitrogen Monoxid, N 2 0.) Nitrous oxid is obtained from the distillation of ammonium nitrate, and appears as a colorless, odorless gas having a somewhat sweetish taste. By pressure it is converted into a liquid, and in this form is stored in iron cylinders for subse- quent use. Physiologic Action. — When freely inhaled, undiluted nitrous oxid causes an increase of blood-pressure, a sense of exhilaration, ringing in the ears, and lividity of the face ; in a minute or two these symptoms are followed by complete un- consciousness. Upon the withdrawal of the anesthetic recov- 128 GENERAL ANESTHETICS. ery ensues in from thirty to sixty seconds. Great excitement, laughter, or a disposition to fight is frequently induced by inhalation of the gas when the supply of air is not completely cut off. Nitrous oxid anesthesia, as ordinarily induced, is caused in part by the specific action of the gas on the cerebrum, and in part by the asphyxia resulting from the exclusion of oxygen from the lungs. According to the researches of Wood and Kemp, the gas has no direct action on the heart or vasomotor center, the increased blood-pressure being due to asphyxia. Nitrous oxid is the safest of the general anesthetics, and, moreover, its use is not followed by any unpleasant after- effects. Hewitt was able to find records of but seventeen deaths from its administration between the years i860 and 1900. Therapeutics. — As an anesthetic, nitrous oxid is especially suitable for minor operations requiring but a short period of unconsciousness. By diluting the gas with sufficient oxygen (20 per cent.) to prevent asphyxia, and administering the mix- ture under a pressure of one and one-quarter atmospheres, to secure free absorption, narcosis can be induced in a minute or two, and maintained almost indefinitely. Anesthesia induced in this way has frequently been employed in operations lasting from thirty minutes to an hour. The disadvantages of nitrous oxid for lengthy operations are the cumbersome apparatus required for its administration and the large quantity of gas needed (200 gallons per hour) for maintaining the anesthesia. ^BTHYLIS BROMIDUM. (Ethyl Bromid ; Hydrobromic Ether, C 2 H 5 Br.) Ethyl bromid is obtained by the distillation of a mixture of ethyl alcohol, sulphuric acid, and potassium bromid. When perfectly pure it forms a colorless, highly volatile, inflammable liquid, having a sweetish taste and a chloroformic odor. On exposure to air it liberates bromin and hydrobromic acid and becomes unfit for use. It should be kept in dark amber- colored, well-stoppered bottles. It must not be confounded with the poisonous ethylene bromid. Physiologic Action and Therapeutics. — Ethyl bromid somewhat resembles chloroform in its anesthetic properties, but it acts more quickly, is inhaled with even less difficulty, is less depressing, and its effects are less lasting. Large doses depress the respiration and lower arterial pressure. After its administration there is a garlicky odor on the breath which &THYLIS CHLORIDUM. 1 29 may persist for a day or two. With this exception it rarely causes disagreeable after-effects, such as headache, nausea, and vomiting Although its use is not entirely devoid of danger, there is good reason for believing that with a pure preparation, cautiously administered, the risk is very little greater than with ether. While not quite so safe as nitrous oxid, it has the advantage of not requiring cumbersome appa- ratus for its administration. Ethyl bromid is a useful anesthetic for short operations. The dose for a child is from 1-3 drams (4-1 1 c.c), and for an adult, from 2-6 drams (8-22 c.c). The patient should be instructed to breathe deeply ; the full dose should be poured at once upon the inhaler (preferably a towel folded into an air-tight cone), and the inhaler should be held firmly over the nose and mouth, and not removed until the anesthesia is com- plete. Anesthetization is usually accomplished within from thirty to forty seconds, and lasts from two to three min- utes. It is not safe to continue the administration for more than two minutes, and under no circumstances should the anesthesia be prolonged by removing the mask and adding more of the drug. The contraindications are severe lesions of the heart, lungs, or kidneys. iETHYLIS CHLORIDUM, U. S. P. (Ethyl Chlorid, C 2 H 5 C1. ) Ethyl chlorid is prepared by the action of hydrochloric acid gas upon absolute ethyl alcohol, the hydroxl group in the latter being replaced by chlorin. It is a colorless, highly vola- tile liquid, having an odor resembling that of chloroform and a burning taste. As its vapor is very inflammable, it should not be used in proximity to a gas-flame or fire. Physiologic Action and Therapeutics. — Ethyl chlorid is a fugaAous general anesthetic. Accompanying the anes- thesia the%; is_ajall of arterial pressure and a decrease in the pulse- rate, due probably Vi |o direct cardiac action. The vapor should be administered weffctoixed with air, preferably from a special apparatus, such as that devised by Apperson. The inhaler is fitted to the face in the usual way and the patient is instructed to breathe naturally. Anesthesia, as a rule, is accomplished in from one to three minutes, from 1 to 2 fluid- drachms (4.0-8.0 c.c.) of the drug being required for the pur- pose. Recovery is usually complete in from two to five minutes. As a general anesthetic, ethyl chlorid is only suited for brief 1 30 ANTICONVULSANTS. surgical operations. Its action is rapid, is not attended by irri- tation of the respiratory mucous membrane, choking sensa- tion, or cyanosis, and is rarely followed by nausea or vomiting; complete muscular relaxation, however, is not obtained. It has an advantage over nitrous oxid in not requiring cumber- some apparatus for its administration and in producing a longer narcosis, and over ethyl bromid in not leaving an offen- sive garlicky odor on the breath. The relative safety of ethyl chlorid remains to be determined. Quite a number of fatal accidents from its use, however, have already been reported. The future will probably accord it a place below that of chloro- form. On account of the intense cold caused by its rapid evapora- tion, ethyl chlorid is frequently employed as a local anesthetic in minor operations. GENERAL ANALGESICS OR ANODYNES. General analgesics or anodynes are remedies which relieve pain without necessarily inducing unconsciousness or general anesthesia. They accomplish their object by depressing the sensory side of the central nervous system. The most power- ful analgesic is opium. While it has the power of relieving pain arising from almost any cause, it is especially useful in pain occasioned by gross lesions — inflammation, traumatism, and morbid growths. In the various so-called functional pains, such as headache and neuralgia, the coal-tar derivatives — anti- pyrin, phenaceti?i, and acetanilid — are more serviceable anal- gesics. The manner of their action is not definitely known, but they probably act upon the perceptive centers in the brain. Camiabis indica somewhat resembles opium in its action as an analgesic, but it is far less powerful. It is especially useful in neuralgia and migraine. The bromids, by depressing the cere- bral cortex, often afford relief in headache, but in other forms of pain they usually fail. Some drugs seem to have an affinity for certain nerves : thus, gelsemium and butyl chloral hydrate are often distinctly valuable in trifacial neuralgia. ANTICONVULSANTS. Certain drugs have the power of controlling cerebral con- vulsions by directly diminishing the excitability of the motor area in the cortex of the brain. A drug that thus depresses the motor centers, and also lessens the power of the motor A NTISPA SMODICS. 1 3 I side of the spinal cord to convey discharges from the brain to the muscles, or lessens the power of the sensory side of the spinal cord to transmit to the brain stimuli from without, has additional value as an anticonvulsant. Anesthetics (ether and chloroform) profoundly affect the brain and spinal cord, first depressing the sensory parts and then the motor. They are especially useful in severe convulsions, such as may occur in hysteria, puerperal eclampsia, and the status epilepticus. Bromids also depress the brain and the spinal cord. While their action is not so powerful as that of the anesthetics, it is much more permanent. They are very useful in epilepsy and in the reflex convulsions of childhood. Chloral appears to have more influence on motor activity than the bro- mids, and is especially useful in convulsions of spinal origin, such as those of strychnin-poisoning and tetanus, although it may be employed with advantage also in uremic, infantile, and puerperal convulsions. It is too depressing for continuous use in essential epilepsy. Antipyrin and Solanum Carolinense (horse- nettle) are of some value in essential epilepsy, but the manner in which they act is not definitely known. Amy I nitrite is of service in aborting threatened convulsions and in breaking up a series of seizures, such as occur in the status epilepticus. Its efficacy has been ascribed by some authorities to direct depres- sion of the central nervous system, and by others to dilatation of the arterioles of the brain. ANTISPASMODICS. Antispasmodics are remedies used to control minor grades of motor excitation and to lessen states of general nervous irritability. They vary in the manner of their action. Some, like hops and lactucarium, are feeble depressants of the nervous system, while others, like asafetida and valerian, probably owe what virtue they possess to the mental effect induced by their strong odor and taste. As a class, antispasmodics are useful in hysteria, nervous excitability, and local spasms. The follow- ing drugs are the most important members of this group: Camphor. Cimicifuga. Asafetida. Lactucarium. Valerian. Hops. Compound spirit of ether. Sumbul. Musk. Viburnum prunifolium. Oil of amber. I32 ANTISPA SMODICS. CAMPHORA, U. S. P. (Camphor, C 10 H l6 O.) Camphor is a whitish, translucent, volatile substance (solid volatile oil or stearopten), having a penetrating odor and a pungent taste, and obtained by distilling the wood of an Oriental tree — Cinnamomum Camphor a. It dissolves freely in all ordinary menstrua except water, in which it is only sparingly soluble. The dose is from 1-5 gr. (0.06-0.3 gm.). Preparations. Dose. Aqua Camphorae, U. S. P. (0.8 per cent.) . . \-\ fl. oz. (15.0-30.0 c.c.). Ceratum Camphorae, U. S. P. (10 per cent.). Linimentum Camphorae, U. S. P. (20 per cent, in cotton-seed oil). Linimentum Saponis, U. S. P. (4.5 per cent.). Spiritus Camphorae, U. S. P. (10 percent.) . 10-30 min. (0.6-2.0 c.c). It also enters into Tinctura opii camphorata. Physiologic Action. — In therapeutic doses camphor stimulates the higher cerebral centers, exerting a calmative influence in the presence of nervous irritability. It has a stimulating effect on the heart, although after large doses the blood-pressure falls, probably from paresis of the vasomotor center. In the stomach it acts as a mild carminative, inducing a sensation of warmth, increasing peristalsis, and expelling flatus. The action of camphor on the respiration has not been fully determined, but the researches of Stockman and Binz indicate that the drug is a stimulant to the respiratory center. Moderate doses exert a feeble anaphrodisiac effect. Applied externally it acts as a stimulant and antipruritic. When taken internally much of it is destroyed in the body, but a part is eliminated in the urine as camphoglycuric acid. Toxic doses of camphor produce languor, vertigo, headache, confusion of thought, tinnitus aurium, gastric irritation, a rapid, feeble pulse, convulsions, and collapse. The convul- sions are of an epileptiform character, and are due to the action of the drug on the cerebral cortex. Therapeutics. — Camphor is employed as an antispas- modic, a circulatory stimulant, carminative, and rubefacient. As an antispasmodic, it has been recommended in hysterical exciteme7it, hiccough, dysmenorrhea, who ping-cough, chordee, and the various climacteric neuroses. As a circulatory stimulant, camphor is exceedingly valuable in adynamic fevers, particularly in typhoid fever and pneu- monia. It not only serves to strengthen the pulse in these affections, but it also acts favorably in lessening the restless- ness and delirium. CAMPHOR A MONOBROMATA. I 33 As a carminative, Camphor is serviceable in tympanites, intestinal colic, and the various forms of choleraic diarrhea. As a rubefacient, it is much used in the form of a liniment in sprains, bruises, and muscular rheumatism. Anderson's powder is a useful antipruritic dusting-powder in simple erythe7na, intertrigo, and urticaria. It consists of from 1-2 drams (4.0-8.0 gm.) of finely pulverized camphor to \ ounce (15.0 gm.) each of powdered starch and zinc oxid. Camphor is a useful remedy in acute coryza, particularly when it is given early in the attack. It may be used internally and also by inhalation, a teaspoonful of powdered camphor being added to a tumbler of boiling water, and the fumes inhaled. Administration. — Camphor may be given internally in the form of the water or spirit, or in substance in pill or cap- sule. In adynamic fevers it is best given subcutaneously dis- solved in sterilized olive oil. From 1-2 gr. (0.06-0.13 gm.) may be dissolved in 15 min. (1.0 c.c.) of the oil, and injected every three or four hours, or even every two hours when the symptoms are very urgent. In coryza the following combina- tion may be employed : Jk Pulveris opii, gr. iij-vj (0.2-0.4 gm.) ; Pulveris camphorse, gr. xij (0.8 gm.) ; Ammonii carbonatis, gr. xxiv-xxxvj (1.5-2.3 gm. ). — M. Fiant capsulae No. xii. Sig. One every three hours. Incompatibles. — Liquefaction results when camphor is triturated with chloral hydrate, menthol, phenol, or thymol. Aqueous solutions precipitate camphor from its alcoholic solu- tion. CAMPHORA MONOBROMATA, U. S. P. (Monobromated Camphor, C 10 H, 5 BrO.) Monobromated camphor is obtained from the union of bromin and camphor in the presence of heat, and occurs as colorless prismatic needles or scales, having a mild cam- phoraceous odor and taste. It is very sparingly soluble in water and glycerin, but freely soluble in alcohol, ether, and chloroform. The dose is from 2-5 gr. (0.13-0.3 gm.)in pill or capsule. Physiologic Action. — In small doses it acts as a sedative to the nervous system. Toxic doses are followed by tremors, muscular relaxation, a marked slowing of the pulse, embar- rassed respiration, epileptiform convulsions, and coma. 1 34 ANTISPASMODICS. Therapeutics. — Monobromated camphor is employed as an antispasmodic and anaphrodisiac. It has been recom- mended in hysteria, delirium tremens, chorea, and whooping- cough, but its use in these affections is only rarely attended with success. In petit mal it is sometimes more effective than the ordinary bromids. Its more important use is as an anaphrodisiac. It often proves very efficacious in abnormal sexual excitement, chordee, spermatorrhea, etc. Its chief draw- back is its tendency to induce heartburn and eructations. In spermatorrhea it may be combined with hyoscin, as in the fol- lowing formula : H; Hyoscinae hydrobromidi, gr. T ^ (0.006 gm.) ; Camphorae monobromatae, £} (4.0 gm.). — M. Fiant pilulae No. xx. Sig. One or two at bedtime. ASAFCETIDA, U. S. P. (Asafetida.) Asafetida is a gum-resin obtained by incising the roots of Ferula fcetida, an umbelliferous plant abounding in Persia and Afghanistan. It appears in the form of irregular masses or tears of a yellowish-brown color, and has a persistent garlicky odor and an acrid taste. It consists of gum, resin, and an essential oil (about 4 per cent.) which is rich in sulphur. The oil is the most active ingredient. The dose is from 3-10 gr. (0.2-0.65 gm.). Preparations. Dose. Emulsum Asafoetidae, U. S. P. (4 per cent. watery emulsion) £-1 fl. oz. (i 5.0-30.0 c.c.). Tinctura Asafcetidae, U. S. P |-i fl. dr. (2.0-4.0 c.c.). Pilulae Asafoetidae, U. S. P. (3 gr.— 0.2 gm.) 1-3 pills. Physiologic Action. — On the circulatory and nervous systems asafetida acts as a feeble stimulant ; on the alimentary canal, as a carminative. Therapeutics. — Asafetida is employed chiefly as an anti- spasmodic and as a carminative. As an antispasmodic it is used in nervous excitement, whooping-cough, and hysteria. Sup- positories of asafetida are sometimes valuable in infantile con- vulsions and in the restlessness of the specific fevers. As a carminative, it is an excellent remedy in infantile colic and the flatident dyspepsia of the aged. An enema of asafetida is one of the most efficacious remedies that we possess in excessive tympanites. Asafetida has also been employed as a stimulating expectorant in chronic bronchitis. VALERIANA. 1 35 Administration. — For continued use the drug is best administered in the form of pills. To children it may be con- veniently administered in the form of suppositories. In tym- panites the official emulsion (4-6 ounces — 120.O-175.O c.c.) should be employed as an enema. VALERIANA, U. S. P. (Valerian.) Valerian is the rhizome and roots of Valeriana officinalis, a native of Europe. Its active principles are a volatile oil and valeric acid. Preparations. Dose. Tinctura Valerianae, U. S. P 1-2 fl. dr. (4.0-8.0 c.c. ). Tinctura Valerianae Ammoniata, U. S. P. (made by macerating valerian in aromatic spirts of ammonia) 1-2 fl. dr. (4.0-8.0 c.c. ). Fmidextractum Valeriance, U. S. P. ... |-i fl. dr. (2.0-4.0 c.c). Physiologic Action. — In moderate doses valerian has a slight stimulant effect on the central nervous system, especially the cerebrum, and on the circulation. Very large doses pro- duce a sense of warmth in the stomach, quickening of the pulse, vomiting, diarrhea, frequent micturition, headache, ver- tigo, and hallucinations. Therapeutics. — Valerian is a valuable remedy for subdu- ing the various nervous phenomena occurring in patients of excitable temperaments. The spasms, headache, palpita- tion, globus, sleeplessness, and flatulent distention of hysteria are often remarkably influenced by the drug. AMMONII VALERAS, U. S. P. (Ammonium Valerate ; Ammonium Valerianate, NH 4 C 5 H 9 2 .) Valerate of ammonia occurs in the form of colorless quad- rangular plates having the odor of valeric acid and a sharp, sweetish taste. It is freely soluble in water and alcohol. Its dose is from 5-10 gr. (0.3-0.6 gm.) in the form of an elixir. It is employed for the same purposes as valerian. FERRI VALERAS. (Iron Valerate; Iron Valerianate, Fe 2 (C 5 H 9 2 ) 6 .) Iron valerate appears as a dark-red amorphous powder, having the odor of valeric acid. It is a useful combination of an antispasmodic with a chalybeate, and may be prescribed with advantage in anemia, associated with nervous excitement 1 36 ANTISPASMODICS. or hysteria. The dose is from 1-3 gr. (0.06-0.2 gm.) in pill form. The following tonic and antispasmodic pill of three valerates is frequently prescribed : R Ferri valeratis, Zinci valeratis, Quininae valeratis, aa gr. xx (1.3 gm.). — M. Fiant pilulae No. xx. Sig. One after meals. ZINCI VALERAS, U. S. P. (Zinc Valerate ; Zinc Valerianate, Zn(C 5 H 9 2 ) 2 + H 2 0.) Zinc valerate appears in the form of white, pearly scales,, having the odor of valeric acid, and a sweetish, astringent, and metallic taste. It is soluble in 100 parts of water and 40 parts of alcohol. The dose is from \- 3 gr. (0.03-0.2 gm.). It has about the same therapeutic value as valerian. SPIRITUS iETHERIS COMPOSITUS, U. S. P. (Compound Spirit of Ether ; Hoffmann's Anodyne.) Hoffmann's anodyne is a colorless, inflammable liquid, hav- ing an ethereal odor and taste. It consists of 325 parts by volume of ether, 650 parts of alcohol, and 25 parts of ethereal oil, the last being an ethereal solution of the product of the dis- tillation of sulphuric acid and alcohol. The dose is from J-2 fl. dr. (2.0-8.0 ex.). Physiologic Action and Therapeutics. — Hare con- cludes, from a careful study of this compound, that its calma- tive effects are largely due to the ether which it contains rather than to the ethereal oil, and that each of its ingredients stimulates the system — the ether the most, and the ethereal oil the least powerfully. Hoffmann's anodyne is an excellent carminative for ex- pelling gas from the stomach. It affords prompt relief in severe paroxysmal palpitation dependent upon gastric flatulence. It is often of service in angina pectoris, especially when the attacks are precipitated by flatulency. In chronic valvular disease, when compensation is partially lost and the patient suffers from restlessness, dyspnea, and insomnia, the compound spirit of ether often acts most favorably. It is sometimes very efficacious in hiccough. A combination like the following will be found useful in asthma : R Ammonii bromidi, gij (8.0 gm.) ; Tincturse belladonnse, fgj (4.0 cc.) ; Tincturse lobeliae, f|[ij (8.0 cc.) ; Spiritus setheris compositi, f^j (30.0 cc.) ; Elixiris aromatici, q. s. ad f§iij (90.0 cc). — M. Sig. A dessertspoonful in water every hour or two during the paroxysm. CIMICIFUGA. I37 The following mixture is often serviceable in severe gastric flatulency : R Spiritus setheris compositi, Spiritus camphorse, aa £ss (2.0 c.c.) ; Spiritus menthas piperita, fr\vj (0.4 c.c). — M. Sig. To be taken in water. MOSCHUS, U. S. P. (Musk.) Musk is the dried secretion from the preputial follicles of Moschus moschiferus, a species of deer found in Central Asia. It appears as reddish-black unctuous grains having a peculiar penetrating odor and a bitter aromatic taste. The dose is from 5-15 gr. (0.3-1.0 gm.), given preferably by the rectum, in suppository or suspended in mucilage. Preparation. Dose. Tinctura Moschi, U. S. P. (5 per cent.) . 1-2 fl. dr. (4.0-8.0 c.c). Therapeutics. — Musk is used as an antispasmodic and as a general stimulant. As Graves first pointed out, it is a most valuable stimulant in typhoid fever and kindred affections, when there are profound nervous exhaustion and circulatory failure. It is also of service in obstinate hiccough, the convul- sions of childhood, and laryngismus stridulus. The great draw- backs to its use are its costliness and the difficulty in obtaining an unadulterated preparation. CIMICIFUGA, U. S. P. (Black Snakeroot, Actaea Racemosa.) Cimicifuga is the dried rhizome and rootlets of Cimicifuga racemosa, a perennial plant growing in the woodlands of North America. It contains a resin, a bitter neutral substance, and a volatile oil. Preparations. Dose. Tinctura Cimicifugae, U. S. P £-2 fl. dr. (2.0-8.0 c.c). Fluidextractum Cimicifugse, U. S. P. . . . 10-30 min. (0.6-2.0 c.c). Extractum Cimicifugse, U. S. P 2-8 gr. (0.1-0.5 g m 0- Physiologic Action. — In large doses cimicifuga causes nausea, headache, vertigo, tremors, muscular relaxation, slowing and weakening of the pulse, anesthesia, and, finally, paralysis of respiration. The anesthesia is due, according to Hutchinson, to paralysis of the sensory side of the spinal cord. The weakness of the pulse is probably due to a direct depres- sant effect exerted on the heart itself. In full doses it seems also to possess the power of stimulating uterine contractions. Therapeutics. — Cimicifuga is a valuable remedy in simple 1 3 8 ANTISPA SMODICS. chorea, ranking next to arsenic in efficiency. It should be given in doses of 10 min. (0.6 c.c.) of the fluid extract three times a day, after meals, and gradually increased to from ^— 1 dr. (2.0- 4.0 c.c). It is sometimes of service in chronic rheumatic affections of the nerves and muscles, like myalgia, pleurodynia, sciatica, and lumbago, but in articular rheumatism it is of little value. It is said to be useful in atonic amenorrhea, menor- rhagia, and sudden cessation of the menses from cold or nervous shock. It has been used in labor to stimulate uterine con- tractions, its action resembling that of quinin rather than that of ergot. Ringer strongly recommends it in combination with gelsemium for the distressing symptoms attending the menopause ; and, according to Simpson, it is highly beneficial in the mental disturbances which sometimes follow pregnancy. It is often of distinct service in relieving the tinnitus aurium accompanying chronic catarrh of the middle ear. It has been used as an expectorant in bronchitis, with free expectoration, and in phthisis. LACTUCARIUM, U. S. P. (Wild Lettuce.) Lactucarium is the concrete milk-juice of Lactuca virosa, a biennial herb cultivated chiefly in Central and Southern Europe. It contains lactucin (a bitter principle), lactucic acid, lactucopicrin, and lactucerin. The dose is from -|-i dr. (2.0- 4.0 gm.). Preparations. Dose. Tinctura Lactucarii, U. S. P \-\ A. dr. (2.0-4.0 c.c). Syrupus Lactucarii, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). Fluidextractum Lactucarii 20-30 min. (1.2-2.0 c.c). Therapeutics. — Lactucarium is a feeble hypnotic, an ano- dyne, and an antispasmodic. Added to cough-mixtures, the syrup is a useful sedative in the acute bronchitis of children. HUMULUS, U. S. P. (Hops.) Hops are the dried strobiles of Humulus Lupulus, a perennial climber largely cultivated in Europe and the United States. They have an aromatic odor, and a bitter, slightly astringent taste. A glandular powder separated from the dried strobiles is also official as Lupulinum (lupulin). Lupulin, of which hops contain from 8 to 15 per cent., appears in the form of minute SUMBUL. I39 yellowish-brown, resinous granules, having a bitter aromatic taste. The chief constituents of hops are cholin (a volatile, liquid alkaloid), a volatile oil, lupamaric acid (the bitter prin- ciple), tannic acid, and a resin. The dose of lupulin is from 5-15 gr. (0.3-1.0 gm.). Preparations. Dose. Tinctura Humuli, |— 2 fl. dr. (2.0-8.0 c.c). Fluidextractum Lupulini, U. S. P 5 -30 m in. (0.3-2.0 c.c). Oleoresina Lupulini, U, S. P 2-5 gr. (0.13-0.3 gm.). Therapeutics.— Hops act as a bitter tonic and as a feeble hypnotic. In the restlessness of fevers and in delirium tremens they are sometimes useful sedatives. They have been found especially serviceable in chordee, spermatorrhea, and vesical irritation. The following suppositories, containing lupulin, afford relief in chordee : R Pulveris opii, gr. vj (0.4 gm.) ; Pulveris camphorae, gr. xxiv (1.5 gm.); Lupulini, 3J(4-ogm.); Olei theobromatis, q. s. — M. Fiant suppositoria No. vi. Sig. Introduce one into the bowel at bedtime. SUMBUL, U. S. P. (Musk-root.) Sumbul is the root of Ferida Sumbul t a perennial herb grow- ing in Central Asia. Its chief constituents are a resin, to which its musk-like odor is due, a fixed oil, angelic acid (sumbulic acid), and valerianic acid. The dose of the root is from 10-30 gr. (0.6-2.0 gm.). Preparations. Dose. Fluidextractum Sumbul, U. S. P ^-1 fl. dr. (2.0-4.0 c.c). Extractum Sumbul, U. S. P 2-5 gr. (0.1-0.3 gm.). Therapeutics. — Sumbul is sometimes useful as an anti- spasmodic in hysteria and allied neuroses. In neurastJienia the extract may be given in pill with iron and arsenic. The following combination, suggested by Bradbury, is very effect- ive in relieving the insomnia, mental depression, and flushing heats commonly occurring at the menopause : R Ammonii bromidi, ^ij(8.ogm.); Fluidextracti sumbul, Tincturse humuli, aa f^iss (45.0 c.c.) ; Spiritus camphorae, f£iij (ll.o c.c.) ; Elixiris aromatici, q. s. ad fjvj (175.0 c.c). — M. Sig. Tablespoonful in water after meals. I40 SPINAL CORD EXCITANTS, VIBURNUM PRUNIFOLIUM, U. S. P. (Black Haw.) Officially viburnum prunifolium is the bark of a tall shrub of the same name, growing in the eastern and southern States of North America. Its chief constituents are viburnin (a bitter principle), valerianic acid, resin, and tannin. Preparation. Dose. Fluidextractum Viburni Prunifolii, U. S. P. . . \-2. fl. dr. (2.0-8.0 c.c). Therapeutics. — Large doses of the fluid extract are said to cause in warm-blooded animals drowsiness, a fall of blood- pressure, muscular relaxation, and a diminution of reflex irri- tability. It is employed chiefly as a uterine and ovarian seda- tive. It has been found useful in habitual abortion occurring in non-syphilitic patients. Combined with opium it is very efficacious in threatened abortion. In non-inflammatory dys- menorrhea it affords great relief when given in doses of 1 dr. (4.0 c.c.) three times a day, beginning five or six days before menstruation. It is sometimes very successful in subduing the menstrual irregularities and nervous distress occurring about the time of the menopause. OLEUM SUCCINI. (Oil of Amber.) Oil of amber is a volatile oil obtained by the destructive dis- tillation of a fossil resin which is yielded by submerged fir trees washed ashore along the coast of Prussia. It is a thin, transparent, yellow liquid, having a balsamic odor and a warm, acrid taste. The dose is from 5-10 min. (0.3-0.6 c.c), in cap- sules or in an emulsion. Therapeutics. — Oil of amber, with camphor or turpen- tine, was at one time held in high repute as a stimulating liniment for the chest in whooping-cough and acute bronchitis. Internally it is sometimes efficacious in obstinate hiccough. SPINAL CORD EXCITANTS. Spinal cord excitants, or excitomotors, are drugs which increase the functional activity of the spinal cord. By stimu- lating the cell-bodies of the lower motor neurons they exag- gerate reflex activity, and if given in toxic dose, induce tetanic convulsions. The origin of the convulsions excited by a drug can be determined in animals by dividing the spinal cord NUX VOMICA. 141 between the occiput and the atlas. Convulsions of cerebral origin cease after section, while those of spinal origin do not. The most important spinal cord excitants are : Strychnin. Cafifein. Brucin. Ammonium salts. Hydrastin. Phenol. With the exception of strychnin and brucin, however, these drugs do not sensibly excite the spinal cord unless given in toxic doses. The indications for using excitomotors as such cannot be stated very definitely. They often prove efficacious, however, when loss of power is dependent upon depression of the motor neurons, and not upon destructive lesions. When there is evidence of inflammation they are absolutely contraindicated. NUX VOMICA, U. S. P. Nux vomica is the seeds of the Strychnos Nux vomica, a. small tree growing in the East Indies. It contains two alka- loids, strychnin and brucin. Strychnin fully represents the action of the crude drug. It is official as Strychnina, which is very sparingly soluble in water, as Strychnines nitratis, which is soluble in 42 parts of water, and as Strychnines sulphatis, which is soluble in 3 1 parts of water. All these preparations appear as colorless crystals or crystalline powders, having an intensely bitter taste. Brucin resembles strychnin in its action, but is less powerful. The dose of strychnin or of either of its salts is from 6 1 - 2 1 o g r - (0.001-0.003 g m -)- Preparations. Dose. Extractum Nucis Vomicae, U. S. P \-\ gr. (0.008-0.03 g m -)- Fluidextractum Nucis Vomicae, U. S. P. . . . 1-5 min. (0.06-0.3 gm.). Tinctura Nucis Vomicae, U. S. P 5-20 min. (0.3-I.3 c.c). Pulvis Nucis Vomicae, 1-5 gr. (0.06-0.3 g 111 -)- Strychnin enters into the glycerite of the phosphates of iron, quinin, and strychnin, the syrup of the phosphates of iron, quinin, and strychnin, the compound syrup of hypophosphites, and compound laxative pills. Physiologic Action. — Circulatory System. — In full me- dicinal doses strychnin raises the blood-pressure and slightly lessens the frequency of the pulse. The first of these effects is chiefly the result of vasoconstriction induced by stimulation of the vasomotor center in the medulla, the heart being stimulated but feebly, if at all. The decreased frequency of the pulse is due to stimulation of the cardiac inhibitory center. 142 SPINAL CORD EXCITANTS. Toxic doses tend to lower the blood-pressure by depressing the vasomotor center ; but during the convulsive seizures in- duced by the drug an enormous increase in the pressure may be observed as a result of the violent muscular contractions. Nervous System. — Strychnin is a powerful stimulant of the spinal cord and medulla. Upon the cerebrum it has compara- tively little influence. Toxic doses increase reflex irritability of the spinal cord to such an extent that the slightest stimulus from the periphery induces violent tetanic convulsions. There is rea- son to believe that this effect is not the result of direct stimulation of the motor cells in the anterior horns, but of decreased resist- ance on the sensory side of the cord, in consequence of which slight impulses from the periphery, instead of reaching and in- fluencing but a limited number of motor cells, as is normally the case, are permitted to spread out and excite the motor cells of the entire cord. Thus, in frogs, convulsions do not follow strychnin injections after division of the sensory roots or par- alysis of the sensory nerve-endings by cocain. After a time, especially in the lower animals, the stimulant effects of strychnin are replaced by those of paralysis, the cen- tral nervous system and motor nerve-endings both sharing in the depression. Special Senses. — The special sense-organs also appear to be sensitive to strychnin, for after its use vision, hearing, and smell become more acute. Muscle. — By increasing the sensitiveness of the spinal cord to all centripetal sensory irritation, stiychnin improves the tonus of both plain and striped muscles throughout the body. Respiratory System. — The respiratory movements are quickened and strengthened by strychnin, owing to its stimu- lant action on the medullary center. Alimentary Canal. — Taken by the mouth, strychnin and the preparations of nux vomica, like other very bitter substances, whet the appetite, increase the secretions, and stimulate the peristaltic movements of both stomach and bowels. Metabolism. — By increasing muscular activity, strychnin augments considerably the consumption of oxygen and the output of carbonic acid. Elimination. — Strychnin is eliminated chiefly by the kid- neys. Its excretion is very slow, and, therefore, the possibility of cumulative effects arising from the prolonged and continuous use of the drug should be borne in mind. Toxicology. — The first evidences of the toxic effects of strychnin are restlessness, anxiety, twitching and starting of the muscles, and stiffness of the neck. If the dose has been NVX VOMICA. 1 43 sufficiently large, spinal convulsions speedily develop, throwing the patient's body into orthotonos or opisthotonos. The con- vulsions are, for the most part, intermittent, and are repeated under the slightest external irritation. The pupils are dilated, the vision is hyperacute, the mind is unaffected, and the stomach is usually retentive. In fatal cases the convulsions become more rapid and severe, and finally death results from asphyxia due to spasmodic fixation of the respirator}* muscles or from exhaustion. In the lower animals very large quanti- ties of the drug may kill by paralyzing the central nervous system or the motor nerve-endings. The fatal dose of strych- nin for man is from J to ij grains (0.032-0.1 gm.). The history of the case, the absence of a wound, the abrupt onset, the intermittent character of the convulsions, and the late involvement of the muscles of the jaw (trismus i will serve to distinguish strychnin-poisoning from tetanus. The history of the case, the emotional excitement, the closed eyes, and the persistent opisthotonos will serve to distinguish hysteria from strychnin-poisoning. Treatment. — Since the slightest stimulus will provoke con- vulsions, the patient should be disturbed as little as possible. If convulsions have already begun, no attempt should be made to use a stomach-pump until the reflex excitability- has been subdued by inhalations of chloroform or amy] nitrite. Tannic acid in solution may be administered as a chemical antidote. The best physiologic antidotes are potassium bro- mid (.5J-ij — 4.0-8.0 gm.) and chloral (20 gr. — 1.3 gm.): when the patient is unable to swallow the chloral, I dr. (4.0 gm.) may be given in an enema. Osterwald observed very bene- ficial effects from oxygen inhalations in strychnin-poisoning in animals. Therapeutics. — Nux vomica or strychnin is used chiefly as a circulatory* stimulant, a respirator}* stimulant, an excito- motor, and a stomachic. As a Circulatory Stimulant. — In simple dilatation of the heart, with or without valvular disease, strychnin often renders good service when combined with digitalis, but used alone it is distinctly inferior to the latter drug. In pneumonia and other infective processes it is an excellent adjuvant to alcohol and digitalis. In the weak heart of the old it is generally a better remedy than digitalis. It is also useful in surgical she:': As a Respiratory Stimulant. — Being both a respiratory and a circulator}* stimulant, strychnin is indicated in diseases of the lungs associated with enfeeblement of the respiration and pulse, such as pneumonia, emphysema, and some cases of 144 SPINAL CORD EXCITANTS. chronic bronchitis and phthisis. In emphysema no single drug is so useful. Employed hypodermically in cases of acute pul- monary edema it is scarcely less efficient than atropin. In poisoning by drugs which depress the heart or respiratory center strychnin is of value. In poisoning by opium, chloral, aconite, ether, or chloroform it should be given hypoderm- ically in full doses. As an Excitomotor. — When paralysis is the result of com- plete destruction of nerve-cells or fibers, strychnin, like all other drugs, will be ineffective ; but when the loss of power is the result simply of depression or exhaustion of the nervous apparatus, it may prove useful. It is commonly prescribed in the hemiplegia following apoplexy, but it is valueless in this condition except, perhaps, as a general tonic. On the other hand, in the various forms of peripheral neuritis, such as plumbic, alcoholic, diphtheritic, and that due to pressure, it is often of considerable service. It should not be used, how- ever, until all acute symptoms of the affection have subsided. In neurasthe7tia minute doses of strychnin with arsenic are sometimes efficacious, but more often the drug is useless or actually harmful. In amaurosis from tobacco, alcohol, or lead it is invaluable. It is thought that intramuscular injections of strychnin aid in restoring power to the affected muscles in acute poliomyelitis. This treatment, however, should not be instituted until three or four weeks after the incidence of the disease. Nux vomica often affords relief in incontinence of urine from atony of the bladder — a condition sometimes met with in old people. It is likewise an excellent remedy in constipation dependent upon atony of the intestinal walls. As a Stomachic. — Nux vomica is often very useful in chronic dyspepsia when there are no manifestations of severe inflammatory trouble. In these cases the chief symptoms are a coated, flabby tongue, anorexia, fulness and distress for some time after eating, deficient secretion of hydrochloric acid, flatulence, and constipation. In such types of indigestion the tincture of nux vomica (5 or 10 drops before meals), with or without hydrochloric acid, often acts most happily. In larger doses it is also of service in dilatation of the stomach due to atony. It is a trustworthy remedy in those cases of marked flatulence, common in elderly people, dependent upon a lack of tone in the walls of the stomach and bowel. Strychnin is contraindicated in gastric affections when there is hypersecretion of hydrochloric acid, and when there are evidences of well-marked inflammation. SPINAL CORD DEPRESSANTS. 1 45 Other Uses. — In hyperemesis not dependent upon organic disease of the stomach, the tincture of nux vomica (1-2 drops) alone, or with wine of ipecac (J— 1 drop), every hour or two, will often afford relief. Good results are sometimes obtained with strychnin as a prophylactic remedy in uterine inertia. It has been recommended by Murrell and Brunton to check the night-sweats of phthisis. It is useful in sexual impotence due to lowered nervous tone. Dana and others speak very favor- ably of strychnin in heroic doses in tic douloureux occurring in anemic and exhausted patients, and when the duration of the disease has not been more than one or two years. The drug is given hypodermically once a day, and the dose is gradually increased from -^ to \ of a grain (0.002 to 0.013 gm.), ten to twenty days being required to reach this maximum. A number of observers (Posner, Feilchenfeld, Ketly, Spaether) speak favorably of the action of strychnin in diabetes insipidus. Administration. — Strychnin sulphate and extract of nux vomica are suitable preparations for use in pills. When a liquid preparation is desired, as in atony or dilatation of the stomach, the tincture will be found reliable. The nitrate of strychnin is sometimes preferred to the sulphate for hypodermic use, but it has no special advantage over the latter. Nervous excitement, restlessness, and twitching of the muscles are indi- cations that the limit of physiologic action has been reached. Incompatibles. — Strychnin is incompatible with tannic acid, alkalies, chlorids, iodids, and bromids. SPINAL CORD DEPRESSANTS. Under this head are considered drugs that lessen reflex action by depressing the neurons of the spinal cord. They may act solely on the motor neurons, impairing their ability to discharge power, or they may act also on the sensory neurons and thus protect the motor neurons from the influence of pe- ripheral irritation. The following are most important members of this group: Physostigma. Hydrated chloral. Gelsemium. Ether. Bromids. Chloroform. Spinal cord depressants are useful in combating symptoms resulting from irritation of the neurons of the lower motor segment. Thus, they are of value in controlling the paroxysms 10 I46 SPINAL CORD DEPRESSANTS. of laryngismus stridulus, the spasms of tetany, and the tremors of paralysis agitans. They are also of service in allaying the hyperexcitability of the lower motor neurons caused by cer- tain poisons, as strychnin and that of tetanus. Finally, spinal cord depressants are not without value in the treatment of convulsive seizures which have a cerebral origin ; for by de- pressing the lower motor neurons they impair their power of transmitting excessive discharges from the brain to the muscles, and by depressing the lower sensory neurons they afford the brain more or less protection from the effects of external stimuli. PHYSOSTIGMA, U. S. P. (Calabar Bean.) Physostigma is the seed of Physostigma venenosum, a perennial climber, growing in West Africa. It contains two alkaloids, physostigmin or cserin, and calabann ; the latter is less important than the former, and resembles strychnin in its action. Preparations. Dose. Tinctura Physostigmatis, U. S. P. ... 5-30 min. (0.3-1.8 c.c). Extraction Physostigmatis, U. S. P . . . \-\ gr. (0.008-0.02 gm.). Physostigmin, or eserin, fairly represents the active properties of the bean. It occurs in yellowish-white crystals, deliques- cent, odorless, bitter, sparingly soluble in water, but readily so in alcohol and dilute acids, and turning pink on exposure. The dose is from 1 \ 3^ gr. (0.0005-0.002 gm.). Two salts are official : Physostigminse sulphas. Physostigminae salicylas. The sulphate is very soluble in water, and the salicylate is soluble in 72.5 parts of water. The dose of either salt is from TT>o-3T) S r - (0.0006-0.002 gm.). Physiologic Action. — Circulatory System. — Small ther- apeutic doses of physostigmin do not affect the circulation. Large doses decrease the pulse-rate and strengthen the beat, probably by acting on the heart-muscle directly. They also raise the blood-pressure, partly by powerfully contracting the intestines and thus driving the blood out of the splanchnic area, and partly by stimulating the muscular coat of the arterioles. Toxic doses lower the blood-pressure by depressing the vasomotor center. Central Nervous System. — In large doses physostigmin lessens reflex activity and induces muscular weakness by PHYSOSTIGMA. 1 47 depressing the motor neurons of the spinal cord. It also de- presses the medullary centers, but it is apparently without influence on the cerebrum, for in poisoning consciousness is preserved until the end. Respiratory System. — Therapeutic doses do not affect the res- piration, but toxic doses kill by paralyzing the respiratory center. Muscles. — Physostigma increases the irritability of both striped and unstriped muscle, and in toxic doses causes fibril- lary tremors and tetanoid contractions. The latter appear to be due to stimulation of the peripheral nerve-endings, as they occur after section of the nerve-trunks, but disappear after injections of curare. Secretions. — Large doses of physostigmin increase the flow of saliva, sweat, mucus, and pancreatic juice by stimulating the nerve-endings in the secretory glands. This action is offset by large doses of atropin. Alimentary Canal. — Physostigmin powerfully increases the peristaltic movements of the stomach and bowel by stimu- lating the nerve-endings in the muscular coat of these organs, and probably also the muscular protoplasm itself. Bye. — Local applications of physostigmin cause marked contraction of the pupil by stimulating the peripheral endings of the oculomotor nerve, and probably also the iris muscle itself. They also induce spasm of accommodation by acting similarly on the ciliary muscle, and decrease intraocular ten- sion, partly by narrowing the pupil and partly by constricting the ocular vessels. Toxicology. — Physostigmin-poisoning is characterized by vertigo, great muscular relaxation, tremors and twitchings of the muscles, abolition of reflex action, contraction of the pupils, slowing of the pulse, salivation, and sometimes colicky pains with nausea and vomiting. Treatment of Poisoning". — This consists in evacuating the stomach by an emetic, in administering atropin as a physio- logic, and tannic acid as a chemical, antidote, and in combating respiratory and cardiac failure with such stimulants as am- monia, strychnin, and alcohol. Therapeutics. — Physostigma has a very limited range of usefulness ; it is chiefly employed to depress the spinal cord, to contract the pupils, to lessen intra-ocular tension, and to stimulate involuntary muscles, especially those of the stomach and intestine. It has been used to depress the spinal cord in tetanus, strychnin-poisoning, and chorea, but in these affections we have far more reliable remedies. I48 SPINAL CORD DEPRESSANTS. The extract sometimes makes a useful addition to cathartic pills intended to relieve constipation dependent upon atony of the intestinal walls. In full doses, preferably hypodermically, it is sometimes serviceable in the excessive tympanites of typhoid fever, and in postoperative intestinal paresis. Ringer has rec- ommended it in chronic bronchitis with dyspnea, due to weak- ness of the bronchial muscles. It has found favor with some practitioners in the treatment of atonic dilatation of the stomach. Eye-affections. — Physostigmin sulphate is used to coun- teract mydriasis produced by atropin, to lessen intra-ocular tension in the early stages of glaucoma, and sometimes alter- nately with atropin to break up adhesions in iritis. In per- ipheral ulceration of the cornea, in the absence of iritis, it often acts better than atropin. Untoward Effects. — Strong solutions instilled into the eye sometimes cause pain in the eye and head, spasm of the ocular muscles, vertigo, and faintness. Administration. — Physostigma may be given internally in the form of the extract, the tincture, or the alkaloid. For hypodermic use physostigmin sulphate is preferable on account of its ready solubility in water. For the same reason the sulphate should be employed in affections of the eye. For continued use it is generally prescribed in solutions containing from -|— I gr. (0.008-0.065 gm.) to the ounce (30.0 c.c), but when a powerful and prompt effect upon the eye is desired much stronger solutions (2-3 gr. — 0.13-0.2 gm.) to the ounce (30.0 c.c.) may be employed. On standing solutions of eserin turn red and lose some of their effectiveness. GELSEMIUM, U. S. P. (Yellow Jasmine.) Gelsemium is the rhizome and root of Gelsemium semper- virens, a climber indigenous to the southern United States. It contains gelseminin and gelsemin. Gelseminin, which repre- sents to a considerable extent the active properties of the crude drug, occurs in the form of white crystals, with a bitterish taste, sparingly soluble in water, and readily soluble in alcohol, ether, and dilute acids. The dose of gelseminin or its salts is from y^o-sV gr. (0.0005-0.002 gm.). Preparations. Dose. Tinctura Gelsemii, U. S. P 5-20 rain. (0.3-1.2 c.c). Fluidextractum Gelsemii, U. S. P 1-5 min. (0.05-0.3 c.c). OTHER SPINAL CORD DEPRESSANTS. 1 49 Physiologic Action. — Circulatory System. — Small doses do not affect the circulation, but very large doses quicken the pulse by depressing the ganglia on the inhibitory nerve. Nervous System. — Gelsemium depresses the spinal cord, especially its motor neurons, and also, though less powerfully, the terminations of the motor nerves. Respiratory System. — Toxic doses kill by paralyzing the respiratory center. Bye. — Locally applied, gelseminin dilates the pupil and paralyzes accommodation, these effects being produced, as with atropin, by depression of the endings of the third nerve. Toxicology. — Gelsemium-poisoning is characterized by vertigo, frontal headache, disordered vision, dilatation of the pupils, ptosis, falling of the jaw, failure of articulation, extreme muscular weakness, slow respiration, a weak, thready pulse, and, finally, collapse. Consciousness is usually retained until near the close of life. Convulsions have been observed in animals, but not in man. Treatment. — Restorative measures consist in evacuating the stomach, administering tannic acid, maintaining the body- temperature, and combating collapse with such stimulants as strychnin, whisky, and ammonia. Therapeutics. — Gelsemium has been employed as an anti- spasmodic in laryngismus stridulus, whooping-cough, asthma, and chorea, but in these affections there are far more efficient remedies. At one time gelseminin was recommended as a mydriatic, but homatropin and atropin are superior, being more prompt and less dangerous. The drug is sometimes distinctly useful in spasmodic affections of the muscles, like torticollis, and in obstinate neuralgia, especially of the trifacial nerve. In the latter, a combination of butyl-chloral hydrate (5 gr. — 0.3 gm.) and gelseminin (y^- gr. — 0.0006 gm.), as recom- mended by Murrell, is particularly efficacious. Ringer has found it useful in some cases of Meniere's disease. On account of the variability of the preparations, they should be given in small doses, gradually increased until such symptoms as vertigo or dimness of vision appear. In persistent torticollis gelseminin may be injected directly into the muscle. OTHER SPINAL CORD DEPRESSANTS. Hydrated Chloral.— The depressant action of hydrated chloral on the motor tracts of the spinal cord is secondary in importance only to that on the cerebrum. In tetanus and strychnin-poisoning it renders valuable service in allaying the irritability of the spinal motor neurons. 150 MOTOR NERVE DEPRESSANTS. Chloroform and Ether. — These drugs depress both the sensory and motor neurons of the spinal cord, but the former more powerfully than the latter. They are useful in checking convulsions which endanger life, whether the motor discharges emanate from the brain or from the spinal cord. As spinal cord depressants they are of value in cerebral convulsions by lessening the power of the sensory columns to transmit to the brain stimuli from without, and also by lessening the power of the motor columns to convey discharges from the brain to the muscles. Bromids. — The bromids depress the entire central nervous system, first the cerebrum, then the spinal cord, and lastly the medulla. As depressants of the spinal cord they are useful in subduing the convulsive seizures of strychnin-poisoning and tetanus. MOTOR NERVE DEPRESSANTS. The most important depressants of the peripheral motor nerves are : Curare. Conium. Belladonna. Gelsemium. Lobelia. Spartein. Pelletierin. Of this group, however, only belladonna, conium, and, per- haps, lobelia are employed for their effect on the nerve-endings. Curare is a resinous extract, obtained from various species of strychnos, growing in South America. Taken by the mouth, it has little or no effect, but introduced into the body through an open wound or by subcutaneous or intravenous injection, it is a powerful paralyzant of the nerve-endings in all striated muscle except that of the heart. It has been used to some ex- tent in hydrophobia and tetanus, but without much success. The dose is from 2V~i g ra i n (0.0032-0.032 gm.), subcutaneously. The action of gelsemium on the motor nerves is subordinate to its action on the central nervous system. Pelletierin, an alkaloid of pomegranate, affects the motor nerve-endings only in toxic doses. The action and uses of belladonna have been fully con- sidered on page 75. Motor nerve depressants are useful in local spasmodic affections like whooping-cough, torticollis, and asthma. COXIUM—L OBELIA. 1 5 I CONIUM, U. S. P. ^Hemlock.) Conium is the fruit of the Conium maadatiim, gathered while yet green. It contains a volatile oil and a yellowish, oily, liquid alkaloid, conii n, which represents the active prop- erties of the drug. Coniin forms with acids crystallizable salts which are soluble in water. The dose of the alkaloid or its salts is from ^ \ gr. (0.003-0.01 gm.). Preparations. Dose. Fluidextractum Conii, U. S. P 2-5 min. (0.1-0.3 c.c.V Extractum Conii h-2 gr. (0.03-0. 13 gm.). Tin cmra Conii |-i fl. dr. (2.0-4.0 c.c). Physiologic Action. — Toxic doses of conium produce a staggering gait, muscular relaxation, paralysis, tremors, ver- tigo, ptosis and dilatation of the pupils (from paresis of the oculomotor nerve), coldness of the surface, and, finally, death from asphyxia. Salivation, nausea, vomiting, and diarrhea may also be observed. Consciousness and sensibility are pre- served until near the end. The dominant action of the drug is on the peripheral motor nerves, which it paralyzes. Its action on the spinal cord con- sists of transient stimulation, followed by profound depression. On the brain it exerts no special influence. Whether the failure of respiration observed in poisoning is the result of paralysis of the respirator}' center or of the nerve- endings in the diaphragm has not definitely been determined. Except in very large doses, conium has but little depressant effect on the heart. Therapeutics. — Conium has been used as an antispas- modic in chorea, paralysis agitans, astJima, and zuhooping- cough, but in these affections it is of less value than other remedies. In the form of vapor it is sometimes useful in allaying the cough of bronchitis. Spitzka and others strongly recommend it in the mental and physical excitement of acute mania. On account of the uncertain strength of the prepara- tions, it is necessary to give the drug in small doses rapidly increased until some effect is produced. LOBELIA, U. S. P. Lobelia is the leaves and tops of Lobelia i?iflata, a weed growing in the wild places of Canada and the United States. It contains lobelic acid and a yellow liquid alkaloid, lobelin. The latter forms, with acids, crvstalline salts, which are soluble 152 MOTOR NERVE DEPRESSANTS. in water. The dose of the sulphate of lobelin is from -|— I gr. (0.01-0.06 gm.). Preparations. Dose. f As an expectorant, IO-30 min. Tinctura Lobelia, U. S. P 1 As an em°tic, C i-2 fl. dr. (2.0-4.0 I c.c). f As an expectorant, 2-5 min. (o. I- 0."2 c.c. ). Fluidextractum Lobelise, U. S. P. . . . j As an emetic, 20-30 min. (1.2- l 2.0 c.c). Physiologic Action. — Lobelia has practically the same action as conium, except that it is more prone than the latter to produce nausea and vomiting. It paralyzes the peripheral terminations of the motor nerves, and appears to be especially depressant to the endings of the vagus distributed to the bronchial muscles. The ingestion of a large dose of the drug (a teaspoonful of the tincture) is followed by nausea, vomiting, and faintness. Toxic doses cause severe burning pain in the esophagus and stomach, persistent vomiting, cold sweats, weakness of the pulse, extreme prostration, and, finally, death from paralysis of the respiratory center. The treatment of lobelia-poisoning consists in the administra- tion of tannic acid and of diffusible stimulants, and in the use of artificial heat to maintain the bodily temperature. Therapeutics. — Lobelia was formerly used as an emetic, but as such it has been almost entirely displaced by less de- pressing drugs. It is, however, an exceedingly useful anti- spasmodic in asthma and in bronchitis associated with spas- modic dyspnea. To secure the best results, it is necessary to give the drug in increasing doses until slight nausea is produced. SPARTEINE SULPHAS, U. S. P. Spartein is a liquid alkaloid obtained from the tops of Cytisns Scoparius, or common broom. It is official as Sparteines sul- phas, a white crystalline or granular powder of a somewhat bitter taste, and freely soluble in water and alcohol. The dose of spartein sulphate is J grain (0.015 gm.), cautiously increased to 1 grain (0.06 gm.). Physiologic Action. — Spartein closely resembles coniin in its action, though it has less effect on the central nervous system, and is less poisonous than the latter. As is the case with coniin, large doses depress the motor nerve-endings and the sympathetic nerve cells. The drug also depresses the SENSORY NERVE DEPRESSANTS. 1 53 heart directly, and so lessens both force and frequency of the cardiac contractions. Under its influence the blood-pressure usually falls, though at first it may slightly rise from constric- tion of the peripheral vessels. Spartein has been employed rather extensively as a substitute for digitalis in cardiac insuffi- ciency, but the actions of the two drugs are entirely dissimilar. SENSORY NERVE DEPRESSANTS. When applied locally a drug may lessen or destroy sensi- bility through a specific action on the peripheral nerves, or, as is the case with ether and ethyl chlorid, through the intense cold produced by its evaporation. A few drugs when taken internally, if the dose be sufficiently large, are capable of pro- ducing numbness of the skin and mucous membranes through a peripheral action. This is true of aconite and the bromids. Sensory nerve depressants are employed locally to relieve pain and to allay itching. The following agents act as local anesthetics : Cocain. Menthol. Tropacocain. Camphorated chloral. Phenol. Iodoform. Esters of benzoic Aconite, acid. Veratrin. Eucain. Orthoform. Anesthesin. Stovain. Novocain. Hydrocyanic acid. Holocain. Ethyl chlorid. Chloretone. Ether. Many of the aromatic oils, like oil of cloves and oil of peppermint, also possess anodyne properties. Cocain (see p. 83). — The application of a cocain solution of moderate strength (6 per cent.) to a mucous membrane is followed in a few moments by pallor and anesthesia. The pallor is due to constriction of the blood-vessels, and is subse- quently replaced by congestion ; the anesthesia is due to the direct action of the drug upon the sensory nerves. Applied to cutaneous surfaces it is without effect, since absorption through the skin is very slight. In the eye it causes, in addi- tion to anesthesia, mydriasis and a slight impairment of accommodation. The uses of cocain as a local anesthetic are various. In operations on the eye, nose, throat, urethra, and rectum, its solu- tions are indispensable in preventing or in lessening pain. I 54 SENSOR Y NER VE DEPRESSANTS. When injected under the skin it is also of established value in many minor operations involvi?ig the cutaneous structures, such as circumcision, opening small abscesses, amputating fingers, and excising small growths. In inflammations and ulcerations of the nose, pharynx, and larynx it may be employed alone or in combination with anti- septic sprays and powders. In acute coryza and hay-fever it gives much relief by lessening the sensibility and the tumes- cence of the tissues. In tuberculous laryngitis it serves a useful purpose in lessening the intense pain and dysphagia. It is also efficacious in diminishing the pain caused by the applica- tion of caustics. For anesthetizing mucous membranes solutions are em- ployed varying in strength from 2-20 per cent. On the nose and throat from 4-6 per cent, solutions are usually sufficient. In the larynx somewhat stronger solutions are required Solutions stronger than 4 per cent, should not be used in the eye on account of the danger of inducing degenerative changes in the corneal epithelium. When the drug is employed sub- cutaneously after the method of Schleich, it is not safe to allow more than 1 grain to remain in the tissues. I£ttcain. — Eucain is a synthetic compound allied chemi- cally to cocain. Two forms are upon the market, which are known respectively as Alpha-eucain or eucain hydrochlorid "a" and Beta-eucain or eucain hydrochlorid " fi." The former, on account of its irritant properties, has been almost completely supplanted by the latter. Beta-eucain occurs as a white, neutral, crystalline powder, soluble in about 30 parts of cold water, making a 3 per cent, solution. It is somewhat less toxic than cocain, and, moreover, its solutions are more stable, and can be sterilized by boiling without losing in effi- cacy. A disadvantage of eucain is that it has no constricting influence on the blood-vessels, in consequence of which it causes hyperemia rather than ischemia. When injected sub- cutaneously it is somewhat more liable than cocain to induce sloughing. For general surgical purposes a 2 per cent, solution (9 gr.- I oz. — 0.6 gm-30.0 c.c.) is generally employed. Holocain. — Holocain is a synthetic compound related chemically to phenacetin. The hydrochlorid, in which form it is always employed, occurs in colorless crystals, having a bitter taste and slightly soluble in cold water. It is very sensitive to alkalies — even the small amount of alkali dissolved out of the glass on boiling a solution of the drug in a test-tube is sufficient to decompose it. TR OP A COCA IN HYDROCHL OR A TE—ORTHOFORM. I 5 5 Experimentally holocain has been found to be more actively poisonous than cocain, and therefore it is not suitable for sub- cutaneous use. It has qualities, however, which make it a very valuable anesthetic in ophthalmic surgery. The instilla- tion into the eye of a few drops of a 1 per cent, solution of holocain causes slight burning, and is followed in from twenty to thirty seconds by complete anesthesia, lasting for from ten to fifteen minutes. It is without effect upon the pupil, the ciliary muscle, the intra-ocular tension, or the corneal epi- thelium. It is more rapid in its action than cocain, and it has, moreover, some bactericidal power. As it has no constricting effect upon the blood-vessels, it lacks the power of cocain to control hemorrhage. Since it acts so quickly and does not cause mydriasis, it is especially valuable in minor operations on the eye, such as the removal of foreign bodies. Norris has found it very efficacious in sluggish corneal ulcers, and de Schweinitz and others have spoken favorably of it in keratitis. A 1 per cent, solution is usually employed. When the eye is inflamed, the effectiveness of both holocain and cocain is distinctly enhanced by the previous application of a solution (1 : 10,000) of adrenalin. Tropacocain Hydrochloric!. — Tropacocain is an alka- loid obtained from the small Java coca leaves. It forms white needles which are readily soluble in water. It resembles cocain in its action, but it is much less toxic, and when applied to mucous membranes it does not cause ischemia. It anesthetizes the eye without affecting the pupil or accom- modation, but it has no advantages over holocain. On account of its lesser toxicity it may replace cocain in solutions intended for infiltration anesthesia, especially when it is necessary to employ large doses of the anesthetic. Block recommends the following solution : Tropacocain hydrochloric!, 3 gr. (0.2 gm.) ; Sodium chlorid, 3 gr. (0.2 gm. ) ; Sterilized distilled water, 3 fl. oz. (100.0 c.c). It has also been used successfully in the production of medul- lary anesthesia, from J— i gr. (0.26-0.05 gm.) being injected for this purpose into the subarachnoid space. Orthofortn. — This synthetic compound is the methyl-ester of meta-amido-para-oxybenzoic acid. It occurs as a white, voluminous powder, without odor or taste, and sparingly soluble in water. Orthoform hydrochlorid is freely soluble in water, but it is too irritating for general use. Orthoform 156 SENSORY NERVE DEPRESSANTS. has pronounced analgesic, antiseptic, and desiccant properties, and for this reason it has been recommended as a dressing for painful wounds and ulcers. When applied pure or in the form of an ointment (10-20 per cent.) to exposed sensory nerve-endings it causes a slight burning sensation, which is soon followed by complete anal- gesia lasting from ten to twenty hours. The prolonged action of the drug is due in large part to the slowness with which it is absorbed. On account of its acid reaction it is too irritating to be applied to sensitive mucous membranes like the eye or to be injected hypodermically. Unfortunately it is not altogether free from toxic properties, and its effects should be carefully watched. Brocq, Asam, Yonge, and others have seen exten- sive erythema, urticaria, eczema, and even gangrene follow its use. A study of the published records indicates that these accidents are more likely to occur from the use of the drug in an ointment than when it is applied directly in the form of a powder. Orthoform has been used successfully as a local remedy in painful wounds, in burns, especially of the third degree, in cancerous and tuberculous ulcerations, and in fissures and ex- coriations of the mucocutaneous junctions. It will be found very efficacious in relieving the pains of tuberculous laryngitis and of fissured nipples. In the former the powdered drug may be used ; in the latter, a saturated alcoholic solution, or an ethereal solution like the following, recommended by Bardet : ij Orthoform gr. lxxx (5.0 gm.); ^Etheris, q. s. ad solv. ; Olei amygdalae expressi, f ^j (30.0 c.c). Added to arsenical pastes (orthoform, 1 part ; acacia, 1 part ; arsenous acid, 2 parts) it materially lessens the painfulness of their caustic action. Its internal use in doses of from 5-10 gr. (0.3-0.65 gm.) has been recommended in gastric ulcer and cancer, but Epstein has observed vomiting and collapse after its administration by the mouth. Orthoform is incompatible with silver nitrate, antipyrin, and bismuth subnitrate. Anesthesin. — This is the ethyl ester of paramidobenzoic acid. It is a white, inodorous powder, tasteless, but producing a sense of numbness when applied to the tongue. It is almost insoluble in water, soluble to the extent of 2 or 3 per cent, in oils, and readily soluble in alcohol. As a local anesthetic, anes- thesin has an action very similar to that of orthoform, but less irritant and less toxic. Locally, it is employed by insufflation STO VAIN— NO VOCAIN—CHL ORE TONE— MENTHOL. I 5 J in pharyngeal and laryngeal affections, as a dusting-powder or ointment in burns and painful ulceratio?zs of the skin, arid in the form of suppositories in hemorrhoids. Internally, it has been used with some success in relieving pain and vomiting the result of gastric ulcer or cancer. The dose is from 5 to IO grains (0.3-0.65 gm.), preferably in cachets. Stovain. — This synthetic compound — the hydrochlorid of an ester of benzoic acid — appears as small white lustrous crys- tals, very freely soluble in water. It is about equal to cocain in anesthetic power, but less toxic, and, moreover, has a vaso- dilating instead of a vasoconstricting effect. It has been rec- ommended particularly for local injections in minor surgical operations (0.5 to 1 per cent, to the extent of 2 grains — 0.13 gm.) and for lumbar anesthesia (10 per cent, solution to the extent of \ to \\ grains — 0.03-0.07 gm.). In a few instances gangrene has been observed after subcutaneous injections. It may be applied to the conjunctiva in 4 per cent, solution, and to other mucous membranes and ulcerated surfaces in from 5 to 10 per cent, solution. In prescribing stovain it should be borne in mind that it is incompatible with alkalis and mercuric salts. Novocain is a benzoic acid ester occurring as a crystalline salt, soluble in an equal weight of water. It is a powerful local anesthetic, more transient in its effect than cocain, but much less toxic and irritant. It may be applied in a 1 to 10 per cent, solution to the eye and in a 5 to 20 per cent, solution to the nose and larynx, with the addition of a little adrenalin solution to prolong the anesthesia. For infiltration anesthesia, a solu- tion of 1 to 2 per cent., also with adrenalin, may be used to the extent of 3 or 4 grains (0.2-0.25 gm.) without fear of toxic effects. It is incompatible with alkalis and alkaline carbonates. Chloretone (see p. 106). — This is a compound formed by the addition of potassium hydrate to equal weights of chloro- form and acetone. It appears as a white, crystalline powder, with a camphoraceous odor and taste. In addition to its use- fulness as a hypnotic it has a definite value as an antiseptic and a local anesthethic. It has been used with considerable success as a dusting-powder in painful wounds. It has also been employed in the form of a saturated solution for pro- ducing infiltration anesthesia, but the results have not been uniformly favorable. Menthol (peppermint camphor). — Menthol is a stearopten obtained from the essential oil of peppermint. It occurs as colorless prismatic or acicular crystals, having the odor of 1 5 8 SENSOR Y NER VE DEPRESSANTS. mint and a camphoraceous taste. It is sparingly soluble in water, but freely so in alcohol, ether, and chloroform. The dose is from 1-3 gr. (0.06-0.2 gm.), in pills, capsules, or in alcoholic solution. Menthol is employed as a local anesthetic and an antiseptic. It makes a useful application in frontal headache and in neu- ralgia of the superficial nerves. For use in these affections it is best dissolved in chloroform or ether. When equal parts of chloral or menthol are heated together in a water-bath, an oily liquid is formed (chloral menthol), which is efficacious in toothache. One part of menthol to 10 of olive oil makes a soothing application for burns. Dissolved in collodion in the proportion of 1 : 4 it forms a useful dressing for small contusions. The inhalation of menthol in the form of a vapor or spray affords considerable relief from the disagreeable symp- toms of acute coryza. The following solution will be found useful in both coryza and acute laryngitis : R Menthol, gr. vj (0.4 gm.) ; Eucalyptol, TT\v (0.3 c.c); Petrolati liquidi, fjj (30.0 c.c). — M. Sig. To be used as a spray several times a day. Liquid petrolatum containing from 5-10 per cent, of men- thol makes an excellent vehicle for various remedies employed in the treatment of chronic rhinitis and chronic laryngitis. The following mixture in the form of a spray has been recommended as a local anesthetic in minor surgical opera- tions : R Menthol, gr. x (0.65 gm.) ; Chloroformi, f£v (18.5 c.c); yEtheris, fgj (30.0 c.c.) —M. Internally, menthol is sometimes used in persistent vomit- ing and gastralgia, but it is rarely successful. Ethyl Chlorid (see p. 1 29).— This compound is produced by the action of dry hydrochloric acid gas on absolute alcohol On account of the intense cold caused by its rapid evapora- tion it is employed as a local anesthetic. It is usually sold in small glass tubes, provided with a lever-spring top. When the lever is depressed, the liquid is expelled as a spray by the heat of the hand. Ethyl chlorid is a convenient local anesthetic for use in minor operations requiring but a single incision, such as opening boils and aspirating pleural or abdominal effusions. It is seldom efficient in operations upon the deeper structures requiring dissection or curetting. PHENOL— VERA TRIN. J 59 As a permanent opacity may result when freezing come in contact with the cornea, caution must be exercised in using ethyl chlorid about the head (Merz-Weigandt). Phenol (see p. 387). — As a local anesthetic phenol acid is chiefly employed to allay itching in jaundice and pruritic skin diseases like eczema and urticaria. It may be used in the strength of \\-2 dr. (5.8-7.8 gm.) to the pint (0.5 L.) of water Iodoform (see p. 319).— On account of its analgesic prop- erties iodoform is a valuable topical remedy in various ulcera- tions of a painful character. It is particularly useful in reliev- ing the pain and dysphagia of tuberculous laryngitis, in which affection it is employed by insufflation, either in a pure form (2-3 gr. — 0.13-0.2 gm.) or mixed with morphin (y~S~T2 S r - — 0.004-0.005 gm.). Suppositories of iodoform are often of service in painful hemorrhoids and in fissure of the anus. Camphorated Chloral. — This is a syrupy liquid made by rubbing together equal parts of camphor and hydrated chloral. It is soluble in alcohol, ether, glycerin, and oils, but it is de- composed by water. It is used as a local anesthetic in neu- ralgia, toothache, and pruritus. In local pruritus the following ointment is sometimes efficacious : R Pulveris c amphorae, Pulveris chlorali hydrati, aa gj (4.0 gm.); Trit. et add. Unguenti aquae rosae, §j (30.0 gm.). — M. Aconite (see p. 60). — The tincture of aconite, rubbed into the affected part, is sometimes useful in relieving the pain of neuralgia and in allaying the itching of chilblains. Ointments containing aconitin (5-10 gr. to the ounce — 0.3-0.6 gm. to 30.0 gm.) are also prescribed in neuralgia, but on account of the extreme virulence of the alkaloid they must be used with great caution. Liniments containing aconite and chloroform are employed with benefit in muscular rheumatism. Veratrin is an alkaloid obtained from the seed of Asagrcea officinalis, a bulbous herb growing in Mexico and Central America. The official preparation is a mixture of pure vera- trin and a number of other less active alkaloids. It is a white, amorphous, or semicrystalline powder, odorless and intensely acrid. It is readily soluble in alcohol, but very slightly so in water. Veratrin has an action very similar to that of aconitin. In the form of the ointment {Unguentum Veratrince, U. S. P.) or oleate {Oleatum Veratrince, U. S. P.) it is occasionally employed as a local remedy in neuralgia. It should never be applied l60 SENSORY NERVE DEPRESSANTS. over large surfaces or where there are any abrasions. In em- ploying it about the face great care must be exercised to keep it out of the eye. Hydrocyanic or prussic acid is employed in medicine only in very dilute solution. The official preparation (Acidum Hydrocyanicum Dilutuni), a 2 per cent, aqueous solution, is a colorless liquid with the odor and taste of bitter almonds. The dose is from 1 to 3 min. (0.05-0.2 c.c). Hydrocyanic acid is a general protoplasmic poison. In moderate doses it first stimulates and then powerfully de- presses the central nervous system, especially the respirator)' vasomotor and cardio-inhibitory centers in the medulla. It also depresses the heart or its contained motor ganglia, and decreases all metabolic processes. Large doses kill almost immediately, the heart and respiration being arrested simul- taneously. After death the blood often retains for a time its bright red color, owing to the formation of cyanhemo- globin, a compound that is less readily reduced than oxy- hemoglobin. Hydrocyanic acid is partially destroyed in the tissues and partially transformed into sulphocyanides, which escape in the urine. Locally applied, even in dilute solution, it produces numbness of the part by depressing the endings of the sensory 7 nerves. Toxicology . — When death is not immediate, the character- istic symptoms of prussic acid poisoning are a sense of numbness in the mouth, salivation, dyspnea, dilatation of the pupils, infrequent pulse, clonic convulsions, involuntary dis- charge of urine and feces, unconsciousness, and collapse. Treatment is rarely effectual on account of the very rapid action of the drug. It consists in artificial respiration and the use of such stimulants as strychnin and atropin. Sodium hyposulphite has also been recommended in order to form an innocuous sulphocyanide. In the form of lotion hydrocyanic acid is sometimes used to relieve itching in eczema and pruritics when there is no abrasion of the skin. Internally, it is often of sendee in relieving gas- tralgia and controlling the pain and vomiting of gastric ulcer and cancer. It has also been used largely to allay cough in advanced phthisis. Dilute prussic acid is very prone to decomposition, and, therefore, the preparations on the market vary considerably in their value. The following formulae will illustrate the manner in which the drug may be prescribed: R Acidi hydrocyanici diluti, fr^ss (2.0 c.c.); Glycerini, fzj (4.0 c.c.); Aquae, q. s. ad f^ij (60.0 c.c). — M. Sig. Apply as directed. {Pruritus. ) MYDRIATICS. l6l Be Bismuthi subnitratis, Jfss (15.0 gm.); Acidi hydrocyanici diluti, ITlxl ( 2 -5 c.c); Aquae, q. s. ad fliv (120.0 c.c). — M. Sig. Shake well. A dessertspoonful before meals. ( Gastric ulcer or catarrh?) R Codeinse sulphatis, gr. iv (0.25 gm. ); Acidi hydrocyanici diluti, Ttl^xxij (2.0 c.c); Syrupi tolutani, q. s. ad f^ij (60.0 c.c). — M. Sig. A teaspoonful every four hours. [Cough of phthisis.) Ether (see p. 1 1 8).: — The application of ether in the form of a spray is one of the oldest methods of producing local anesthesia. The sensory nerves are benumbed by the intense cold which is occasioned by the rapid evaporation of the drug. This method may be employed preliminary to opening small abscesses or performing paracentesis. MYDRIATICS. The size of the pupil is regulated by the unstriped muscle- fibers of the iris, of which there are two sets — concentrically arranged constrictor fibers and radiating dilator fibers. Two antagonistic nerves control these muscles : the oculomotor, which when stimulated contracts the pupil through the agency of the constrictor fibers, and the sympathetic, which when stim- ulated dilates the pupil through the agency of the dilator fibers. Mydriasis or dilatation of the pupil may be brought about in a variety of ways : By paralyzing the oculomotor center in the medulla; by paralyzing the peripheral filaments of the oculomotor nerve ; by paralyzing the constrictor muscle of the iris ; by stimulating the sympathetic center in the medulla ; by stimulating the peripheral fibers of the sympathetic nerve, or by stimulating the radiating muscular fibers of the iris itself. All mydriatics impair more or less the accommodative power of the eye; that is, its power of adjusting itself to vision at different distances. The agency through which the adjust- ment is effected is the ciliary muscle. In accommodating for near objects this muscle contracts, the suspensory ligament relaxes, the lens, owing to its inherent elasticity, becomes more convex. Of the mydriatics, kyoscin, hyoscyamin, and atropin are the most powerful cycloplegics or paralyzants of the ciliary muscle, and cocain and euphthalmin are the least pow- erful. Another property of mydriatics is their power of increasing the intra-ocular tension, and so favoring the development of 11 1 62 MYDRIATICS. , glaucoma when a tendency to that affection already exists. Dilatation of the pupil mechanically increases the intra-ocular pressure by narrowing the angle between the iris and the cornea, thus impeding the escape of humor from the eye through the small openings communicating with the canal of Schlemm. Of the mydriatics, cocain and euphthalmin have the least effect on the intra-ocular tension. Mydriatics are employed to facilitate ophthalmoscopic ex- amination, to paralyze accommodation when estimating refrac- tive errors, to rest the iris and to prevent or break loose adhe- sions in iritis, to enlarge the field of vision in nuclear cataract, when the periphery of the lens is still clear, and to allay irritation in inflammation of the cornea. The most important local mydriatics are : Atropin. Hyoscin or scopolamin. Homatropin. Cocain. Methylatropin (eumydrin). Euphthalmin. Hyoscyamin. Atropin Sulphate (see p. 75). — Atropin dilates the pupil by paralyzing the oculomotor nerve-endings in the sphincter muscle of the iris, and destroys the power of accommodation by paralyzing the nerve-endings in the ciliary muscle. It also increases the intra-ocular tension. After the installation into the eye of a drop or two of a solution of atropin (4 gr.-i fl. oz. — 0.26 gm-30.0 c.c.) mydriasis begins in fifteen minutes, and attains its maximum in about half an hour. Accommo- dation is not affected so quickly, paralysis not being complete within an hour and a half. On the other hand, mydriasis persists somewhat longer than the suspension of accommoda- tion. The effect of an atropin solution of the strength indicated does not usually disappear completely for about ten days. Atropin may be used as a simple mydriatic to facilitate oph- thalmoscopic examination, but euphthalmin, cocain, and hom- atropin are as efficient for this purpose and cause less incon- venience to the patient. As it paralyzes accommodation it is a reliable mydriatic for general use in refraction work, but many ophthalmologists prefer cycloplegics which have a less persistent action. In iritis it is indispensable in preventing and in breaking up adhesions between the iris and the capsule of the lens. In acute keratitis it is also very useful in allaying ciliary irritation. As a simple mydriatic \ gr. (0.016 gm.) to the ounce (30.0 c.c.) is sufficient, and the mydriasis from this solution does not HOMATROPIN HYDROBROMID — COCAIN HYDROCHLOR. 163 last longer than four or five days. As a cycloplegic, a solution of 4 gr. (0.26 gm.) to the ounce (30.0 c.c.) should be instilled into the eye, one drop at a time, three times for at least a day. A solution of the same strength is generally used in iritis. In keratitis a solution containing 1-2 gr. (0.65-0.13 gm.) to the ounce (30.0 c.c.) will be effective. Homatropin Hydrobromid. — Homatropin is an artificial alkaloid obtained by heating tropin (a component of atropin) with mandelic acid, in the presence of dilute hydrochloric acid. It is employed in the form of the hydrobromid {Homatropince Hydrobrornidum, U. S. P.), which is freely soluble in water. Like atropin, it dilates the pupil and paralyzes accommoda- tion. Its action is complete within an hour, and lasts from two to three days. It has an advantage over atropin in the shorter duration of its effects. It is, however, several times more costly than the natural alkaloid. To paralyze the accom- modation a solution of 8-12 gr. (0.5-0.8 gm.) to the ounce (30.0 c.c.) must be instilled in the conjunctival sac six or eight times at intervals of five or ten minutes. In facilitating oph- thalmoscopic examination a solution of 1-2 gr. (0.06-0. 1 3 gm.) to the ounce (30.0 c.c.) is sufficient. Methylatropin or eumydrin has properties similar to those of atropin, though it is not so poisonous. As a mydri- atic it acts more quickly than atropin, but its effects are less lasting. It is applied in from 1 to 2 per cent, solution. Hyoscyamin (see p. 81). — This alkaloid is obtained from hyoscyamus and other Solanacece. It is official in the form of hydrobromid (Hyoscyamince Hydrobromid tun) and the sul- phate {Hyoscyarnino? Sulphas), both of which salts are freely soluble in water. Upon the eye hyoscyamin acts like atropin in dilating the pupil and paralyzing the accommodation, but its effects are less lasting, being not more than six or seven days in duration. Some ophthalmologists prefer it to atropin for this reason. It is usually employed in the strength of 2 grains (0.13 gm.) to the ounce (30.0 c.c). Hyoscin or Scopolamin Hydrobromid (see p. 82). — This drug dilates the pupil, paralyzes accommodation, and increases intra-ocular tension in the same way as atropin ; but it acts more powerfully and quickly and its effects are of much shorter duration. Its chief drawback is its greater tendency to cause constitutional disturbance. It may be employed in the strength of 4 grains (0.26 gm.) to the ounce (30.0 c.c). Cocain Hydrochlorid (see p. 83).— The instillation into the eye of a few drops of a 4 per cent, solution of cocain causes, in from ten to fifteen minutes, in addition to local anes- 1 64 M YDRIA TICS. thesia, marked dilatation of the pupil. The mydriasis attains its maximum in about an hour, and persists for from twelve to fifteen hours. It is of peripheral origin, and is probably caused by stimulation of the sympathetic nerves. Cocain only slightly impairs accommodation. In strong solutions it has an injurious effect upon the corneal epithelium. As the effect of cocain on the pupil is of short duration, and as it does not seriously disturb accommodation, it is a convenient mydriatic for retinal examinations. In iritis atropin is distinctly preferable on account of its forcible action and lasting effect. The mydriasis induced by cocain is readily overcome by the instillation into the eye of a few drops of a 1 per cent, solution of eserin. Stronger solutions of cocain than 4 per cent, should not be used in the eye on account of the danger of causing degenerative changes in the corneal epithelium. Euphthalmin. — This synthetic alkaloid is the hydro- chlorid of the mandelic acid derivative of eucain B. It occurs in the form of a white crystalline powder, soluble in cold water. Its solution can be sterilized by boiling, and may thus be kept for a long time. If a few drops of a 4 per cent, solution be placed in the conjunctival sac, mydriasis begins in a few minutes, attains its maximum in about half an hour, and passes away within six or seven hours. While its mode of action has not been fully determined, it is probable that the drug dilates the pupil by paralyzing the peripheral ends of the oculomotor nerve. Euphthalmin does not injure the corneal epithelium; it does not irritate the conjunctiva; it gives rise to no constitutional disturbance ; and it only slightly impairs accommodation. Contrary to what has been stated, however, it does increase to some extent the intra-ocular tension, and Knapp has observed glaucoma follow the use of a 7.5 per cent, solution. On account of the brief duration of its action on the pupil, and its slight cycloplegic influence, it is perhaps the best agent we possess for simple ophthalmoscopic purposes. Solutions varying from 4 to 6 per cent, are usually employed. According to Jackson the following solution is more active in dilating the pupil and at the same time less persistent in its effect than a stronger solution of euphthalmin alone : Euphthalmin, I part ; Cocain hydrochlorid, I " Distilled water, 100 parts. MYOTICS. 165 MYOTICS. Myosis or contraction of the pupil may result from causes the reverse of those mentioned as being capable of bringing about mydriasis. Morphin, when taken internally in large doses, contracts the pupil by stimulating the oculomotor center. Physostigmin and pilocarpui, applied quickly to the eye, cause contraction of the pupil by stimulating the peripheral endings of the oculomotor nerve, and probably also the iris muscle itself. Both drugs also lessen intra-ocular tension by widen- ing the angle between the iris and the cornea, thus favoring the escape of humor from the eye, and, in strong solution, in- duce spasm by accommodation. Arecolin apparently has a similar action. Physostigmin or Eserin Sulphate (see p. 146). — This is the most commonly used myotic. When a gentle, con- tinuous action is desired, a solution containing from \-\ gr. (0.008-0.065 gm.) to the ounce (30.0 c.c.) is sufficient, but when a prompt and powerful action is necessary, a solution containing from 2-3 gr. (0.13-0.2 gm.) to the ounce (30.0 c.c.) may be employed. The maximum effect of these solutions is secured in from one-half to three-quarters of an hour, and persists from a few hours to several days. On standing, solu- tions of physostigmin turn red and lose some of their effect- iveness. Pilocarpin Hydrochloric! (see p. 258). — The action of pilocarpin on the eye is very much like that of physostigmin, but less powerful. It is employed in solution of from 1-4 gr. (0.065-0.26 gm.) to the ounce (30.0 c.c). Arecolin Hydrobromid. — This is the hydrobromid of a liquid alkaloid obtained from areca catechu, or betel-nut. It is a white crystalline salt, soluble in water. In the form of \ or 1 per cent, solution (2J-4J gr. to the ounce — 0.14-0.3 gm. to 30.0 c.c.) it is a powerful myotic. Contraction of the pupil begins in from three to five minutes, reaches its maxi- mum in from ten to fifteen minutes, and is accompanied by spasm of the ciliary muscle. The pupil returns to its normal condition within an hour or two. Its action is more rapid, but at the same time more transient, than that of physostigmin. Its power of lowering tension in glaucoma is apparently equal to that of eserin, and in Bietti's hands it proved successful in a case of glaucoma in which physostigmin had failed. Arecolin has been used with asserted success as an anthel- mintic, and, according to Frohner and Clemesma, it is, when injected hypodermically, a more powerful sialagogue than pilocarpin. 1 66 EMETICS. EMETICS. Vomiting is a reflex act consisting of a forcible spasmodic contraction of the abdominal muscles and diaphragm. While the contraction of the muscular coat of the stomach may- assist in the act, it is not an essential factor, for Magendie found that when the stomach was removed and was replaced by a bladder filled with water, emesis could still occur. The afferent impulses which excite vomiting travel from the stom- ach through the sensory fibers of the vagus to a center in the medulla closely connected with the respiratory center, and thence the efferent impulses are conducted through the phrenics, the spinal nerves, and the vagus to the muscles concerned in the act. Theoretically, a drug may cause vomiting either by directly affecting the center in the medulla or by indirectly affecting it through irritation of the sensory nerve-endings in the stomach. It is not always an easy matter to determine the exact mode of action of an emetic. If the drug be injected into a vein, it may act directly on the vomiting center, or, being eliminated through the stomach, it may act reflexly by irri- tating the sensory nerves of that organ ; or again, if the drug be given by the mouth, it may irritate the stomach and pro- voke emesis through a reflex action, or, being absorbed, it may excite the vomiting center directly. If, however, a drug acts more promptly when injected subcutaneously than when it is given by the mouth, and if vomiting follows its injection after the stomach has been replaced by a bladder filled with water, or after all the arteries leading to the stomach have been ligated, it may be assumed that its action is chiefly a direct one on the center in the medulla. The action of apomorpliin is purely central, while that of copper sulphate, zinc sulphate, yellow sulphate of mercury, alum, mustard, ipecac, and antimony is probably entirely peripheral, although some writers believe that the last two drugs have some direct influence on the medulla. Emetics may be employed for one of three purposes : To expel irritating food or poisons from the stomach ; to expel foreign bodies, false membrane, or excessive secretion from the respiratory tract ; and to expel mucus and bile from the gall-ducts in catarrhal jaundice. Emetics should be avoided or used with extreme caution in advanced pregnancy and in persons suffering from aneurysm, atheroma, or hernia. Apomorphin Hydrochloric! (see p. 273).— This drug is IPECA CUANHA -MERCl 'R \ ' SUBSULPHA TE. 1 67 the most prompt and reliable emetic that we possess ; more- over, it causes little nausea, and it is effective when admin- istered hypodermically. It is very useful in poiso?iing, espe- cially when swallowing is impossible, or when the state of the stomach is such as to prohibit the use of a mechanical or irritant emetic. In acute alcoholism it is exceedingly effectual. In some cases of narcotic poisoning, on account of the decreased sensitiveness of the medullary center, apormorphin, like other emetics, may prove inactive. As an emetic the drug should be administered hypodermically, although it will provoke vomiting when given by the mouth if the dose be sufficiently large. It must be borne in mind that in the very young and infirm considerable depression may attend its action. The dose is from T V~ ir § T - (0.005-0.01 gm.). Solutions are most conveniently prepared from tablets containing the requisite dose. Both tablets and solution are liable to deteriorate with age and on exposure to light and air. Ipecacuanha (see p. 269). — This drug is a safe and fairly prompt emetic. Its action is not so vigorous or so depressing as that of the mineral emetics. It is especially adapted for children, in whom it may be employed to unload the stomach of irritant food or to expel tenacious mucus from the air- passages. The syrup and the wine are eligible preparations, and either may be given to children in doses of from \-2 fl. dr. (2.0-8.0 ex.). Tartar Emetic (see p. 271;. — The use of antimonial prepa- rations as emetics is fortunately obsolescent. As their action is slow and is attended with prolonged nausea and depression, apomorphin, ipecacuanha, zinc sulphate, or mustard should always be selected in their stead. £inc Sulphate (see p. 367). — As an emetic zinc sulphate is employed chiefly in narcotic poisoning. The dose is from 10-30 gr. (0.65-2.0 gm.), repeated in fifteen or twenty minutes, if necessary. Copper Sulphate (see p. 366). — This drug is a more prompt and powerful emetic than zinc sulphate. In phos- phorus poisoni?ig it serves a double purpose : it not only unloads the stomach, but it also acts as a partial antidote by coating the phosphorus with an insoluble phosphid of copper. The dose of copper sulphate is from 5-10 gr. (0.3-0.65 gm.), and when this amount has been administered without effect, it is best not to repeat it, but to resort to some other emetic. Mercury Subsulphate (Turpeth Mineral). — This drug was formerly used in doses of 2-3 gr. (o. 1 3-0.2 gm.) as an emetic in croup. Although certainty, quickness of action, 1 68 ANTI-EMETICS. tastelessness, and small bulk are in its favor, it cannot be recommended on account of its exceedingly irritant properties. Alum. — Powdered alum is a safe but somewhat uncertain emetic. It may be given to children in doses of a teaspoonful, in syrup, and repeated once or twice if vomiting does not ensue. Mustard. — Mustard flour is a prompt and energetic emetic. It may replace zinc sulphate or copper sulphate in narcotic poisoning. It is contraindicated when there is acute gastritis. The dose is a tablespoonful stirred up in a glass of water, and repeated in ten or fifteen minutes if necessary. ANTI-EMETICS. The treatment of vomiting must be modified according to the cause. In the vomiting of intestinal obstruction it is only in rare instances that anything short of operative interference brings relief. Severe vomiting is sometimes an early mani- festation of chronic Bright's disease, and when such is the case, gastric sedatives are of little avail ; our main reliance must be on eliminant measures. Reflex vomiting is not un- common, and may be associated with lesions in various parts of the body, as the bowel, gall-bladder, kidney, lung, internal ear, or the uterus or its appendages. In this type of vomiting treatment, to be really curative, must be directed to the orig- inal cause. The exact etiology of the vomiting of pregnancy is still undetermined, and hence its treatment must be in a measure empiric. There is a growing conviction, however, that hyper- emesis gravidarum is dependent upon several co-operative factors, the most important of which are the presence in the blood of irritant toxins ; reflex irritation from uterine displace- ment or from inflammatory lesions of the uterus or its append- ages ; circulatory disturbances in the medulla ; and, finally, in certain cases, a neurotic or hysteric element. In this form of vomiting remedies directed solely to the stomach generally prove ineffective. To rid the body of noxious materials warm baths, mild laxatives, and saline injections into the bowel or under the skin are useful remedies. Saline transfusions are particularly efficacious in that they dilute the poisons circu- lating in the blood, increase elimination, serve to maintain the arterial pressure, and help to nourish the patient. Pelvic irri- tation should receive careful attention. In some cases drugs ANTI-EMETICS. 1 69 that raise the arterial pressure on the medulla, like strychnin, act beneficially; in others, vasodilators, like nitroglycerin, give better results. Drugs that directly depress the vomiting center are sometimes serviceable ; chloral and bromids are the best of this class ; morphin, as a rule, is badly borne. In neurotic subjects firmness tempered with kindliness and encouragement is essential to success. When the hysterical element is very pronounced, the Weir-Mitchell treatment can be recommended with considerable confidence. When the measures which have been indicated, after a thorough trial prove futile, and the life of the patient is jeopardized by the incessant vomiting, there ought to be no question in the mind of the practitioner as to the advisability of terminating the pregnancy. A curious form of vomiting is that which is known, for want of a better name, as nervous vomiting. It is not associated with any anatomic lesion of the stomach or with changes in the quantity or quality of the food, nor is it apparently of reflex character. In many instances it is evidently a symptom of hysteria. In this condition anti-emetics — cerium oxalate, menthol, hydrocyanic acid, and bismuth — are sometimes useful, but they more often fail. Suppositories of valerian, asafetida, and belladonna may prove efficacious. Lavage followed by the administration of silver nitrate (gr. \ — 0.016 gm.) often serves to allay the irritability of the gastric nerves. Hot com- presses, sinapisms, or blisters over the epigastrium are indi- cated. A spray of ethyl chlorid along the spine and over the stomach has given good results. Galvanism with a current of low density, one pole (negative) over the back of the neck and the other (positive) within the stomach, may afford prompt relief. In many cases it is necessary to keep the patient per- fectly quiet in the recumbent position, and to feed exclu- sively by the rectum. In intractable cases the Weir-Mitchell treatment should be given a thorough trial. Vomiting dependent upon cancer of the stomach is some- times controlled temporarily or lessened by anti-emetics. Cerium oxalate, ice-cold carbonated water, chloroform, hydro- cyanic acid, and bismuth may be tried. Morphin hypoder- mically or by the rectum is also useful. When there is ob- struction of the pylorus, lavage is of great service. When the vomiting of ulcer is not relieved promptly by gastric sedatives, the patient should be kept at complete rest for a few days and nourished by rectal injections. Counter- irritation by means of small blisters over the epigastrium is useful. Inhalations of vinegar will often allay the nausea and vomiting resulting from etherization. I70 GASTRIC ANTACIDS. From the foregoing it is evident that while anti-emetics are often exceedingly useful, they should be regarded as only palliative remedies or as adjuvants to more important curative measures. Anti-emetics may accomplish their purpose directly by acting on the center in the medulla, or indirectly by allay- ing irritability of the sensory nerve-endings in the stomach. To the first class belong: Opium. Bromids. Hydrated Chloral. To the second class belong : Carbonated water. Chloroform. Ice. Silver nitrate. Bismuth subnitrate. Menthol. Hydrocyanic acid. Lime-water. Carbolic acid. Ipecac (minute doses). Cocain. Cerium oxalate. All these agents, with the exception of cerium oxalate, are considered under other headings. CERII OXALAS, U. S. P. (Cerium Oxalate ; Ce 2 (C 2 4 ) 3 -f 9H 2 0.) Cerium oxalate is a white, odorless, and tasteless powder, insoluble in water or alcohol. In doses of from 6 to 15 gr. (0.3-1.0 gm.), preferably in the form of a dry powder, it is a very useful anti-emetic, acting mechanically, like bismuth subni- trate, by coating the wall of the stomach. It is not absorbed from the gastro-intestinal tract and is non-toxic. It has been chiefly employed against the vomiting of preg- nancy ; but it is far more efficacious in allaying vomiting caused by irritation of the mucous membrane of the stomach, such as occurs in gastritis, gastric ulcer, and gastric cancer. A combination like the following is often effective : j£ Cerii oxalatis, Bismuthi subnitratis, aa sjiss (6.0 gm.) ; Pulveris ipecacuanha, gr. iij (0.2 gm.). — M. Ft. chat-tube No. xii. Sig. one powder every hour. GASTRIC ANTACIDS. Gastric antacids are drugs employed to neutralize acidity of the stomach-contents. Some drugs, like the carbonate and bicarbonate of sodium, have the power of lessening not only the acidity of the stomach-contents, but also that of the SOD II BICARBONAS. 171 urine. Others, like ammonia and ammonium carbonate, serve as antacids in the stomach, but are eliminated in such a form that they have no influence on the reaction of the urine. Again, there are other drugs, like the vegetable salts of potas- sium and lithium, which have very little effect upon the acidity of the stomach, but, being eliminated as alkaline carbonates, render the urine less acid. Gastric antacids are employed to neutralize the organic acids (lactic, butyric, and acetic) resulting from fermentation of the stomach-contents, and which excite eructations, heart- burn, and gastralgia ; to lessen the acidity in cases of hyper- chlorhydria ; and to antagonize poisons of an acid character. It is generally believed that alkalies and alkaline carbonates, when taken before meals, stimulate gastric secretion, but the experiments of Reichmann and others have clearly shown that they produce no such effect. What efficacy they have in mild derangement of digestion is to be attributed to their power of neutralizing excessive acidity, dissolving tenacious mucus, and stimulating the stomach wall itself. The most important antacids are : Sodium bicarbonate. Magnesium carbonate. Lime-water. Calcium carbonate. Magnesia. Ammonia. SODII BICARBONAS, U. S. P. (Sodium bicarbonate; NaHC0 3 .) Sodium bicarbonate is a white, opaque, odorless powder, having a cooling, faintly alkaline taste. It is soluble in 12 parts of water and insoluble in alcohol. The dose is from 5-3° g r - (0.3-2.0 gm.). Preparations. Dose. Mistura Rhei et Sodae, U. S. P 1-2 fl. dr. (2.0-8.0 c.c). Pulvis Effervescens Compositus (Seidlitz Powder), U. S. P. Trochisci Sodii Bicarbonatis, U. S. P., contain z\ gr. (0.18 gm.) each. Therapeutics. — Sodium bicarbonate is extensively used in diseases of the stomach to neutralize abnormal acids or hydrochloric acid when in excess. Given before meals in small doses (3-5 gr. — 0.2-0.3 gm.), with some bitter stomachic, it often affords prompt relief in mild forms of indigestion. Given an hour or two after meals it allays the burning pain, eructa- tions, and palpitation due to the acids of fermentation. Given at the height of digestion in large doses it relieves the painful 172 GASTRIC ANTACIDS. crises of hyperchlorhydria. Large doses of sodium bicarbonate are also useful in neutralizing the hydrochloric superacidity encountered in gastric ulcer. In the chronic gastro-intestinal catarrh of childhood, characterized by capricious appetite, tympanites, eructations, troubled sleep, and hard, lumpy, mucous stools, sodium bicarbonate with a bitter and a mild laxative often gives excellent results. In daily doses of from 5-10 dr. (20.0-40.0 gm.) it has been employed successfully by Huchard and others in averting diabetic coma. In fully developed coma the drug should be given intravenously in 3 to 5 per cent, acid solution to the extent of one or two pints. The subcutaneous injection of alkaline solutions should be avoided, as not rarely they cause sloughing. Sodium bicarbonate is sometimes used externally as a seda- tive dressing in superficial burns. A 5 to 10 per cent, solu- tion is an excellent remedy for thrush. It is employed as a detergent in many washes designed for chronic catarrhal affec- tions of the nasopharynx ', and it is an ingredient of the well- known Dobell's solution, which may be prescribed as follows : ij Sodii bicarbonatis, Sodii boratis, aa gj (4.0 gm.) ; Phenolis, gr. xxx (2.0 gm.) ; Glycerini, f!|j (30.0 c.c.) ; Aquae, Oij (1.0 L.). — M. Sodium bicarbonate is incompatible with acids, metallic salts, and alkaloids. LIQUOR CALCIS, U. S. P. (Solution of Calcium Hydroxid ; Lime-water.) Lime-water is a saturated aqueous solution of calcium hydroxid made by slaking lime with water. It is a clear, color- less liquid, odorless, and having a saline, slightly caustic taste. It contains about 0.17 per cent, of calcium hydroxid. The dose is from -1—2 fl. oz. (15.0-60.0 c.c). Preparations. Linimentum Calcis, U. S. P. (lime liniment, Carron oil), contains equal volumes of lime-water and linseed oil. Lotio Hydrargyri Flava (yellow-wash), \ dr. (2.0 gm.) of corrosive sublimate to I pint (o. 5 L. ) of lime-water. Lotio Hydrargyri Nigra (black-wash), I dr. (4.0 gm. ) of calomel to I pint (0.5 L.) of lime-water. Therapeutics. — In all conditions in which cows' milk is the chief article of diet, lime-water may be added to the milk, to prevent the formation in the stomach of hard curds. OTHER ANTACIDS. 1 73 In the diarrhea of children and in typhoid fever it is especially useful when employed in this way. It is sometimes a useful remedy in obstinate vomiting, particularly when the latter is due to a high degree of acidity. In chronic gastric catarrh with excessive secretion of mucus, washing out the stomach with a weak solution of lime-water (i : 10) before breakfast may be practised with great benefit. Inhalations of atomized lime-water have been recommended for their solvent effect in diphtheria and fibrinous bronchitis. As an alkaline astringent lime-water is sometimes employed as an injection in vaginitis, leucorrhea, and urethritis. It may be used also as an injection in seat-worms, although it is in- ferior to an infusion of quassia. Carron oil is used as a soothing application for burns and scalds. It has received its name from being so extensively used by the workmen in the found- ries at Carron, Scotland. OTHER ANTACIDS- Magnesia (see p. 199).' — Magnesia or magnesium oxid is official in two forms : light or calcined magnesia {Magnesii Oxiduni) and heavy magnesia {Magnesii Oxidum Po?iderosuni). Both forms occur as white, insoluble powder, odorless, and having a slightly earthy taste. Heavy differs from light mag- nesia not only in its weight, but also in its not readily uniting with w r ater to form a gelatinous hydroxid. The dose of either oxid is from 10-60 gr. (0.65-4.0 gm.). Magnesia combines the usefulness of an antacid with that of a mild laxative. When there is constipation, it may be given instead of sodium bicarbonate or combined with that drug in all conditions in which an antacid is indicated. In the diarrhea of childhood, when there is unnatural acidity of the prima? vice, it is an excellent laxative for removing sour, indi- gestible food. In ulcer of the stomach it may be advantageously combined with bismuth to control constipation. Magnesium Carbonate (see p. 200). — This drug is used in the same doses and for the same purposes as magnesia. Calcium Carbonate (see p. 377). — Calcium carbonate or chalk is an unirritating antacid and a feeble astringent. It is very useful in diarrhea with acidity of the pri?nce via?, and it may be combined with bismuth subnitrate in the treatment of gastric ulcer when there is a marked tendency to looseness of the bowels. It is a chemical antidote to all the poisonous acids. 174 STOMACHICS. Ammonia (see p. 41). — Aromatic spirit of ammonia, in doses of from 20-30 min. (1.2-2.0 c.c), may be used instead of sodium bicarbonate to relieve the headache, heart-burn, and pyrosis arising from acid fermentation in the stomach. STOMACHICS. Stomachics are drugs which sharpen the appetite and pro- mote the functional activity of the stomach. The most im- portant members of this class of remedies are : Gentian. Condurango. Quassia. Taraxacum. Calumba. Eupatorium. Nux vomica. Serpentaria. Cinchona. Cascarilla. Chirata. Wild cherry. Chamomile. Alcohol. Hydrastis. Orexin. All stomachics, with the exception of the last two in the fore- going list, contain a bitter principle. Taken by the mouth, bitters improve the appetite, and, by stimulating the gustatory nerve-endings, reflexly increase the salivary and gastric secre- tions. Being more or less irritant to the mucous membrane of the stomach and bowel, they also augment the peristaltic movements. With the exception of cinchona and nux vomica, which have important constitutional actions, they probably exert no direct influence beyond the digestive organs. To be effective, they should be taken in liquid form a short time before eating As a class, stomachics are useful in atony of the stomach, in chronic gastritis when the mucous membrane is not very irritable, and in the early stages of cancer. They are contraindicated in all conditions involving the stomach in which there is marked irritability or hypersecretion. GENTIANA, U. S. P. (Gentian.) Gentian is the root of Gentiana lutea, a perennial herb growing in the mountainous districts of Central and Southern Europe. It contains an extremely bitter glucosid, gentio- picrin, and gentisic or gentianic acid, which is inert. QUASSIA— CALUMB A. 1 75 Preparations. Dose. Tinctura Gentianae Composita, U. S. P. ] (contains also bitter orange-peel and 1 1-2 fl. dr. (4.0-8.0 c.c). cardamom) ' J Fluidextractum Gentianae, U. S. P. . . . 10-30 min. (0.6-2.0 c.c.). Infusion Gentianae Compositum .... $-2 fl. oz. (15.0-60.0 c.c). Extractum Gentianae, U. S. P 2-5 gr. (0.13-0.3 gm.). Therapeutics. — Gentian is one of the most reliable of the bitter tonics. It is often of great value in the milder forms of chronic indigestion, in the dyspepsia of phthisis, and in the early stages of cancer. It is an excellent restorative in the conva- lescence of acute fevers. In indigestion it may be advantage- ously combined with an alkali, as in the following formula : R Sodii bicarbonatis, ^ij (8.0 gm.) ; Infusi gentianse compositi, f^vj (180.0 c.c). — M. Sig. A tablespoonful before meals. QUASSIA, U. S. P. Quassia is the wood of Picrasma excelsa, or of Quassia amara, a tree resembling the common ash, growing in the West Indies. It contains a bitter crystalline principle, quassin, but no tannic acid. The dose of quassin is from ^— \ gr. (0.002-0.02 gm.). Preparations. Dose. Tinctura Quassiae, U. S. P ^-1 fl. dr. (2.0-4.0 c.c). Fluidextractum Quassiae, U. S. P. . . 10-20 min. (0.6-I.2 c.c). Extractum Quassiae, U. S. P 1-3 gr. (0.06-1. 2«gm.). Infusion Quassiae \-2 fl. oz. (15.0-60.0 c.c). Therapeutics. — As a stomachic, quassia may be used in the same class of cases as gentian. The rectal injection of an infusion made by adding an ounce (31.0 gm.) of quassia chips to a pint (0.5 L.) of water is an effi- cient anthelmintic against seat-worms (Oxyuris vermicularis). To secure the best results the bowel should first be thoroughly cleansed by means of a simple soap-and-water enema. As quassia does not contain tannic acid, its preparations are not incompatible with the salts of iron. CALUMBA, U. S. P. (Columbo.) Calumba is the root of Jateorhiza palmata, growing in Eastern Africa. It contains an alkaloid, berberin, a neutral principle, columbin, and columbic acid, all of which are bitter. Preparations. Dose. Tinctura Calumbse, U. S. P i-2 fl. dr. (2.0-8.0 c.c). Fluidextractum Calumbae, U. S. P. . . 10-30 min. (0.6-2.0 c.c). Extractum Calumbae 2-5 gr. (o. 13-0.3 gm.). Infusum Calumbae £-2 fl. oz. (15.0-60.0 c.c.). 176 STOMACHICS. Therapeutics. — Calumba is a pure, unirritating bitter, and may be prescribed with confidence in the various conditions in which stomachics are indicated. It may be combined with either acids or alkalies, and since it contains no tannin, it does not form a black, unsightly mixture with the salts of iron. In atony of the stomach it may be combined witn nux vomica, as in the following formula : R Tincturae capsici, TTLxvj (i.oc.c). Tincturae nucis vomicae, f^ij (8.0 c.c). Tiincturae calumbae, q. s. ad f^ij (60.0 c.c). — M. Sig. A teaspoonful in water before meals. CHIRATA, U. S. P. (Chiretta.) Chirata is the entire plant of Swertia chirayita, growing in the mountains of Northern India. It contains a bitter crystal- line glucosid, chiratin, and ophelic acid, which is also bitter. Preparations. Dose. Fluidextractum Chiratae, U. S. P.' . . . 10-30 min. (0.6-2.0 c.c). Tinctura Chirata? £-1 fl. dr. (0.2-4.0 c.c). Infusion Chiratae £-2 fl. oz. (15.0-60.0 c.c). Therapeutics. — In addition to its virtues as a bitter stom- achic, chirata is supposed to possess decided cholagogue prop- erties. It is useful in those forms of indigestion which are associated with so-called bilious attacks. Like quassia and calumba, it is free from tannic acid ; it is therefore not incom- patible with iron salts. ANTHEMIS, U. S. P. (Chamomile.) Chamomile is the flower-heads of Anthemis nobilis, a per- ennial plant cultivated in Western Europe, and to some extent in the United States. It contains a volatile oil, a bitter prin- ciple, anthemin, and a small amount of tannin. Chamomile is a mild stomachic and carminative, and is usually employed in the form of an infusion (unofficial), of which 1-2 fl. oz. (30.0-60.0 c.c.) may be givea CONDURANGO. Condurango is the bark of Gonolobus Condurango, a climb- ing vine indigenous to Ecuador. It contains tannin and one or two bitter glucosids. It is usually employed in the form of the fluid extract in doses of from 20-60 min. (1.2-4.0 c.c). Therapeutics. — Condurango was first recommended by TAR AX A CUM—E UP A TORIUM. 1 7 7 Friedreich in 1874 as a curative remedy in cancer of the stomach. Later, Immermann and Riess reported cases in support of this view ; but the testimony of numerous impar- tial observers has proved conclusively that the drug is with- out specific action. Notwithstanding the adverse opinion as to its curative power, nearly all who have used the drug agree that it often acts most beneficially on the concomitant catarrh, sharpening the appetite, lessening the pain, and promoting digestion. In some cases of simple gastric catarrh it is also efficacious. It may be prescribed with hydrochloric acid, as in the following formula: R Acidi hydrochlorici diluti, fjiss (6.0 c.c); Fluidextracti condurango, Glycerini, aa fzvj (22.5 c.c); Vini xerici, q. s. ad fjfiv (120.0 c.c). — M. Sig. A dessertspoonful in water after meals. TARAXACUM, U. S. P. (Dandelion.) Taraxacum is the root of Taraxacum officinale, growing in Europe and North America. It contains a crystalline bitter principle, taraxacin. Preparations. Dose. Fluidextractum Taraxaci, U. S. P. . „ . . £—2 fl. dr. (2.0-8.0 c.c). Extractum Taraxaci, U. S. P 5-30 gr. (0.3-2.0 gm.). Therapeutics. — Taraxacum is a mild stomachic, possess- ing feeble laxative properties. EUPATORIUM, U. S. P. (Boneset; Thoroughwort.) Eupatorium is the leaves and flowering tops of Eupatorium perfoliatum, a perennial plant growing in North America. It contains a bitter crystalline glucosid, eupatorin, tannin, and a volatile oil. Preparations. Dose. Fluidextractum Eupatorii, U. S. P. . . £-1 fl. dr. (2.0-4.0 c.c). Infusion Eupatorii 1-4 fl. oz. (30.0-120.0 c.c). Therapeutics. — Eupatorium is employed as a stomachic and diaphoretic. Large doses excite vomiting and purging. The infusion, taken while hot, has long been a popular house- hold remedy in colds and muscular rheumatism, 12 1^8 STOMACHICS. SERPENTARIA, U. S. P. (Virginia Snakeroot.) Serpentaria is the rhizome and roots of Aristolochia Serpen- taria, a perennial herb growing in the woods of the Eastern and Southern United States. It contains a bitter principle, aristolochin, a resin, tannin, and a volatile oil. Preparations. Dose. Tinctura Serpentariae, U. S. P. \-2 fl. dr. (2.0-8.0 c.c). Fluidextractum Serpentariae, U. S. P. . . . 10-30 min. (0.6-2.0 c.c). Tinctura Cinchonee Composita, U. S. P., con- tains 2 per cent, serpentaria 1-4 fl. dr. (4.0-15.0 c.c). Infusum Serpentariae £-2 fl. oz. (15.0-60.0 c.c). Therapeutics. — Serpentaria is believed to possess, in addi- tion to its properties as a bitter tonic, the power of increasing the secretions, especially the sweat and the urine. Large doses are capable of causing nausea and vomiting. Serpen- taria has been extensively employed as a stomachic in atonic dyspepsia, and, combined with more potent remedies, like nux vomica and cinchona, as a tonic in the convalescent stage of acute fevers. Garrod believes it to be a remedy of some power in chronic rheumatism. CASCARILLA. Cascarilla is the bark of Croton Eleuteria, a shrub growing in the Bahama Islands. It contains a bitter principle, cascarillin t a volatile oil, a resin, and tannin. Preparations. Dose. Tinctura Cascarillae |— 2 fl. dr. (2.0-8.0 c.c). Fluidextractum Cascarillae 10-30 min. (0.6-2.0 c.c). Infusum Cascarillae \-z fl. oz. (15.0-60.0 c.c). Extractum Cascarillae 5-10 gr. (0.3-0.65 gm.). Therapeutics. — The action of cascarilla resembles some- what that of serpentaria. For two centuries it was a favorite remedy in Germany and France in low fevers, diarrhea, and dysentery. At present it is rarely employed except as a bitter tonic. Mineral acids should not be given with the tincture or the fluid extract, since they precipitate the resin. PRUNUS VIRGINIANA, U. S. P. (Wild Cherry.) Prunus virginiana is the bark of Prunus serotina, a large tree growing in North America. It contains tannic acid, a OTHER STOMACHICS. 1 79 bitter principle, a non-crystalline glucoside — amygdalitis and a ferment — emulsin. Hydrocyanic acid is formed from the union of the last two constituents in the presence of water. Preparations. Dose. Fluidextractum Pruni Virginianae, U. S. P. . . £-1 fl. dr. (2.0-4.OC.C.). Syrupus Pruni Virginianae, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). Infusum Pruni Virginianae, U. S. P ^-2 fl. oz. (1 5.0-60.0 c.c). Therapeutics.— Wild cherry is a bitter tonic and a feeble nerve-sedative. It has been extensively employed in phthisis to allay irritable cough, its efficacy being attributed to the hydrocyanic acid. The amount of acid present, however, is so small that it can scarcely be of therapeutic value. It has also been used on the recommendation of Allbutt to combat the dyspnea and dyspepsia of heart-disease, but Allbutt him- self admits that it is only in the very early stages of the dis- ease that it exerts any decided influence. On account of its agreeable taste it is an excellent vehicle for unpalatable drugs. OREXIN. ( Phenyl-dihydro-chin-azolin.) Orexin is a complex synthetic compound derived from chinolin. The tannate of orexin being freest from irritating properties is the best preparation for medicinal use. This salt appears as a yellowish- white, odorless powder, having a chalky taste. It is insoluble in water, but readily soluble in dilute hydrochloric acid. The dose is from 5-8 gr. (0.3-0.5 gm.), in capsules or tablets. Therapeutics. — Orexin possesses the power to a certain extent of sharpening the appetite, stimulating the secretion of hydrochloric acid, and increasing the motor activity of the stomach. It is sometimes useful in restoring the appetite in the early stages of phthisis, in chlorosis, in neurasthenia, and in convalescence from acute diseases. Penzoldt and Hermann! have spoken very favorably of it in the vomiting of pregnancy. It is contraindicated in organic diseases of the stomach — cancer, ulcer, and gastritis — and in cases of hyperacidity. It should be given two or three times a day, two hours before meals, and followed by a draft of half a glass of water. OTHER STOMACHICS. Alcohol (see p. 43). — In small quantities dilute alcohol augments the flow of the gastric secretion, stimulates the peristaltic movements, and accelerates absorption. Large amounts retard digestion. In the form of light claret, dry l8o DIGESTANTS. sherry, or whisky, it is often of service in dyspepsia associated with atony in the stomach, particularly in old persons ; but the greatest caution is necessary in ordering it on account of the danger of inducing the alcohol habit. All alcoholic prepara- tions are contraindicated when there is hyperesthesia of the stomach or hypersecretion of acid. Nux Vomica (see p. 141). — On account of its general tonic properties nux vomica has a decided advantage over many other bitters. It not only sharpens the appetite and increases secretion, but it probably has more effect than any other stomachic on the muscular movement of the stomach and intestines. In chronic i?idigestion, when there are no evi- dences of decided irritation, it is often very efficient. In dila- tation of the stomach the result of atony it is our most valuable drug, and should be given in full doses. It is also useful in those cases of marked flatulence, common in elderly people, and dependent upon a lack of tone in the walls of the stomach and bowel. Cinchona (see p. 415). — Cinchona to a certain extent shares with nux vomica the advantage of being a general tonic as well as a stomachic. The compound tincture of cinchona (Hux- ham's tincture) is specially serviceable as a bitter tonic in the convalescence of acute febrile diseases. The indigestion re- sulting from overwork is often promptly relieved by a combi- nation of quinin in small doses with nux vomica, as in the following formula : R . Quininse sulphatis, gr. x (0.65 gm.) ; Ferri lactatis, gr. xx (1.3 gm.); Extracti nucis vomicae, gr. v (0.3 gm.) ; Pulveris ipecacuanhae, gr. iij (0.2 gm.) ; Oleoresinae capsici, gr. ij (0.13 gm.). — M. Fiant pilulae No. xx. Sig. One after meals. Hydrastis (see p. 379). — Hydrastis is a useful bitter tonic in asthenic gastritis with motor insufficiency. In addition to its virtues as a stomachic, it is an active stimulant to intestinal peristalsis. According to the researches of Rutherford and of Cerna, it increases the flow of bile. The drug may be employed in the form of the fluid extract (|— I fl. dr. — 2.0- 4.0 c.c.) or of its chief alkaloid, hydrastin (-|— \ gr. — 0.0 1 - 0.03 gm.). DIGESTANTS. Of the agents which take part in the process of natural digestion the most important from the standpoint of the thera- peutist are hydrochloric acid, pepsin, and the enzymes contained ACIDUM HYDROCHLORICUM. l8l in the pancreatic secretion — trypsin, amylopsin, and steapsin. Hydrochloric acid, the natural acid of the stomach, is the most valuable of all digestants. It aids digestion not only directly, but also indirectly by stimulating the activities of the stomach, by preventing fermentation, and by assisting in the conversion of pepsinogen into the active pepsin and of labzymogen into the active labferment. As a remedy, hydrochloric acid is indicated in all conditions associated with inacidity or marked hypoacidity. Pepsin, being absent from the gastric juice far less frequently than hydrochloric acid, is distinctly less useful as a remedy than the latter. It is of service, however, in conditions asso- ciated with apepsia or hypopepsia, such as the advanced stages of chronic gastritis, atrophy of the gastric glands, and carcinoma. Of the pancreatic enzymes, trypsin digests proteids, amy- lopsin acts upon starches, and steapsin decomposes fats. Since these enzymes act best in alkaline or neutral solutions, and the contents of the stomach are naturally acid, it is argued by some authorities that artificial pancreatic extracts can possess no medicinal value ; but it should be remembered that the contents of the stomach do not normally become acid until from ten to fifteen minutes after the ingestion of the food, that in indigestion the secretion of acid is often delayed, and that at least one of the constituents of the pancreatic secretion — trypsin, a more powerful proteolytic enzyme than pepsin — retains its effectiveness even in solutions that are somewhat acid. The digestants in common use are : Hydrochloric acid. Pancreatin. Pepsin. Diastase. Papayotin. ACIDUM HYDROCHLORICUM, U. S. P. (Hydrochloric or Muriatic Acid ; HC1.) The official acid is a colorless, fuming liquid, of a pungent odor and an intensely acid taste. It contains 31.9 per cent, by weight of absolute hydrochloric acid. The dose is from 3-6 min. (0.2-0.4 c.c.) well diluted. Preparation. Dose. Acidum Hydrochloricum Dilutum, U. S. P., contains 10 per cent, of absolute hydrochloric acid 5-20 min. (0.3-1.2 c.c). 1 82 DIGESTANTS. Toxicology. — In overdoses, hydrochloric acid, like other mineral acids, acts as an irritant poison, causing intense burn- ing pain, vomiting and purging of mucous and bloody mate- rial, and collapse. The treatment consists in antagonizing the poison by soda, lime, chalk, soap, or other alkalies ; in pro- tecting the stomach by demulcents ; in combating collapse with diffusible stimulants, administered hypodermically ; and in relieving pain with morphin. Therapeutics. — Hydrochloric acid is useful in certain conditions of the stomach associated with inacidity or hypo- acidity, such as chronic asthenic gastritis, atrophy of the gastric glands, and cancer of the stomach. It is contraindicated, even though the normal acid is wanting, when there is any evidence of active inflammation. In the continued fevers it sometimes acts beneficially as a refrigerant and digestant, the gastric juice in these cases being generally deficient. The strong acid is sometimes employed externally as an eschar otic. Administration. — In indigestion the acid should be given after meals, well diluted, care being taken to rinse the mouth thoroughly after its exhibition. It may be prescribed with a bitter tonic, as in the following formula : R. Strychninse sulphatis, gr. j (0.065 gm.) ; Acidi hydrochlorici diluti, fgij (8.0 c.c.) ; Pepsini, £iss (6.0 gm.) ; Tincturse cardamomi composite, f^ss (15.0 c.c.) ; Aquae, q. s. ad fjiv (120.0 c.c). — M. Sig. A teaspoonful in water after meals. Incompatibles. — Hydrochloric acid is incompatible with oxids, alkalies, carbonates, and hydrates, with many metallic salts, with albumin, and with some glucosids (glycyrrhizin). In the above formula the hydrochloric acid sets free insoluble carminic acid, but its formation is of no moment. PEPSINUM, U. S. P. (Pepsin.) Pepsin is a proteolytic ferment obtained from the glandular layer of fresh stomachs from healthy pigs. To be up to the official standard, it should be capable of digesting, under favorable conditions, not less than 3000 times its own weight of freshly coagulated and disintegrated egg-albumen. It occurs as a yellowish-white, amorphous powder, or as yellow translucent scales, having a faint odor and slightly acidulous or saline taste. It is soluble in about 50 parts of water, more PA NCR EA TINUM. 1 8 3 so in water containing hydrochloric acid, and insoluble in alco- hol. The dose is from 5-20 gr. (0.3-1.3 gm.). Therapeutics. — Pepsin is sometimes of service in chronic gastritis, atrophy of the gastric glands, and cancer, but, as a rule, it is less efficacious than pancreatin, and both are inferior to dilute hydrochloric acid and bitters. Care should be taken to secure a reliable preparation. Pepsin should be given in full doses, with hydrochloric acid, after meals. Most substances destroy or impair the proteolytic action of the drug, especially alcohol and alkalies. PANCREATINUM, U. S. P. (Pancreatin.) Pancreatin is a mixture of enzymes naturally existing in the pancreas of warm-blooded animals, and usually obtained from the fresh pancreas of the hog or ox. It appears as a yellow- ish-white, amorphous powder, having a faint odor and a meat- like taste. To be up to the official standard it should be capable of converting not less than 25 times its own weight of starch into substances soluble in water. The dose is from 5- 20 gr. (0.3-1.3 gm.). In faintly alkaline solution pancreatin has the power of emul- sifying fats, and of converting proteids into diffusible peptones, and starches into sugars. In the presence of more than traces of mineral acids or large amounts of alkalies it soon becomes inert. Pancreatin is extensively used for peptonizing milk and other foods, the process being as follows : Mix 5 gr. (0.3 gm.) of pancreatin and 20 gr. (1.3 gm.) of sodium bicarbonate in a small teacupful of cool water, and pour into a bottle contain- ing a pint (0.5 L.) of fresh milk. Place the bottle in water so hot that the hand can be held in it without discomfort for a minute. As thoroughly digested milk has an unpleasant bitter taste, it is well to arrest digestion at the end of fifteen or twenty minutes by raising the milk for a few seconds to the boiling-point or by placing the bottle on ice. Pancreatin is a useful aid to digestion in conditions asso- ciated with hypoacidity. It should be combined with sodium bicarbonate and given immediately before or during meals, so that its digestive powers can be exercised in the stomach before the contents become distinctly acid. DIASTASE. Diastase is an amylolytic ferment obtained from malted grain — wheat, barley, oats, and rice. It ir. a yellowish-white 1 84 CARMINA TI VES. or brownish-yellow amorphous powder, tasteless, soluble in water, but insoluble in alcohol ; I part, under favorable con- ditions, should convert 2000 parts of starch into dextrin and maltose. The dose is from 3-5 gr. (0.2-0.3 g m -)- Extracts of malt containing a variable quantity of diastase are extensively employed. They are marketed in 3 forms : A thin liquid closely resembling beer ; a thick brown, syrupy liquid, containing much saccharine material ; and a dry pow- der, containing, in addition to diastase, dextrin, dextrose, and the salts of barley. These extracts are used as digestants and as general tonics, but their value has been much overrated. Chittenden finds that although diastase will act in neutral or alkaline solutions, it is most effective in solutions that are slightly acid. It may be given before meals when there is difficulty in digesting starchy foods. PAPAYOTIN. (Papain ; Papoid ; Caroid.) Papayotin is an albuminous ferment obtained from Carica Papaya, true papaw, or melon tree, growing in the tropics. It is a grayish-white amorphous powder, tasteless, and without odor. It is quite soluble in water and glycerin, but insoluble in alcohol and ether. The dose is from 5-10 gr. (0.3-0.6 gm.). It is claimed for papayotin that it will convert proteids into peptone, starch into maltose, and emulsify fats ; and that, although it will act in neutral or acid solutions, it is most active in solutions of an alkaline reaction. Clinical experience with the preparations on the market indicates that the drug is of doubtful value. CARMINATIVES. Carminatives are drugs that aid in the expulsion of gas from the stomach or intestines. The origin of the word is somewhat obscure ; it is probably derived from carmen, a card for wool — that is, a cleanser, but according to some authori- ties it is derived from carmen, a charm. The gases found in the alimentary canal are swallowed with the food, are formed by the action of acid upon the carbonates contained in the saliva and food, or they are generated through fermentation or putrefaction of food. The most common cause, how- ever, of abnormal accumulation of gas is fermentation. CAPSICUM. 185 Excessive accumulations of flatus distend the viscus, excite spasm of its muscular fibers, and thus occasion distress or actual pain. Carminatives prove effective probably by- relaxing the spasm, especially at the orifices, thus allowing the gas to escape. A form of distention occurs that is dependent upon atony of the walls of the stomach rather than upon an excessive accumulation of gas. In this condition carminatives are of little use. Although carminatives are chiefly valuable in expelling gas already formed, they also possess the power, to a very limited extent, of preventing the formation of flatus, for by quickening the gastric circulation and probably by increasing glandular activity, they play the part of stomachics, thus aiding digestion and lessening fermentation. As a class, carminatives are of service also in allaying spas- modic contraction of the intestine caused by irritants other than flatus ; thus they are effective in relieving colicky pains caused by irritant food or drugs, provided the irritation has not been sufficient to set up an inflammatory condition, in which case drugs of this class should be avoided. Carmina- tives are frequently combined with purgatives to prevent the griping pains that the latter are likely to induce when admin- istered alone. With the exception of alcohol, ether, and chloroform, carmi- natives are aromatics containing volatile oils as their chief active ingredients. The most important drugs of this class are : Capsicum. Ginger. Fennel. Pepper. Cinnamon. Coriander. Peppermint Cajuput. Asafetida. Spearmint. Anise. Ether. Cardamom. Pimenta. Compound Cloves. Sassafras. spirit of ether Nutmeg. Caraway. Chloroform. Turpentine. Carminatives are usually administered by the mouth, but asafetida and turpentine are often exceedingly efficacious in removing intestinal flatus when they are administered in the form of enemata. CAPSICUM, U. S. P. (Cayenne Pepper; African Pepper.) Capsicum is the fruit of Capsicum fastigiatum, a small shrub growing in tropical America, in Asia, and in Africa. Its active principle is probably capsaicin, which appears in the form of 1 86 CARMINA TIVES. colorless crystals of an exceedingly pungent character. The dose of the powdered drug is from 1-3 gr. (0.06-0.2 gm.). Preparations. Dose. Tinctura Capsici, U. S. P 10-20 min. (0.6-1.2 c.c.) Fluidextractum Capsici, U. S. P I- 2 min. (0.06-0. 1 2 c.c). Oleoresina Capsici, U. S. P \- I min. (0.016-0.06 c.c). Pilulae Podophylli, Belladonnse et Capsici, U. S. P. I- 2 pills. Emplastrum Capsici, U. S. P. Physiologic Action and Therapeutics. — Externally applied, capsicum excites burning and redness, and in concen- trated form even vesication. When taken internally in small doses, it produces a sense of warmth in the stomach, stimu- lates peristalsis, and aids in the expulsion of flatus. Large doses produce severe irritation of the gastro-intestinal and the genito-urinary tract, characterized by pain, vomiting, purging, and dysuria, with scanty, dark-colored urine. It is employed chiefly as a rubefacient, stomachic, and carminative. In the form of a liniment it is sometimes an excellent remedy in wry- neck, muscular rheumatism, and sprains. Capsicum plaster is an efficient counterirritant in pleurodynia and bronchitis. Combined with cantharides (tincture of cantharides, tincture of capsicum, and alcohol, of each, \ fl. oz. — 15 c.c.) it is fre- quently employed as a stimulating lotion in alopecia areata. A gargle consisting of half an ounce (15 c.c.) of the tincture in half a pint (235 c.c.) of water has been much used in domestic medicine in sore throat with relaxation of the uvula, but the remedy is inferior to many others, and in severe inflammations it is calculated to do harm. In the gastric catarrh following an alcoholic debauch, and characterized by fetid breath, a heavily furred tongue, ano- rexia, nausea, and a sinking sensation in the epigastrium, the tincture of capsicum in ten-drop doses is an invaluable sto- machic. In the flatulent dyspepsia of the aged, especially of old gourmands, it is a useful adjuvant to other stomachics. Cay- enne pepper in small doses may be employed to promote the absorption of certain drugs, notably of quinin. In obstinate constipation due to deficient peristalsis a small amount of the oleoresin may be added advantageously to a cathartic pill. PIPER, U. S. P. (Black Pepper.) Black pepper is the unripe fruit of Piper nigrum, a climbing vine cultivated in the East Indies. It contains a crystalline MENTHA PIPERITA— MENTHA VIRIDIS. 1 8? neutral principle, piperin, an aromatic volatile oil, and a pun- gent resin. Preparations. Dose. Piperina, U. S. P. 1-5 gr. (0.06-0.3 gm.). Oleoresina Piperis, U. S. P £-2 min. (0.03-0.1 c.c). Therapeutics. — Pepper is used chiefly as a condiment. Owing to its carminative properties, the oleoresin is sometimes added to cathartic pills. Piperin was at one time considered to be of value in malarial fever, but for lack of satisfactory- evidence of its efficacy its use in this affection has been entirely abandoned. MENTHA PIPERITA, U. S. P. (Peppermint.) Peppermint is the leaves and tops of Mentha piperita, a perennial herb growing in wet places throughout the Temper- ate Zone. Its active principle is a greenish-yellow volatile oil, having a strong, characteristic odor and a pungent taste, followed by a sense of coolness when air is drawn into the mouth. When subjected to refrigeration, it yields the stear- opten, menthol (p. 157). Preparations. Dose. Oleum Menthae Piperitae, U. S. P 1-5 min. (0.06-0.3 c.c). Spiritus Menthae Piperitae, U. S. P. (10 per cent.) 10-30 min. (0.6-2.0 c.c). Aqua Menthae Piperitae, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). The oil also enters into the official compound pills of rhu- barb and vegetable cathartic pills. Therapeutics. — Peppermint has long been employed as a carminative for relieving flatulence and colic, especially in young children. It is particularly useful in covering the taste of unpalatable medicines. The oil, or better still menthol, is sometimes effective, when applied locally, in relieving the milder forms of neuralgia. MENTHA VIRIDIS, U. S. P. (Spearmint.) Spearmint is the leaves and tops of Mentha spicata, a peren- nial herb growing wild in Europe and North America. Its active principle is a volatile oil. 1 88 CARMINA TIVES. Preparations. Dose. Oleum Menthae Viridis, U. S. P 1-5 min. (0.06-0.3 c.c). Spiritus Menthae Viridis, U. S. P. (10 per cent.) 10-30 min. (0.6-2.0 c.c). Aqua Menthae Viridis, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). Spearmint is the therapeutic equivalent of peppermint CARDAMOMUM, U. S. P. (Cardamom.) Cardamom is the fruit of Elettaria repens, a perennial herb cultivated in the mountainous regions of India. Its active principle is a volatile oil, of which it contains about 5 per cent. Preparations. Dose. Tinctura Cardamomi, U. S. P 1-2 fl. dr. (4.0-8.0 c.c). Tinctura Cardamomi Composita, U. S. P. (con- tains also cinnamon, caraway, cochineal, and glycerin) 1-2 fl. dr. (4.0-8.0 c.c). Pulvis Aromaticus, U. S. P. (contains also ginger, cinnamon, and nutmeg) 10-30 gr. (0.6-2.0 gm.). Cardamom also enters into the compound extract of colo- cynth, compound tincture of gentian, tincture of rhubarb, and aromatic tincture of rhubarb. Therapeutics. — It is used as an agreeable aromatic for disguising the taste of other drugs, and as an adjuvant to simple bitters in flatulent dyspepsia. When free acids are added to the compound tincture of cardamom, they separate from the cochineal insoluble carminic acid, but this incompatibility is of no particular importance. CARYOPHYLLUS, U. S. P. (Cloves.) Cloves are the unexpanded flowers of Eugenia aromatica, an evergreen indigenous to the East Indian Islands, and culti- vated to some extent in South America and Africa. They contain a yellow volatile oil of a characteristic odor and a pungent, spicy taste. The chief constituent of the oil is Eugenol. Preparations. Dose.. Oleum Caryophy Hi, U. S. P I -5 min. (0.06-0.3 c.c). Eugenol, U. S. P 1-5 min. (0.06-0.3 c.c). They also enter into compound tincture of lavender, aro- matic tincture of rhubarb, and wine of opium. Therapeutics. — Cloves are used as a counterirritant, local anesthetic, and carminative. They are one of the active ingre- MYR IS TIC A— ZINGIBER. 1 89 dients of the spice-poultice, which consists of powdered cloves, ginger, and cinnamon, of each, one or two teaspoonfuls ; flour, a tablespoonful ; whisky, sufficient to make a mass moist enough to spread on soft flannel. In this form they are a useful rubefacient for applying to the abdomen of children suffering from diarrhea. As a carminative, the oil is a useful addition to laxative pills, aiding materially in preventing griping. In intestinal colic brought on by exposure a drop or two of the oil in a teaspoonful of paregoric, repeated at short intervals, often gives speedy relief. The oil is also a popular remedy for toothache, being applied on a pledget of cotton to the cavity of the tooth. MYRISTICA, U. S. P. (Nutmeg.) Nutmeg is the seed of Myristica fragrans, an evergreen tree growing in the Molucca Islands and neighboring East India Islands. It contains a volatile oil, upon which its aromatic properties depend, and a fixed oil. Preparation. Dose. Oleum Myristicse, U. S P 1-5 min. (0.06-0.3 c.c). Nutmeg also enters into aromatic powder, compound tinc- ture of lavender, aromatic tincture of rhubarb, aromatic spirit of ammonia, and troches of sodium bicarbonate. In large doses nutmeg acts as a narcotic poison, producing headache, vertigo, delirium, stupor, coma, and, finally, death from respiratory paralysis. Like cloves, it is employed as a carminative and a local anodyne. ZINGIBER, U. S. P. (Ginger.) The rhizome of Zingiber officinale, a perennial herb growing in tropical countries. It contains a volatile oil having the odor of ginger, and a viscid resinous principle having a hot, pungent taste. Preparations. Dose. Tinctura Zingiberis. U. S. P 20-60 min. (1.2-4.0 c.c). Fluidextractum Zingiberis, U. S. P. . . 10-30 min. (0.6-2.0 c.c.). Syrupus Zingiberis, U. S. P £-4 fl. dr. (2.0-15.0 c.c). Oleoresina Zingiberis, U. S. P ^-2 min. (0.03-0.1 c.c). Ginger also enters into compound powder of rhubarb and aromatic powder. Therapeutics. — It is employed as a carminative and as a flavoring agent. 1 90 CARMINA TIVES. CINNAMOMUM. (Cinnamon.) The United States Pharmacopoeia recognizes 2 varieties of cinnamon : Cinnamomum Saigonicum (Saigon cinnamon), a species cultivated in the neighborhood of Saigon, the capital of French Cochin-China, and Cinnamomum Zeylanicum (Ceylon cinnamon). Cinnamon contains a volatile oil and a small amount of tannin. The oil consists chiefly of cinnamic aide- kyd, which on exposure is oxidized into resin and cinnamic acid. The official oil is distilled from Cassia or Chinese cin- namon. Preparations. Dose. Oleum Cinnamomi, U. S. P 1-5 min. (0.06-0.3 c.c). Cinnaldehydum, U. S. P £-3 min. (0.03-0.2 c.c.). Spiritus Cinnamomi, U. S. P. (10 percent. of oil) 10-30 min. (0.6-2.0 c.c). Tinctura Cinnamomi, U. S. P. (10 per cent. of cinnamon) \~2. fl. dr. (2.0-8.0 c.c). Aqua Cinnamomi, U. S. P \-\ fl. oz. (15.0-30.0 c.c). Cinnamon also enters into aromatic fluidextract, infusion of digitalis, compound tincture of cardamom, compound tincture of lavender, compound tincture of gambir, wine of opium, and aromatic powder. Therapeutics. — Cinnamon possesses carminative and feebly astringent properties. The oil is an active antiseptic. Cinnamon- water is an agreeable vehicle for diarrhea mixtures. The oil has been used to some extent as an antiseptic in surgi- cal dressings. Very favorable results have been reported from the use of cinnamon in influenza. Cinnamic acid and its sodium salt have been highly extolled by Landerer, Heusser, and others in the treatment of tubercu- losis. It is claimed that intravenous injections of sodium cin- namate (\ gr. — 0.008 gm. — every forty-eight hours, gradually increased to \ gr. — 0.02 gm.) induce a marked hyperleukocy- tosis and favor the formation of cicatricial tissue around the tuberculous area. A careful review of the reported cases, however, does not warrant the belief that this method of treat- ment is any more effective than other methods that are far less painful. OLEUM CAJUPUTI, U. S. P. (Oil of Cajuput.) Oil of cajuput is a thin, bluish-green, volatile oil distilled from the leaves of Melaleuca Leucadendron, a small tree grow- ing in the East India Islands. It has a camphoraceous odor ANISUM— SASSAFRAS. I9I and an aromatic, bitter taste. The dose is from 2-10 min. (0.12-0.6 c.c.) in emulsion, in capsules, or on sugar. Therapeutics.— Cajuput oil is one of the most efficient of the carminatives. It is an excellent adjunct to other remedies in the flatulent dyspepsia of the aged. Combined with opium it is undoubtedly useful in diarrhea with choleraic symptoms. It has been used also as a rubefacient in muscular rheumatism and as a parasiticide in ringworm. ANISUM, U. S. P. (Anise.) Anise is the fruit of Pimpinella Anisum, a small plant culti- vated in Southern Europe and North America. It contains a volatile oil having the characteristic odor of anise and a sweetish, aromatic taste. Preparations. Dose. Oleum Anisi, U. S. P 2-5 min. (0.12-0.3 c.c). Aqua Anisi, U. S. P 2-8 fl. dr. (8.0-30.0 c.c). Spiritus Anisi, U. S. P. (10 per cent, of oil) . 1-2 fl. dr. (4.0-8.0 c.c). Anise also enters into camphorated tincture of opium, com- pound spirit of orange, aromatic elixir, compound syrup of sarsaparilla, and troches of opium and licorice. Therapeutics. — Although anise is an effective carminative, it is used chiefly as a flavoring agent. PIMENTA, U. S. P. (Allspice.) Allspice is the nearly ripe fruit of Pimenta officinalis, an evergreen tree growing in the West Indies and South America. It contains a volatile oil, the active constituent of which is Eugenol. Preparation. Dose. Oleum Pimentae, U. S. P 1-5 min. (0.06-0.3 c.c). Oil of pimenta enters into spirit of myrcia, or bay-rum. SASSAFRAS. Sassafras is official as the bark {sassafras) and as the pith (sassafras medulla) of Sassafras variifolium, a shrub or tree growing in Eastern North America. It contains a fragrant, aromatic, volatile oil and a fair amount of tannin (6 per cent). 192 CARMINATIVES. Preparations. Dose. Oleum Sassafras, U. S. P 1-5 min. (0.06-0.3 c.c). Mucilago Sassafras Medulbe, U. S. P. (2 per cent.) 1-8 fl. dr. (4.0-30.0 c.c). Sassafras also enters into compound fluid extract of sarsapa- rilla, compound syrup of sarsaparilla, and troches of cubeb. CARUM, U. S. P. (Caraway.) Caraway is the fruit of Carum Carvi, an herb indigenous to Asia, and cultivated in Europe and North America. Its active ingredient is a volatile oil. Preparation. Dose. Oleum Cari, U. S. P 1-5 min. (0.06-0.3 c.c). Caraway also enters into compound tincture of cardamom and compound spirit of juniper. FCENICULUM, U. S. P. (Fennel.) Fennel is the fruit of Fceniculum vulgare, grown chiefly in Southern Europe. It contains an aromatic volatile oil. Preparations, Dose. Oleum Foeniculi, U. S. P 1-5 min. (0.06-0.3 c.c). Aqua Foeniculi, U. S. P 1-8 fl. dr. (4.0-30.0 c.c). Fennel also enters into compound licorice powder, com- pound spirit of juniper, and compound infusion of senna. CORIANDRUM, U. S. P. ( Coriander. ) Coriander is the fruit of Coriandrum sativum, an herb grown in all parts of Europe and the United States. It contains a volatile oil. Preparation. Dose. Oleum Coriandri, U. S. P 1-5 min. (0.06-0.3 c.c). Coriander also enters into confection of senna, syrup of senna, and compound spirit of orange. CATHARTICS. 1 93 The carminative properties of asafetida, ether, compound spirit of ether y chloroform, and turpentine are discussed else- where in this volume. CATHARTICS. Cathartics are drugs that are employed in medicine to cause evacuation of the bowels. They may act by irritating the in- testines or by augmenting the fluid of the feces. In the first in- stance intestinal peristalsis is increased directly, and in the second instance it is increased indirectly by distention of the bowel. Vegetable cathartics (castor oil, rhubarb, aloes, jalap, podo- phyllum, etc.), calomel, and phenolphthalein act through their irritant properties. These drugs also render the stools more or less watery ; but this effect is to be ascribed to the rapid evacuation of the intestinal contents and the escape of much liquid that would otherwise be reabsorbed, or, in case the action of the drug has been more or less violent, to the devel- opment of a true inflammatory process with serous exudation. Saline cathartics do not irritate the bowel unless given in very large doses. On the other hand, they retard the absorp- tion of liquids (if in isotonic or hypotonic solution) and with- draw water from the blood (if in hypertonic solution), and thus, by distending the bowel, stimulate peristaltic movements. Only salts that are difficult of absorption, like the sulphates, phosphates, and tartrates, have a purgative effect. Magnesium sulphate is especially active in this respect, as neither its basic nor its acid ion is readily absorbed. Nitrates, chlorides, ace- tates, and other rapidly absorbed salts induce diuresis rather than purgation because they draw water from the tissues into the blood, and so increase the capillary pressure in the kidneys. It has long been accepted as a fact that certain cathartics, like mercury and sodium phosphate, stimulate the liver and increase the secretion of bile, and, in consequence, these drugs have been known as cholagogues or cholagogue purgatives. Not much evidence, however, can be adduced in support of this assump- tion. It is true that the group of symptoms to which the term " biliousness " is applied often disappears as by magic after the administration of a full dose of calomel, but there is no proof that these symptoms are due to inactivity of the liver ; on the contrary, there is much to support the view that they are due solely to some derangement of the stomach and intestines. Nor can the dark green color of the stools that is observed after the administration of certain cathartics be claimed as an evidence 13 194 CATHARTICS. of increased secretion, for it is doubtless due, in large part, to the rapid flow of bile into the lower bowel and its escape from decomposition and reabsorption. Rutherford ligated the common bile-duct, inserted a cannula into it, and then noted the effect that the injection of certain drugs into the duod- enum had upon the flow of bile. From his experiments he concluded that the following drugs increase the secretion of bile: Podophyllin. Jalap. Aloes. Sodium sulphate. Rhubarb. Sodium phosphate. Colchicum. Rochelle salt. Iridin. Euonymin. Colocynth. Ipecacuanha. Corrosive sublimate. Unfortunately, Rutherford's experiments were too few in number and his results too often contradictory to justify his conclusions, and, moreover, recent investigations, especially those of Stadelmann and Pfafif,, have failed completely to con- firm the facts embodied in Rutherford's report. The only body known to have a decided cholagogue action is bile itself, although salicylic acid and its salts also promote the biliary secretion to a slight extent. The colicky pains induced by cathartics are probably the result of scybala interrupting the regular peristaltic move- ments, and throwing the muscular fibers into violent spasm. This view is confirmed by the experiments of Cash, who found that the slightest weight sufficed to check the onward move- ment of the substance in the intestine and to set up contrac- tions of a painful character. Classification. — Cathartics have been variously classified according to the intensity of their action and the character of the stools they produce. Since the effect of any cathartic is dependent, to a great extent, upon the dose, the time of ad- ministration, the susceptibility of the patient, and the state of the bowel, it is evident that a classification based upon physi- ologic action must necessarily be an imperfect one ; neverthe- less, when its limitations are fully recognized, such a classifi- cation is the most convenient one that can be adopted. Cathartics, therefore, may be divided into laxatives, purgatives, drastics, and hydragogues. Laxatives are the least irritating of all the cathartics, and ordinarily produce stools that are nearly normal in appearance and consistence. Many articles of food, such as molasses, INDICA TIONS. 195 bran bread, figs, prunes, apples, etc., serve as laxatives. The most important drugs belonging to this class are : Manna. Cassia fistula. Tamarind. Euonymus. Cascara sagrada. Butternut. Frangula. Iris. Magnesia. Leptandra. Sulphur. Ox-gall. Purgatives are more powerful than laxatives, and usually produce one or more copious stools of a semiliquid consist- ence. The difference between the action of a laxative and that of a purgative is mainly one of degree : laxatives in large doses act as purgatives, and the latter in small doses act as laxatives. The most important purgatives are : Aloes. Castor oil. Rhubarb. Calomel. Senna. Blue mass. Drastics have a violent action, and in overdoses produce the symptoms of acute enteritis. The most important are : Croton oil. Podophyllum. Colocynth. Jalap. Gamboge. Elaterium. Scammony. Bryonia. Hydrag-ogues produce large watery stools and give rise to but slight irritation. The principal ones are : Magnesium sulphate. Potassium and sodium tartrate. Sodium sulphate. Sodium phosphate. Magnesium citrate. Some of the drastics, especially jalap, elaterium, and bryo- nia, in appropriate doses, are efficient hydragogues. Indications. — To Relieve Constipation. — In simple acute constipation the prompt administration of a cathartic or the employment of an enema is nearly always advisable. In chronic constipation the result of atony of the bowel a resort should first be had to dietetic and hygienic measures, but, these failinc, a laxative should be prescribed. As a rule, the I96 CATHARTICS. use of laxatives in these cases, even when habitual, is less baneful than the persistent constipation. Indeed, mild vege- table cathartics are often taken for indefinite periods without producing, harmful effects. Brodie speaks of a man, eighty- six years of age, who for threescore years took an aloetic pill every night. To Remove Irritants from the Bowel. — In the beginning of acute diarrhea it is generally well to administer a dose of castor oil, calomel, or Epsom salts, to rid the bowel of undi- gested material, ptomains, and micro-organisms. In poisoning, if the irritant has escaped from the stomach into the bowel, a purgative should take the place of an emetic. To Promote Absorption. — Hydragogue cathartics, especially the salines, are often useful in cardiac and renal dropsy. They not only remove directly from the body a certain amount of fluid, but, by depleting the blood, promote the reabsorption of the lymph that has accumulated in the tissues. In serous effusions of an inflammatory character, such as are met with in pleurisy and pericarditis, cathartics are rarely serviceable. Certain drugs, such as digitalis and quinin, may prove inef- fective until the bowel has been unloaded and the portal system depleted by the administration of a brisk cathartic. To Remove Excrementitious Substances from the Blood. — In uremia and puerperal eclampsia the administration of cathartics is a measure of the greatest value in securing the elimination of noxious material. To Relieve Cerebral Congestion. — In acute cerebral congestion and mania cathartics serve a useful purpose, since, by inviting blood to the bowel, they tend to deplete the brain. In cerebral hemorrhage, also, they may do good by prevent- ing further extravasation. Administration. — Cathartics are most commonly admin- istered by the mouth. The salines are given in solution ; the vegetable preparations, most conveniently in the form of pills. In chronic constipation a combination of several drugs usually gives rise to less pain and is more effective than a single drug. A little of the extract of belladonna or a drop of one of the aromatic oils is frequently employed as an adjuvant to prevent griping. When atony of the bowel is pronounced, extract of nux vomica or physostigma may be added to the pill to enhance its stimulating effect. The time of administration is a factor to be considered in prescribing any cathartic. Pills of the vegetable cathartics are likely to cause less inconve- nience if administered after the evening meal or on going to ADMINISTRA TION. 1 97 bed. Salines or saline mineral waters act more promptly and powerfully when given before breakfast. Very often an enema is the most satisfactory means of unloading the bowel. A metal syringe with a piston or one made entirely of soft rubber may be employed for the purpose. The syringe should be filled with the fluid ; all the air should be expelled from it before the nozzle is inserted. The patient should lie near the edge of the bed, on the left side, with the knees drawn up. A towel should be held against the anus on withdrawing the nozzle, so that the fluid may be retained in the bowel for several minutes. An enema may act by dis- tending the bowel (mechanically), by softening the intestinal contents, or by directly irritating the intestinal walls. A simple enema is one composed of cool or tepid water or of soap and water. For an infant, 1 or 2 ounces (30.0-60.0 c.c.) may be employed ; for a child, from 4 to 8 ounces ( 1 20.0-240.0 c.c.) ; and for an adult, from 1 to 2 pints (0.5-1.0 L.). The injec- tion may be made more powerful by adding, in the case of an adult, 1 ounce (30.0 c.c.) of castor oil, J ounce (15.0 c.c.) of molasses, or from 1 to 2 drams (4.0-8.0 c.c.) of turpentine. The following enema, official in the British Pharmacopeia, is very useful : Magnesium sulphate I ounce (30.0 c.c.). Olive oil 1 ounce (30.0 c.c). Mucilage of starch 15 ounces (445.0 c.c). A small enema of glycerin (1-2 drams — 4.0-8.0 c.c.) is gen- erally very efficacious. In cases of fecal impaction an enema of warm salad or linseed oil (6-8 ounces — 180.0-240.0 c.c.) or an infusion of ox-gall often proves serviceable. In some cases of chronic indigestion with constipation flushing out the lower bowel with from 6 to 8 pints (3.0-4.0 L.) of tepid water, two or three times a week, by means of a soft-rubber tube passed well up into the sigmoid flexure, is followed by excel- lent results. It is well to remember that bulky enemata containing hard soap are occasionally followed, after the lapse of a few hours, by a scarlatiniform, measly, or urticarial rash. The introduction into the rectum of suppositories made of yellow soap, glycerin, or gluten is another means frequently employed to unload the bowel. It has been shown that certain drugs — aloin, colocynthin, and cathartic acid — will produce catharsis when given hypo- dermically. The irritation caused by the injections of these substances, however, is so severe as to forbid the employ- ment of this method of administration except under unusual circumstances. 198 CATHARTICS. MANNA, U. S. P. Manna is a concrete saccharine exudation from Fraxinus Ornus, a small tree a native of Sicily and other Mediterranean islands. It occurs in the form of yellowish-white or brownish- white three-edged pieces or fragments, having a crystalline structure, a honey-like odor, and a sweetish, faintly acrid taste. Its chief constituent is mannite (50-80 per cent.), a sweet crystalline principle soluble in water. In doses of from I to 2 ounces (15.0-60.0 gm.) manna acts as a mild laxative. It is usually given in combination with other cathartics. Preparation. Dose. Infusum Sennse Compositum, U. S. P. (Black Draft) 1-4 fl. oz. (30.0-120.0 c.c). TAMARINDUS, U. S. P. (Tamarind.) Tamarind is the preserved pulp of the fruit of Tamarindus indica, a large tree indigenous to Africa, and cultivated in the West Indies. It is a gentle laxative, about equal in power to the fig and prune. Its aperient properties are due chiefly to the potassium salts of tartaric, citric, malic, and acetic acids, of which it contains from 8 to 12 per cent. The dose is from I to 8 drams (4.0-30.0 gm.). Preparation. Dose. Confectio Sennae, U. S. P 1-2 dr. (4.0-8.0 gm.). RHAMNUS PURSHIANA, U. S. P. (Cascara Sagrada; Chittem Bark.) Cascara sagrada is the bark of Rhaimius Purshiana, a small tree growing in Northern California, Oregon, and Washington. It is allied to Rhamnus Frangula (buckthorn) and to Rham- nus cathartica (buckthorn). It contains emodin and other anthracene derivatives, 1 and so is allied chemically to frangula, rhubarb, aloes, and senna. Preparations. Dose. Fluidextractum Rhamni Purshianae, U. S. P. . 10-30 min. (0.6-2.0 c.c). Fluidextractum Rhamni Purshianse Aromati- cum,U. S. P IO-30 min. (0.6-2.0 c.c). Extractum Rhamni Purshianse, U. S. P. . . . 2-8 gr. ( 1. 3-0.5 gm.). 1 These bodies are substitution products of anthraquinone. Among them are emodin, cathartin, frangulin, aloin, and chrysophanic acid. Recently three syn- thetic anthracene compounds have been put upon the market as substitutes for the crude drugs : purgatin, exodin, and purgen (phenolphthalein). FRANGULA—MAGNESII OXIDUM. 1 99 Therapeutics. — Cascara sagrada is used exclusively as a tonic laxative, and in habitual constipation due to torpor of the bowel it is a most reliable remedy. It possesses a great advantage over many cathartics in not readily losing its effect when frequently taken ; indeed, in many cases the dose can be diminished gradually and still give satisfactory results. In most cases a single dose at bedtime will afford relief, but sometimes small doses (10 drops) after each meal are more effective. On account of its unpleasant bitter taste the fluid extract is best given in some aromatic syrup or cordial, as in the following formula : R Fluidextracti rhamni purshianae, Fluidextracti sarsaparillae compositi. Glycerini, aa f^j (30.0 c.c). — M. Dose : A teaspoonful or more. FRANGULA, U. S. P. (Buckthorn.) Frangula is the bark of Rhamnus Frangula, a shrub grow- ing in Europe and Northern Asia. When fresh, it is a power- ful irritant, but its action is modified by age, and therefore the Pharmacopeia specifies that it should be at least one year old before being used. It contains a crystalline glucosid, fran- gulin. Preparation. Dose. Fluidextractum Frangulae, U. S. P \-\ fl. dr. (2.0-4.0 c.c.y Frangula has an action not unlike that of senna. In this ¥ country it has been almost entirely displaced by Rhamnus Purshiana. MAGNESII OXIDUM, U. S. P. (Light Magnesia; Calcined Magnesia; Magnesium Oxid ; MgO.) Light magnesia is a white, very light, odorless powder, having an earthy taste. It is almost insoluble in water, insolu- ble in alcohol, but soluble in dilute acids. The dose as a laxative is from 30-60 gr. (2.0-4.0 gm.). Preparations. Dose. Pulvis Rhei Compositus, U. S. P. (6$ per cent.) 30-60 gr. (2.0-4.0 gm.). Ferri Hydroxidum cum Magnesii Oxido, U. S. P 2-4 fl. oz. (60.0-120.0 c.c). Therapeutics. — Magnesia is partly converted by the acids of the stomach into soluble salts that have a laxative 200 CA THA R TICS. action ; it therefore combines the properties of an antacid with those of a mild aperient. It is not a suitable drug for habitual use in simple chronic constipation, since, when not thoroughly- acidified, there is a possibility of its forming intestinal concre- tions. It may replace sodium bicarbonate, however, when ex- cessive acidity exists with constipation. In ulcer of the stomach it may be combined with bismuth subnitrate to control con- stipation. It may be given with syrup of rhubarb in the early stages of acute diarrhea to rid the bowel of any sour, acrid material that may give rise to irritation. It is also an antidote in arsenic poisoning, and is doubly efficient in the form of ferric hydrate with magnesia. MAGNESII OXIDUM PONDEROSUM, U. S. P. (Heavy Magnesia ; Heavy Calcined Magnesia ; Magnesium Oxid; MgO.) Heavy magnesia is three and a half times heavier than light magnesia, and, unlike the latter, does not readily unite with water to form a gelatinous hydrate. It has the same proper- ties and uses as light magnesia. MAGNESII CARBONAS, U. S. P. (Magnesium Carbonate; (MgC0 3 ) 4 .Mg(OH) 2 +5H 2 0.) Magnesium carbonate occurs in light, white, friable masses or as a light white powder, free from odor, and having a slightly earthy taste. It is almost insoluble in water, insolu- ble in alcohol, but soluble in dilute acids with active efferves- cence. The dose as a laxative is from 20-60 gr. (1.3-4.0 gm.). Magnesium carbonate has the same therapeutic value as magnesia, but when there is much acid in the stomach, it is likely to cause unpleasant eructations of gas. SULPHUR. (S.) The United States Pharmacopeia recognizes 3 forms of sulphur : Sulphur Sublimatum. Sulphur Lotum. Sulphur Praecipitatum. Sublimed sulphur (flowers of sulphur) is a fine yellow powder having a slightly characteristic odor and a faintly acid taste. It is insoluble in water, but partially soluble in absolute alcohol, ether, chloroform, boiling solutions of alka- CASSIA FISTULA. 201 line hydrates, oil of turpentine, and many other oils. It usually contains small quantities of sulphuric acid, arsenic sulphid, and other impurities. The dose is from 10 to 120 gr. (0.65-8.0 gm.). Washed sulphur is prepared by digesting for three days sublimed sulphur in weak ammonia water. There are 2 official preparations of washed sulphur : Unguentum Sulphuris (15 per cent). Pulvis Glycyrrhizae Compositus (8 per cent.). Precipitated sulphur (milk of sulphur) is a fine, almost white powder, without odor or taste. It is prepared by pre- cipitating calcium sulphid with diluted hydrochloric acid. The dose is from 10 to 120 gr. (0.65-8.0 gm.). Physiologic Action and Therapeutics. — When sul- phur is taken internally, a considerable portion passes out unchanged ; some, however, is converted by the alkaline secre- tions of the bowel into hydrogen sulphid and other sulphids. It is to the latter compounds that sulphur owes its active prop- erties. They are the cause of the mild catharsis and the offen- sive flatus that follow the ingestion of sulphur. Being partially absorbed, they escape from the lungs and skin as sulphids, and from the kidneys as sulphates. Sulphur may be employed as a laxative when a very mild action is desirable, as in pregnancy, hemorrhoids, fissure of the anus, and prolapse of the bowel. The dose as a laxative is from I to 2 dr. (4.0-8.0 gm.) in syrup or molasses. Sulphur has a long-standing reputation, both as an internal remedy and as a local application, in chronic articular rheumatism. Externally, it is much used as a stimulant and parasiticide in certain chronic diseases of the skin. It is often useful in eczema, comedo, acne, and psoriasis, and it may be prescribed in an ointment having the strength of from \ to 2 dr. (2.0-8.0 gm.) to the ounce (30.0 gm.). It is absolutely contraindicated in the acute stages of any skin disease. In parasitic diseases, like scabies and ringworm, it is a reliable remedy. CASSIA FISTULA, U. S. P. (Purging Cassia.) Purging cassia is the fruit of Cassia Fistula, a tree exten- sively cultivated in all tropical countries. It contains about 60 per cent, of sugar, with albuminoids and organic salts. The dose is from 1-4 dr. (4.0-15.0 gm.). It has a mild laxative 202 CATHARTICS. action, but on account of its tendency to cause griping, it is prescribed only in combination with other remedies. Preparation. Dose. Confectio Sennae, U. S. P. (16 per cent.) . . 1-2 dr. (4.0-8.0 gm.). EUONYMUS, U. S. P. (Wahoo.) Euonymus is the bark of the root of Euo?iymus atropur- pureiis, growing in Eastern North America. It contains a soluble, amorphous glucosid, euonymin, which affects the cir- culation like digitalis. The dose of the latter is from |— 3 gr. (0.03-0.2 gm.). Preparations. Dose. Extractum Euonymi, U. S. P 1-5 gr. (0.065-0.3 gm.). Fluidextractum Euonymi, U. S. P 5-20 min. (0.3-1.3 c.c). The cathartic action of euonymus resembles that of podo- phyllum, although it is less powerful. It has been credited with cholagogue as well as laxative properties, but although it undoubtedly hastens the elimination of bile and prevents the reabsorption of that secretion, there is not sufficient proof to warrant the belief that the drug actually increases the func- tional activity of the liver. Combined with other cathartics, euonymus is a useful remedy in the condition popularly known as " biliousness." JUGLANS. (Butternut.) Butternut is the bark of the root of Juglans cinerea, a large tree belonging to the walnut family, and growing in North America. Preparation. Dose. Extractum Juglandis 5~io gr. (0.3-0.65 gm.). Its action somewhat resembles that of rhubarb, for which it has been used as a substitute. It is seldom employed at the present day. IRIS. (Blue Flag.) Blue flag is the rhizome and roots of Iris versicolor, a peren- nial herb growing in the swampy places of North America. It contains an acrid resin and possibly an amorphous alkaloid. LEPTANDRA—FEL BO VIS. 203 Preparations. Dose. Fluidextractum Iridis 10-20 min. (0.6-1.3 c.c). Extractum Iridis 1-4 gr. (0.06-0.25 gm.). Iris in sufficient dose produces active catharsis with bilious stools. Its action resembles that of podophyllum, though milder. At one time held in high esteem, it has at present fallen into disuse. LEPTANDRA, U. S. P. (Culver's Root.) The rhizome and roots of Veronica virginica, a perennial herb growing in the eastern portion of the United States. It contains a crystalline glucosid, leptandrin, which is to be dis- tinguished from an impure resin also known as leptandrin. Preparations. Dose. Fluidextractum Leptandrse, U. S. P 10-60 min. (0.6-4.0 c.c). Extractum Leptandrse, U. S. P 1-5 gr. (0.06-0.3 gm.). Pilulse Catharticae Vegetabiles, U. S. P. . . 1-3 pills. In the fresh state leptandra is a violent gastro-intestinal irri- tant. Preparations made of the dried root have a laxative or purgative effect, according to the dose, but they are somewhat uncertain in their action. Leptandra has been largely super- seded by more reliable remedies. FEL BOVIS, U. S. P. (Oxgall.) Purified oxgall (Fel Bovis Purificatum, U. S. P.) only is used in medicine. It is prepared by evaporating to a pilular con- sistence fresh oxgall that has been subjected for several days to the action of alcohol. It is a yellowish-green, soft solid, having a peculiar odor and a partly sweet and partly bitter taste. The dose is from 5-15 gr. (0.3-1.0 gm.). Physiologic Action and Therapeutics. — Bile is an active cholagogue and an uncertain laxative. That it is a true hepatic stimulant, increasing both the liquid and the solids secreted by the liver, has been amply confirmed by Rosenberg, Stadelmann, Joslin, and other investigators who have experimented on both animals and human beings with permanent biliary fistulae. When bile is not present in the intestines, the digestion of fat is materially aided by the administration of oxgall by the mouth. In the test-tube bile suspends peptic digestion by precipitating the soluble proteids (proteoses and peptones) and probably also pepsin ; but in the 204 CATHARTICS. living subject, when the fat is excessive in the stools, it has been shown that it promotes the digestion of proteid food. Careful bacteriologic studies do not indicate that bile pos- sesses the pronounced antiseptic properties that are generally attributed to it. It is probable that the fetid character acquired by the stools in the absence of bile is due to impaired intestinal digestion, and, therefore, to better opportunities for the action of bacteria, rather than to the withdrawal of any antiseptic in- fluence exerted directly by the bile itself. Bile is too uncertain in its action to be employed as an ordinary laxative. In fecal impaction, however, a solution of oxgall, containing an ounce to a pint of water (30.0 gm.-o.5 L.), often makes a very serviceable enema. When, for any reason, the biliary secretion is lacking in the intestine, oxgall may be used as an adjuvant to certain cathartics — podophyl- lum, jalap, rhubarb, and scammony — that are ordinarily inac- tive when bile is not present. In cases of biliary fistula or of obstruction of the common duct it may be used to promote the digestion of fats and proteids, and to prevent, indirectly, putrefactive changes in the intestinal contents. It is best administered in capsules, about two hours after meals. ALOE, U. S. P. (Aloes.) Aloes is the inspissated juice prepared from the leaves of several species of the genus Aloe, a familiar example of which is the American century plant. It contains a neutral crystal- line principle, aloin, a resin, and a trace of volatile oil. Aloin consists of a number of anthracene derivatives closely allied to those contained in rhubarb, cascara, and senna. It is less reliable than the crude drug. The dose of aloes is from 1-10 gr. (0.065-0.65 gm.). Preparations. Dose. Aloinum, U. S. P £-2 gr. (0.016-0. 13 gm.). Aloe Purificata, U. S. P 1-10 gr. (0.065-0.65 gm.). Tinctura Aloes, U. S. P \-2 fl. dr. (2.0-8.0 c.c). Tinctura Aloes et Myrrhse, U. S. P. ( 10 per cent, of each, with glycyrrhizse) |-2 fl. dr. (2.0-8.O c.c). Pilulse Aloes, U. S. P. (about 2 gr.— 0.13 gm.) 1-5 pills. Pilulse Aloes et Ferri, U. S. P. (about I gr. — 0.065 gm. — each of aloes and ferrous sul- phate) 1-3 piUs. Pilulse Aloes et Mastiches, U. S. P. (Lady Webster's pills ; about 2 gr. — 0.13 gm. — of aloes, with mastich and red rose) .... 1-5 pills. Pilulse Aloes et Myrrhse, U. S. P. (2 gr. — 0.13 gm.) 1-4 pills. ALOE. 205 Preparations. Dose. Pilulae Laxativse Composite, U. S. P. {\ gr. — 0.013 gm. of aloin, with strychnin, extract of belladonna, and ipecac) . 1-3 pills. Pilulse Rhei Composite, U. S. P. {\\ gr.— 0.1 gm.— each) . 1-3 pills. Aloes also enters into compound extract of colocynth (50 per cent.), compound tincture of benzoin (2 per cent.), com- pound cathartic pills, and vegetable cathartic pills. Physiologic Action and Therapeutics. — Aloes is a slowly acting but brisk purgative. A dose of 2 or 3 grains ordinarily produces one or two copious, dark-brown stools in the course of ten or twelve hours. The evacuation is gener- ally attended with more or less griping pain. Large doses congest the pelvic viscera and irritate the rectum. It has been shown that a part of that which is ingested escapes from the body in the urine, and, in the case of nursing women, in the milk. Aloes also causes catharsis when introduced into the system through channels other than the mouth, such as the skin and the rectum. When injected into the bowel, however, it is active only when combined with a solvent, like oxgall or glycerin. Aloin is slower in its action and somewhat less certain in its effects than aloes. Aloes is rarely used singly as a cathartic, but in simple, persistent constipation it is very effi- cacious in combination with other remedies, particularly with nux vomica, belladonna, ipecac, rhubarb, or podophyllum. Chlorosis with constipation often yields to pills of aloes and iron. Contrary to what was formerly believed, the use of aloes is not contraindicated by the existence of hemorrhoids unless inflammation has developed ; indeed, the drug often benefits indolent piles by overcoming the sluggishness of the bowel that led to their development. Since it congests the pelvic organs, aloes is sometimes serviceable as an emmenagogue in amenorrhea associated with troublesome constipation, and that is not dependent upon inflammation of the uterus or adnexa. When dysentery, cystitis, or inflammation of any pelvic organ is present, aloes should be avoided. On account of the possibility of its causing abortion it is best not to use it during pregnancy. Aloes is usually administered in the form of pills. The liquid preparations, on account of their disagreeable taste, are rarely employed. Meyer has shown that the action of the drug is increased by the addition of potassium carbonate or ferrous sulphate. 206 CA THAR TICS. RHEUM, U. S. P. (Rhubarb.) Rhubarb is the root of Rheum officinale, and other species of Rheum, a perennial herb, resembling garden rhubarb, but of larger growth, and a native of China, Thibet, and other Asiatic countries. It contains a number of anthracene bodies {emodin, cathartin, and chrysophanic acid) and a considerable quantity of tannic acid. Chrysophanic acid has not the purgative action of the other anthracene bodies, owing to its rapid absorption. The dose of rhubarb is from 5-30 gr. (0.3-2.0 gm.). Preparations. Dose. Tinctura Rhei, U. S. P. (20 per cent., with cardamom) 1-2 fl. dr. (4.0-8.0 c.c). Tinctura Rhei Aromatica, U. S. P. (20 per cent., with aromatics) ^-1 fl. dr. (2.0-4.0 c.c). Fluidextractum Rhei, U. S. P 10-30 min. (0.6-2.0 c.c). Extractum Rhei, U. S. P 5-10 gr. (0.3-0.65 gm.). Mistura Rhei et Sodse, U. S. P. (1.5 per cent, of the fluid extract with sodium bi- carbonate, fluid extract of ipecac, and spirit of peppermint) £-2 fl. dr. (2.0-8.0 c.c). Syrupus Rhei, U. S. P. ( 10 per cent, of fluid extract) 1-6 fl. dr. (4.0-22.5 c.c). Syrupus Rhei Aromaticus, U. S. P. (spiced syrup of rhubarb : 15 per cent, of aromatic tincture) 1-6 fl. dr. (4.0-22.5 c.c). Pulvis Rhei Compositus, U. S. P. (Gregory's powder : rhubarb, 25 ; magnesia, 65 ; gin- ger, 10) 20-60 gr. (1.3-4.0 gm.). Pilulse Rhei Composite, U. S. P. (rhubarb, 2 gr. — 0.13 gm. ; aloes, i\ gr. — 0.1 gm. ; myrrh; and oil of peppermint) .... 1-5 pills. Physiologic Action and Therapeutics.— In appropriate doses rhubarb acts as a purgative and stomachic. It affects the bowel more promptly than aloes, a full dose of from 20- 30 gr. (1.3-2.0 gm.) usually producing evacuation in from four to eight hours. On account of the tannic acid that it contains it frequently causes constipation as a secondary effect. Doses of from 1-3 gr. (0.065-0.2 gm.) often exert no cathartic influ- ence, but act upon the stomach as a tonic and mild astringent. It is eliminated in the various secretions — urine, milk, and sweat — and imparts to them a yellowish color. Rhubarb is an excellent remedy for removing irritant ma- terial from the bowel in the beginning of acute diarrhea. In the dyspeptic diarrhea of childhood the withdrawal of all food for several hours and the administration of a few doses of the aromatic syrup with magnesia generally affords prompt relief: SENNA. 207 $ Magnesii oxidi, gr. x l ( 2 .6 gm.) ; Syrupi rhei aromatici, f^vj (22.5 c.c); Aquae menthae piperitae, q. s. ad ff j (30.0 c.c). — M. Sig. A teaspoonful repeated once or twice for a child two years old. Rhubarb alone is not a suitable remedy for chronic consti- pation, but benefit is often derived from a combination of small doses with other cathartics. Mild attacks of indigestion the result of overindulgence, frequently yield to the union of rhu- barb with an antacid : & Pulveris nucis vomicae, gr. xii (0.8 gm.); Pulveris rhei, gr. xxiv (1.5 gm.) ; Sodii bicarbonatis, ^j (4.0 gm.). — M. Fiant chartulae No. xii. Sig. One before meals. SENNA, U. S. P. Senna is the leaflets of Cassia acutifolia and of Cassia angustifolia, small shrubs growing respectively in Africa and India. It contains a number of anthracene bodies, chief of which is cathartin or carthartinic acid. The dose is from 1—3 dr. (4.0-12.0 gm.). Preparations. Dose. Fluidextractum Sennae, U. S. P 1-2 fl. dr. (4.0-8.0 c.c). Syrupus Sennae, U. S. P. (25 per cent.) . . . 1-4 fl. dr. '4.0-16.0 c.c). Infusum Sennae Compositum, U. S. P. (Black Draft: senna, 6; fennel, 2; manna, 12; Epsom salts, 12) 1-4 fl. oz. (30.0-120.0 c.c). Confectio Sennae, U. S. P. (10 per cent., wilh cassia fistula, tamarind, prune, fig, sugar, and coriander oil) 1-2 dr. (4.0-8.0 gm.). Pulvis Glycyrrhizae Compositus, U. S. P. (18 per cent, of senna, with licorice, sulphur, sugar, and fennel oil) ... ^-2 dr. (2.0-8.0 gm.). Senna (1.5 per cent of the fluid extract) also enters into compound syrup of sarsaparilla. Physiologic Action and Therapeutics. — Senna is an energetic purgative. A full dose produces in from four to six hours one or two yellowish, loose, or even watery, stools, the evacuation being attended with considerable griping and flat- ulence. Its action is more irritating than that of rhubarb, and more prompt and powerful than that of aloes. Very large doses cause nausea, vomiting, violent purging, and depression. Cathartinic acid also acts when injected subcu- taneously. Like rhubarb, senna imparts to the urine a deep yellow or red color, the pigmentation being due to the pres- ence of chrysophanic acid. Senna is a safe and reliable purga- tive for unloading the bowel in simple, acute constipation. Its 208 CATHARTICS. tendency to cause griping is in a measure corrected by giving it with an aromatic or a saline. Compound licorice powder, in doses of a teaspoonful, more or less, at bedtime, is a popu- lar household remedy in habitual costiveness. PHENOLPHTHALEIN. (Purgen.) Phenolphthalein is an artificial anthracene derivative, pre- pared by the interaction of phenol and phthalic anhydride. It is a white crystalline powder, soluble in 600 parts of water and in 10 of alcohol. The dose is from 1 to 8 gr. (0.6-0.5 gm.) in powder, capsule, or pill. Phenolphthalein is an agreeable, fairly reliable, but slowly acting purgative. In the doses indicated it appears to have no other action. OLEUM RICINI, U. S. P. (Castor Oil.) Castor oil is a fixed oil expressed from the seed of Ricinus communis, a plant indigenous to India, but extensively culti- vated in other countries having a warm or temperate climate. It is a pale-yellowish, viscid oil, having a faint odor and a slightly acrid, offensive taste. It is freely soluble in alcohol. It is composed chiefly of ricinolein, the glycerid of ricinoleic acid, which is the purgative principle. The seeds themselves are never used for medicinal purposes. They contain ricin, an intensely poisonous proteid body, which, when injected into the blood of an animal, causes, after the lapse of several days, anorexia, vomiting, diarrhea, and profound prostration. In fatal poisoning the chief postmortem lesions are extensive ecchymoses of the mucous and serous membranes, tumefac- tion of the abdominal lymph-glands, and numerous areas of necrosis in the various organs. The dose of castor oil for an infant is from 1-2 dr. (4.0-8.0 c.c); for an adult, ^-1 ounce (15.0-30.0 c.c). Physiologic Action and Therapeutics. — Castor oil is a mild purgative, unloading the bowels thoroughly in from four to six hours, without causing much colic or flatulence. While its fate in the body has not been definitely determined, it is probable that it escapes from the stomach unchanged, and that in the presence of the intestinal juices saponification occurs with the liberation of ricinoleic acid, which is subse- quently converted into ricinoleates. The latter induce catharsis by stimulating the muscular coat of the bowel, and are proba- HYDRARGYRI CHLORIDUM MITE. 209 bly absorbed, since the oil is known to impart its purgative properties to the milk when given to nursing women. Castor oil is not a suitable remedy for habitual constipa- tion, but on account of its mild and speedy action it is perhaps the best remedy we possess to remove irritant material from the bowel in the beginning of acute inflammatory diarrhea. It is also an excellent laxative for use during pregnancy or labor. When it is desirable to add an oil to a lotion intended for the scalp, castor oil is generally selected on account of its solubility in alcohol. The leaves of the castor oil plant are said to promote the flow of milk when applied to the breasts. Many substances have been suggested to disguise the dis- agreeable taste of castor oil, which is the main objection to its employment; those in common use are the oils of pepper- mint, gaultheria, and cinnamon. Wood speaks favorably of a combination of equal parts of glycerin and castor oil flavored with a drop or two of one of the above-named oils. It is often given in the froth of porter, beer, or soda-water. It may be prescribed in emulsion, but in this form it is bulky and not so effective. The best method of administering it is in flexi- ble capsules containing a dram (3C.0 c.c.) or more. HYDRARGYRI CHLORIDUM MITE, U. S. P. (Mild Mercurous Chlorid; Calomel; Hg 2 Cl 2 .) Calomel is a white, odorless, tasteless powder, insoluble in all ordinary menstrua. The dose is from yV -10 § r - (0.0065- 0.65 gm.). Preparations. Dose. Pilulae Antimonii Composite (Plummer's Pills; § gr. — 0.04 gm. — of calomel and sulphurated antimony with guaiac and castor oil) 1-2 pills. Pilulae Cathartics Composite, U. S. P. (1 gr. — 0.06 gm. — of calomel, with gamboge, compound extract of colocynth, and extract of jalap) 1-3 pills. Calomel acts as a laxative or as a purgative according to the method of its administration and the susceptibility of the patient Unlike other cathartics, its effect does not increase in direct ratio with the dose. Fractional doses repeated every half hour until 1 or 2 gr. (0.065-0.13 gm.) have been taken generally operate more freely than a dose of 10 gr. (0.65 gm.) taken at once. Calomel produces a thorough evacuation, the stools being large and loose, and commonly charged with undecomposed bile. Its action is not usually accompanied 14 2IO CATHARTICS. by much griping, but in some persons the drug excites more or less nausea. The change that calomel undergoes in the body is still a matter of dispute. It was formerly supposed that at least a portion was converted into mercuric chlorid by the hydrochloric acid of the stomach, but the experiments of Bucheim, Winkler, and Jeannel prove that such a conversion is impossible at the temperature of the body. It is more probable, as Jeannel suggests, that in the presence of the alka- line juices of the intestines the drug is changed into a gray oxid, a compound that is freely soluble in oily alkaline mix- tures, such as are naturally present in the duodenum. Whether or not calomel directly increases the secretion of bile is another question that has evoked considerable discussion, and to which no definite answer can be given at the present time. There can be no doubt that the amount of bile discharged in the stools is actually increased under its influence, but the evidence, experimental and clinical, does not favor the view that calomel increases the quantity of bile formed by the liver ; on the contrary, it suggests that the drug, through its stimu- lant action on the duodenum, merely speeds the flow of bile through the intestines and prevents its reabsorption. No remedy is so useful as calomel in the condition known zs" biliousness" which is characterized by a thickly coated tongue, fetid breath, heavy urine, headache, and depression of spirits. A sixth of a grain (o.Oi gm.) may be given every fifteen or twenty minutes until I gr. (0.065 gm.) has been taken. If the bowels do not move freely, the mercurial may be followed by Epsom salts or a Seidlitz powder. Attacks of indigestion associated with clay-colored stools, in either children or adults, are often relieved by a few small doses of calomel. In dyspeptic diarrhea it is not quite so effica- cious as castor oil in removing undigested food from the bowel, but it has advantages in its tastelessness and small bulk. In the beginning of acute disease, especially the specific infections, it is an excellent cathartic for unloading the bowels without exciting irritation. In chronic heart disease with venous engorgement of the digestive organs calomel is of the utmost value in relieving the tension in the portal circulation, and without its aid digitalis often proves ineffectual. Massa Hydrargyri, TJ. S. P. (Blue Mass) is made by triturating mercury, 33 ; glycyrrhiza, 10 ; althaea, 15 ; glycerin, 9; and honey of rose, 33. It is employed for the same pur- poses as calomel, although it is less active. The dose is from ^—15 gr. (0.0 1 6-1.0 gm.). Hydrargyrum cum Creta, TJ. S. P. (mercury with chalk ; OLEUM TIG LI I. 211 gray powder). — This is an intimate mixture of mercury, honey, and chalk, containing 38 per cent, of mercury. It is weaker than blue mass. The dose is from 1-10 gr. (0.065-0.65 gm.). OLEUM TIGLII, U. S. P. (Croton Oil.) Croton oil is a fixed oil expressed from the seeds of Croton Tiglium, a small tree, indigenous to China, but extensively cul- tivated in India and the Philippine Islands. It is a yellowish, viscid oil, having a faint odor and an acrid, burning taste. In addition to several inactive fatty acids it contains crotonoleic acid, which is present both as a free acid and as a glycerid. The dose of the oil is from -J— 2 min. (0.03-0.12 c.c). Physiologic Action and Therapeutics. — When applied to the skin, croton oil causes redness and burning, followed by a copious eruption of pustules. When taken internally, it acts as a violent drastic cathartic, causing in from one to two hours several copious movements, which are partly formed and partly watery. The evacuations are usually attended with considerable pain, and not infrequently with nausea. Large doses produce all the symptoms of a severe gastro-enteritis. As croton oil contains a certain amount of free crotonoleic acid, it causes, when swallowed without a demulcent, a burn- ing sensation in the fauces and stomach, but its maximum irri- tant effect is not manifested until it reaches the intestine, where the bulk of the acid is liberated from the oil by saponification. On account of the ease with which it can be administered croton oil is a well-adapted cathartic for cases in which deglu- tition is seriously affected. Its prompt irritant action on the bowel makes it also a useful revulsant in cases of cerebral congestion. Thus, it may be given with advantage in uremia, apoplexy, and acute mania. It is also useful in very obstinate constipation, such as occurs in chronic lead-poisoning. As it acts promptly when simply placed on the back of the tongue, it is often selected as a cathartic for the insane. Its use is contraindicated whenever there is inflammation of the gastro-intestinal tract. The drug is best administered in a little olive oil or in a pill with bread-crumb as an excipient. Croton oil is sometimes used externally as a counterirritant. It is rarely applied to the skin in the pure state, a mixture with from 2 to 4 parts of some indifferent oil generally being pre- ferred. A liniment is official in the British Pharmacopoeia that is made of 2 parts of the oil with 7 parts each of oil of 212 CATHARTICS. cajuput and alcohol. This liniment may be applied to the chest in chronic bronchitis, phthisis, or fibrinous pleurisy. A mixture of croton oil (i part) and tincture of iodin (3 parts) employed as a pigment often acts very well in neuritis. COLOCYNTHIS, U. S. P. (Colocynth.) Colocynth is the fruit of Citrullus Colocynthis deprived of its rind. The plant grows in arid places in Asia, Africa, and Southern Europe. The chief cathartic principle is colocynthin, a bitter glucosid. Preparations. Dose. Extractum Colocynthidis, U. S. P 2-5 gr. (0.13-0.3 gm.). Extractum Colocynthidis Compositum, U. S. P. (extract of colocynth, 16; aloes, 50; resin of scammony, 14; cardamom, 6; soap, 14) . . 5-20 gr. (0.3-1.3 gm.). Pilulae Catharticae Composite, U. S. P. (each pill contains about 1^ gr. — 0.08 gm. — of compound extract of colocynth; I gr. — 0.06 gm. — of calomel ; \ gr. — 0.02 gm. — of resin of jalap ; \ gr. — 0.015 gm. — of gamboge) 1-3 pills. PiJulse Catharticae Vegetabiles, U. S. P. (each pill contains about 1 gr. — 0.06 gm.— of compound extract of colocynth ; \ gr. — 0.02 gm. — of resin of jalap; \ gr. — 0.03 gm. — of extract of hyos- cyamus; \ gr. — 0.015 gm. — of extract of lep- tandra; \ gr. — 0.015 g m - — °f resin of podo- phyllum ; oil of peppermint 1-3 pills. Physiologic Action and Therapeutics. — Colocynth is a powerful drastic cathartic, producing in full doses copious watery stools, which are often accompanied by griping. Very large doses excite intense inflammation of the whole alimen- tary tract, which may prove fatal. The drug is too irritant to be used alone. At the present time it is prescribed in combi- nation with other remedies only in obstinate chronic constipa- tion. It is not a suitable cathartic for habitual use, but it may be employed now and then to secure a thorough evacuation of the bowels. CAMBOGIA, U. S. P. (Gamboge.) Gamboge is a gum-resin from Garcinia Hanburii, a laurel- like tree growing in the East Indies. Its active principle is cambogic acid. The dose is from -|— 5 gr. (0.03-0.3 gm.). Preparation. Dose. Pilulae Catharticae Compositae, U. S. P. (about \ gr. — 0.015 gm. — in each pill) 1-3 pills. SCAMMONIUM—PODOPHYLL UM. 2 1 3 Physiologic Action and Therapeutics. — Gamboge is an extremely irritating drastic cathartic, fully capable in large doses of causing fatal gastro-enteritis. It is never used alone, but in combination with less powerful cathartics it is some- times employed in obstinate chronic co?istipation. SCAMMONIUM, U. S. P. (Scammony.) Scammony is a resinous exudation from the living root of Convolvulus Scammonia, a perennial herb growing in Western Asia. Its active principle is a resin, scammonin, which appears to be identical with jalapin. The dose of scammony is from I- IO gr. (0.06-0.6 gm.). Preparations. Dose. Resina Scammonii, U. S. P 2-8 gr. (0.13-0.5 gm.). Extractum Colocynthidis Composition, U. S. P. (14 per cent.) 5-20 gr. (0.3-1.3 gm.). Physiologic Action and Therapeutics. — Scammony has been used as a drastic cathartic since the time of Hip- pocrates. It is more powerful than jalap, but less irritating than gamboge. It is rarely employed except in the form of the " compound cathartic pill." PODOPHYLLUM, U. S. P. (May Apple; Mandrake.) Podophyllum is the rhizome and roots of Podophyllum peltatum, a perennial herb growing in moist shady places in Canada and Northern United States. It contains two isom- eric glucosids — podophyllotoxin and picropodophyllin. Preparations. Dose. Resina Podophylli, U. S. P. (Podophyllin) . \-\ gr. (0.008-0.03 gm.). Fluidextractum Podophylli, U. S. P 5-20 min. (0.3-1.2 c.c.). Pilulse Podophylli, Belladonna; et Capsici, U. S. P. (each pill contains \ gr. (0.016 gm.) of resin of podophyllum, \ gr. (0.008 gm.) of extract of belladonna, and J gr. (0.32 gm.) of capsicum) 1—2 pills. The resin also enters into vegetable cathartic pills. Physiologic Action and Therapeutics. — In full doses podophyllum is an active, irritant cathartic. It produces its effects slowly, however — rarely earlier than ten or twelve hours after its administration — the evacuations being copious and liquid, and generally attended with much griping pain. It is said to act as a cathartic when applied to an open wound or 214 CATHARTICS. administered subcutaneously. It is believed by many prac- titioners to possess the power of directly increasing the secretion of bile, but very little evidence can be adduced to support this claim. Podophyllum is especially prized as a cathartic in habitual constipation, associated with so-called " bilious attacks." To many persons the action of the drug is very agreeable, but in others it causes severe pain and depression. When combined with other cathartics only those should be selected which are also slow in action, such as aloes and calomel. Extract of belladonna or hyoscyamus may be added to prevent griping. The resin is the most reliable preparation. A combination like the following often makes a useful dinner pill : R Resinae podophylli, gr. iv (0.26 gm.): Aloes purificatae, gr. xx-xl (1.3-2.6 gm.) ; Extracti nucis vomicae, Extracti belladonnas, aa gr. iv (0.26 gm.). — M. Fiant pilulae No. xx. Sig. One at bedtime. JALAPA, U. S. P. (Jalap.) Jalap is the dried tuberous root of Exogonium Purga, a perennial herb growing in Mexico. It contains two active glucosids, convolvulin and jalapin. The dose is from 5-30 gr. (0.3-2.0 gm.). PreparationSo Dose. Resina Jalapae, U. S. P 1-5 gr. (0.065-0.3 gm.). Pulvis Jalapae Compositus, U. S. P. (35 per cent, of jalap and 65 per cent, of potassium bitartrate) 15-60 gr. (1.0-4.0 gm.). Pilulae Catharticae Compositae, U. S. P. (£ gr. — 0.02 gm. — of extract) 1-3 pills. Pilulae Catharticae Vegetabiles, U. S. P. (£ gr. — 0.02 gm. — of extract) 1-3 pills. Physiologic Action and Therapeutics. — Jalap is a powerful hydragogue cathartic. It acts generally within three or four hours, and produces copious watery stools. It not infrequently excites nausea and colic, but its action is less harsh than that of either gamboge or scammony. According to Stadelmann, it is inactive in the absence of bile, the latter probably serving as a solvent. Except as an ingredient of " compound cathartic pills " or " vegetable cathartic pills " jalap is not employed in simple constipation. It is used espe- cially for the removal of dropsical effusions, and for this pur- pose it is frequently combined with a saline, as in the official compound jalap powder. Associated with calomel jalap is ELATERIUM— BRYONIA. 21 5 sometimes a valuable depletive in chronic heart disease with congestion of the portal circulation. ELATERIUM. Elaterium is a substance deposited by the juice oi Ecb allium Elaterium y or squirting cucumber, a vine growing on the shores of the Mediterranean Sea. It is of uncertain strength and is not official, but its active properties are fully represented by a neutral principle, elaterin (Elaterinum, U. S. P.), which is official. The latter occurs in minute white scales or crystals, without odor, and having an acrid, bitter taste. It is almost insoluble in water, but readily soluble in chloroform and hot alcohol. The dose of elaterium is from \-\ gr. (0.008-0.03 g m -)- Preparations. Dose. Elaterinum, U. S. P irWV S 1 *- (0.002-0.0065 gm.). Trituratio Elaterini, U. S. P. (10 per cent., with sugar of milk) \-\ gr. (0.016-0.065 gm.). Physiologic Action and Therapeutics. — Elaterium is a decided irritant to all tissues. Given internally it is, perhaps, the most powerful of the hydragogue cathartics, producing large watery stools, with some griping, and, occasionally, nausea. Its action is more vigorous than that of jalap and less harsh than that of gamboge or colocynth. In overdoses it is a violent, acrid poison. In appropriate doses elaterium is often very useful in reduc- ing local serous effusions (hydrothorax, hydropericardium, ascites) and the general dropsy of cardiac or renal disease. On account of its prompt action it may be employed also as a derivative in cerebral congestion and uremia. Elaterium itself, probably on account of its adulteration, is unreliable, and, therefore, only official preparations should be prescribed. BRYONIA. (Bryony.) Bryonia is the root of Bryonia alba and of Bryonia dioica t a perennial climbing plant growing in Central and Southern Europe. Its active principle is probably bryonin, an intensely bitter, soluble glucosid. Preparation. Dose. Tinctura Bryoniae I -2 fl. dr. (4.0-8.0 c.c). Bryonia is a drastic, hydragogue cathartic. It was formerly 2l6 CATHARTICS. a much esteemed remedy in general dropsy and local effusions, but at present it is very rarely used. MAGNESII SULPHAS, U. S. P. (Magnesium Sulphate; Epsom Salt; MgS0 4 + 7H 2 0.) Magnesium sulphate occurs in small, colorless, rhombic prisms or acicular crystals, odorless, and having an unpleasant, bitter, saline taste. It is soluble in 1.5 parts of water, and in- soluble in alcohol. The dose is from 1-8 dr. (4.0-30.0 gm.). Preparations. Dose. Magnesii Sulphas Effervescens, U. S. P. . . 1-8 dr. (4.0-30.0 gm.). Infusum Sennae Compositum ( 1 2 per cent.), U. S. P 1-4 fl. oz. (30.0-120.0 c.c). Physiologic Action. — The saline cathartics, of which magnesium sulphate may be taken as a type, produce evacua- tion of the bowels chiefly by increasing the amount of fluid in the intestine. Unlike the vegetable cathartics, they are but feeble stimulants to peristalsis. They hinder the absorption of fluid taken with food, and they also abstract fluid directly from the tissues and blood. The increased bulk and weight of the intestinal contents give an impetus to peristalsis and purgation follows, but there is little direct irritation of the mus- cular coat of the bowel, as occurs with the vegetable cathartics. Under ordinary conditions saline cathartics are absorbed from the intestine very slowly and in but small quantities, the greater part escaping from the body in the stools. Their action, therefore, appears to be a purely local one, and this view is supported by the fact that they do not produce catharsis when injected intravenously. It is a noteworthy fact that when a saline cathartic is administered to an anhydremic subject, instead of the blood yielding its water to the intestine, the process is reversed, and the blood attracts fluid from the bowel, the salt is in large part absorbed, and purgation does not ensue. Saline cathartics, by concentrating the blood, primarily lessen the secretion of urine ; subsequently, however, they may be absorbed from the intestine in sufficient quantity to exert a diuretic effect. In full doses and in concentrated solution magnesium sul- phate is an active hydragogue cathartic, producing in the course of a few hours copious watery stools without much pain or systemic disturbance. Its chief drawback is its ten- dency to excite nausea. Dilute solutions are much less active as purgatives, but, being more readily absorbed, they increase MAGNESII SULPHAS. 21 J the flow of urine. Meltzer has shown that magnesium salts, when injected intravenously, inhibit the respiration and cause paralysis of the entire body ; that, when applied directly to a nerve, they produce complete nerve block, and that, when injected into the spinal meninges, they cause gen- eral anesthesia, muscular relaxation, and sleep lasting for sev- eral hours. Therapeutics. — Since Epsom salt is free from irritant properties, it is an excellent cathartic for removing undigested material from the bowel in acute enteritis and colitis. On account of its unpleasant taste and large bulk, however, it is not so convenient for children as calomel, or even castor oil. As it increases the fluidity of the intestinal contents it is well suited for use in cases of fecal accumulation. In chronic con- stipation a saline taken in small dose before breakfast is some- times more efficacious than a vegetable cathartic. It is an excellent remedy for reducing dropsical effusions, both local and general. Recently several competent observers have tes- tified to the value of Epsom salt in the treatment of tropical dysentery. Doses of from 1-2 dr. (4.0-8.0 gm.) are recom- mended to be given in some aromatic water, and continued until the stools lose their mucous character. Magnesium sulphate is also used as an antidote to acute lead-poisoning and to carbolic acid poisoning. With sugar of lead it forms an insoluble sulphate, and with carbolic acid an innocuous phenolsulphonate. As a result of Meltzer's observations, intraspinal injections of Epsom salt (2-4 c.c. of a 25 per cent, solution) have been employed to some extent in controlling the convulsions of teta- nus. Although the treatment seems to have been decidedly beneficial in a number of severe cases, great caution is urged in adopting it, owing to the frequency with which marked depression of the respiration occurs. Administration. — When a full hydragogue effect is de- sired, the drug should be given before breakfast, in one large dose, and with but a small quantity of water. In cases of general dropsy the restriction of liquids after the administration of the salt makes its action still more effective. Solutions of Epsom salt are rendered more accept- able to the stomach by the addition of magnesium carbonate (20-30 gr. — 1.3-2.0 gm.). Cathartic enemata are rendered more active by the addition of Epsom salt. The following enema, recommended by Noble, will be found very efficacious in cases of marked intestinal torpor : 2l8 CATHARTICS. R Magnesii sulphatis, !|ij (60.0 gm.) ; Olei terebinthinae, fSss (15.0 c.c); Glycerini, ffj (30.0 c.c); Aquas, q. s. ad fgiv (120.0 c.c). — M. Incompatibles. — Magnesium sulphate is incompatible with lead acetate, silver nitrate, alkaline carbonates, and lime- water. From solutions of sodium phosphate it precipitates the insoluble magnesium phosphate, and from solutions of Rochelle salt, after a time, the insoluble magnesium tar- trate. SODII SULPHAS, U. S. P. (Sodium Sulphate; Glauber's Salt ; Na 2 S0 4 +ioH 2 0.) Sodium sulphate occurs in large, colorless, transparent prisms, or granular crystals, odorless, and of a bitter, saline taste. It is soluble in 2.8 parts of water. The dose is from 2-8 dr. (8.0-30.0 gm.). Therapeutics. — Glauber's salt is a powerful hydragogue cathartic, producing large watery stools, accompanied by griping and borborygmi. Epsom salt, being far less irritating, has largely superseded it. It enters into the mixture known as artificial Carlsbad salt, which makes an efficient mild saline aperient : R Sodii sulphatis, ^v (150.0 gm.) ; Sodii bicarbonatis, ^ij (60.0 gm.) ; Sodii chloridi, g] (30.0 gm.). — M. Sig. A teaspoonful in a tumblerful of hot water half an hour before breakfast. The sulphates of sodium and magnesium are the active ingredients in certain natural mineral waters, such as Hun- yadi Janos, Friedrichshall, Carlsbad, Rubinat, and Pullna. POTASSII ET SODII TARTRAS, U. S. P. (Potassium and Sodium Tartrate ; Rochelle Salt; KNaC 4 H 4 6 + 4H 2 0.) Rochelle salt occurs in colorless, transparent, prismatic crystals, or as a white powder, odorless, and having a cooling, saline taste. It is soluble in 1.2 parts of cool water and in less than 1 part of boiling water. The dose is from 1-4 dr. (4.0-16.0 gm.). Preparation. Dose. Pulvis Effervescens Compositus, U. S. P. (Seidlitz powder) . 1 powder. (The blue paper contains sodium bicarbonate, 40 gr. — 2.6 gm. — and potassium and sodium tartrate, 120 gr. — 8.0 gm. The white paper contains tartaric acid, 35 gr. — 2.3 gm. The contents of each paper should be dissolved separately, the two solutions mixed, and the whole taken while effervescing.) SOD II PHOSPHAS—MAGNESII CITRAS. 2 1 9 Therapeutics. — Rochelle salt may be used as a hydra- gogue cathartic in the same class of cases in which magne- sium sulphate is indicated. It is less active than the latter salt, but more agreeable to take. Seidlitz powder is a very mild saline cathartic. The carbonic acid evolved during effer- vescence not only makes the solution palatable, but exerts a sedative influence on the stomach. SODII PHOSPHAS, U. S. P. (Sodium Phosphate; Na 2 HP0 4 +l2H 2 0.) Sodium phosphate occurs in large, colorless, prismatic crys- tals, odorless, and having a cooling, saline taste. It is solu- ble in 5.5 parts of water, and insoluble in alcohol. The dose for a young child is from 1-10 gr. (0.065-0.65 gm.); for an adult, J-4 dr. (2.0-16.0 gm.). Preparations. Dose. Sodii Phosphas Effervescens, U. S. P. ... 1-8 dr. (4.0-30.0 gm.). Sodii Phosphas Exsiccatus, U. S. P 1 0-60 gr. (0.65-4.0 gm.). Liquor Sodii Phosphatis Compositus, U. S. P. (each fl. dr. (4.0 c.c.) contains I dr. (4 gm.) of sodium phosphate, with citric acid and sodium nitrate) 1-3 fl. dr. (4.0-1 1.0 c.c). Therapeutics. — Sodium phosphate in small doses acts as a laxative ; in large doses, as a purgative. Its mild action and agreeable taste commend it especially for children, to whom it may be given in milk or other food. It is useful also in the less severe forms of constipation occurring in adults. In chronic gastric catarrh with constipation small doses in hot water before meals often have a very happy effect not only on the bowel, but also on the stomach. Taken in the same way, sodium phosphate is a valuable depletive in simple catarrhal jaundice secondary to duodenitis. MAGNESII CITRAS. (Magnesium Citrate; Mg 3 2C 6 H 5 7 + i4H 2 0.) Magnesium citrate is official as the solution of magnesium citrate (Liquor Magnesii Citratis). This preparation is an effervescing solution of magnesium citrate containing a small quantity of sugar and free citric acid. In doses of from 6-12 fl. oz. (180.0-360.0 c.c.) it is a very pleasant, but some- what irritating, cathartic. It is suitable for occasional use, when it is desired simply to evacuate the alimentary canal. It should not be employed when there is any inflammation of the gastro-intestinal tract. 220 DIURETICS. DIURETICS. Diuretics are agents that increase the flow of urine. They may act (i) by increasing the general arterial pressure; (2) by dilating the vessels of the kidney ; (3) by increasing the water content of the blood (salt action) ; (4) by directly stimulating the renal epithelium. (1) General Circulatory Stimulants. — The chief representa- tives of this class of diuretics are : Digitalis. Convallaria. Strophanthus. Apocynum. Squill. Part of the diuretic effect of squill is to be attributed to direct stimulation of the renal epithelium. Dilators of the Renal Vessels. — Local dilatation of the vessels of the kidney, if not accompanied by a reduction of the general arterial pressure, increases the secretion of urine. There is some reason to believe that the purin derivatives — caffein, theobromin, theophyllin — increase urine production, partly by inducing local changes in the renal circulation. Salines. — Salts that are readily absorbed from the aliment- ary canal cause diuresis by drawing water into the blood and distending the renal vessels. Salts that are difficult of absorp- tion, like the magnesium and sulphate ions, draw water into the bowel and act as cathartics. The following drugs owe their diuretic properties to salt action : Potassium bicarbonate. Potassium nitrate. Potassium carbonate. Potassium chlorate. Potassium bitartrate. Lithium carbonate. Potassium acetate. Lithium citrate. Potassium citrate. Lithium benzoate. Dextrose and other sugars, owing to their high osmotic equiv- alents, also induce diuresis, hence the polyuria of diabetes mellitus. Direct Renal Stimulants. — The chief members of this group are : Caffein. Calomel. Theobromin. Blue mass. Theophyllin. Scoparius. As pointed out above, there is some evidence to show that caffein, theobromin, and theophyllin act partly by dilating the kidney vessels. DIURETICS. 221 Buchu, uva ursi, oil of turpentine, copaiba, and cubeb also have a specific effect on the renal epithelium, but they are used chiefly to stimulate the mucous membrane of the genito- urinary tract and to inhibit bacterial growth in the urine and very rarely as diuretics. They are considered under the heading " Stimulants to the Genito-urinary Tract." Concerning the influence of drugs upon the solids eliminated by the kidneys, we have at present very little definite knowl- edge. Large quantities of water frequently increase the solids of the urine, but it has been shown that this is due to the flush- ing out of waste-products and not to any increase of proteid metabolism. It is commonly believed that the alkaline diuretics hasten oxidation in the tissues, and in consequence increase nitrogenous elimination, but it has not been satisfactorily dem- onstrated that these drugs have such an action. Many of the investigations undertaken to decide the question have been attended by numerous opportunities for error, and those that have not been have given such conflicting results that no con- clusions can be drawn from them. Digitalis, strophantus, and caffein have no pronounced effect on the excretion of the solids normally found in the urine, but the last sometimes induces a slight glycosuria. Certain drugs which have no special activity as diuretics notably increase the solid constituents of the urine. Thus, salicylic acid increases the elimination of urea, uric acid, and sulphur compounds ; colchicum probably increases the excre- tion of uric acid, and thyroid extract, by increasing the destruction of the proteids of the tissues, very decidedly augments the output of nitrogen and phosphates. Diuretics are employed for the following purposes : 1. To Remove Excrementitious Matters From the Blood. — They are useful for this purpose when the secretory function of the kidneys is impaired or suspended, as it often is in acute febrile diseases, in passive congestion of the kidneys, and in some forms of Bright's disease. 2. To Promote the Absorption and Excretion of Dropsical Effusion. — For obvious reasons diuretics are less efficacious in dropsy resulting from organic disease of the kidneys than in that resulting from lowered arterial tension. 3. To Lessen Irritation of the Genito-urifiary Tract. — For this purpose alkaline diuretics are useful when the urine is too concentrated or is excessively acid. They also relieve the distressing symptoms occasioned by uric acid gravel and uric acid stones, not by exercising a solvent action on the concre- tions, but by producing a more copious secretion of urine. 222 DIURETICS. DIGITALIS, U. S. P. Digitalis has very little, if any, influence on the renal epithe- lium ; it produces diuresis mainly through its stimulant action on the heart and blood-vessels. In the dropsy of heart disease it is preeminent as a diuretic when used in doses just sufficient to maintain the proper degree of tension in the renal blood-vessels. We must remem- ber, however, that by giving it too freely we may cause exces- sive constriction of the arterioles, and thereby defeat the object for which we have employed it. Various opinions are held as to the advisability of using digitalis to excite the secretory function of the kidneys in acute Bright s disease. In deciding this question a very important factor to be considered is the state of the circulation. We believe that when the pulse is strong, when the second sound of the heart at the aortic cartilage is accentuated, and when dropsy is absent or is slight, the drug should not be employed. On the other hand, when there are evidences of lowered arterial tension and when dropsy is marked, it is often of great service in reestablishing elimination through the kidneys. In chronic parenchymatous nephritis it may be used to increase the flow of urine and to reduce the dropsy, but, like all other diuretics, it is a very uncertain remedy. In chroyiic interstitial nephritis so long as the arterial tension is high and the urine is abundant, there is, of course, no indication for diuretics ; but late in the disease, when dilatation of the heart supervenes and occasions oliguria, dropsy, dyspnea, and a weak, irregular pulse, digitalis is our most reliable remedy. In dropsy of hepatic origin the drug may be combined with mercury, as in the well- known Niemeyer's pill (p. 5 2 )> but its action is often disappoint- ing. In serous effusions of an inflammatory character, such as are encountered in pleurisy and pericarditis, it is of doubtful utility. STROPHANTHUS, U. S. P. Strophanthus is a somewhat more active diuretic than digitalis, probably because it raises the blood-pressure without constricting the renal arteries. It is possible, too, that this drug has a very slight irritant action on the renal epithelium. It may be employed in the same class of cases in which digitalis has been recommended. CAFFEINA, U. S. P. (Caffein.) CafTein is a very powerful diuretic, acting for the most part, it is generally believed, directly on the renal epithelium. It THE OBR OMINA— THE CIN. 223 increases the secretion of water to a greater extent than it does the output of solids, and, therefore, it lowers the specific gravity of the urine. After the ingestion of much sugar- forming food it sometimes gives rise to a slight glycosuria. It may be employed in any form of general dropsy except that of acute nephritis. In cardiac dropsy it not infrequently sur- passes digitalis in its power of producing diuresis, and a com- bination of digitalis and caffein may prove more effective than either drug singly. In chronic parenchymatous nephritis also caffein may succeed when digitalis has failed. Its tendency to cause insomnia must always be borne in mind. THEOBROMINA. (Theobromin.) Theobromin is an alkaloid closely related to caffein, and obtained from the seeds of Theobroma Cacao, or chocolate tree, extensively grown in South America and the West Indies. It occurs in minute whitish crystals, of a bitter taste, and spar- ingly soluble in water and alcohol. The dose is from 3-10 gr. (0.2-0.65 gm.). Owing to their ready solubility in water the double salts, theobromin-sodium and sodium acetate {agurin) and theobromin-sodium and sodium salicylate (diuretin), are preferred by some practitioners to the pure alkaloids. These compounds are decomposed on exposure and are incompatible with acids. Either salt may be given in doses of from 5 to 1 5 gr. (0.3-1.0 gm.) in peppermint-water or in capsules. The action of theobromin resembles that of caffein, but it has much less influence than the latter on the brain and circu- latory system. It produces diuresis mainly through its in- fluence on the renal epithelium. It is eliminated in the urine partly unchanged and partly in the form of xanthin bodies, to which, like caffein, it is closely allied. Theobromin may be used as a diuretic in the same class of cases as caffein. On account of its inferior rank as a circula- tory stimulant it is not so generally useful as digitalis in the dropsy of cardiac origin, but it will be found an excellent adjuvant to that drug in some cases. In chronic nephritis, when degeneration of the kidneys is far advanced, like other diuretics, it often proves ineffectual in removing the dropsy. THEOCIN. (Theophyllin.) Theocin is a synthetic xanthin derivative, isomeric with theobromin (dimethyl xanthin). It is identical with theophyl- 224 DIURETICS. lin, a natural alkaloid existing in small quantities in tea (Thea sinensis). The artificial product is a white crystalline sub- stance with a slightly bitter taste. It is soluble in about 200 parts of water. Theocin is a powerful diuretic, but its effects are evanescent, rarely lasting more than four or five days. Like theobromin, it has little influence upon the circulation, but acts directly by stimulating the renal epithelium. It may be employed in dropsy from any cause, excepting that of acute nephritis. It is usually well borne, but untoward effects, such as nausea and vomiting, headache and vertigo, are not uncommon. To secure the best results its administration should be followed after a few days by that of digitalis or an alkaline diuretic. The dose of theocin is from 5-8 gr. (0.3-0.5 gm.) in hot liquid, after meals. CONVALLARIA, U. S. P. The action of convallaria resembles that of digitalis. While it has advantages in not having any cumulative effect and in not disturbing the stomach, it is distinctly inferior to digitalis both as a circulatory stimulant and as a diuretic. It occasion- ally succeeds, however, in cases of cwdiac dropsy in which digitalis has been tried without avail. SCILLA, U. S. P. (Squill.) Squill is the bulb of the Urginea maritima, a perennial herb growing on the shores of the Mediterranean Sea. According to Merck, it contains three active constituents, scillitin, scilli- toxin (scillain), and scillin. No principle, however, that has yet been isolated represents fully the properties of the crude drug. The dose of powdered squill is from 1-3 gr. (0.065- 0.2 gm.). Preparations. Dose. Acetum Scillsg, U. S. P 10-30 min. Fluidextractum Scillae, U. S. P 1-3 min. (0.06-0.2 c.c). Tinctura Scillse, U. S. P . 5-20 min. (0.3-1.2 c.c). Syrupus Scillae, U. S. P i-l fl. dr. (2.0-4.0 c.c). Syrupus Scillae Compositus, U. S. P. (fl. ext. of squill, 8 per cent. ; fl. ext. of senega, 8 per cent. ; tartar emetic, 0.2 per cent.) . . 10-60 min. (0.6-4.0 c.c). Physiologic Action and Therapeutics. — Squill has an influence on the circulation very similar to that of digitalis. It also produces diuresis, partly by increasing the quantity of blood flowing through the kidneys, and partly, there is reason SCOPARIUS—APOCYNUM. 225 to believe, by directly stimulating the renal epithelium. Large doses cause vomiting and purging, and, in addition, if much of the drug be absorbed, albuminuria and hematuria. Squill is employed chiefly as a stimulating expectorant (see p. 288) and as a diuretic. For the latter purpose it is rarely given by itself, but in combination with digitalis. Reference has already been made to the value of a combination of digi- talis, squill, and blue-mass in some cases of cardiac and hepatic dropsy. It is contraindicated in acute nephritis. As a diuretic it is usually prescribed in substance and in pill form. SCOPARIUS, U. S. P. (Broom.) Scoparius is the tops of Cytisus Scoparius, a shrub indigenous to Western Asia and Southern Europe, and cultivated in the United States. It contains a liquid alkaloid, spartein, and a neutral principle, scoparin. The salts of spartein, of which the sulphate is official, are crystalline solids. Scoparin is rarely used; its dose by the mouth is from 5-15 gr. (0.3-1.0 gm.). Preparations. Dose. Fluidextractum Scoparii £-1 fl. dr. (2.0-4.0 c.c). Decoctum Scoparii (1 oz.-l pint — 30.0 gm.- 0.5 L.) 1-3 fl. oz. (30.0-90.0 c.c). Physiologic Action and Therapeutics. — The chief effect of moderate doses of scoparius is an increase in the flow of urine. The diuresis is not due to the spartein, which has an action similar to that of coniin (see p. 151), but to the scoparin, which probably acts directly on the kidney. Large doses cause vomiting and purging. Scoparius, alone or with digitalis, is sometimes efficacious in cardiac dropsy. The decoction is gen- erally employed. APOCYNUM, U. S. P. (Canadian Hemp.) Apocynum is the root of Apocynum cannabinum, a perennial plant growing in North America, from Canada to Florida. In addition to tannin and a bitter extractive, it contains an indif- ferent resinous principle, apocynin, and an active glucosid, apocynein. Preparation. Dose. Fluidextractum Apocyni, U. S. P 5-10 min. (0.3-0.6 c.c). Physiologic Action and Therapeutics. — Apocynum, through its glucosid, apocynein, has an action on the circula- 15 226 DIURETICS. tion resembling that of digitalis. Like the latter, also, it in- creases the flow of urine. In large doses it is an active irritant to the gastro-intestinal tract, causing severe vomiting and purging. Apocynum has been used as a diuretic in cardiac and renal dropsy \ but it is unreliable and prone to disturb the stomach. VEGETABLE SALTS OF POTASSIUM. Physiologic Action. — In very large doses potassium is a depressant to both the nervous system and the circulatory system, especially to the latter. In the case of the vegetable salts of potassium, however, the action of the base is subordi- nate to that of the acid radical, and a depressant effect is never observed except after a very large dose of the salt or after its prolonged administration. The chief effect of a moderate dose of any one of the vegetable salts of potassium is an increased secretion of urine. The mineral salts of the urine, both of potassium and sodium, are increased, but the evidence is not convincing that the salts of potassium hasten oxidation in the tissues, and in consequence augment nitrogenous elimination. In large doses they impart an alkaline reaction to the urine. The claim made by some authorities that they increase the secretion of bile has not been substantiated by recent inves- tigations. Therapeutics. — It is an established fact that acute rheu- matism is favorably influenced by the administration of the vegetable salts of potassium, but until we have a clearer understanding of the nature of this disease it would be use- less to speculate upon the modus operandi of the remedies employed in its treatment. Thirty grains (2.0 gm.) of the alkali should be given every three or four hours until the urine becomes neutral or slightly alkaline. Excellent results are often obtained by combining an alkaline salt with a salicylic compound. Alkalis in copious drafts of water are efficient adjuvants to colchicum in the treatment of gout ; but it is not known whether they act by hindering the formation of uric acid, by promoting the solution of uric acid compounds, or simply by benefiting gastric catarrh, relieving constipation, and stimulat- ing the activity of the kidneys. Alkalis or mineral waters containing them are apparently of service in acute catarrh of the bile-ducts and in cholelithiasis, probably by relieving coexisting duodenal catarrh, and not by exerting any direct influence on the bile itself or its concretions. VEGETABLE SALTS OF POTASSLUM. 227 They are also useful in relieving dysuria that is due to excessive acidity of the urine, and through their diluent action they tend to mitigate the suffering occasioned by uric acid gravel and uric acid calculi. In acute Bright s disease they serve to main- tain the excretion through the kidneys and to render the urine less irritating. Finally, the vegetable salts of potassium are efficient sedative expectorants in the beginning of acute bronchitis, especially when the secretion is viscid and scanty. Incompatibles. — The vegetable salts of potassium are in- compatible with acids, mineral salts, and alkaloidal salts. POTASSII BICARBONAS, U. S. P. (Potassium Bicarbonate ; KHC0 3 .) Potassium bicarbonate occurs in colorless prismatic crystals, odorless, and of a saline, alkaline taste. It is soluble in 3 parts of water, and almost insoluble in alcohol. The dose is from 10-30 gr. (0.65-2.0 gm.) in solution well diluted. On account of its unpleasant taste it is less frequently prescribed than the citrate and acetate of potassium. Potassium bicar- bonate is used in making the following preparations : Liquor potassii arsenitis (Fowler's solution), U. S. P. Liquor potassii citratis, U. S. P. Liquor magnesii citratis, U. S. P. POTASSII CARBONAS, U. S. P. (Potassium Carbonate; K 2 C0 3 .) Potassium carbonate is a white, granular, deliquescent pow- der, alkaline in reaction, and caustic to the taste. It is freely soluble in water, but insoluble in alcohol. The dose is from 10-30 gr. (0.65-2.0 gm.), but on account of its irritant proper- ties it is rarely used internally. From potassium carbonate the following preparations are made : Mistura ferri composita, U. S. P. Pilulse ferri carbonatis (Blaud's Pills), U. S. P. POTASSII BITARTRAS, U. S. P. (Potassium Bitartrate ; Cream of Tartar ; KHC 4 H 4 6 .) Potassium bitartrate occurs in colorless or slightly opaque, rhombic crystals, or as a white powder, odorless, and of an acidulous taste. It is soluble in about 200 parts of water, and very sparingly soluble in alcohol. The dose is from 1 5-60 gr. 228 DIURETICS. (1.O-4.O gm.). Unlike the other vegetable salts of potassium, the bitartrate resists oxidation in the body, and, therefore, much of it is eliminated unchanged. As it is not readily absorbed from the alimentary canal, it is also an aperient. The double tartrate of potassium and sodium (Rochelle salt) is formed by adding potassium bitartrate to a hot solution of sodium car- bonate, Preparation. Dose. Pulvis Jalapae Compositus, U. S. P. (jalap, 35 ; potassium bitartrate, 65) 15-60 gr. (1.0-4.0 gm.). POTASSII ACETAS, U. S. P. (Potassium Acetate ; KC 2 H 3 2 .) Potassium acetate occurs as a white powder or as crystal- line masses, very deliquescent, odorless, and of a saline taste. It is soluble in 0.4 part of water and in 2 parts of alcohol. The dose is from 15-60 gr. (1.0-4.0 gm.). On account of its ready solubility, pleasant taste, and freedom from irritant properties, potassium acetate is a favorite alkaline diuretic. POTASSII CITRAS, U. S. P. (Potassium Citrate; K 8 C 6 H 5 O t + H 2 0.) Potassium citrate occurs in transparent, prismatic crystals or white, granular powder, deliquescent on exposure to air, odor- less, and having a pleasant saline taste. It is soluble in 0.5 part of water, but sparingly soluble in alcohol. The dose is from 15-60 gr. (1.0-4.0 gm.). Preparations. Dose. Liquor Potassii Citratis, U. S. P. (neutral mixture) \-i fl. oz. (15.0-30.0 c.c). Potassii Citras Effervescens, U. S. P. . . . 30-90 gr. (2.0-6.0 gm.). The citrate of potassium has properties closely resembling those of acetate of potassium, and the two salts may be used interchangeably. The solution of potassium citrate is used in mild febrile conditions to promote the secretion of the skin and kidneys. POTASSII NITRAS, U. S. P. (Potassium Nitrate ; Saltpeter; KN0 8 .) Potassium nitrate occurs as colorless, transparent, rhombic prisms, or as a crystalline powder having a cooling, saline taste. It is permanent in the air. It is soluble in 3.6 parts of water, and sparingly soluble in alcohol. The dose is from 5-20 gr. (0.3-1.3 gm.), in solution, well diluted. POTASSII CHLORAS. 229 Physiologic Action.— Beyond being more irritating to the stomach, the effect of potassium nitrate in moderate doses is not materially different from that of the vegetable salts of potassium. Like the latter, it increases the flow of urine through its direct action on the secreting cells of the kidneys. In large doses potassium nitrate is not only more irritating than the vegetable salts, but, owing to the relatively greater influence of the metallic base, — potassium, — it is distinctly more depressing to the heart and nervous system. The drug is partly eliminated in the urine and saliva unchanged ; a greater part undergoes reduction in the tissues, but its educts are at present unknown. Toxicology. — Toxic doses produce the symptoms of acute gastro-enteritis, profound muscular weakness, and collapse. In some instances diuresis is replaced by oliguria or anuria. Therapeutics. — Potassium nitrate may be employed as a diuretic in general dropsy, but its utility is no greater than that of the acetate or bitartrate of potassium, which are less irri- tating to the gastro-intestinal tract. Inhalation of the smoke of burning niter paper is sometimes effective in asthma. POTASSII CHLORAS, U. S. P. (Potassium Chlorate ; KC10 3 .) Potassium chlorate occurs in the form of colorless, crystal- line plates, odorless, and of a cooling saline taste. It is sol- uble in 16 parts of water, and sparingly soluble in dilute alcohol. The dose is from 3-10 gr. (0.2-0.65 gm.), in solu- tion, well diluted. Preparation. Dose. Trochisci Potassii Chloratis, U. S. P. (each contains about 2^ gr. — 0.15 gm.) 1-4 troches. Physiologic Action. — When applied in dilute form to mucous membranes, potassium chlorate produces a stimulating and alterative effect ; in concentrated form it is a decided irri- tant. When taken internally it does not, as was formerly believed, yield its oxygen to the blood, but it passes out of the body unchanged. Most of it — more than 90 per cent. — escapes in the urine, but, according to Isambert, small quanti- ties can be recovered from the saliva, the tears, and the milk of nursing women. The only appreciable effect of moderate doses, well diluted, is an increase in the flow of urine. Con- centrated solutions, even of therapeutic doses, give rise to a 230 DIURETICS. burning sensation in the stomach, followed by nausea and vomiting. Jacobi 1 was the first to point out that the practice of giving the drug internally in large doses was a dangerous one, and to prove that many deaths that had been attributed to other causes were in reality due to potassium chlorate poisoning. Toxicology. — The symptoms of potassium chlorate poi- soning are the resultant of the drug's action on the heart, digestive tract, kidneys, and blood. Through its basic radical it depresses the circulation, and through its acid radical it irritates the stomach, intestines, and kidneys, and also effects a peculiar change in the blood — namely, the conversion of hemoglobin into methemoglobin, a compound very tenacious of its oxygen. The first symptoms of poisoning are thirst and abdominal pain, followed by vomiting and purging. Cya- nosis is almost constantly present, and is accompanied by dyspnea and the usual phenomena of cardiac failure. The urine is scanty, dark colored, and albuminous, and on micro- scopic examination reveals numerous pigmented tube-casts and granular detritus derived from the red blood-cells. Jaun- dice is often present, and in many cases death is preceded by coma and convulsions. The immediate cause of death may be heart failure, asphyxia, or uremia, according as the action of the poison has been most pronounced on the circulation, blood, or kidneys. Apart from gastro-enteritis and nephritis, the most striking postmortem change is that which involves the blood. The color of the blood is changed to a chocolate hue, oxyhemoglobin is replaced by methemoglobin, and many of the red cells are decolorized and more or less disintegrated. The organs generally may be chocolate colored from the accumulation in the tissues of liberated blood-pigment. In the recorded cases the minimum fatal dose for an adult has been 4 drams ; for a child of four years, 3 drams ; and for an infant, I dram. The treatment of poisoning consists in evacuating the stomach and in administering demulcents and diluents. Subcutaneous injections of normal salt solution may be tried. Therapeutics. — Potassium chlorate makes an excellent local application in inflammatory affections of the mouth and throat. Thus, it is valuable in the various forms of stomatitis and in acute pharyngitis. In these affections a solution of from 10-20 gr. (0.65-1.3 gm.) to the ounce (30.0 c.c.) may be used as a wash or gargle. In acute pharyngitis tannic acid or some preparation containing it is frequently added to the solution. 1 Medical Times, April, 1861. LITHII CARBONAS. 23 I In scarlatina and diphtheria it is generally advisable to avoid solutions of potassium chlorate, and to select an agent that, if swallowed, will not contribute to the existent renal irritation. In ulcerous stomatitis this salt is almost a specific, and may be used internally as well as locally. The dose for a child of three years is from 2-3 gr. (0.13-0.2 gm.), well diluted, every three hours. Benefit from its internal administration is to be attrib- uted to its continuous elimination in the saliva. Tincture of ferric chlorid may be used as an adjuvant, as in the following formula : &. Potassii chloratis, gr. xl (2.6 gm.) ; Tincturae ferri chloridi, tt\xxxij (2.0 c.c.) ; Syrupi zingiberis, fgvj (22.5 c.c.) ; Aquae, q. s. ad f^ij (60.0 c.c). — M. Sig. A teaspoonful in water every three hours. It is generally believed that salivation is less likely to result from the continuous use of mercury when a solution of potas- sium chlorate is used at the same time as a mouth-wash. In some cases of syphilis troches of the salt are useful as preven- tives of both mercurial stomatitis and of mucous patches. Incompatibles. — Owing to rapid oxidation or reduction violent explosion may occur when potassium chlorate is triturated with such substances as tannic acid, phosphorus, pulverized charcoal, sulphur, sulphids, sugar, hyposulphites, hypophosphites, and ammonium chlorid. Mixtures of potas- sium chlorate, tincture of ferric chlorid, and glycerin, when warm, are liable to explode. The salt reacts with strong hydrochloric acid, setting free chlorin gas ; with potassium iodid it may form the exceedingly irritant potassium iodate, and from syrup of ferrous iodid it may precipitate free iodin. LITHII CARBONAS, U. S. P. (Lithium Carbonate ; Li 2 C0 3 .) Lithium carbonate occurs as a white powder, odorless, and of an alkaline taste. It is soluble in 75 parts of water and insoluble in alcohol. Its dose is from 5-20 gr. (0.3-1.3 gm.). Physiologic Action and Therapeutics. — The effect of the vegetable salts of lithium is very similar to that of the corresponding salts of potassium ; like the latter, they increase the quantity of urine and lessen its acidity. Lithium salts were originally recommended in the treatment of gout and the uric acid diathesis because it was found that outside of the body lithium united with uric acid to form a more soluble salt than 232 OTHER DIURETICS. did either sodium or potassium ; but as it has been clearly dem- onstrated that alkaline medication is without influence on the urates present in the blood or tissues, it is very doubtful whether the salts of lithium are any more potent in these diseases than the vegetable salts of potassium. The natural mineral waters are extensively employed in the treatment of gout and nephrolithiasis, but any efficacy that they may pos- sess is probably dependent upon the depurant action of the water itself and not upon the small amount of salt they contain. LITHII CITRAS, U. S. P. (Lithium Citrate ; Li 3 C 6 H 5 7 -f 4.H 2 0.) Lithium citrate is a white, deliquescent powder, odorless, and of a cooling, alkaline taste. It is soluble in two parts of water and insoluble in alcohol. Its dose is from 5-20 gr. (0.3-1.5 gm.). Preparation. Dose. Lithii Citras Effervescens, U. S. P 1-2 dr. (4.0-8.0 gm.). Lithium citrate is the therapeutic equivalent of lithium car- bonate, and may be substituted for the latter when a solution is preferred to a powder. LITHII BENZOAS, U. S. P. (Lithium Benzoate; LiC 7 H 5 2 .) Lithium benzoate occurs in the form of a white powder or small shining scales, permanent in the air, odorless, and of cooling, sweetish taste. The dose is from 5-30 gr. (0.3-2.0 gm.). This drug was recommended in the treatment of gout on the ground that it would prove especially active as a uric acid solvent, the acid radical uniting with proteid derivatives to form the soluble hippuric acid, and the basic radical uniting with free uric acid to form a readily soluble urate. This rea- soning, however, has been shown to be fallacious by recent studies on uric acid formation and elimination, and, moreover, in practice, lithium benzoate has been found to be less efficacious in gouty conditions than the other salts of lithium. OTHER DIURETICS* Calomel (see p. 330). — Several theories have been advanced to explain the diuretic action of this drug ; the most tenable one is that it acts directly on the renal epithelium. It is espe- cially useful in the dropsy of cardiac disease, but it is not with- STIMULANTS TO THE GENITO-URINARY TRACT. 233 out value in serous effusions of hepatic or renal origin. A few large doses (2-3 gr. — 0.13-0.2 gm.) may be given, opium being added, when necessary, to prevent purging ; or small doses (f gr. — 0.016 gm.) may be employed as adjuvants to digitalis and squill. _ Spirit of Nitrous Ether (see p. 262).— Sweet spirit of niter is an agreeable remedy of feeble diuretic power. Each of its components — ethyl nitrite, ether, and alcohol — probably contributes to its activity. It is useless in general dropsy, but it is very efficacious in relieving oliguria that is due to febrile disease or active congestion of the kidneys. The usual dose as a diuretic is from 1-2 fl. dr. (4.0-8.0 c.c). Incompatible s. — Spirit of nitrous ether is incompatible with antipyrin, iodids, ferric sulphate, tincture of guaiacum, muci- lage of acacia, and tannic acid. STIMULANTS TO THE GENITO-URINARY TRACT. Under this heading will be considered those drugs that stimulate the mucous membrane of the whole genito-urinary tract. All these act also upon the secretory cells of the kid- neys, and increase more or less the quantity of urine, but this influence is subordinate to that exerted upon the mucous mem- branes over which the urine flows. Many of them contain antiseptic principles that are eliminated by the kidneys, and that are powerful enough to inhibit the growth of bacteria and to prevent decomposition of the urine. In large doses these drugs are capable of producing acute inflammation of the bladder and urethra, and even of the kidneys themselves. The most important members of this group are : Copaiba. Oil of erigeron. Cubeb. Buchu. Matico. Uva ursi. Oil of sandalwood. Chimaphila. Turpentine. Pareira. Juniper. Cantharides. The combined stimulant and antiseptic properties of these drugs make them useful remedies in subacute and chronic pyelitis, cystitis, and urethritis. They are contraindicated when the inflammation is of an acute character. 234 STIMULANTS TO THE GENITO-URINARY TRACT. COPAIBA, U. S. P. (Balsam of Copaiba; Copaiva.) Copaiba is the oleoresin of Copaiba Langsdorffi and other species of Copaiba, a small tree growing in the northern states of South America. It is a yellowish or brownish viscid liquid, having a peculiar, aromatie odor and a bitter, acrid taste. It contains a volatile oil (40.9 per cent.), resins, a bitter principle, and copaivic acid. The dose of copaiba is from 5-30 min. (0.3-2.0 c.c.) in capsule or emulsion. Preparation. Dose. Oleum Copaibae, U. S. P 5-15 min. (0.3-1.0 c.c). Physiologic Action and Therapeutics. — In therapeu- tic doses copaiba acts as a stimulant to mucous membranes. As its active principles are eliminated chiefly by the kid- neys and lungs, it particularly influences the mucous mem- brane of the genito-urinary tract and bronchi. The drug also excites diuresis, and imparts to the urine decided antiseptic properties. The resins and most of the oil are excreted by the kidneys, but a part of the oil escapes through the lungs and skin. The oil appears in the urine in part unchanged, and in part in combination with glycuronic acid. Urine contain- ing the resins of copaiba responds to the nitric acid test for albumin, but the resinous precipitate can be distinguished by its rapid disappearance on the addition of alcohol. Fehling's solution may also be reduced by urine containing the educts of copaiba. In large doses copaiba acts as an irritant, causing burning in the stomach, vomiting and purging, lumbar pains, frequent micturition, and even strangury. In some persons the administration of the drug is followed by an eruption on the skin, urticarial, scarlatinoid, or morbilliform in type. In inflammatory diseases of the genito-urinary tract, such as pyelitis, cystitis, and urethritis, copaiba is a useful remedy; it should not be used, however, until the most acute symptoms have subsided. In gonorrhea, after the discharge has become well established, the drug affords considerable relief and tends to prevent complications. It may be combined advantageously with other drugs, like cubeb and salol, which tend to render the urine sterile. As a simple diuretic it has been well recommended in dropsy due to cirrhosis of the liver. In subacute and chronic bronchitis with profuse purulent expectoration it is sometimes beneficial, but generally it is less useful than oil of eucalyptus CUB EB A— MA TICO. 235 or the preparations of guaiacol. Copaiba has a long-standing reputation as a stimulant application for indolent ulcers. Both copaiba itself and the oil are eligible preparations. On account of their unpleasant taste they should always be pre- scribed in capsules or as an emulsion. CUBEBA, U. S. P. (Cubeb.) Cubeb is the unripe fruit of Piper Cubeba, a perennial climber indigenous to Borneo and the neighboring islands. It contains a volatile oil (5-15 per cent), a resin, cubebic acid, and cubebin, which is inert. The dose of powdered cubeb is from \-2 dr. (2.0-8.0 gm.). Preparations. Dose. Fluidextractum Cubebae, U. S. P 10-30 min. (0.6-2.0 c.c). Oleoresina Cubebae, U. S. P 5-15 min. (0.3-1.0 c.c). Oleum Cubebae, U. S. P 5-15 min. (0.3-1.0 c.c). Trochisci Cubebae, U. S. P. (each, contains about \ gr. (0.02 gm.) of oleoresin) . . . 1-5 troches. Physiologic Action and Therapeutics. — Cubeb pos- sesses properties closely resembling those of copaiba ; hence it may be employed to meet the same indications as the latter. A combination of the two is often more effective than either alone. Cubeb is somewhat less liable than copaiba to disturb digestion or to cause cutaneous rashes. Troches of cubeb are useful in relieving hoarseness and fatigue of the larynx result- ing from prolonged use of the voice. The oleoresin is the most active preparation ; it should be given in capsules or as an emulsion. MATICO, U. S. P. Matico is the leaves of Piper angustifolium, a shrub growing in Mexico and South America. It contains a volatile oil, a resin, tannin, and artanthic acid. Preparation. Dose. Fluidextractum Matico, U. S. P J-2 fl. dr. (2.0-8.0 c.c). Physiologic Action and Therapeutics. — Matico some- what resembles cubeb in its action, and has been given in the same class of cases. The leaves, on account of their hairy surfaces, favor coagulation and arrest bleeding when applied to small wounds. The drug is rarely employed at the present time. 236 STIMULANTS TO THE GENITO-URINARY TRACT. OLEUM SANTALI, U. S. P. (Oil of Santal; Oil of Sandalwood.) Oil of santal is a volatile oil distilled from the wood of San- talum album, a small tree growing in India and the East Indian Islands. It is a thick, pale-yellow liquid, having a strong, aro- matic odor and a pungent, spicy taste. It is soluble in alcohol. The dose is from 5-20 min. (0.3-1.2 ex.), in capsules or as an emulsion. Oil of santal resembles copaiba in its action, but is less irritant. TEREBINTHINA, U. S. P. (Turpentine.) Turpentine is a concrete oleoresin obtained from Pinus palus- tris and other species of Pinus growing in the Southern United States, especially in North Carolina. When subjected to dis- tillation it yields a volatile oil, oleum terebinthince, and a solid residue, resin. OLEUM TEREBINTHINA, U. S. P. (Oil of Turpentine; Spirit of Turpentine.) Oil of turpentine is a limpid, colorless, highly inflammable liquid, having a characteristic odor and taste. It contains sev- eral terpene hydrocarbons. The rectified oil is made by dis- tilling the ordinary oil with lime-water, and is the preparation always selected for internal use. Preparations. Dose. Oleum Terebinthinse Rectificatum, U. S. P. . 5-20 rain. (0.3- 1. 2 c.c). Emulsum Olei Terebinthinse, U. S. P. (15 percent.) j-2 fl. dr. (2.0-8.0 c.c). Linimentum Terebinthinae, U. S. P. ( oil of turpentine, 35 ; resin cerate, 65 ) . Terpin hydrate (see p. 289) is a crystalline compound obtained by the inter- action of oil of turpentine, alcohol, and nitric acid. Terebene (see p. 288) is a liquid hydrocarbon made by oxidizing oil of turpen- tine with strong sulphuric acid. Physiologic Action. — When applied to the skin, oil of turpentine acts as an irritant, producing redness and burning, and, if the contact be prolonged, vesication. The drug has decided antiseptic properties, and is capable, even in dilute form, of preventing fermentation and putrefaction. Internally, in full doses, it causes a sense of warmth in the stomach, quick- ened respiration, and an increase in the rate and tension of the pulse. It escapes from the body through the respiratory tract and the kidneys, and imparts to the urine an agreeable odor TEREBINTHINM. 237 resembling that of violets. In overdoses it produces abdom- inal pain, nausea, vomiting, embarrassed respiration, a rapid, feeble pulse, great muscular relaxation, lumbar pains, dysuria, scanty bloody urine, delirium, and finally coma. In therapeutic doses oil of turpentine acts as a circulatory stimulant and diuretic. In the alimentary canal it plays the part of a carminative and an antiseptic. On leaving the body it imparts its peculiar stimulant and antiseptic properties to the urine and the secretions of the respiratory tract. In suscepti- ble persons an erythematous or papular eruption may result from either its internal or its external use. Therapeutics. — Externally oil of turpentine is used as a rubefacient in various inflammatory affections, such as bro?ichi- tis, pleurisy, pneumonia, gastritis, and enteritis. It is best applied in these cases in the form of a stupe made by sprinkling freely with the oil a piece of flannel which has first been soaked in boiling water and then wrung dry. It may be allowed to remain on the affected part from ten to twenty minutes, according to the sensitiveness of the skin. Turpentine lini- ment makes an excellent application in muscular rheumatism and chilblains. Oil of turpentine is a reliable carminative, and may be ad- ministered either by the mouth or by the rectum. Trouble- some tympanites will often yield to the application of a stupe to the abdomen and the rectal injection of a pint of soapy water containing a tablespoonful of the oil. The oil is a valuable adjunct to alcohol in certain cases of typhoid fever. It is useful when the tongue is dry, brown, and fissured ; when there is a tendency to muttering delirium ; and when there is marked abdominal distention. It sometimes acts favorably as a stimulant and antiseptic in subacute and chronic inflammations of the genito- urinary tract, such as cystitis and urethritis. It may be employed as an expectorant in subacute and chronic brojichitis, when the expectoration is copious and purulent, but generally terebene will be found more agreeable. With some practitioners it has acquired a reputation as a hemo- static in passive hemorrhage from the stomach, intestines, lungs, or kidneys. Some cases of purpura hemorrhagica are favorably influenced by the oil. Oil of turpentine, J— I fl. oz. (15.0-30.0 c.c), with castor oil, has been used as an anthelmintic to destroy tape-worm, but there are other remedies equally effective and decidedly less dangerous. A mixture of 3 parts of oil of turpentine and 2 of ether, on 238 STIMULANTS TO THE GENITO-URINARY TRACT the recommendation of Durande, of Dijon, was at one time largely employed as a solvent of gall-stones, but it has been abandoned from the lack of evidence as to its efficacy. Oil of turpentine is a powerful deodorant. In the form of vapor it may be employed to overcome the fetid odor of the breath in bronchiectasis and gangrene of the lung. It is service- able for removing the odor from the hands after postmortem examinations. Madden has found it efficacious in destroying the offensive character of the discharges in cancer of the uterus. He recommends a douche composed of a tablespoonful each of the oil and magnesia to a quart of boiling water ; the mix- ture is to be cooled and thoroughly stirred before being used. The penetrating odor of iodoform is lost to a great extent in the presence of turpentine. Whatever may have been the merits of old preparations of the oil in phosphorus-poisoning ; it is certain that the present article of commerce is entirely without efficacy. Contraindications. — It should not be prescribed when there is acute inflammation of the stomach, intestines, or genito-urinary tract. Administration. — Oil of turpentine may be administered on lumps of sugar, in capsules, or in emulsion. Incompatibles. — Bromin, iodin, nitric acid, and strong sul- phuric acid act with violence on oil of turpentine. RESINA, U. S. P. (Rosin ; Resin ; Colophony.) Rosin is the hard, transparent, amber-Colored residue left after distilling off the volatile oil from turpentine. Preparations. Ceratum Resinse, U. S. P. (rosin, 35 parts ; yellow wax, 15 parts; lard, 50 parts). Ceratum Resinae Compositum, U. S. P. (rosin, 22.5 parts ; yellow wax, 22.5 parts; suet, 30 parts; turpentine, 1 1.5 parts; linseed oil, 13. 5 parts). Emplastrum Resinae (rosin, 14 parts; lead-plaster, 80 parts; yellow wax, 6 parts). Therapeutics. — Rosin cerate and compound rosin cerate are chiefly employed as stimulating applications for indolent ulcers. Rosin plaster is no longer official, rubber adhesive plaster {Emplastrum Adhcesivum) having been substituted for it. As it is less irritating to the skin, however, than the rubber adhesive plaster, it is to be preferred to the latter for strapping JUNIPER US— BUCHU. 239 the chest in fracture of the ribs and in pleurisy, and for making compression over indolent leg-ulcers. JUNIPERUS. (Juniper.) Juniper is the fruit of Jtiniperus communis, an evergreen shrub growing in Northern Europe, Asia, and America. It contains a volatile oil, resin, and a non-crystalline principle, juniperin. Preparations. Dose. Oleum Juniperi, U. S. P 3-5 min. (0.2-0.3 ex.). Spiritus Juniperi, U. S. P. (5 per cent, of oil of juniper) ^-1 fl. dr. (2.0-4.0 c.c). Spiritus Juniperi Compositus, U. S. P. (equiv- alent to gin) . . 1-4 fl. dr. (4.0-15.0 c.c). Physiologic Action and Therapeutics. — Juniper is a more active diuretic than most of the stimulants to the genito- urinary tract. The compound spirit is useful in increasing the flow of urine in passive congestion of the kidneys resulting from chronic heart disease. Its combination with a vegetable salt of potassium enhances its effect. In subacute and chronic inflammatory diseases of the genito-urinary tract it is not generally so useful as copaiba, oil of santal, or buchu. OLEUM ERIGERONTIS, U. S. P. (Oil of Erigeron; Oil of Fleabane.) Oil of erigeron is a volatile oil distilled from the fresh, flower- ing herb of Erigeron canadensis, an annual shrub growing in waste places in North America. It is a pale-yellow liquid, having a persistent aromatic odor and taste. The dose is from 5-15 min. (0.3-1.0 c.c), on sugar, in capsules, or as an emul- sion. Oil of erigeron resembles oil of turpentine in its action, but it is less powerful. It has been used to some extent as a sub- stitute for copaiba and oil of santal in the treatment of cystitis and gonorrhea. It has an established reputation as an internal hemostatic in hemorrhage from the uterus, lungs, intestines, and kidneys, especially when the bleeding is slight but persistent BUCHU, U. S. P. Buchu is the leaves of Barosma betulina, growing in South- ern Africa. Its active principle is a volatile oil, from which is derived barosma camphor or diosphenol. 24O STIMULANTS TO THE GEN/TO- URINARY TRACT. Preparation. Dose. Fluidextractum Buchu, U. S. P £-1 fl. dr. (2.0-4.0 c.c. ). Physiologic Action and Therapeutics. — In therapeutic doses buchu acts as a stimulant to the mucous membrane of the genito-urinary tract. It is a feeble diuretic. The volatile oil is eliminated by the kidneys, and imparts to the urine an aromatic odor. Its presence also makes the urine more or less antiseptic. Overdoses may produce vomiting, purging, and strangury. Buchu is useful in the less severe forms of subacute and chronic cystitis. It is especially efficacious in chronic irritability of the bladder, manifested by frequent desire to urinate. In subacute cystitis it may be advantageously combined with an alkali, as in the following formula : R Fluidextracti buchu, fjvj (22.5 c.c); Potassii citratis, 5ss (15.0 c.c.) ; Spiritus getheris nitrosi, f§j (30.0 c.c); Syrupi limonis, fjij (60.0 c.c) ; Aquae, q. s. ad f^vj (180.0 c.c). — M. Sig. A tablespoonful in water every three hours. UVA URSI, U. S. P. (Bearberry. ) Uva ursi is the leaves of Arctostaphylos Uva-ursi, an ever- green shrub growing in the northern parts of Europe, Asia, and North America. It contains two glucosids, — arbutin and ericolin, — tannic acid, and an inert, resinous principle, urson. Its virtues depend very largely on arbutin, which appears as white, crystalline needles, of a bitter taste, and freely soluble in alcohol and hot water, but sparingly soluble in cold water. The dose of arbutin is from 2-5 gr. (0.13-0.3 gm.). Preparation. Dose. Fluidextractum Uvse Ursi, U. S. P \-2 fl. dr. (2.0-8.0 c.c). Physiologic Action and Therapeutics. — Uva ursi in therapeutic doses stimulates the mucous membrane of the genito-urinary tract, increases the activity of the kidneys, and renders the urine slightly antiseptic. It is excreted by the kidneys partly unchanged and partly as hydroquinon. Both uva ursi and arbutin may impart to the urine a dark-green color that is probably due to the presence of pigments derived CHIMAPHILA—CANTHARIS. 24I from the oxidation of hydroquinon. As uva ursi contains a considerable quantity (6-8 per cent.) of tannic acid, it has well- marked astringent properties. For the same reason its prepa- rations are incompatible with spirit of nitrous ether. Uva ursi may be employed to meet the same indications as buchu, but it is generally less efficient. CHIMAPHILA, U. S. P. (Pipsissewa.) Chimaphila is the leaves of Chimaphila umbellata, a peren- nial indigenous to North America, Northern Europe, and Northern Asia. It contains tannic acid, arbutin, ericolin, urson, and a neutral, crystalline principle, chimaphiiin. Preparation. Dose. Fluidextractum Chimaphilse, U. S. P. . . . \-l fl. dr (2.0-4.O ex.), Chimaphila has the same action and uses as uva ursi. PAREIRA, U. S. P. (Pareira Brava.) Pareira is the root of Chondrodendron tomentosum, a climb- ing tree growing in Brazil and Peru. It contains tannic acid and an alkaloid, buxin. Preparation. Dose. Fluidextractum Pareirse, U. S. P \-2. fl. dr. (2.0-8.0 c.c). Pareira has been used in the same class of cases as buchu. CANTHARIS, U. S. P. (Cantharides ; Spanish Flies.) Cantharides (see p. 440) in moderate doses is an active stim- ulant to the mucous membrane of the genito-urinary tract. In large doses it is a powerful irritant, causing intense abdominal pain, vomiting and purging, frequent micturition, dysuria, pria- pism, and scanty, albuminous, and at times bloody urine. The tincture, in doses of from 1-3 min. (0.06-0.2 c.c), has been used with advantage in certain cases of chronic parenchymatous ne- phritis. The greatest caution, however, must be exercised in le 242 SEDATIVES TO THE GENITO-URINARY TRACT. in its administration, since if there be any remnant of an active inflammatory process, or if the drug be used too freely, serious harm may ensue. Henderson claims to have used cantharides successfully in a case of persistent hematuria, in which other remedies had been tried without avail. The drug has also been recommended in chronic pyelitis, cystitis, and urethritis. SEDATIVES TO THE GENITO-URINARY TRACT. Certain drugs play indirectly the part of sedatives to the genito-urinary tract by removing the causes of irritation. Thus, the alkaline diuretics afford relief from dysuria and frequent micturition, when these symptoms are due to ex- cessive acidity of the urine. Mineral waters, through their diluent action, soothe the mucous membrane when uric-acid calculi are present. Again, boric acid, salol, and urotropin, through their antiseptic and acidifying properties, subdue the distressing symptoms resulting from ammoniacal fermentation of the urine. But apart from these drugs, which allay irrita- tion by changing the character of the urine, there are others which exert a direct sedative influence on the urinary passages themselves. In this class are belladonna (see p. 75), hyoscy- amus (see p. 8 1), and perhaps zea. These remedies may be employed for their sedative effect when there is acute inflam- mation or excessive irritability of the bladder or urethra. ZEA, U. S. P. (Corn-silk.) Zea is the styles and stigmas of Zea Mays, or Indian corn. Its active constituents are a resin and maizenic acid. Preparations. Dose. Fluidextractum Zeae -|— 2 fl. dr. (2.0-8.0 c.c). Decoctum Zese (5 per cent.) 1-2 fl. oz. (30.0-60.0 c.c). Physiologic Action and Therapeutics. — Corn-silk acts as a feeble diuretic and as a sedative to the mucous membrane of the genito-urinary tract. It is very useful in acute cystitis and in the various forms of vesical irritability. URIC- ACID SOLVENTS. 243 URIC-ACID SOLVENTS. Under this heading will be considered certain drugs that are employed to prevent the precipitation of insoluble urates in the body, or to effect the solution of uratic concretions that have already been formed. The alkalis and the alkaline mineral waters were among the first agents to be used for these pur- poses. That these remedies are often beneficial in gout cannot be denied, but that they owe their efficacy to a solvent action is exceedingly doubtful. Uric acid does not, as was formerly supposed, exist as such in the blood or tissues, but is present in the blood chiefly as a soluble quadriurate, and in the tissues as a solid and stable biurate. The only way in which alkalis could affect the quadriurate in the blood would be by hinder- ing its conversion into the insoluble biurate, but there is suffi- cient experimental evidence to show that these remedies have no such retarding effect. Nor can it be assumed that their usefulness depends upon their influence on the alkalinity of the blood, for it has been shown by Klemperer, Magnus-Levy, and others that the alkalinity of the blood in gout is very little, if at all, diminished, and that, moreover, considerable variations in alkalinity are met with in health. We are able, by the administration of alkalies, to keep the uric acid in the urine from precipitating, and possibly to redis- solve uric-acid gravel. This is accomplished, according to von Noorden, even with a urine that is still weakly acid, by the removal of the monophosphate of sodium, which, in particular, renders the urine insolvent, the biphosphate of sodium remain- ing as an active solvent. There is, however, very little evidence to support the belief that uratic deposits in the tissues or well- formed calculi in the pelvis of the kidney or bladder can be redissolved by the administration of alkalis. Finally, it has not been proved that the constitutional symptoms of gout, which are so often ameliorated by alkaline medication, are due to the formation of uric acid; on the contrary, there is much tes- timony to substantiate the view that uric acid itself is not pecu- liarly toxic. Until we possess a more complete knowledge of the pathogenesis of gout, no adequate explanation of the favor- able action of the alkalis can be given. Doubtless much of the good that accrues to gouty patients from sojourns at watering-places is to be attributed to strict regimen, temperate living, agreeable exercise in the open air, and the liberal use of pure water, rather than to the specific action of any salts that may be contained in the waters. Knowing that benzoic acid was eliminated in the urine chiefly 244 APHRODISIACS AND ANAPHRODISIACS. as the soluble hippuric acid, Ure assumed that the drug would be efficacious as a uric-acid solvent in gout and nephrolithiasis. In consequence, the acid itself and its salts have been repeat- edly recommended in these conditions. But the assumption is opposed to the results of more recent investigations, which have shown that the hippuric acid is formed in the kidney, and not in the blood, and, moreover, that its formation is not attended by a corresponding decrease in the excretion of uric acid. Piperazin, or diethylendiamin, has been highly recom- mended for its solvent effects in gout and nephrolithiasis, but in the experience of many observers it has proved to be en- tirely inert. It is prepared by the action of ammonia on ethyl- ene bromid or chlorid, and appears as colorless, acicular crys- tals, very hygroscopic, and freely soluble in water. Its dose is from 5-10 gr. (0.3-0.65 gm.), well diluted. The only appreciable effect of such doses is a moderate increase in the quantity of urine. The excretion of uric acid, even in the presence of gouty concretions, is not increased. Large doses may cause nausea, malaise, stupor, muscular weakness, tremors, and inco- ordination. Solutions of 1 or 2 per cent, in normal urine will readily dissolve fragments of uric acid calculi in the test-tube, but the amount of unoxidized piperazin appearing in the urine after ordinary doses have been administered by the mouth has been shown to be without solvent action. Gouty tophi have been removed by the local injections of the drug, but the treat- ment is said to be very painful. Lycetol, or dimethylpiperazin tartrate, and lysidin, made by the interaction of ethylendiamin hydrochlorid and sodium acetate, are claimed to be more pow- erful solvents of uric acid than piperazin. Tunnicliffe and Rosenheim believe that the tartrate of piper- idin, a derivative of piperin, in doses of 15 grains (1.0 gm.), is an excellent solvent of gouty concretions. Weiss, Frankel, Ewald, and others have recently advocated the use of quinic acid, in combination with lithium (urosin) or with piperazin (sidonal). According to Weiss, quinic acid decreases the amount of uric acid in the urine, hippuric acid appearing in its stead. APHRODISIACS AND ANAPHRODISIACS. Aphrodisiacs are agents which stimulate the sexual appe- tite and increase the virile power. Sexual impotence results from a variety of causes ; in consequence its treatment, to be successful, must vary accordingly. In one instance the symp- tom is due to diabetes, in another to locomotor ataxia, and in APHRODISIACS AND ANAPHRODISIACS. 245 still another to neurasthenia. The last is by far the most common cause of acquired impotence, and its diverse etiology must be carefully considered in formulating any special line of treatment. General hygienic measures should never be neg- lected. Judicious physical exercise, fresh air, and careful feeding are necessary to improve the nutritive functions. Abstinence from all sexual excitement is absolutely essential. Iron and arsenic are indicated when there is anemia. Hydro- therapy, massage, and electricity are valuble adjuvants in the treatment. Electricity, locally applied, often proves especially effective. A large electrode — the positive — should be applied over the lumbar spine, while the negative electrode is applied over the spermatic cord or perineum. A current of from 5 to 10 milliamperes is sufficient. Hirt has repeatedly seen good effects follow the introduction of a metal-tipped sound into the urethra as far as the fossa navicularis, while the positive pole (anode) is placed over the lumbar cord, the current at the negative pole being made and broken several times. In many instances the psychic element is the all-important factor, and when such is the case, treatment must be directed to the mind rather than to the body. Advice calculated to promote con- fidence, to give encouragement, and to distract the patient's thoughts from his infirmity will be the most effectual. The chief drugs for which special aphrodisiac action has been claimed are : Nux vomica. Cantharides. Phosphorus. Yohimbin. In certain cases of impotence nux vomica proves very useful, not only through its general tonic influence, but also through its stimulant action on the sexual centers of the spinal cord. Phosphorus is generally believed to possess the power of improving the nutrition of the central nervous system, and, in consequence, to be of value in the various manifestations of nervous exhaustion. Whether this be true or not, small doses of phosphorus are often beneficial in sexual neurasthenia. The drug may be prescribed as phosphorus in doses of from 1 ^ - 3^5- gr. (0.00064.— 0.0013 gm.), or as phosphid of zinc, in doses of from ^-/ f Z x - (0.003-0.006 gm.). Cantharides in large doses, by irritating the bladder and urethra, sometimes induces sexual emotions and erections, but in doses that can be regarded as safe the drug is entirely without aphrodisiac influence. Yohimbin is an alkaloid or a mixture of alkaloids obtained 246 APHRODISIACS AND ANAPHRODISIACS. from the bark of the Cameroon tree — johimbehe. According to Lowey, it stimulates the sexual appetite and produces a marked congestion of the testes. The dose is from ^ 2 - \ gr. (0.005-0.01 gm.). Berger and Eulenberg have employed it with asserted excellent results in sexual neurasthenia. Krav- koff, however, who has very recently made a careful study of yohimbin, finds that the congestion of the sexual organs is not due to any specific action of the drug, but to its general vasodilating effect, and that while it possesses no aphrodisiac influence, it is, in the doses recommended, distinctly toxic. Orchitic and ovarian extracts, when first introduced, enjoyed for a time the reputation of being aphrodisiacs. Anaphrodisiacs are drugs which allay sexual desires. The most important members of this group are : Hyoscin. Camphor. Bromids. Lupulin. Anaphrodisiacs are useful in satyriasis, nymphomania, sper- matorrhea, priapism, and chordee. Hyoscin and the bromids are the most reliable of all drugs for subduing morbid excita- bility of the genital organs. Camphor in itself is of little value, but the monobromated camphor is often efficacious. Spermatorrhea and impotence are not infrequently associated symptoms in neurasthenia, and when such is the case, an an- aphrodisiac, such as hyoscin, may be given at bedtime to over- come the irritable weakness of the sexual apparatus, while general roborant measures are employed to combat the nervous exhaustion. In some 'instances seminal incontinence is the result of a local cause, such as persistent constipation, hemor- rhoids, prostatic hypertrophy, phimosis, extreme sensibility of the prostatic urethra, or loading of the urine with crystals of uric acid or calcium oxalate. It is needless to say that under these circumstances the removal of the local irritation is of paramount importance. The local application of cold water, or even of ice, avoidance of stimulating food, sleeping on a hard mattress without too much covering, the adjustment of some mechanical device to prevent the patient from sleeping on his back, are measures calculated to lessen the sensibility of the genital organs. When the emissions occur toward morning and are excited by distention of the bladder, it is a good plan to have the patient form the habit of voiding his urine at 1 or 2 o'clock in the morning. EMMENAGOGUES. 247 EMMENAGOGUES. Emmenagogues are remedies that promote the menstrual flow. They may act indirectly by removing the remote pathologic cause of amenorrhea, or they may act directly by stimulating the uterus itself. There are very few indications for the employment of direct emmenagogues. In a large class of cases the suppression of the menstrual flow is dependent upon some general cause which has resulted in constitutional enfeeblement ; thus it may be due to anemia, persistent consti- pation, tuberculosis, Bright's disease, extreme obesity, or myx- edema. In such cases treatment should be directed to the primary disease, there being rarely any indication to address remedies to the amenorrhea as such. In conjunction with measures calculated to improve the general nutrition iron will be found efficacious in chlorosis, purgatives, especially aloes, when there is obstinate constipation, and thyroid extract when myxedema is the primary factor. In some cases absence of menstruation is dependent upon a pronounced defect in the development of the genital organs or upon atresia of the genital passages. Under such circumstances, emmenagogues would, of course, be of no avail. Again, amenorrhea may be a symptom of uterine or ovarian disease, and when such is the case, it is manifestly improper to goad the affected organs with stimulating drugs. Occasionally suppression is associated with some psychic disturbance, such as grief, anxiety, or fear. In these cases restoration of the catamenia usually occurs after a time without recourse to special medication. Acute suppres- sion from exposure to cold should be treated by rest in bed, hot sitz-baths, hot drinks, and hot applications to the abdomen and genitals. Constipation should be relieved by a laxative dose of aloes, and febrile reaction controlled with such remedies as aconite or spirit of nitrous ether. The only indications for treating amenorrhea as such by the use of direct uterine stimulants are: (i) When the suppression itself is the cause of painful symptoms — that is, when there is a menstrual molimen without bloody discharge ; (2) when the menses do not return upon the restoration of the general health, as is sometimes the case in girls during the developmental period. The following drugs are the most important direct emmena- gogues : 248 EM MEN A GOG UES. Salts of manganese. Apiol. Senecio. Cantharides. Myrrh. Pennyroyal, Tansy. Savine. Oxalic acid. Rue. Pulsatilla. In addition to these drugs, electricity, particularly faradism, locally applied, has been highly extolled as a direct uterine stimulant in amenorrhea dependent upon imperfect develop- ment of the internal genitals or upon atrophy caused by superinvolution. One pole should be applied over the sa- crum and the other above the pubes, or, better, within the uterine cavity. MANGANUM. (Manganese; Mn.) The finding of traces of manganese in the red-blood cells and other tissues led to the recommendation of its salts in the treatment of chlorosis and other forms of anemia, but in the judgment of competent observers the drug is valueless as a hematinic. Ringer was the first to recommend potassium per- manganate as an emmenagogue, and there is sufficient evidence at present fully to establish its worth in this respect. It prob- ably acts directly on the uterus, and not indirectly through any influence exerted on the blood. It is most efficacious when given a few days before the expected menstrual period. It should be prescribed in doses of from 1-3 gr. (0.065-0.2 gm.), in pills made with kaolin or soft paraffin, and these should be taken after meals in large drafts of water. As potassium permanganate is a highly irritating salt, and, moreover, as it is at once decomposed in the stomach into the black oxid of manganese, the latter preparation (Mangani Dioxidum Prae- cipitatum, U. S. P.), which is free from irritant properties, may be substituted with advantage. Its dose is from 2-5 gr. (0.1- 0.3 gm.). APIOL. Apiol is an oleoresin obtained from Apium Petroselinum, or garden parsley. It is a greenish oily liquid from which a crys- talline stearoptene is obtained, known as white apiol. The dose of apiol is from 5-10 min. (0.3-0.6 c.c), in capsules. When given for a few days before the expected period it is a fairly reliable emmenagogue. It was formerly recommended as a substitute for quinin in malaria, but it proved to be useless. SENECIO— ACID l\V OXALICUM. 249 SENECIO. (Ragwort; Life Root.) Senecio is the entire plant of Senecio aureus, a perennial herb growing in the northern and western parts of the United States. In the form of a fluid extract or tincture it has been highly recommended as a corrective of functional amenorrhea and dysmenorrhea. Murrell compares its action to that of potassium permanganate. The dose of the fluid extract is from J-i fl. dr. (2.0-4.0 c.c.i; of the tincture, 1-2 fl. dr. (4.0- 8.0 c.c). CANTHARIS, U. S. P. (Cantharides.) The stimulant influence of cantharides on the uterus is probably the indirect effect of its irritant action on the urinary passages. Small doses of the tincture — 1-3 min. (0.06- 0.2 c.c.) — are generally prescribed in combination with other members of the same class, as in the well-known emmenagogue mixture of Dewees, which Wood regards as the most effective combination ever made in atonic amenorrhea. The formula of Dewees' mixture is as follows : R Tincturce ferri chloridi, fjiij (11.0 c.c); Tincturze cantharidis, f^ss (2.0 c.c.) ; Tincturae aloes, f|ss~(i5.o c.c.) ; Tincturae guaiaci ammoniatae, ^E^ ss (45 -° c - c -) '■> Syrupi, q. s. ad f^vj (180.0 c.c). — M. Sig. A tablespoonful three times a day. ACIDUM OXALICUM. I Oxalic Acid; H 2 C 2 4 - H 2 0.) Oxalic acid occurs as transparent, prismatic crystals of a very acid taste. It is readily soluble in water and in alcohol. Physiologic Action and Therapeutics. — Oxalic acid is a powerful uterine stimulant, in full doses quite capable of exciting labor pains and of expelling the product of concep- tion. As Poulet first demonstrated, it is an efficient emmen- agogue if given in doses of -J— J- gr. (0.016-0.02 gm.), thrice daily. Larger doses should not be given. Talley has reported a case of acute poisoning in an anemic girl from the admin- istration of three doses of J gr. (0.03 gm.) each, at intervals of four hours. On account of its irritant properties it should be taken well diluted, after meals. Oxalic acid is an active germicide, and its saturated solution has been highly recommended by Kelly and others as a dis- infectant for the hands. 250 EMMENAGOGUES. Toxicology. — The poisonous properties of oxalic acid do not depend solely upon its corrosive action, for the neutral oxalates may also cause death by paralyzing the central ner- vous system. The resemblance of the drug to Epsom salts has led to many fatal mistakes. When swallowed in a concen- trated form it causes the usual symptoms of an irritant poison ; when taken in dilute form it is absorbed and induces muscu- lar weakness, cyanosis, coma, and collapse. The chemical antidote is chalk or lime, which acts by forming an insoluble and inert calcium oxalate. The salts of potassium and sodium cannot be used as antidotes since they form soluble and poison- ous oxalates. MYRRHA, U. S. P. (Myrrh.) Myrrh is a gum-resin obtained from Commiphora Myrrha, a small tree growing in eastern Africa and Arabia. It appears in the form of brownish-red irregular-shaped tears, having an agreeable aromatic odor and a bitter acrid taste. Preparations. Dose. Tinctura Myrrhae, U. S. P 10-30 min. (0.6-2.0 c.c). Tinctura Aloes et Myrrhse, U. S. P. (10 per cent, of each) \-2 fl. dr. (2.0-8.0 c.c). Mistura Ferri Composita, U. S. P. (Griffith's mixture; ferrous sulphate, 6; myrrh, 18; sugar, 18; potassium carbonate, 8; spirit of lavender, 60; rose-water, to make 1000) . . 1-4 fl. dr. (4.0-15.0 c.c). Pilulse Aloes et Myrrhae, U. S. P. (aloes, 2 gr.— 0.13 gm. ; myrrh, I gr. — 0.06 gm.) .... I -4 pills. Pilulae Rhei Compositae, U. S. P. (aloes, \\ gr. — 0.1 gm.; rhubarb, 2 gr. — 1.3 gm.; myrrh, I gr. — 0.06 gm.) 1-5 pills. Therapeutics. — Myrrh is used as an emmenagogue and as a stimulant to mucous membranes. When employed-as an emmenagogue, it is usually associated with iron or aloes. The tincture, diluted with water, or with a weak solution of borax or potassium chlorate has been extensively employed as a local application in ptyalism, ulcerative stomatitis, and spongy gums. B Potassii chloratis, gr. xl. (2.6 gm.) ; Tinctura? myrrhae, f^* ss (45 -° cx -) I Tincturae benzoinae comp., f^vj (24.0 c.c.) ; Liquoris antiseptici, q. s. ad f§iv ( 1 15.0 c.c). — M. Sig. Teaspoonful in a wineglassful of water as a mouth- wash every two hours. Myrrh was also used at one time as a stimulant expectorant in chronic bronchitis, but it has been replaced by more efficient remedies. HEDE OMA—SABINA. 2 5 I HEDEOMA, U. S. P. (Pennyroyal.) Pennyroyal is the leaves and tops of Hedeoma pulegioides, an annual herb indigenous to North America. It contains a vola- tile oil, a bitter principle, and tannin. Preparations. Dose. Oleum Hedeomse, U. S. P 3~io min. (0.2-0.6 c.c). Infusum Hedeomce 1-2 fl. oz. (30.0-60.0 c.c). Therapeutics. — Pennyroyal, in the form of a hot infusion, has a popular reputation as an emmenagogue which is not altogether unmerited. It is especially employed in acute suppression brought on by exposure. TANACETUM. (Tansy.) Tansy is the leaves and tops oiTanacetum vulgare, a peren- nial herb growing wild in Europe and Asia, and naturalized in North America. Its active principle is a volatile oil. Preparation. Dose. Oleum Tanaceti' 1-3 min. (0.06-0.2 c.c.). Physiologic Action and Therapeutics. — Tansy has long been used as a domestic remedy in amenorrhea, the herb itself being generally employed in doses of from J— 1 dr. (2.0-4.0 gm.), in decoction. The oil has also been taken frequently in order to produce abortion, many times with ill success, but with grave or even fatal results to the mother. Large doses of the oil cause severe abdominal pain, vomiting, epileptiform convulsions, coma, and collapse. Tansy was for- merly employed as an anthelmintic, but this use of the drug is now obsolete. SABINA, U. S. P. (Savine.) Savine is the tops of Juniperus Sabina, an evergreen shrub growing in northern Europe, Asia, and America. Its active constituent is a volatile oil. Preparations. Dose. Oleum Sabinae, U. S. P 3-6 min. (c.2-0.4 c.c). Fluidextractum Sabinse, U. S. P 5-15 min. (0.3-1.0 c.c). 252 OXYTOCICS, OR ECBOLICS. Physiologic Action and Therapeutics. — The action of oil of savine resembles that of oil of juniper, but it is more irritant. Large doses cause abdominal pain, vomiting, purg- ing, anuria, unconsciousness, and collapse. In pregnant women the intoxication generally culminates in abortion. Owing to the fact that expulsion of the fetus does not occur until the irrita- tion of the intestinal canal and kidneys is sufficiently violent to endanger life, many cases of fatal poisoning have resulted from the use of the drug as an abortifacient. Oil of savine has long borne a reputation in amenorrhea and in certain forms of Men- orrhagia, but at the present time it is rarely prescribed. RUTA. (Rue.) Rue is the leaves of Ruta graveolens, a perennial plant indigenous to Southern Europe, and cultivated in this country. It contains a volatile oil. Its action is similar to that of savine. The dose of the oil is from 3-6 min. (0.2-0.4 c - c -)- PULSATILLA. Pulsatilla (see p. 65) has been recommended in sudden sup- pression of menstruation induced by chill, but its use as an emmenagogue is superfluous. OXYTOCICS, OR ECBOLICS. Oxytocics are drugs that tend to accelerate parturition by increasing the expulsive force of the uterus. It is conceivable that they may act directly by stimulating the unstriped muscle of the uterus, or indirectly by influencing a center for uterine contraction supposed to exist in the lumbar spinal cord. The chief oxytocics are : Ergot. Hydrastis. Quinin. Cotton-root bark. Corn smut. Indications. — Oxytocics may be employed during labor to hasten the expulsion of the fetus ; at the close of labor, to prevent or to check postpartum hemorrhage ; and in the puerperium to overcome certain forms of subinvolution. ERGOTA, U. S. P. (Ergot; Ergot of Rye ; Secale Cornutum.) . Ergot is the sclerotium of a parasitic fungus, Claviceps pur- purea, which replaces the grain of common rye, Secale cereale* ERG OTA 253 The sclerotium represents a stage in the life-history of the fungus which is intermediate between that of the mycelium or spawn, and that of the spore-bearing thallus. Ergot is obtained principally from Russia, Germany, and Spain. The official preparation is horn shaped, about an inch (2 or 3 cm.) long, and -§- inch (3 mm.) thick ; externally it is purplish black, and internally, whitish with pinkish striae. It has a peculiar heavy odor and an oily, disagreeable taste. The chemistry of ergot has not been definitely determined. Kobert separated in an impure state three bodies — ergotinic acid, cornutin> and sphace- linic acid — and subsequently Jacobj demonstrated that the ac- tivities of sphacelinic acid depended upon an unstable resinous body, sphacelotoxin. None of these constituents, however, rep- resents completely the activities of the crude drug. Ergotinic acid is a sapotoxin. Taken by the mouth, it causes gastro- intestinal irritation, but nothing more, as it is not absorbed. Injected intravenously, it induces paralysis of the central ner- vous system. Cornutin is an alkaloid. It first stimulates and then depresses the central nervous system, particularly the medulla. Lethal doses cause restlessness, salivation, vomiting, purging, clonic convulsions, and, finally, death from asphyxia. Sphacelotoxin is the most important constituent of ergot. It has a fourfold action : it produces severe irritation of the ali- mentary canal ; it causes constriction of the arterioles, extreme enough in some animals to induce gangrene of certain periph- eral parts ; it excites contractions in the uterus, which, if gravid, may result in abortion, and, in very large doses, it depresses the central nervous system. Preparations. Dose. Vinum Ergotse, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). Fluidextractum Ergotse, U. S. P \- 1 fl. dr (2.0-4.0 c.c). Extractum Ergotae, U. S. P 5—15 gr. (0.3-1.0 gm.). Ergotin (Bonjean's Ergotin : a purified hydro- alcoholic extract of ergot) 3-logr. (0.2-0.65 gm.). Physiologic Action. — Circulatory Action. — The sub- cutaneous injection of ergot in moderate doses is followed by constriction of the arterioles, with an increase in the arterial pressure, which is due to the stimulant effect of the drug on the vasomotor center, and probably, also, to its direct action on the muscular coats of the vessels. When the injection is made intravenously the blood-pressure is first lowered and then raised, the primary fall, according to Wood, being due to temporary depression of the heart from direct contact with the drug. After toxic doses there may be a marked and continuous fall in the blood-pressure from depression of both the vasomotor center and the heart. The 254 OXYTOCICS, OR ECBOLICS. rise of blood-pressure is often accompanied by slowing of the heart, which seems to be due to stimulation of the inhibitory center in the medulla. The gangrene observed in chronic poisoning is the result of prolonged constriction of the arterioles and the consequent formation of hyaline thrombi. Among the lower animals the gangrenous effect of ergot is readily produced in fowls and pigs, but not in cats, dogs, or rabbits. Nervous System. — Ordinary doses of ergot, if not long con- tinued, have no appreciable influence on the nervous system. In one form of chronic poisoning, however, nervous phenomena are pronounced. These include paresthesia, anesthesia, con- vulsions, tonic contractions of the limbs, ataxia, mental dulness, and dementia. Grigorjeff has found postmortem in animals slowly poisoned with ergot degenerative changes in the central nervous system, especially in the posterior columns of the spinal cord. Alimentary Canal. — Ergot increases the peristaltic move- ments of both the stomach and intestine, probably through its direct action on their muscular coats. Even in therapeutic doses it may excite nausea and vomiting. Uterus. — In the parturient woman small doses of ergot induce uterine contractions which often closely resemble the rhythmic contractions observed in normal labor. After full doses, however, the contractions usually become very power- ful, and uninterrupted or tetanic. The preparations of the drug on the market vary so much in activity that it is quite difficult to predict the effect of an average dose in a given case. The influence of ergot on the gravid but non-parturient uterus is less marked, but there is ample evidence to show that in animals it is capable of originating expulsive movements that culminate in abortion. It is not definitely known whether the ecbolic action of ergot is due to direct stimulation of the unstriped muscle of the uterus itself, or to an influence exerted on the uterine center in the spinal cord. It is probably in part, at least, of peripheral origin. Muscles. — On the voluntary muscle ergot has no effect, but it seems to have a stimulant influence on the involuntary muscle throughout the body. Toxicology. — In acute ergot poisoning the symptoms most commonly observed are nausea, vomiting, intense thirst, cold- ness of the surface, headache, stupor, and generalized purpura, The pulse may be unduly slow, or, after very large doses, rapid and feeble. Chroiiic ergot poisoyiing has not been uncommon. In nearly every instance it has resulted from eating bread made of ERGOTA. 255 ergotized grain. It assumes two forms : Spasmodic ergotism and gangrenous ergotism. The first is characterized by ma- laise, inordinate craving for food, vomiting, diarrhea, headache, disordered vision, tinnitus aurium, formication, numbness of the extremities, ataxia, convulsive seizures, painful contractions of the muscles, and mental hebetude, followed by delirium or acute dementia. Gangrenous ergotism is characterized by exhaustion, cold- ness of the surface, cyanosis, aching of the limbs, and the development of gangrenous areas in various parts of the body, especially in the fingers and toes. Cataract has also been fre- quently observed. Therapeutics. — Ergot may be used during parturition, cautiously and in small doses, to hasten the expulsion of the fetus, when the cause of the delay is simply uterine inertia, and not mechanical obstruction, but it is very rarely necessary. Its use in full doses, especially when dystocia is the result of contracted pelvis, rigid os uteri, displacement of the uterus, abnormal presentation, or other physical abnormity, may prove disastrous by exciting tetanic contraction and conse- quent asphyxia of the child or even rupture of the uterus. At the close of labor, after the head is born, ergot is very useful in preventing postpartum hemorrhage. It may be used also after the removal from the uterus of any abnormal con- tents — retained placenta, clots, etc. — to control hemorrhage that has already occurred. It is a useful adjuvant in the treatment of certain cases of subinvolution of the uterus , but the possibility of its affecting the child through the mother's milk must be borne in mind. The treatment of 'uterine fibroids with repeated injections of ergot, as recommended by Hildebrandt in 1872, has met with a very limited success. By contracting the blood-vessels of the uterus, however, the drug may tempo- rarily control hemorrhage, and in rare instances check the growth of the tumor, or even bring about its involution. The treatment is adapted only to small intramural fibroids that are soft and vascular. While the efficacy of ergot in certain forms of metrorrhagia has been conclusively proved, there is no satisfactory evidence that the drug is of value in other forms of hemorrhage, such as hemoptysis, hematuria, or hematemesis. On the contrary, our knowledge of its physiologic action indicates that it may be productive of harm. Granting that ergot can lessen the caliber of eroded, degenerated, or seriously wounded vessels, there is no reason for supposing that its influence is restricted to the vessels concerned in the bleeding, and if such is not the 256 OXYTOCICS, OR ECBOIICS. case, the universal constriction of the arterioles induced by the drug, and the consequent rise in the general blood press- ure must favor the escape of blood from the injured vessels and militate against the formation of an occluding thrombus. Ergot has been used with some success in diabetes i?tsipidus (Da Costa, Ringer), in colliquative sweats (Wood), and in head- aches of a migraine type (Thomson). It has also been recom- mended in a variety of other affections, such as diabetes melli- tus, acute meningitis, myelitis, splenic enlargements, acute dysentery, and hyperemic skin diseases, but it has not borne the test of experience. Administration. — The preparations of ergot on the market are exceedingly variable in strength ; some are absolutely inert. The best preparation for internal use is a good fluid extract. It is less liable to excite nausea when taken after meals. In urgent cases the drug should be given hypoder- mically, notwithstanding its tendency to produce local inflam- mation. The injections should not be made directly beneath the skin, but deeply into a muscle. An aqueous solution of the extract, freshly prepared and filtered, may be employed. Bonjean's ergotin is unreliable. OTHER OXYTOCICS- Quinin (see p. 416). — This drug has some power of in- creasing the rapidity and energy of the uterine contractions when they have once begun ; its action, however, is inconstant. The contractions are much less prolonged than those excited by ergot, and are probably due to an influence exerted directly on the uterine muscle. As the drug does not seem capable of originating labor-pains, it cannot be considered an active ecbolic, and the cases of abortion that have been reported as following its administration have no doubt been due either to an idiosyncrasy or to the original disease for which the quinin was prescribed. According to some obstetricians, its use during labor distinctly increases the tendency to postpartum hemor- rhage. Hydrastis (see p. 379).— Both the natural alkaloid of this drug, hydrastin, and its artificial derivative, hydrastinin, are of considerable value in controlling hemorrhage from the uterus. It is definitely known that both drugs induce constriction of the peripheral vessels, but whether their efficacy in metrorrhagia is due, in part, to their power of exciting contraction of the uterine muscle is a moot question. Many writers, how- ever, maintain that these alkaloids have pronounced ecbolic DIAPHORETICS, OR SUDORIFICS. 2$? properties, and are capable, in sufficient dose, of producing abortion. As a uterine hemostatic hydrastinin is preferable to hydras- tin. It is particularly efficacious in simple menorrhagia of young girls and in metrorrhagia following abortion or resulting from disease of the adnexa. Hemorrhages resulting from the presence of cancer or fibroids are not much affected by the drug. The dose of the official hydrastinin hydrochlorid is from \- 1 gr. (0.016-0.065 gm.). When a prompt effect is re- quired, it should be given hypodermically in the form of a 10 per cent, aqueous solution. , Cotton-root Bark. — This drug {Gossypii Cortex, U. S. P.) is said to have been much valued among the slaves of the South as an abortifacient. Some obstetricians have claimed for it an action resembling that of ergot. The dose of the fluid extract as an ecbolic is from J-2 fl. dr. (2.0-8.0 c.c). Com Smut. — This drug {Ustilago Maydis) is a fungus growing on the stems and tassels of Zea Mays, or Indian corn. According to some obstetricians, the fluid extract, in doses of from J-i fl. dr. (2.0-4.0 c.c), induces in the parturient uterus vigorous but intermittent contractions, and is, therefore, a useful stimulant when the labor pains are feeble from ex- haustion. DIAPHORETICS, OR SUDORIFICS. Diaphoretics are agents that promote the secretion of sweat. They may act by stimulating the terminations of the secretory nerves, by stimulating the cells in the central nervous system (sweat centers) from which those nerves arise, by dilat- ing the blood-vessels of the skin, or, reflexly, by irritating per- ipheral sensory nerves. The activity of the sweat glands may also be increased by external heat, muscular exercise, dyspnea, strong emotion, and nausea. Although dilatation of the cutaneous vessels promotes per- spiration when other conditions are not unfavorable, the mechanism of sweat secretion is in large measure independent of the blood-flow. Thus, in fever the flushed skin may be unnaturally dry, while in collapse, with pallid skin, there may be free perspiration. External heat may act partly by inducing hyperemia of the skin, but that it acts chiefly by stimulating the sweat-fibers reflexly through the cutaneous sensory nerves appears evident from the fact that exposure of a part to a high 17 258 DIAPHORETICS, OR SUDORIFICS. temperature does not cause sweating if all the nerves leading to the part be severed. Muscular exercise probably acts by increasing the flow of blood to the glands and by stimulating the peripheral nerves and nerve-centers. Dyspnea acts by increasing the proportion of venous blood, the latter being a powerful stimulant of the sweat-centers. Strong emotions affect secretion probably also by action on the nerve-centers. The sweating that attends nausea is, no doubt, induced reflexly by stimulation of the sweat-centers through the sensory nerves of the stomach. Among drugs, pilocarpin owes its diaphoretic effect to stimulation of the nerve-endings in the gland-cells, while alcohol and opium favor sweating, probably by dilating the skin vessels. The drugs most commonly employed as diaphoretics are : Pilocarpus (pilocarpin). Spirit of nitrous ether. Opium. Ammonium acetate. Ipecacuanha. Warburg's tincture. Indications. — Diaphoretics are given : (1) To promote the absorption of dropsical fluid ; (2) to rid the system of peccant matters ; and (3) to arrest the development of local conges- tions or inflammations that have resulted from exposure to cold. ■ PILOCARPUS, U. S. P. ( Jaborandi. ) According to the Pharmacopeia pilocarpus is the leaflets of Pilocarpus microphyllus and of Pilocarpus Jaborandi, shrubs growing in South America. It contains three alkaloids — pilo- carpin, pilocarpidin, and isopilocarpin — which produce similar effects, but pilocarpin is the most active, and is present in larger quantity (J-J per cent.) than the others. Jowett, in a recent investigation, was unable to find in the leaves at present obtainable any trace of an alkaloid answering to the descrip- tion of jaborin, discovered by Harnack and Meyer, and which is said to resemble atropin in its action. Pilocarpin yields soluble crystalline salts, of which the ni- trate (Pilocarpine Nitras, U. S. P.) and the hydrochlorid (Pilo- carpine Hydrochloridum, U. S. P.) are most commonly em- ployed. The dose of either of these salts is from -^-\ gr. (0.005-0.03 gm.). Preparation. Dose. Fluidextractum Pilocarpi, U. S. P 20-60 min. (1.2-4.0 c.c). PILOCARPUS. 259 Physiologic Action. — Secretion. — The dominant action of pilocarpin is on the secretory glands of the body. Under its influence the sweat and saliva are enormously increased. It increases also, but to a less extent, the lacrimal, nasal, bron- chial, gastric, and intestinal secretions. Milk, bile, and urine are not materially increased. As its effect on secretion is com- pletely suspended by atropin, it would seem to be due to stimulation of the peripheral fibers of the nerves supplying the glands. Circulatory System. — The action of pilocarpin on the circu- lation has not been definitely determined. In certain animals, like the frog, cat, and rabbit, it appears first to stimulate and then to depress the peripheral fibers of the vagus, in conse- quence of which the pulse is primarily slowed and then quick- ened. After large doses the pulse again becomes slow, and the blood pressure falls considerably below normal, owing to weakness of the heart and vasomotor center. In man the cir- culation appears to be affected in a somewhat different manner ; the pulse-rate is usually increased, the peripheral vessels are dilated, and the blood pressure is lowered. Not infrequently, however, there is a distinct rise in the arterial pressure, especi- ally at first. Although the evidence, derived from experimental sources, is in some respects contradictory, clinical experience is in accord with the view that pilocarpin, at least in full doses, is a circulatory depressant. Nervous System. — In therapeutic doses pilocarpin has no action on the central nervous system. In certain animals toxic doses induce convulsions which are probably of spinal origin. Respiration. — Small doses are without effect; toxic doses depress the respiratory center. In the presence of a weakened circulation the drug tends to induce pulmonary edema. Muscles. — Pilocarpin excites contractions in the unstriped muscle of the iris, stomach, intestines, bladder, uterus, and spleen, probably by stimulating the terminations of the nerve- fibers supplying the muscle. Alimentary Canal. — Nausea and vomiting are sometimes induced by jaborandi or pilocarpin, especially when the drug is given by the mouth. This effect is probably caused by its irritant action on the peripheral nerves of the stomach. It also increases both gastric and intestinal peristalsis. Eye. — Pilocarpin, especially when applied locally, contracts the pupil by stimulating the terminal filaments of the oculo- motor nerve. It also decreases the intra-ocular tension. 260 DIAPHORETICS, OR SUDORIFICS. Blood. — It has been shown that pilocarpin, probably from some influence exerted on the spleen and lymphatic glands, increases the lymphocytes of the blood. Temperature. — Coincident with the profuse diaphoresis which the drug excites, and probably dependent upon it, there is a well-marked fall in the body-temperature. Toxicology. — The chief phenomena of pilocarpin poison- ing are salivation, profuse sweating, nausea and vomiting, serous purging, contraction of the pupils, muscular tremors, and collapse. Atropin is an effective physiologic antidote. Idiosyncrasy and Untoward Effects. — The action of pilocarpin in man is by no means constant. Occasionally even small doses are followed by severe cardiac depression or pul- monary edema. Swelling of the salivary glands, profuse sali- vation, and strangury have also been observed after its adminis- tration. On the other hand, there may be a peculiar insus- ceptibility to its action, as in a case reported by Hare, in which a woman of thirty years received f gr. (0.05 gm.) of pilocarpin hydrochlorid hypodermically in half an hour without any effect. According to Ringer, children are far less susceptible than adults. Therapeutics. — Pilocarpin in doses of from ^ ^ 2 gr. (0.004-0.005 gm.) is very useful in promoting moderate dia- phoresis in acute and chronic parenchymatous nephritis. It tends to avert uremia by relieving the congestion of the kidneys and by ridding the blood of poisonous matters. Its action should be supplemented by external heat, and any depression or faintness should be combated with strychnin or ammonia. The remedy may be repeated every other day or even every day. Samuel West believes that there is no more useful drug in chronic interstitial nephritis than pilocarpin in small doses by the mouth. He finds that headache, irritability, digestive disturbances, and dry skin often yield rapidly to a dose or two. In acute uremia larger doses, \-\ gr. (0.01-0.02 gm.) may be employed in conjunction with hot-air or vapor baths. In puerperal eclampsia the drug is very often badly borne. In general dropsy, especially that due to Bright's disease, pilo- carpin is a valuable aid to absorption. In local effusions, how- ever, such as occur in the pleura and pericardium, it is rarely effective. It is sometimes employed for its diaphoretic effect in muscular rheumatism^ acute coryza, and acute sthenic affec- tions. Daily injections of pilocarpin (l gr. — 0.0 1 gm.), as first em- ployed by Politzer in 1880, have given gratifying results in OTHER DIAPHORETICS. 26 1 some forms of acute and subacute labyrinthine disease, charac- terized by deafness, tinnitus aurium, and vertigo. The action of pilocarpin on the eye is much like that of eserin, but it is decidedly less powerful. It has been used to lessen intra-ocular tension in glaucoma, but eserin is more reli- able. When, however, a gentle but persistent stimulant effect on the ciliary muscle is desirable, as in cases of accommodative asthe- nopia, pilocarpin will be found very serviceable. As an adju- vant to mixed treatment daily injections of pilocarpin have sometimes proved efficacious in intractable cases of syphilitic keratitis. There is sufficient evidence to prove that the internal administration of pilocarpin promotes the growth of hair, and at the same time renders it darker and coarser. Favorable results from the hypodermic use of the drug in extensive alo- pecia and alopecia areata have been reported by Simon, Pick, Morris, Pringle, and others, but the practice of applying the remedy in the form of lotions to the scalp in premature bald- ness is of doubtful utility. Contraindications. — The existence of grave cardiac or pulmonary lesions prohibits its use. Caution should be exer- cised in giving pilocarpin to women advanced in pregnancy, as the drug possesses some power as an abortifacient. Administration. — On account of the uncertain alkaloidal strength of the fluid extract and its greater tendency to cause vomiting, one of the salts of pilocarpin is usually preferable. The latter may be given by the mouth, but when a prompt effect is desired, it should be given hypodermically. Its dia- phoretic action is greatly facilitated by the application of heat to the patient. Circulatory failure should be combated with ammonia, strychnin, or alcohol, and pulmonary edema with hypodermic injections of atropin. According to Tyson, a freshly prepared infusion may be injected into the rectum with prompt results. Four ounces (120.0 c.c.) of hot water should be poured on a dram (4.0 gm.) of jaborandi leaves, and, when sufficiently cool, strained and injected. OTHER DIAPHORETICS. Opium (see p. 91). — As a diaphoretic, opium is usually employed in the form of Dover's powder, or powder of ipecac and opium. This preparation, in doses of from 5-10 gr. (0.3- 0.6 gm.), produces a mild sudorific effect, and is useful in breaking up acute catarrhal conditions of the respiratoy organs and in relieving so-called muscular rheumatism. It should be re: A.vr;j:-yr:\T.\\\ borne in mind that large doses not infrequently cause nausea :er. :he <:o:: Spirit of Nitrous Ether >- e ::;'.— - . S Iritus : bei is N U S P.) is an alcoholic solu- tion of ethyl nitrite, yielding, when freshly preparec > than n times its c .me of nitrogen dioxid, the equivalent of about 4 per cent, of pure ethyl nit: inflammable liquid, having a pale yellowish or gre< tint, a pleasant ethereal odor, and a sharp, burning taste. On exposure to light and air it rapic urates. The dos. an adult is from |~2 fl. dr. (:.ChS.o ex.) ; for a child, 10-30 min. (0.6- _ D c c In medicinal doses nitrous ether, acts as a mild diaphoie diuretic, and antispasmodic When the patient is kept well cover; e. //':. r ::> e.eiee i:vi>: . pronounced than its diuretic effect, and the reverse is when the patient is lightly covered Toxic doses produce :ptoms resembling poisoning by amyl nitrite and o nitrites. Sweet spirit of niter is a useful remedy in the fnild febrile affections of children ; it is best given in small doses, well diluted with hot water, at frequent in: s A s a dti : s efficacious in relieving oliguria due to fever or acute cott- f:-sr:\- . . -' ;';.'• ":.:".v:/ Incompatibles. — Iodids, ferric sulphate, mucilage of aca tannic acid, tincture of guaiacum, and antipyrin. acetan Ammonium Acetate. — 7e.i< ;^:r.;::-::-.; - . ie. the form of its official solution, the spirit of minder :s U 5 ng as the patient warm or cool it acts as a feeble diaphoretic or diuretic often used in febrile diseases as a vehicle it of nitrous ether or aconite Its dose is from 1-4 e- 15 c Warburg's Tincture see ;e _ee\ — 77.5 \w doses of 7 - Q ex is capable of inducing cori - sating. To be effect I should en undilu. drinks should be withheld. It has been highly commended in :he • .e. './..: \; ;.ve ./" ->:.:.'.: r.:.' v: :\ ■^ ■ ANTIHYDROTICS. Antihydrotics are agents thai check Theoretical! nay ad by lessen the ..it-centers ; by depressing the terminal ibers the sea AX Til I YDR O TICS. 26 3 nerves, or, possibly, the secretory gland-cells themselves ; or by stimulating the respiratory center. Brunton has called attention to the close relation existing between respiratory depression and the occurrence of colliquative sweats. He states that when the respiratory center is exhausted from any cause it responds less readily than the sweat-centers to the stimulating influence oi venous blood, in consequence of which profuse sweating results. This teaching accords with the well- known fact that respiratory stimulants are frequently efficacious in controlling the night-sweats o( phthisis. The most import- ant antihydrotics are : pin. ^aricin. Sulphuric acid. Picrotoxin. Camphoric acid. Tellurium compounds. Thallium acetate. Gallic acid, ergot, and zinc oxid have also been employed, but they are of little value. In addition to the internal reme- dies, certain external applications are useful in controlling excessive perspiration ; thus, sponging the surface with vinegar and water or a hydro-alcoholic solution of tannic acid or alnm sometimes affords relief. A weak solution of formalin, as recommended by Hirschfeld, is a powerful antihydrotic, but its irritant effects on the eyes and respiratory tract forbid its use when the sweating is general. Recently, Strasburger has substituted for the formalin solution a dusting-powder of ta?ino- form, a condensation product of tannin and formaldehyd. The application, at bedtime, of a powder composed of 1 part of tannoform to 2 parts of talcum, is said to render excellent service in preventing the night-sweats of phthi In local hyperidrosis internal remedies are rarely of benefit ; the best results are obtained from external applications, the most effective being dusting-powders containing tannoform, salicylic acid, or boric acid, or a pigment of formalin and alco- hol. Atropin (see p. 75). — This is the most powerful of the anti- hydrotics. It checks the secretion of the sweat-glands by paralyzing the terminations of the secretory nerves. In doses of from yJt - ttht g r - f 0.0003 2-0.00064 gm.) at bedtime it often effectually controls the exhausting night- sweats of phthisis ; unfortunately, however, its repeated use is frequently attended by untoward symptoms, such as dryness of the throat, thirst, and dimness of vision. The tincture of belladonna is some- times employed as a lotion in local hyperidrosis occurring about the hands and feet. 264 ANTIHYDR O TICS. Sulphuric Acid (see p. 448). — Aromatic sulphuric acid has been used longer and perhaps more extensively than any of the other antihydrotics. Its power, however, compared with that of drugs more recently introduced, is very feeble. It should be given in doses of from 5-10 min. (0.3-0.6 c.c.) largely diluted with cool water. ACIDUM CAMPHORICUM, U. S. P. (Camphoric Acid; C 8 H u (COOH) 2 .) Camphoric acid is a crystalline powder made by oxidizing camphor with nitric acid. It is odorless, of a slightly acid taste, soluble in 160 parts of cold water, and readily soluble in alcohol and ether. The dose is from 20-30 gr. (1.3-2.0 gm.). On account of its sparing solubility in water it is best prescribed in powders, in capsules, or in an elixir. Therapeutics. — Camphoric acid is an antiseptic and anti- hydrotic. As an antiseptic it has been used both internally and externally, but in this respect it is inferior to many other drugs in common use. It is of much greater service in checking excessive perspiration, but the manner of its action is unknown. As it is rapidly eliminated in the urine it is best given about two hours before the time at which the sweating is likely to occur. Its drawback is its tendency to cause nausea and vomiting. AGARICIN. Agaricin is a crystalline body obtained from Polyporus officinalis, a fungus growing on the larch tree. The fungus itself (white agaric or purging agaric), although an active irritant, was recommended for excessive sweating by de Haen as early as 1768. Agaricin is an impure form of agaric or agaricic acid, which appears as a white, lustrous powder, odor- less, almost tasteless, and slightly soluble in water and alcohol. The dose of agaricin is from \- 1 gr. (0.016-0.065 gm.), and of agaric acid, -J-— i gr. (0.01-0.03 gm.). The latter is the less irritating and more reliable preparation. Physiologic Action and Therapeutics. — When admin- istered by the mouth in large doses agaricin acts as an irritant and induces severe vomiting and purging. According to Hof- meister, when it is administered to animals subcutaneously or intravenously in sufficient dose it first stimulates and then depresses the centers of the medulla oblongata, death ulti- mately resulting through cardiac or respiratory paralysis. The drug is chiefly interesting to the therapeutist on account PICROTOXINUM— TELLURIUM. 265 of its effect on the perspiration. Like atropin, it arrests the secretion of sweat probably by paralyzing the nerve-endings in the sudoriferous glands. Unlike atropin, however, it has no influence on the salivary or lacrimal secretions. Agaric acid is preferable to agaricin, being less liable to cause nausea. As it is absorbed slowly it should be given several hours before the time of the expected sweating. It may be prescribed in the form of a pill or powder. PICROTOXINUM. (Picrotoxin.) Picrotoxin is a neutral principle obtained from fish berries — Anamirta cocculns and Anamirta paniculata, growing in India and the Malayan Islands. It is a colorless, shiny, crystalline powder, odorless, and of an intensely bitter taste. It is soluble in alcohol and in acidulous or alkaline solutions, but only sparingly so in water. The dose is from -g ^ ■ £ gr. (0.0008- 0.002 gm.). Physiologic Action and Therapeutics. — The domi- nant action of picrotoxin appears to be upon the centers in the medulla oblongata. In animals toxic doses produce violent clonic convulsions, acceleration of the respirations, slowing of the pulse, a marked rise in the arterial pressure, and vomiting. Death often results from asphyxia induced by the convulsive seizures. Picrotoxin has been recommended in a variety of conditions, but it is mainly useful in controlling the night-sweats of phthi- sis. The manner of its action is unknown ; but it may act indirectly, as Cushny suggests, by increasing the respirations and thus preventing the stimulant effect of partial asphyxia on the sweat-centers. As an antihydrotic it often succeeds when atropin and camphoric acid have failed. It is best given by the mouth, at bedtime, in the form of a pill or tablet. The tincture of Cocculus indicus (Anamirta paniculatd) is a reliable remedy for head lice. TELLURIUM. The most important tellurium compounds from a thera- peutic standpoint are the tellurates of sodium and potassium. These appear as white crystalline powders, soluble in water. The dose of either salt is from \— | gr. (0.02-0.05 gm.). Physiologic Action and Therapeutics. — In warm- blooded animals large doses of any one of the tellurium com- pounds cause vomiting, diarrhea, somnolence, weakening of 266 EXPECTORANTS. the reflexes, paralysis, unconsciousness, respiratory failure, convulsions, and death. A characteristic feature of the poison- ing is the development of a strong garlicky odor in the breath a few minutes after the administration of the drug. This odor has been determined by Hofmeister to be due to the forma- tion of methyl tellurid. In man full doses of sodium or potassium tellurate arrest perspiration, impart an alliaceous odor to the breath, and impair slightly the digestion. Tellu- rium compounds undergo partial reduction in the body, and, according to Gies, are eliminated in the metallic form in the feces and as methyl tellurid in the breath, urine, feces, and epi- dermal secretions. As the antihydrotic action of tellurium is offset by pilocarpin (Czapek and Weil), it is probably due to depression of the peripheral secretory nerves. The tellurates have been recommended by Neusser, Combe- male, and Dubiquet, and others for their antihydrotic effects in advanced phthisis, but the garlicky odor of the breath, often persisting several weeks after treatment has been suspended, is a strong objection to their use. THALLII ACETAS. (Thallium Acetate ; T1C 2 H 3 2 .) Thallium acetate occurs in the form of white deliquescent crystals which are readily soluble in water and alcohol. The dose is from 1-3 gr. (0.065-0.2 gm.) in pills. Physiologic Action and Therapeutics. — Although thallium possesses decided toxic properties, these are not manifest when its salts are administered in therapeutic doses and for short periods. Combemale, Huchard, and others have found the acetate very effective in controlling the night- sweats of phthisis. Unfortunately, however, its continued use is not infrequently followed by alopecia. This untoward effect was observed in 8 of 34 cases in which Vossaux employed it as an antihydrotic. Huchard also has reported a case of total baldness following the administration of a dozen pills. The drug should be given about an hour before the expected sweating, and not repeated for more than four successive nights. EXPECTORANTS. Expectorants are drugs that modify the secretion of the air-passages, affect its quantity, and facilitate its expulsion. The exact manner of their action is obscure. Those that pro- EXPECTORANTS. 267 mote secretion and render it less viscid in character, and, therefore, more easy of removal, are generally termed seda- tive expectorants. Most of the latter are also emetics, and, no doubt, owe their power of increasing secretion very largely to their nauseating properties. As a rule, they are employed as expectorants in much smaller doses than are required to produce vomiting, but occasionally vomiting itself renders valuable service in expelling mechanically excessive accumulations of tenacious mucus from the bronchi. The increased secretion which these drugs induce may be of ser- vice in depleting the congested bronchi, in protecting their surfaces from the air, in diluting and washing out the irritant, and, possibly, in exercising a bactericidal influence. The sedative expectorants in common use are : Ipecacuanha. Quebracho. Antimony (tartar emetic). Lobelia. Apomorphin. Potassium citrate. Sedative expectorants are indicated in acute bronchitis, par- ticularly in the early stage, when there is hard cough with little or no sputum. Drugs that stimulate the mucous membrane of the respira- tory tract and lessen the quantity of sputum are known as stimulant expectorants. Some of them appear to act by im- parting tone to the relaxed membrane, and others also by exercising an antiseptic influence on the secretions. The most important stimulant expectorants are : Ammonium chlorid. Sanguinaria. Ammonium carbonate. Garlic. Benzoin (benzoic acid). Grindelia. Balsam of Peru. Creosote (guaiacol). Balsam of tolu. Tar. Ammoniac. Squill. Eucalyptus. Oil of sandalwood. Oil of myrtle (myrtol). Copaiba. Senega. Cubeb. Oil of turpentine (terebene ; terpin hydrate). Stimulant expectorants are indicated in subacute and chronic bronchitis, especially when there is free expectoration. Adjuvants to Expectorants. — When cough is dispropor- tionate to expectoration and is in itself a source of distress, drugs may be combined with expectorants which lessen the ex- citability of the respiratory center or of the afferent and efferent 268 EXPECTORANTS. nerves of lung. The most reliable drugs for this purpose are opium (morphin, codein, heroin), dilute hydrocyanic acid, chloro- form, bromids, hyoscyamus, and cannabis indica. Sometimes cough is dependent to a great extent upon excessive irritability of the fauces ; if this be the case, demulcents — licorice, gly- cerin, acacia — will be found useful adjuvants. When the respiratory center has become weakened through persistent cough, strychnin will prove beneficial. The same remedy also renders valuable aid when the pulmonary circulation is slug- gish, owing to insufficient cardiac power. When bronchial catarrh excites asthma, antispasmodics — belladonna, Hoff- mann's anodyne, chloroform, bromids — should be associated with expectorants. Lobelia is particularly useful in these cases, because it is both an expectorant and a depressomotor. Administration. — Expectorants, as a rule, are most effective when administered by the mouth. Sometimes, how- ever, inhalations act beneficially in allaying cough, facilitating expectoration, and lessening fetor of the breath. Except in the case of very volatile substances, it is doubtful whether vapors or sprays penetrate beyond the trachea and the main bronchial divisions. There are several methods of inhalation intended to influence the mucous membrane of the respira- tory tract. The simplest plan consists in breathing deeply the warm vapor arising from the surface of boiling water. For this purpose a volatile expectorant — compound tincture of benzoin, terebene, creosote — may be dropped into a wide- mouthed jug nearly filled with hot water, and the vapor con- ducted to the nose and mouth through a cone made of stiff paper or a folded napkin. Inhalations of this class are rarely useful, except in acute bronchitis. More complicated, but somewhat more serviceable, are the various hand-ball and steam 'atomizers designed to reduce medicated fluids to a nebular form. In chronic bronchitis the cold spray has an advantage over the steam spray in being less relaxing in its effect on the throat and trachea. Another method of administering medicated vapors is by the so-called respirator. One of the most useful of the latter contrivances is the oronasal respirator devised by Dr. Burney Yeo, which consists of a perforated zinc mask, shaped to fit over the nose and mouth, and held in position by tapes passed around the ears. This mask incloses a sponge which is charged from time to time with the volatile inhalant. Creosote (with an equal amount of spirit of chloroform), turpentine, tere- bene, eucalyptol, and menthol are the drugs most frequently used in the respirator. IPECACUANHA. 269 The intralaryngeal injection of drugs into the trachea some- times affords great relief in chronic bronchitis, in bronchi- ectasis, and even in phthisis. If they are skilfully made, they rarely excite cough or other discomfort. Some bland oil, like olive oil, is usually made the vehicle for the active drug — guaiacol (1 : 100 or 1 : 50) or menthol (1 : 50). SEDATIVE EXPECTORANTS. IPECACUANHA, U. S. P. (Ipecac.) Ipecac is the root of Cephaelis Ipecacuanha, or of Cephaelis acuminata, a perennial shrub growing in Brazil and other South American States. According to Paul and Cownley, it contains three alkaloids — emetin, cephaelin, and psychotrin. The does of the powdered drug as an expectorant is from J-2 gr. (0.03- O.13 gm.) ; as an emetic, 15-30 gr. (1.0-2.0 gm.). Preparations. Dose. Fluidextractum Ipecacuanha, U. S. P As an expectorant 2-5 nun- (0.I-0.3 c.c.) ; as an eme- tic, 15-30 min. (1.0-2.0 c.c). Syrupus Ipecacuanhae, U. S. P. As an expectorant, 10-60 min. (0.6-4.0 c.c.) ; as an emetic, 2-4 fl. dr. (8.0- 15.0 c.c). Vinum Ipecacuanhae, U. S. P As an expectorant, 10-60 min. (0.6-4.0 c.c) ; as an emetic, 2-4 fl. dr. (8.0- 15.0 c.c). Tinctura Ipecacuanha et Opii, U. S. P. ( I gr. — 0.065 gm. — each of ipecac and powdered opium in 10 min. — 0.6 c.c.) 5-15 min. (0.3-I.0 c.c). Pulvis Ipecacuanhae et Opii, U. S. P. (Dover's powder: ipecac, I part; powdered opium, I part; sugar of milk, 8 parts) 5-iO gr. (0.3-0.6 gm.). Pilulre Laxativse Compositse, U. S. P. (each pill contains aloin,^ gr. (0.013 gm.) ; strychnin, y£ f gr. (0.0005 g™- > extract of belladonna, \ gr. (0.008 gm. ; ipecac, ^ gr. (0.004 gm.); with licorice and syrup 1-3 pills. Physiologic Action. — Ipecac is a powerful local irritant. When rubbed into the skin it causes erythema and vesication ; when applied to mucous membranes it produces redness, swelling, and an increase of secretions. In some persons the mucous membrane of the respiratory tract is so sensitive to the drug that the inhalation of an exceedingly small quantity of the powder is sufficient to excite lacrimation, sneezing, run- 270 EXPECTORANTS. ning from the nose, and asthmatic breathing. The ingestion of a full dose of ipecac is followed in a short time by nausea, vomiting, and a marked increase of the secretions of the nose, mouth, and bronchi. These effects are due to cephaelin and emetin. Both alkaloids are active emetics, but the former is decidedly more powerful in this respect than the latter. The emesis is probably of peripheral origin, though the drug is believed by some writers to act also on the vomiting center in the medulla. The subcutaneous injection of a toxic dose of emetin is followed by nausea, vomiting, purging, and collapse. It is well-established clinically that small doses of ipecac promote both the cutaneous and bronchial secretions. Therapeutics. — Ipecac is chiefly employed as a sedative expectorant, an emetic, an anti-emetic, an antidysenteric, and a diaphoretic. Expectorant. — Ipecac is an excellent expectorant in acute bronchitis before secretion has been established. In chronic bronchitis, when the sputum is scanty and viscid, it is also ser- viceable. In the form of a spray the wine, diluted with twice its bulk of water, as recommended by Murrell, is often very efficacious in " winter cough " and bronchial asthma. Emetic. — Ipecac, though not very prompt in its action, is a certain and safe emetic. It is especially useful in children, in whom it is frequently employed to unload the stomach of irritant material. In capillary bronchitis, when the bronchi become filled with mucus and asphyxia is threatened, ipecac may be given in doses sufficient to excite emesis, with the hope of forcibly expelling the secretion. In poisoning more prompt emetics, like apomorphin or zinc sulphate, are pre- ferable. Anti-emetic. — Ipecac in minute doses sometimes succeeds in controlling persistent vomiting that is not dependent upon any organic disease of the stomach. The wine is the best preparation; it should be given in doses of from J— I minim (0.03-0.06 c.c.) every half-hour or hour. In some instances its efficacy is enhanced by the addition of an equal quantity of the tincture of nux vomica. Antidysenteric. — Ipecac has a long-standing reputation in acute tropical dysentery ; a large dose of from 30-40 gr. (2.0- 2.6 gm.) should first be given to induce vomiting, and after this has occurred smaller doses of from 3-5 gr. (0.2-0.3 gm.) should be given at intervals of two hours. To insure the re- tention of the latter doses, 5 min. (0.3 c.c.) of laudanum may be administered fifteen minutes before each dose of ipecac. A ANTIMONII ET POTASSII TARTRAS. 2J\ successful result is usually indicated by the appearance within twelve hours of copious tarry stools. In the sporadic dysen- tery of temperate zones this treatment is of little value. Diaphoretic. — The mild and agreeable diaphoretic effect of ipecac in the form of Dover's powder has made the latter a favorite remedy in the initial stage of acute coryza, in so-called muscular rheumatism, in influenza, and in acute suppression of the menses. Other Uses. — Ipecac has been recommended as a hemo- static since Trousseau's time, but its use in hemorrhage is at present obsolescent. Rutherford and Vignal concluded, from their experiments on dogs, that ipecac is a direct hepatic stimulant, but the work of other investigators has served to throw considerable doubt on this conclusion. In minute doses (-|— \ gr. — 0.008-0.016 gm.) it is an excellent adjuvant to strychnin in indigestion dependent upon motor insufficiency. In atony of the bowel, also, it often makes a useful addition to cathartic pills. Administration.— For producing emesis either the wine or the syrup may be selected ; in children the syrup, \- 2 fl. dr. (2.0-8.0 c.c.), is preferable. Paul and Cownley recommend cephaelin as a powerful and certain emetic, free from depress- ing effects when given in doses of from ^ - I gr. (0.006-0.01 gm.), but it is too costly for ordinary use. The preparations and alkaloids of ipecac are all too irritating to be administered hypodermically. As an expectorant the wine, 'syrup, or fluid extract may be employed. A combination of ipecac with an alkaline expectorant, as in the following formula, is often effective in the first stage of bronchitis : R Vini ipecacuanha, fgiiss ( 10.0 c.c.) ; Potassii citratis, giij (12.0 gm.); Tincturse opii camphoratee, Syrupi acaciee, aa £f j (30.0 c.c.) ; Aquae, q. s. ad f^vj (180.0 c.c). — M. Sig. A tablespoonful every four hours. ANTIMONII ET POTASSII TARTRAS, U. S. P. (Tartar Emetic; (KSbOC t H 4 6 ) 2 -f H 2 0.) Tartar emetic is the only official preparation of antimony. It occurs in the form of colorless crystals or a white granular powder, having a sweetish metallic taste, soluble in 15.5 parts of cold water and insoluble in alcohol. The dose as an expectorant is 2 a o - 4" S r - (0.003-0.008 gm.) ; as an emetic, J-i gr. (0.03-0.06 gm.). 272 EXPE CTO RANTS. Preparations. Dose. Vinum Antiraonii, U. S. P. (4 parts of tartar emetic in 1000). As an expectorant 10-20 min. (0.6-1.2 c.c). As an emetic 1-4 fl. dr. (4.0-15.0 c. c. ). Syrupus Scillse Compositus, U. S. P. (0.2 percent, with squill and senega). . . . 5-60 min. (0.3-4.0 c.c. ). Tartar emetic is also contained in compound licorice mixture. Physiologic Action. — Save that it is more irritant and is absorbed with greater difficulty, tartar emetic, like other anti- monial preparations, has an action similar to that of arsenic. When applied to the skin in ointment it produces papules, vesicles, pustules, and, if the contact be prolonged, diffuse ab- scesses. Taken internally in small doses (J- \ gr. — 0.008-0.016 gm.) it causes nausea and some increase in the perspiration and secretions of the mouth and respiratory tract. Large doses (1-2 gr. — 0.065-0.13 gm.) produce persistent vomiting with saliva- tion, copious sweating, and marked depression. Still larger doses are followed by choleraic discharges from the bowel, painful cramps, and collapse. The emesis occasioned by tartar emetic is probably the result of the direct irritant action of the drug on the stomach, though some writers believe that it is partly of cerebral origin. The marked depression and ultimate collapse after large doses are due partly to the violent emesis, partly to paralysis of the vessels of the splanchnic area, and partly to weakening of the heart itself. In fatal poisoning postmortem examination reveals intense congestion of the alimentary canal with hemorrhagic extravasations, and also cloudy swelling and fatty degeneration of the parenchymatous organs. Antimony is excreted chiefly by the stomach and bowel, but in small part by the kidneys, skin, and respiratory tract. The treatment of a ntimonial poisoning consists in the adminis- tration of tannin to form an insoluble salt, in washing out the stomach, and in combating collapse with diffusible stimulants and external heat. Therapeutics. — Tartar emetic is an efficient expectorant in acute bronchitis when there is hard cough with little or no expectoration. It may be prescribed conveniently in the form of wine of antimony, as in the following formulae : Bt Vini antimonii, fgij (8.0 c.c.) ; Spiritus setheris nitrosi, rfj (30.0 c.c.) ; Tincturse opii camphoratse, f^ ss ( r 5-° c.c.) ; Liquoris potassii citratis, q. s. ad fjiv (120.0 c.c). — M. Sig. A dessertspoonful in water every two or three hours. APOMORPHIN^ HYDROCHLORIDUM. 273 R Vini antimonii, TTl x l (2.5 c.c.) ; Syrupi tolutani, f^j (30.0 c.c.) ; Liquoris ammonii acetatis, q. s. adfgiij (90.0 c.c). — M. Sig. A teaspoonful eveiy two hours for a child of two years. Tartar emetic was formerly used also as an emetic, a dia- phoretic, circulatory depressant, and counterirritant, but for these purposes it has been almost entirely displaced by other and less poisonous remedies. Incompatibles. — Tartar emetic is incompatible with tannic acid, mineral acid, alkaline carbonates, and lime water. APOMORPHIN^ HYDROCHLORIDUM, U. S. P. (Apomorphin Hydrochlorid.) Apomorphin is an artificial alkaloid obtained by abstracting from morphin a molecule of water. It is prepared by main- taining at a high temperature for several hours, in a sealed retort, a mixture (1 : 20) of morphin and strong hydrochloric acid. The hydrochlorid of this alkaloid appears as minute grayish- white, acicular crystals, having a faintly bitter taste, and acquiring a greenish tint on exposure to light and air. It is soluble in about 40 parts of water or alcohol. The dose as an expectorant is from ^V~ 2V § r - (0-002-0.003 gm.) ; as an emetic, from ^ \ gr. (0.005-0.01 gm.). Physiologic Action. — In man the subcutaneous injection of 3^- gr. (0.006 gm.) of apomorphin is followed within fifteen minutes by nausea and vomiting. The emesis is accom- panied by muscular relaxation, quickening of the pulse, free perspiration, and a marked increase in the nasal, faucial, and bronchial secretions. The vomiting is of centric origin. On the central nervous system apomorphin appears to have first a stimulant, and then a paralyzant, effect. The heart is not influenced by therapeutic doses, but toxic doses induce paralysis. The rapid pulse observed after emetic doses is due, according to Reichert, to stimulation of the accelerators. Therapeutics. — Apomorphin is employed as an emetic and as a sedative expectorant. Emetic (see p. 166). — The certainty and promptness of its action and its freedom from irritant properties when adminis- tered hypodermically make it almost an ideal emetic in poison- ing, especially when swallowing is impossible or the state of the stomach is such as to forbid the use of emetics having a peripheral action. In young children and infirm subjects con- siderable caution must be exercised in its employment, since its action may be attended with profound exhaustion or even collapse. 18 274 EXPECTORANTS. Expectorant. — Apomorphin is a useful expectorant in both acute and chronic bronchitis, when the sputum is scanty and viscid. As it is eliminated rather rapidly, it should be given at comparatively short intervals — that is, every two or three hours. Apomorphin in small doses (g 1 -^ gr. — 0.002 gm.) has also some soporific effect for which it has been especially recommended in delirium tremens. Administration. — As an emetic apomorphin should be administered hypodermically. Solutions can be conveniently prepared from tablets containing the requisite dose. Both tablets and solution are liable to deteriorate with age and on exposure to light and air. As an expectorant it should be given by the mouth in the form of a solution, pill, or capsule. Incompatibles. — Alkalis, potassium iodid and ferric chlo- rid. It is said to be incompatible also with heroin. Apocodein Hydrochlorid. — This compound is prepared from codein after the manner of preparing apomorphin from morphin. It is an amorphous, yellow powder, soluble in water and alcohol. It has been recommended chiefly as an expecto- rant, in doses of from |—i gr. (0.05-0.065 gm.). ASPIDOSPERMA. (Quebracho.) Quebracho is the bark of Aspidosperma Quebracho-bianco, an evergreen tree growing in South America. It contains several alkaloids, the most important of which is aspidospermin. The aspidospermin of commerce, however; is really a mixture of the various alkaloids, and may be given in doses of from }-l gr. (0.03-0.065 gm.). Preparation. Dose. Fluidextractum Aspidospermatis 20-60 min. (1.2-4.0 c.c). Physiologic Action and Therapeutics. — Several of the alkaloids of quebracho resemble apomorphin in their action in that they first stimulate and then depress the central nervous system. Like apomorphin also they induce nausea and in- crease the secretions of the throat and bronchi. Only one alka- loid, however, is an active emetic, and that is aspidosamin. Aspidospermin in small dose is apparently an active respira- tory stimulant. Because of its influence on respiration and bronchial secre- tion quebracho has been found useful in bronchitis associated with asthma or emphysema. STIMULANT EXPECTORANTS. 2J$ OTHER SEDATIVE EXPECTORANTS, I,obelia (see p. 151). — Lobelia, like other nauseants, in- creases the bronchial secretions. In large dose it also de- presses the fibers of the vagus distributed to the bronchial muscles. Owing to this combined action, the drug is espe- cially valuable in bronchitis with asthma. The dose of the tincture of lobelia as an expectorant is from 10-30 min. (0.6- 2.0 c.c.); of the fluid extract, from 2-5 min. (0.1-O.3 c.c). Potassium Citrate (see p. 228). — This and other vegetable salts of potassium are useful expectorants in the early stages of acute bronchitis. The citrate is generally preferred to the other salts, owing to its less unpleasant taste. It may be prescribed in doses of from 20-30 gr. (1.3-2.0 gm.), in combination with a nauseant like ipecac or antimony. STIMULANT EXPECTORANTS. AMMONII CHLORIDUM, U. S. P. (Ammonium Chlorid ; Sal Ammoniac; NH 4 C1.) Ammonium chlorid is a white crystalline powder, odorless, of a cooling, saline taste, and permanent in the air. It is solu- ble in 2 parts of cold water and in 50 parts of alcohol. The dose is from 5-20 gr. (0.3-1.3 gm.). Preparation. Trochisci Ammonii Chloridi, U. S. P. (each contains ammonium chlorid, l\ gr. — O.I gm. ; licorice extract, 3 gr. — 0.2 gm.; with tragacanth, sugar, and syrup of tolu). Physiologic Action. — The chief effect of ammonium chlorid when administered by the mouth in moderate doses is to increase and render less viscid the mucous secretion of the bronchi, and perhaps, also, of the stomach and bowel. While it lacks the stimulant influence of ammonium carbonate on the circulation and respiration, its action on the mucous membranes is much more prolonged than that of the latter salt. Very large doses have an irritant action and excite the symptoms of gastro-enteritis. Blood dyscrasia with great muscular weak- ness has been observed after the prolonged use of ammonium salts in large doses. Ammonium chlorid is eliminated in the urine for the most part unchanged. Therapeutics. — Ammonium chlorid is particularly useful as an expectorant in acute bronchial catarrh after the symptoms of the initial stage have passed. It is sometimes successfully employed also in chronic bronchitis when the sputum is chiefly thick, tenacious mucus. In subacute and chronic pharyngitis or laryngitis lozenges of ammonium chlorid or a warm spray 276 EXPECTORANTS. of the salt (5 gr.-i oz. — 0.3 gm.-30.o c.c.) may prove bene- ficial. The drug has found favor with some practitioners in subacute gastro-intestinal catarrh and in catarrhal jaundice. A solution of ammonium chlorid — 5 gr. (0.3 gm.) to \ ounce (15.0 c.c.) each of alcohol and water — makes an excel- lent lotion in contusions with much ecchymosis. Administration. — The drug is generally given in aqueous solution to which licorice is added to disguise its unpleasant salty taste. It may also be prescribed in the form of com- pressed tablets to be taken after meals in several ounces of water : R Ammonii chloridi, ^iiss (10.0 gm.) ; Syrapi scillse, f^v (18.5 c.c.) ; Tincturse opii deodorati, TT\, xl (2.5 c.c.) ; Extracti glycyrrhizae, gj (4.0 gm.) ; Glycerini, fjss (15.0 c.c); Aquae, q. s. ad f^iv (120.0 c.c). — M. Sig. A dessertspoonful in water four times a day. In chronic bronchitis with inspissated secretions an iodid may be combined with ammonium chlorid, as in the following formula : R Ammonii iodidi, £ss (2.0 gm.) ; Ammonii chloridi, ^ij (8.0 gm.); Syrupi pruni Virginianae, f§ij (60.0 c.c.) ; Aquas, q. s. ad fjiv (120.0 c.c). — M. Sig. A dessertspoonful in water every four hours. Incompatibles. — Alkalis, mineral acids, tartaric acid, and soluble salts of silver and lead. AMMONII CARBONAS, U. S. P. (Ammonium Carbonate ; NH 4 HC0 3 . NH 4 NH 2 C0 2 .) The ammonium carbonate of commerce is a mixture of am- monium bicarbonate (acid carbonate) and ammonium carbam- ate. It occurs in white, translucent masses having a strong ammoniacal odor and a sharp saline taste. It is soluble in about 4 parts of cold water, and is decomposed by boiling water, with the elimination of carbon dioxid and ammonia. On exposure to air it is converted into an opaque white pow- der of ammonium bicarbonate. The dose is from 5-10 gr. (0.3-0.8 gm.). Preparation. Dose. Spiritus Ammonise Aromaticus, U. S. P. (am- monium carbonate, 3.4; ammonia water, 9; aromatic oils; water to make 100 parts) . . 20-60 min. (1.0-4.0 c.c). BENZOINUM. 277 Physiologic Action. — In therapeutic doses ammonium carbonate acts as a circulatory stimulant, a respiratory stim- ulant, and an expectorant. Its action is prompt, but evanescent. In large doses it is an irritant and capable of provoking emesis. It is eliminated in the urine as urea. Therapeutics. — Ammonium carbonate may be substituted for the water or one of the spirits of ammonia in combatting syncope, collapse, and other forms of sudden heart failure. As a stimulant expectorant it is especially useful in bronchitis as- sociated with cardiac or respiratory weakness. In pneumonia, both croupous and catarrhal, it often acts beneficially in facili- tating expectoration and in stimulating the circulation. In pulmonary emphysema, when the dyspnea and cyanosis are greatly exaggerated by attacks of acute bronchial catarrh, it acts admirably in conjunction with strychnin and digitalis. Mixed with half its bulk of stronger water of ammonia and scented, it constitutes the " smelling-salts," a popular remedy for syncope. Administration. — On account of the rapidity with which ammonium carbonate is decomposed after absorption it is necessary, to secure the desired effect, to administer it at inter- vals of not more than two hours. It is always given in solution, the favorite vehicle being syrup of acacia. Incompatibles. — It is incompatible with acids, acid salts, alkaloidal salts, and ferric salts. BENZOINUM, U. S. P. (Benzoin; Gum Benzoin.) Benzoin is a balsamic resin obtained from Styrax Benzoin, a large tree growing in Sumatra, Java, Borneo, and Siam. It contains several resins, benzoic acid (15-20 per cent), a vola- tile oil, cinnamic acid, and vanillin. It is soluble in about 5 parts of warm alcohol and in solutions of the fixed alkalis. Benzoic acid is soluble in 2 parts of alcohol and very spar- ingly soluble in water. The salts of benzoic acid — ammonium, lithium, and sodium — are readily soluble in water. Preparations. Dose. Tinctura Benzoini, U. S. P 20-60 min. ( 1. 2-4.0 c.c). Tinctura Benzoini Composita, U. S. P. (Friar's or Turlington's Balsam : 10 per cent., with aloes, tolu, and storax) . . . 20-60 min. (1.2-4.0 c.c). Adeps Benzoinatus, U. S. P. (2 per cent.). Acidum Benzoicum, U. S. P 5-20 gr. (0.3-1.3 gm.). Ammonii Benzoas, U. S. P 5~3° g r « (0.3-2.0 gm.). Lithii Benzoas, U. S. P 5-30 gr. (0.3-2.0 gm.). Sodii Benzoas, U. S. P S~3° S r ' (0.3-2.0 gm.). 278 EXPECTORANTS. Benzoic acid (0.4 per cent.) also enters into camphorated tincture of opium, or paregoric. Physiologic Action. — Benzoic acid is an antiseptic of considerable power and a stimulant to the mucous membranes. In health moderate doses do not affect the functions of the body beyond increasing, to a variable degree, the nitrogenous output and lessening the quantity of ethereal sulphates and of indican in the urine. It escapes from the body rapidly, chiefly through the kidneys, and for the most part in the form of hip- puric acid — a compound of benzoic acid with the proteid derivative, glycocoll. It is generally believed that benzoic acid increases the acidity of the urine, but according to W. W. Ashhurst, who has investigated the subject very carefully, sodium benzoate, at least, has little or no influence on the acidity of urine that is already acid, but that it does render al- kaline urine acid ; not so much by its presence, however, as by its power of arresting ammoniacal fermentation. In large doses benzoic acid and benzoates have an irritant action on the stomach, and in consequence excite nausea and vomiting. Therapeutics. — The compound tincture of benzoin painted over the part and allowed to dry is a useful protectant for small wounds. A combination of the compound tincture with 4 parts of glycerin makes an efficient application in chapped nipples, hands, or lips. A dram (4.0 c.c.) to a pint (0.5 L.) of boiling water may be used as an inhalant in acute laryngitis and bronchitis. The tincture may be prescribed internally also in subacute and chronic bronchitis when expectoration is very viscid. Benzoic acid itself often affords prompt relief in phosphaturia, and in cystitis with ammoniacal urine. Sodium benzoate, in doses of from 5-10 gr. (0.3-0.6 gm.), is a very useful remedy in acute pharyngitis and tonsillitis. Owing to the fact that benzoic acid is eliminated as the soluble hippuric acid, it was hoped that the benzoates would prove of value in gout, but experience has shown that they are of no avail. Senator and others have recommended the benzoates in rheumatism, but they have been found to be far less efficacious than the salicylates. The treatment of phthisis by intravenous injections of cin- namic acid (see p. 190), so highly recommended by Landerer, is very painful and does not seem to have given any better results than can be obtained by other means. Administration. — Benzoic acid is best administered in capsules or pills. The benzoates may be administered in solu- tion or in powders. The tinctures are incompatible with aque- ous preparations. BALSAMUM TQLUTANUM. 279 BALSAMUM PERUVIANUM, U. S. P. (Balsam of Peru.) Balsam of Peru is a brownish-black, syrupy liquid, obtained by bruising the bark of Toluifera Pereira, a large tree growing in Central America. It has a smoky, vanilla-like odor and a bitter, persistent taste. It is soluble in alcohol, chloroform, and glacial acetic acid. It contains resins, cinnamic and ben- zoic acids, and traces of vanillin. The dose is from 5-30 min. (0.3-2.0 c.c). Therapeutics. — Balsam of Peru is chiefly employed as a protectant and parasiticide. It was at one time used as a stimulant expectorant in chronic bronchitis, but it has been entirely replaced by more elegant remedies. It is still occa- sionally employed as a stimulant protectant dressing in bed- sores and other ulcers. Alone, or in combination with sulphur, it is a reliable remedy in scabies, in which disease it may be prescribed as follows : R Sulphuris prsecipitati, Balsami Peruviani, aa gij (8.0 gm.) ; Olei olivse, f^ss (15.0 c.c); Adipis, q. s. ad ^ij (60.0 gm.). — M. BALSAMUM TOLUTANUM, U. S. P. (Balsam of Tolu.) Balsam of tolu is a yellowish-brown, semiliquid mass, obtained by incising the bark of Toluifera Balsamum, an ever- green tree growing in South America. It has a vanilla-like odor and a mild, aromatic taste, and is soluble in alcohol, ether, and chloroform, but is insoluble in water. It contains resin, a volatile oil, vanillin, and cinnamic and benzoic acids. The dose is from 5-30 gr. (0.3-2.0 gm.). Preparations. Dose. Syrupus Tolutanus, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). Tinctura Tolutana, U. S. P £-1 fl. dr. (2.0-4.0 c.c). fin crura Benzoini Composita, U. S. P. (4 percent.) 20-60 min. (1.2-4.0 c.c). Therapeutics. — Balsam of tolu has but feeble medicinal properties. It is chiefly employed on account of its agreeable flavor as a vehicle in cough-mixtures. 280 EXPECTORANTS. AMMONIACUM. (Ammoniac.) Ammoniac is a gum-resin obtained by puncturing the stems of Dorema Afnmoniacum, a plant growing in Persia and Tur- kestan. The dose is from 10-30 gr. (0.65-2.0 gm.). Therapeutics. — Ammoniac was once much used as a stimulant expectorant and a counterirritant, but it has been largely superseded by more efficient remedies. EUCALYPTUS, U. S. P. Eucalyptus is the leaves of Eucalyptus Globulus, or gum-tree, a native of Australia, and cultivated in Europe and Southern United States. It contains a volatile oil (6 per cent.), from which is obtained a neutral body, eticalyptol. The latter is a colorless liquid, having a camphoraceous odor and a pungent, spicy taste, and on exposure to a temperature below 30 F. solidifying into a mass of needle-shaped crystals. It is in- soluble in water, but freely so in alcohol. Preparations. Dose. Fluidextractum Eucalypti, U. S. P. ... 20-60 min. (1.2-4.0 c.c). Oleum Eucalypti, U. S. P 3-10 (0.2-0.6 c.c). Eucalyptol, U. S. P 3-10 (0.2-0.6 c.c). Eucalyptol also enters into the official antiseptic solution (Liquor Antisepticus). Physiologic Action. — Oil of eucalyptus is a local irritant. When applied to the skin, evaporation being prevented, it causes redness and even vesication. When taken internally in large doses (20 min. — 1.2 c.c), it causes a sense of burning in the throat and stomach, nausea, looseness of the bowels, and some mental exhilaration, which in turn is followed by a feeling of calm. Toxic doses depress the spinal cord, medulla, and heart, and in consequence induce extreme muscular weakness, a fall of temperature, a feeble pulse, shallow respiration, and finally death from asphyxia. The drug is eliminated by all the emunctories, and, like turpentine, it imparts the odor of violets to the urine. Both eucalyptol and the oil have pronounced antiseptic properties. Therapeutics. — Eucalyptus was at one time used as a sub- stitute for quinin in malaria, but its value in this disease was OLEUM MYRTI— SENEGA. 28 1 never established, and to-day it is rarely, if ever, employed. In subacute and chronic bronchitis attended with copious expecto- ration the oil is an exceedingly useful expectorant. As an inhalant, also, oil of eucalyptus is sometimes efficacious in diminishing profuse expectoration in bronchiectasis and phthisis. A dram (4.0 c.c.) may be added to an ounce (30.0 c.c.) of liquid petrolatum and used in an atomizer; or eucalyptol alone or in conjunction with terebene may be used in an inhalation respirator. Eucalyptol in the form of an oily spray acts very favorably in subacute and chronic rhinitis, if used after the nares have been thoroughly cleansed with an alkaline wash. The following formula, suggested by Douglass, is an excellent one : JJ Thymol, gr. x (0.65 gm.) ; Menthol, gr. xx (1.3 gm.) ; Eucalyptol, gtt. xx (0.6 c.c.) ; Olei cubebse, gtt. xl (1.2 c.c); Benzoinol, f|yj (175.0 c.c). — M. Oil of eucalyptus is sometimes used as a urinary antiseptic in cystitis and urethritis. Administration. — The oil and eucalyptol are the best preparations for internal use. They may be given on sugar, in capsules, or in an emulsion. OLEUM MYRTI. (Oil of Myrtle ; Myrtol.) Oil of myrtle is a greenish-yellow, volatile oil, distilled from the leaves and flowers of Myrtus communis, the common Eu- ropean myrtle. It has properties almost identical with those of eucalyptol. The dose is from 3-10 min. (0.2-0.6 c.c). It is an excellent stimulant expectorant in bronchorrhea, bronchi- ectasis, and fibroid phthisis. Eichhorst has used it with satis- faction in pulmonary gangrene. SENEGA, U. S. P. Senega is the root of Polygala Senega, a perennial herb growing in woody places in North America. It contains a white, amorphous body — senegin — belonging to the saponin group of glucosids. 282 EXPECTORANTS Preparations. Dose. Fluidextractum Senegae, U. S. P 5-20 min. (0.3-1.2 c.c. V Syrupus Senega, U. S. P \-z fl. dr. (2.0-8.0 c.c). Syrupus Scillae Compositus, U. S. P. (fl. ext. of squill, 8 per cent. ; fl. ext. of senega, 8 per cent. ; tartar emetic, 0.2 per cent.) 10-60 min. (0.6-4.0 c.c). Physiologic Action and Therapeutics. — Senega is a local irritant and emetic. It is chiefly used, however, as a stimulant expectorant in subacute and chronic bronchitis with copious expectoration. It is often prescribed in combination with squill. SANGUINARIA, U. S. P. (Bloodroot.) Sanguinaria is the rhizome of Sanguinaria canadensis, a perennial herb growing in the woods of North America. It contains an alkaloid, sanguinarin. Preparations. Dose. Tinctura Sanguinariae, U. S. P IO-30 min. (0.6-2.0 c.c). Fluidextractum Sanguinariae, U. S. P. . . 1-5 min. (0.06-0.3 c.c). Physiologic Action and Therapeutics. — Sanguinaria is a powerful irritant. In large doses it excites nausea and vomiting. Toxic doses of sanguinarin cause salivation, violent intestinal peristalsis, spinal convulsions, and, finally, cardiac and respiratory failure. Sanguinaria has been employed as an emetic and a stimulant expectorant, but it is now mostly re- placed by more efficient and less dangerous drugs. ALLIUM. (Garlic) Garlic is the fresh bulb of Allium sativum, a plant indigen- ous to Southern Europe and cultivated in North America. Its active principle is a volatile oil. Preparation. Dose. Syrupus Allii 1-4 fl. dr. (4.0-15.0 c.c). Therapeutics. — Garlic was at one time a favorite stimulant expectorant, especially for children ; it has been superseded, however, by more agreeable remedies. CREOSOTUM. 283 GRINDELIA, U. S. P. Grindelia is the leaves and flowering tops of Grindelia robusta and Grindelia squarrosa, perennial herbs growing in North America, west of the Rocky Mountains. It contains resin, a bitter principle, and a volatile oil of a terebinthinate odor. Preparation. Dose. Fluidextractum Grindeliae, U. S. P. . . . 15-60 min. (1.0-4.0 c.c). Therapeutics. — Grindelia is a very useful remedy in bronchitis complicated with asthma. It may be prescribed alone or in combination with other antiasthmatics, as in the following formula : R Sodii iodidi, zj (4.0 gm.) ; Fluidextracti grindelise, fgss (15.0 c.c.) ; Tincturse lobelioe, Tincturae belladonnae, aa fz,ij (8.0 c.c.) ; Fluidextracti glycyrrhizse, fzjij (u.oc.c); Syrupi tolutani, q. s. ad f^iij (90.0 c.c). — M. Sig. A teaspoonful every three or four hours. The fumes of burning grindelia leaves are also efficacious in allaying the cough and relieving the dyspnea of asthma. A lotion consisting of an ounce (30.0 c.c.) of the fluid extract to a pint of water (0.5 L.) has been highly recommended in rhus poisoning and erysipelas. It should be applied on cloths and allowed to evaporate. CREOSOTUM, U. S. P. (Creosote.) Creosote is a mixture of phenols, chiefly guaiacol and creosol, obtained during the distillation of wood-tar, preferably of that derived from the beech. It is a colorless or faintly yellow, oily liquid, having a penetrating, smoky odor and a burning, caustic taste. It is soluble in 150 parts of water, and in all proportions in alcohol, ether, chloroform, and oils. Much of the creosote of commerce is impure carbolic acid. Notable quantities of the latter, however, may be detected by one of the following tests : first, by the formation of a coagu- lum when equal quantities of the suspected liquid and collo- dion are mixed in a dry test-tube, and, secondly, by the absence of turbidity when one or more volumes of water are added to an intimate mixture of equal volumes of the liquid and glycerin. The dose of creosote is from 1-10 min. (0.06- 0.6 c.c), gradually increased to the limit of tolerance. 284 EXPECTORANTS. Preparation. Dose. Aqua Creosoti, U. S. P. (about 1 per cent.) 1-4 fl. dr. (4.0-15.0 c.c). Physiologic Action. — The action of creosote closely resembles that of carbolic acid, but it is much less irritant and toxic. Very large doses, however, produce all the symptoms commonly observed in carbolic-acid poisoning — namely, burn- ing pain, nausea and vomiting, vertigo, collapse, and almost simultaneous failure of the heart and respiration. As pointed out by Hare, soluble sulphates — Epsom or Glauber salts — are chemical antidotes. Like all members of the phenol group, creosote is a powerful antiseptic. The drug is eliminated in large part by the kidneys as guaiacol sulphate and creosol sulphate of potassium, but a certain proportion escapes from the body through the lungs. Therapeutics. — Creosote is employed chiefly as an expec- torant, an antiseptic, and a local anesthetic. Expectorant. — Creosote and its derivatives are useful ex- pectorants in chronic bronchitis and bronchiectasis with copious purulent sputum. So long ago as Addison's time creasote was used as a remedy for phthisis. This use was revived by Bouchard and Gembert in 1877, anc * again by Sommerbrodt in 1887. While it has been shown conclusively that the drug has no specific influence on the tubercle bacilli in the lung, nevertheless the testimony of numerous observers is convinc- ing that it has a positive value in allaying cough, lessening ex- pectoration, and lowering temperature. It should be given in small doses gradually increased, and at once withdrawn if the stomach shows any intolerance. The best results are seen in phthisis attended with abundant sputum. Whether the drug has any other action than that of an expectorant and intestinal antiseptic is not known. Antiseptic. — Creosote is a valuable internal antiseptic in chronic gastric catarrh with flatulence and in simple dyspeptic di- arrhea. Creosote water has been recommended as a disinfectant lotion for sloughing ulcers y uterine cancer, etc., but for such a pur- pose it has no advantage over a dilute solution of carbolic acid. Local Anesthetic. — Inhalations of creosote are often use- ful in allaying the cough of laryngitis, bronchitis, and phthisis. Ten min. (0.6 c.c.) of creosote to 10 ounces (300.0 c.c.) of boiling - water makes a good inhalation when the catarrh is acute. A mixture of equal parts of creosote and spirit of chloroform, employed in a respirator, often serves to control the painful paroxysms of cough in phthisis. Doses of from 1-2 min. (0.06-0.1 c.c.) are sometimes efficacious in the vomit- CREOSOTUM. 285 ing of pregnancy, peptic ulcer, and gastric ca7icer. In toothache a drop or two on a pledget of cotton may be inserted in the cavity of the tooth. In the form of an ointment or lotion (10 min.-i oz. — 0.6-30.0 gm.) it has been successfully employed to allay itching in chilblains, pruritus, and chronic eczema, but its odor is objectionable. Administration. — For internal use it is important to secure a preparation that is comparatively free from carbolic acid. The initial dose should be small (1-3 min. — 0.06-0.2 c.c), and the amount gradually increased to 10-15 min. (0.6—1.0 c.c). In some cases of phthisis so much as 60 or even 100 min. (4.0-6.0 c.c.) three times daily are well borne, but such large doses are usually unnecessary. Creosote should be admin- istered after meals, and withdrawn on the first appearance of indigestion. Small doses may be given in capsules, but large doses should be given well diluted with cod-liver oil, milk, or a weak wine. In phthisis the drug has been administered hypodermically, the injections consisting of 1 part of creosote to 2 of olive or almond oil. This method of administration, however, is painful, and has little if any advantage over that by the mouth. Intratracheal injections have also been em- ployed, but guaiacol is preferable for this mode of administra- tion. In diarrhea creosote may be prescribed in a powder of bismuth, as in the following formula : R Creosoti, rr\xij (0.75 c.c.) ; Morphinse sulphatis, gr. j (0.065 gm.) ; Bismuthi subnitratis, ^ss (15.0 gm.). — M. Fiant chartulae No. xii. Sig. One every three hours. Incompatibles. — Strong nitric and sulphuric acids act violently upon creosote. It reduces silver salts and may ex- plode when triturated with* oxid of silver. It is also incom- patible with ferric chlorid. Creosote Carbonate (Creosotal). — This is an oily liquid containing a mixture of the carbonates of the various phenols found in creosote. Its chief ingredient is guaiacol carbonate. It is odorless, of a slightly bitter taste, insoluble in water, but freely so in alcohol, ether, and oils. It has pronounced advan- tages over creosote in having but little taste and in being more acceptable to the stomach. It may be employed in the same class of cases as creosote. Leyden and Cornet have highly recommended it in pulmonary tuberculosis. The dose is from 1-3 min. (0.06-0.2 c.c), gradually increased to 10-20 min. (0.6-1.2 c.c), thrice daily. It may be given in capsules or in oil, milk, claret, or beef-tea. 286 EXPECTORANTS. Guaiacol, U. S. P.— This phenol derivative is the chief constituent of creosote, from which it is obtained by fractional distillation. It is a colorless, oily liquid, having a rather un- pleasant aromatic odor and taste. It is slightly soluble in water, but freely so in alcohol and ether. It readily unites with acid radicles to form crystalline compounds. The dose is from 1-3 min. (0.06-0.2 c.c), gradually increased to 20 min. (1.2 c.c). It should be given in the same manner as creosote. The action of guaiacol resembles that of carbolic acid and creosote. In toxic doses it causes burning in the stomach, The action of guaiacol resembles that of carbolic acid and creasote. In toxic doses it causes burning in the stomach, nausea and vomiting, brown-red urine, unconsciousness, and collapse. Wyss has reported a case of fatal poisoning in a girl of nine years from a dose of 80 min. (5.0 c.c). It is absorbed and eliminated with great rapidity, undergoing partial oxidation in the body, and appearing in the urine as glycur- onates and ether sulphates. When applied to the skin in suf- ficient quantity (20—30 min. — 1. 2-2.0 c.c), evaporation being prevented, it causes in fever a marked fall of temperature. This antipyretic effect follows immediately upon its absorption, is attended with copious perspiration and depression, and is of comparatively short duration. Guaiacol has been used internally as a substitute for creosote in chronic bronchitis and pulmonary tuberculosis, but it is now largely replaced by the more elegant carbonates of creosote and guaiacol. Intralaryngeal injections into the trachea of a mixture of guaiacol (1-2 per cent.) and olive oil are sometimes very useful in allaying cough in chronic pulmonary diseases. From 10-20 min. (0.6-1.2 c.c.) of the mixture may be injected once or twice a day. Guaiacol cannot be recommended as an antipyretic, since its external application in typhoid fever, tuberculosis, and other infections is sometimes followed by profound exhaustion and even by collapse. The drug has proved of some value as a local anesthetic. In epididymitis and orchitis the gentle inunction of an ointment of guaiacol and lanolin (1 : 5), followed by the application of a snugly fitting suspensory bandage, affords much relief. In laryngeal tuberculosis an oily spray of guaiacol (20-40 per cent.) is sometimes useful. Gttaiacolis Carbonas, U. S. P. — Guaiacol carbonate is produced by the action of carbonyl chlorid on the sodium salt of guaiacol. It is a white, crystalline powder, neutral in reac- tion, odorless and tasteless, insoluble in water, and slightly so in alcohol, glycerin, and oils. The dose is from 3-10 gr. (0.2- O.65 gm.), gradually increased to 30 gr. (2.0 gm.), thrice daily. According to Hesse, guaiacol carbonate is distinctly less PIX LIQUID A. 287 poisonous than either guaiacol or creosote. On account of its freedom from odor and taste it is often much better borne than creosote. It is an excellant expectorant in purulent bronchitis, bronchiectasis, and phthisis. In doses of 10 grains (0.65 gm.), gradually increased to 20 grains (1.3 gm.), thrice daily, it has been highly recommended by Luff and others in rheumatoid arthritis. As it undergoes reduction in the intes- tine, it may be employed also as an intestinal antiseptic. It may be prescribed in pills, capsules, or powders. R Strychninae sulphatis, gr. \ (0.016 gm.) ; Codeinse sulphatis, gr. ij (0.13 gm.) ; Guaiacoli carbonatis, gr. 1 (3.0 gm.) ; Terebeni, TT^ 1 (3.0 c.c). — M. Pone in capsulas No. xxiv. Sig. Two capsules every four hours {subacute bronchitis). Potassium Guaiacol Sulphonate (Thiocol). — This compound occurs as a white, odorless powder, of a faintly bitter and then sweetish taste. It represents about 60 per cent, of guaiacol. Its chief advantage over the carbonate of guaiacol is its ready solubility in water. It may be given in doses of from 5-30 gr. (0.3-2.0 gm.), thrice daily, in some aromatic water. Other preparations of guaiacol are sometimes employed, such as the benzoate (benzosol), phosphite (guaiacol-phos- phal), cinnamate (styracol), and glycerol-ether (guaiamar), but they have no special advantages. PIX LIQUIDA, U. S. P. (Tar.) Tar is an empyreumatic oleoresin obtained by the destructive distillation of Pinus palustris and other species of Pinus. It is a thick, blackish liquid, having a terebinthinate odor and a pungent taste. It is only sparingly soluble in water, but freely so in alcohol, oils, and alkaline solutions. Its active con- stituents are guaiacols and creosols. When subjected to dis- tillation it yields a volatile oil — oil of tar. The dose is from 3-15 gr. (0.2-1.0 gm.). Preparations. Dose. Oleum Picis Liquids, U. S. P 1-5 min. (0.06-0.3 c.c.). Syrupus Picis Liquids, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). Unguentum Picis Liquidse, U. S. P. (50 per cent.). A water (Aqua Picis Liquidse) is also in use. It is made by shaking together I part of tar and 4 parts of water frequently for twenty-four hours, decanting and filtering. The dose is from 1-4 fl. oz. (30.0-120.0 c.c). 288 EXPECTORANTS. Physiologic Action and Therapeutics. — Tar is a local stimulant and an antiseptic. It is chiefly employed in medicine as an expectorant, and as a local remedy in certain chronic skin diseases. In chronic bronchitis with abundant sputum and hard, paroxysmal cough it sometimes succeeds after other remedies have failed. It may be given in pills or capsules, or in the form of the syrup or water. Murrell has found inhala- tions of tar-water also useful in the same class of cases. In chronic eczema and psoriasis, when the lesions are sluggish, an ointment of tar makes a useful application ; the official oint- ment is generally too strong, J-2 dr. (2.0-8.0 gm.) to the ounce (32.0 gm.) of lard being quite sufficient in the majority of cases. It should always be employed tentatively, as in some persons the skin is exceedingly sensitive to the drug. It is absolutely contraindicated if the inflammation is at all active. OTHER STIMULANT EXPECTORANTS. Squill (see p. 224). — Syrup of squill, in doses of j—i fl. dr. (2.0-4.0 c.c.), is an excellent expectorant in the later stages of acute bronchitis. The compound syrup of squill contains, in addition to squill, senega and tartar emetic, and is too depress- ing for ordinary use. As syrup of squill contains free acetic acid, it is incompati- ble with ammonium carbonate and other alkaline carbonates. Oil of Santal (see p. ^36). — When pure, this drug often proves a useful expectorant in subacute and chronic bronchitis, with heavy, purulent sputum. Its chief drawback is its ten- dency to disturb the stomach. It should be given in doses of from 5-20 min. (0.3-1.2 c.c), in capsules or in an emulsion. Terebene and oil of eucalyptus are efficient synergists. Copaiba and Cubeb'(see pp. 234 and 235). — The oil of copaiba and the oleoresin of cubeb have been employed as ex- pectorants in chronic bronchitis with profuse purulent sputum, but they are neither so efficacious nor so elegant as terebene, oil of eucalyptus, and the preparations of guaiacol. Smoking cigarettes containing cubeb sometimes affords relief in the paroxysms of asthma. Lozenges of cubeb are useful in re- lieving hoarseness and fatigue of the larynx resulting from pro- longed use of the voice. Oil of Turpentine (see p. 236). — This drug, once much used as an expectorant in chronic bronchitis, has been largely replaced by terebene and terpin hydrate. Terebene (Tere- benum, U. S. P.) is a liquid hydrocarbon made by oxidizing oil of turpentine with strong sulphuric acid. The dose is from 5-10 min. (0.3-0.6 c.c). Terpin hydrate is a crystalline FERRUM. 289 compound obtained by the interaction of oil of turpentine, al- cohol, and nitric acid. The dose is from 2-15 gr. (0.1 3-1.0 gm.). Terebene is one of the most satisfactory remedies we possess in bronchitis with free expectoration. In phthisis, also, it is of service when the catarrhal symptoms are prominent. In moderate doses it is usually well received, but large doses may excite nausea or irritation of the kidneys and bladder. As it is insoluble in water, it should be given in capsules, on sugar, in an emulsion, or in an elixir. It may also be inhaled, either as a spray or from the sponge of a respirator. Terpin hydrate has therapeutic properties similar to those of terebene, but it is less active. It may be given in pills, in capsules, or in an elixir. Terpinol, an oily body derived from terpin hydrate, has been employed as an expectorant in doses of from 3-15 min. (0.2-1.0 c.c). It is not so efficient as terebene. TONICS. Tonics are drugs that impart strength or tone to the tissues. In one sense every drug that favorably influences disease is a tonic, since, by removing the cause of debility, it serves to restore normal vitality. The term, however, is cus- tomarily restricted to remedies that have a more or less gen- eral invigorating effect, without necessarily exerting a specific influence on any one organ. A more exact knowledge of the pharmacologic action of drugs and a clearer appreciation of the primary causes of general weakness and malnutrition have tended to diminish gradually, but steadily, the number of remedies grouped under this heading. The following drugs may still be classed conveniently as tonics : Iron. Calcium phosphate. Phosphorus. Calcium hypophosphite. Cod-liver oil. Nux vomica, cinchona, and arsenic also exert a tonic influ- ence, but as this is subordinate to their other actions, these drugs have been considered in other groups. FERRUM, U. S. P. (Iron; Fe.) Iron is official in the form of fine, bright, non-elastic wire. Physiologic Action. — As iron is a constituent of the 19 29O TONICS. normal body, it may be regarded as a food as well as a medicine. It is especially abundant (0.4 per cent) in hemoglobin, and its presence in this compound is intimately associated with the function of the red corpuscles to carry oxygen from the lungs to the tissues. When iron is taken in therapeutic doses it acts as an astringent, causing more or less constipation. Large doses have an irritant effect and disturb digestion. It is now definitely known that both inorganic and organic preparations of the metal are capable of absorption. Only a small portion, however, of the quantity ingested enters the blood, the larger portion being discharged from the bowel as a sulphid and an albuminate, the stools, owing to the presence of the former, acquiring a deep black color. Absorption takes place mainly in the duodenum, the iron entering the general circulation probably as an albuminate. According to Macallum, trans- portation is effected through the agency of the leukocytes, and, more especially, of the blood-plasma. The amount that is absorbed varies with the nature of the preparation and the quantity that is administered. From the blood the iron is de- posited temporarily in the spleen, liver, and bone-marrow, and in one of these organs, perhaps the liver, it is converted into hemoglobin. That which is absorbed in excess of the require- ments of the blood is not eliminated in the secretions, but escapes from the body through the intestinal epithelium. Even when injected directly into a vein, the iron reappears chiefly in the intestines, and the amount of the metal in the urine is not materially increased. In health the iron naturally contained in food is all-sufficient for the needs of the system, and the administration of medici- nal iron is not followed by any notable increase in the number of red blood-cells or their hemoglobin value. In certain forms of anemia, however, especially chlorosis, chalybeate prepara- tions increase the amount of hemoglobin and, to a less extent, the number of red blood-cells. Whether the drug acts simply by furnishing material for the corpuscles or by stimulating the functional activity of the blood-making organs is not known. Untoward Effects. — The continued use of iron, especially of the ferric salts, frequently excites indigestion, constipation, and headache. Discoloration of the tongue and teeth also occasionally follows its use, and is thought to be due to the formation in the mouth of a black sulphid or tannate. Therapeutics. — The most important indication for the use of iron is anemia. The best effects are seen in chlorosis, in which disease the drug has almost a specific action. In secondary anemia the results of its use are less decisive, but FERRUM. 29I after the removal of the cause it serves to hasten the restora- tion of the blood to its normal condition. Iron plays indirectly the part of an emmenagogue in amenorrhea dependent upon anemia. Some of its salts are used as astringents and styptics. Contraindications. — The chief contraindication is gastric irritation. It is generally badly borne, probably on account of impaired digestion, in febrile diseases and in gout. Administration. — Ordinarily iron should be administered by the mouth and after meals. The least astringent prepara- tions are the carbonate, citrate, ammonioferric citrate, am- monioferric tartrate, pyrophosphate, and reduced iron. The numerous organic compounds of iron with albumin have no great advantages over many of the older inorganic salts, but they are less liable to disturb digestion, and are, probably, somewhat more readily absorbed. In exceptional cases iron may be given hypodermically. For this purpose a freely soluble preparation, such as ammonioferric citrate, should be selected, and the solution should be freshly prepared and well diluted. Incompatibles. — Ferrous and ferric salts are incompatible with all preparations containing tannic or gallic acid ; with ammonia, alkaline carbonates, and mucilage of acacia. FERRUM REDUCTUM, U. S. P. (Reduced Iron; Iron by Hydrogen; Quevenne's Iron.) Reduced iron is a fine, grayish-black, insoluble powder, without odor or taste. When pure it is quite free from irritat- ing properties, and, being but feebly astringent, it has little tendency to cause constipation. It is employed only as a hematinic. It maybe given in doses of from 1-5 gr. (0.06-0.3 gm.), in pills, capsules, or lozenges. FERRI CARBONAS. (Iron Carbonate; Green Ferrous Carbonate; FeC0 3 .) Iron carbonate is an unstable compound which is readily converted into ferric hydrate on exposure to air. It is not official. Preparations. Dose. Ferri Carbonas Saccharatus, U. S. P. (con- tains 15 per cent, of freshly precipitated ferrous carbonate, protected from oxida- tion by sugar) 5-15 gr. (0.3-1.0 gm.). Mistura Ferri Composita, U. S. P. (com- pound iron mixture; Griffith's Mixture: carbonate of iron in suspension with potassium sulphate, myrrh, and sugar) . 1-4 fl. dr. (4.0-15.0 c.c). 292 TONICS. Preparation. Dose. Massa Ferri Carbonatis, U. S. P. (Vallet's Mass : about 42 per cent, of ferrous car- bonate with sugar and honey) 3-5 gr. (0.2-0.3 S 111 -)- Pilulas Ferri Carbonatis, U. S. P. (Blaud's Pills: each pill contains about I gr. — 0.06 gm. — of ferrous carbonate, made with crystallized ferrous sulphate and potassium carbonate) ........ 1-3 pills. Therapeutics. — These preparations are comparatively free from astringency, and are convenient forms in which to admin- ister iron. They are used solely in anemia. The saccharated carbonate and the pills of the carbonate (Blaud's pills) are the favorite preparations. The former should be given also in pills or else in capsules. Griffith's mixture is superfluous. Some practitioners prefer Blaud's pills made according to the original formula (equal parts of potassium carbonate and dried ferrous sulphate) to those made according to the official formula. The former contain a certain amount of free potas- sium carbonate. FERRI CHLORIDUM, U. S. P. (Ferric Chlorid; Sesquichlorid or Perchlorid of Iron; Fe 2 Cl 6 -4- 12 H 2 0.) Ferric chlorid occurs in deliquescent, orange-yellow crystal- line pieces, having an astringent, chalybeate taste. It is not used internally, but sometimes externally as an astringent or a styptic. Preparations. Dose. Liquor Ferri Chloridi, U. S. P. (contains about 29 per cent, of the crystallized salt) 3-10 min. (0.2-0.6 c.c). Tinctura Ferri Chloridi, U. S. P. (contains about 13 per cent, of anhydrous ferric chlorid, with alcohol, water, and a trace of nitrous ether) 5-30 min. (0.3-2.0 c.c). Liquor Ferri et Ammonii Acetatis, U. S. P. (Basham's Mixture: Tincture of ferric chlorid, 4 parts; dilute acetic acid, 6 parts; solution of ammonium acetate, 5° parts; aromatic elixir, 12 parts; glycerin, 12 parts; water, to make 100 parts) . . 1-4 fl. dr. (4.0-15.0 c.c). Therapeutics. — The solution of ferric chlorid may be used locally as a styptic in controlling bleeding after the ex- traction of teeth, removal of tonsils, or application of leeches. In postpartum hemorrhage it should not be used except as a last resort. It may occasionally be of service in hematemesis and entrorrhagia, on account of its local action, but it cannot possibly do good in other internal hemorrhages. FERRUM. 293 External pedunculated piles have been successfully treated by injecting them, after they have been clamped, with a few minims of the tincture. The treatment of aneurysm by injec- tions of ferric chlorid, as first advised by Pravaz, is dangerous, and fortunately obsolete. The tincture, in the strength of \-\ fl. dr. (2.0-4.O c.c.) to the ounce (30.0 c.c.) of water, may be used as an astringent application in chronic pharyngitis and laryngitis. Ferric chlorid in the form of the tincture or the solution is a valuable local remedy in pharyngeal diphtheria. It may be prescribed as follows : R Tincturae ferri chloridi, fgj-iij (4.0-1 1.0 c.c); Glycerini, f^ss (15.0 c.c); Aquae, q. s. ad f^j (30.0 c.c). — M. Or as Loffler's solution : R Menthol, giiss ( 10.0 gm.) ; Toluol, fgx (36.0 c.c.) ; Alcoholis absoluti, f^ij (60.0 c.c.) ; Liquoris ferri chloridi, fgj (4.0 c.c). — M. The tincture is an efficient hematinic in anemia, but it is more liable than many of the other preparations of iron to injure the teeth, disturb digestion, and induce constipation. Basham's mixture is a favorite chalybeate diuretic in chronic nephritis ; only small doses, however, should be given, and even these should be withheld if the drug causes constipation and headache. The tincture has long been regarded as a spe- cific in erysipelas. This claim cannot be substantiated, although the drug is of benefit in some cases. It may be given in doses of from 15-20 min. (i. 0-1.2 c.c.) every two or three hours. Administration. — The tincture of ferric chlorid should be taken after meals, well diluted, through a tube. Ferrum Dialysatum {Dialyzed Iron). — This is an un- official preparation of the oxychlorid of iron from which acidul- ous matter has been removed by dialysis. It is a dark-red, tasteless, neutral liquid, quite free from astringency. It is a very unstable compound, and undergoes rapid decomposition in the stomach. It is an extremely feeble chalybeate, but a useful antidote in arsenical poisoning. The dose as a hematinic is from 10-30 min. (0.6-2.0 c.c.) ; as an antidote, | fl. oz. (15.0 c.c.) frequently repeated. FERRI HYDROXIDUM, U. S. P., AND FERRI HYDROXIDUM CUM MAGNESII OXIDO, U. S. P. (Ferric Hydroxid; Fe (OH) 3 and Ferric Hydroxid with Magnesia.) These preparations are used exclusively as antidotes in ar- senical poisoning. The former may be precipitated from any 294 TONICS. liquid preparation of iron by adding to it an alkali (ammonia or sodium carbonate) ; the latter, by adding magnesia in excess. If a caustic alkali has been employed, such as ammonia, the excess should be removed by transferring the precipitate to a muslin filter, squeezing it and washing it with fresh water. Ferric hydroxid with magnesia is preferable, since it needs no washing, and since the magnesia itself is antidotal. These preparations should be freshly made and given freely, while still moist, in doses of a tablespoonful or more every few minutes. FERRI SULPHAS, U. S. P. (Ferrous Sulphate; Green Vitriol; FeS0 4 -f 7H 2 0.) Ferrous sulphate occurs as pale, bluish-green, efflorescent prisms, having a saline, styptic taste. The dose is from 1-5 gr. (0.06-0.3 gm.). Preparations. Dose. Ferri Sulphas Exsiccatus, U. S. P 1-3 gr. (0.06-0.2 gm.). Ferri Sulphas Granulatus, U. S. P. ... 1-5 gr. (0.06-0.3 g m -)- Mistura Ferri Composita (Griffith's Mix- ture) 1-4 rl. dr. (4.0-15.0 c.c). Pilulae Aloes et Ferri (contain about 1 gr. — 0.06 gm. — of each) 1-3 pills. Pilulse Ferri Carbonatis (Blaud's Pills) . . 1-3 pills. Therapeutics. — Sulphate of iron is an active astringent. It may be employed as a hematinic in anemia attended by re- laxation of the bowels. The dried sulphate should be selected for pills. Crude ferrous sulphate, or copperas, is used as a disinfect- ant and deodorizer for privies, cess-pools, etc., but its germi- cidal power is very feeble. FERRI SUBSULPHAS. (Ferric Subsulphate; Basic Ferric Sulphate ; Monsel's Salt ; Fe 4 0(S0 4 ) 5 .) Ferric subsulphate is a yellow, hygroscopic, astringent powder, freely soluble in water. Preparation. Dose. Liquor Ferri Subsulphatis, U. S. P. (Mon- sel's Solution) 3-5 min. (0.2-0.3 c.c). Therapeutics. — Monsel's solution is a prompt and power- ful styptic, which is somewhat less irritant in its action than the solution of ferric chlorid. It is employed chiefly as a local hemostatic. When used too freely it produces hard black clots, which may serve to conceal deep-seated hemorrhage. For this reason it should not be poured into the wound, but FERRUM. 295 applied directly to the bleeding surface on a pledget of cotton. In hematemesis a few drops in water may prove efficient. It has been recommended in the form of a spray in hemoptysis, but it is of doubtful utility. FERRI ET AMMONII SULPHAS, U. S. P. (Ferric Ammonium Sulphate; Ammonioferric Alum.) Ammonioferric alum occurs as pale-violet, efflorescent crys- tals, odorless, and of a sour, styptic taste. It is a more powerful astringent than ordinary alum (aluminum and potassium sulphate). It has been employed in saturated solu- tion as a hemostatic in capillary bleeding, and in weak solutions as an astringent injection in leukorrhea. FERRI IODIDUM. (Ferrous Iodid ; Protiodid of Iron; Fel 2 .) Ferrous iodid occurs in grayish-white, crystalline masses which are soluble in water with partial decomposition. It is rarely used in the pure form. Preparations. Dose. Syrupus Ferri Iodidi, U. S. P. (contains 5 per cent, by weight of ferrous iodid) . . 5-60 min. (0.3-4.0 c.c). Pilulae Ferri Iodidi, U. S. P. (contain about I gr. — 0.06 gm. — of ferrous iodid) 1-3 pills. Therapeutics. — Iodid of iron may be employed when it is desirable to combine an alterative with a chalybeate. It is a very useful preparation in tuberculous adenitis, syphilitic cachexia, and rachitis. It is usually well tolerated by children, to whom the syrup may be given in doses of from 3-20 min. (0.2-1.2 c.c), thrice daily, after meals. J. C. Wilson has found large doses of the syrup efficacious in articidar rheuma- tism and other forms of acute arthritis after failure with salicylic compounds. As the syrup is injurious to the teeth, it should be taken well diluted, and the mouth should be thoroughly rinsed after its administration. FERRI CITRAS, FERRI PHOSPHAS, AND FERRI TARTRAS. These compounds are known as the scale preparations, be- cause concentrated solutions of them are spread on plates of glass and allowed to evaporate, so that the salts may be obtained in the form of scales. The following are official: 296 TONICS. Preparations. Dose. Ferri Citras, U. S. P 2-5 gr. (0.13-0.3 gm.). Ferri et Ammonii Citras, U. S. P. (contains 16 per cent, of metallic iron) 5-10 gr. (0.3-0.6 gm.). Ferri et Quininse Citras, U. S. P. (contains 1 1.5 per cent, of quinin and 13.5 per cent, of metallic iron) 5-IO gr. (0.3-0.6 gm.). Ferri et Quininae Citratis Solubilis, U. S. P. (same strength as preceding preparation, but more soluble) .... 5~io gr. (0.3-0.6 gm.). Ferri et Strychninse Citras, U. S. P. (con- tains 1 per cent, of strychnin and 16 per cent, of metallic iron) 1-5 gr. (0.065-0.3 gm.). Ferri et Ammonii Tartras, U. S. P. (con- tains 13 per cent, of metallic iron) . . 5-10 gr. (0.3-0.6 gm.). Ferri et Potassii Tartras, U. S. P. (contains 15 per cent, of metallic iron) 5~io gr. (0.3-0.6 gm.). Ferri Phosphas Solubilis, U. S. P. (the solubility of this salt is dependent upon the presence of free sodium citrate) . . 3-10 gr. (0.2-0.6 gm.). Ferri Pyrophosphas Solubilis, U. S. P. (the solubility of this salt is dependent upon the presence of free sodium citrate) . . 3-10 gr. (0.2-0.6 gm.). From iron and quinin citrate, bitter wine of iron {Vinum Ferri Amarum, U. S. P.) is prepared, and from iron and ammo- nium acetate wine of iron ( Vinum Fetri, U. S. P.) is prepared. The dose of either wine is from 1-3 fl. dr. (4.0-1 1. o c.c). Iron phosphate enters into the glycerite of the phosphates of iron, quinin, and strychnin {Glyceritum Ferri, Quininee et Strychnines Phosphatum), the dose of which is 10-30 min. (0.6-2.0 c.c), and the syrup of the phosphates of iron, quinin, and strychnin (Syrupus Ferri, Quinines et Strychnince Phosphatum, U. S. P.), the dose of which is from 1-2 fl. dr. (4.0-8.0 c.c). Therapeutics. — The scale preparations of iron are mild and agreeable hematinics. They are comparatively free from astringency, and are usually well borne by the stomach. On account of their solubility they are well adapted for administra- tion in liquid form. FERRUM ALBUMINATUM. Bunge first demonstrated that iron exists in the tissues and in various food-stuffs in the form of a nucleo-albuminate. He subsequently succeeded in separating such a compound from the yolk of eggs, and this he called hematogen. The latter differs from ordinary iron salts in being very resistant to the action of sulphids. According to Bunge, inorganic prepara- tions of iron are not absorbed to any extent by the healthy FERRUM. 297 mucous membrane of the alimentary canal, and are useful in anemia only by disposing of the sulphureted hydrogen in the intestine, and thus protecting the food-iron from reduction until its absorption has been accomplished. Recent investiga- tions have proved conclusively that Bunge's view is fallacious, and that inorganic iron compounds are quite capable of absorp- tion and assimilation. Albuminates and peptonates of iron, however, are often better borne by the stomach than the in- organic salts, are less injurious to the teeth, and are, perhaps, somewhat more readily absorbed. Many attempts have been made to produce artificially, and in a way that can be prac- tically utilized, compounds having the characteristics of Bunge's hematogen. Schmiedeberg obtained from pig's liver a compound containing from 6-8 per cent, of iron, which he called ferratin. Later this preparation was obtained in larger quantities by the action of iron salts on egg-albumen. It is a fine, reddish powder, without odor or taste, insoluble in water, but soluble in dilute alkalis. The dose is from 3-10 gr. (0.2- 0.6 gm.). It may be given in capsules, powders, or tablets, or with milk. Kobert has obtained two compounds — hemogallol and hemol — from ox-blood by reducing the hemoglobin with pyrogallol and zinc dust respectively. The dose of either compound is from 2-8 gr. (0.13-0.5 gm.). Ferri l/actas {Ferrous Lactate). — This preparation occurs in pale, greenish-white, crystalline crusts, having a slight characteristic odor and a sweetish, ferruginous taste. It is slowly soluble in water. It may be given in doses of from 1-5 gr. (0.06-0.3 gm.). Ferri Oxalas (Ferrous Oxalate). — This salt occurs as a pale-yellow, odorless, crystalline powder, insoluble in water. It has been lauded by Quincke and by Hayem as a hematinic in chlorosis, but it does not seem to have any special advantages. The dose is from 3-5 gr. (0.2-0.3 gm.). Ferri Hypophosphis, U. S. P. (Ferric Hypophosphite). — This salt occurs as a white, odorless, and almost tasteless powder, slightly soluble in water. It has no special advan- tages. The dose is from 5-10 gr. (0.3-0.6 gm.). It is con- tained in the compound syrup of hypophosphites {Syrupus Hypophosphitum Compositus, U. S. P.), the dose of which is from 1-4 fl. dr. (4.0-15.0 c.c). Ferri Valeras {Ferric Valerate). — This compound is a dark-red, amorphous powder, having the odor of valerian and a mild styptic taste. It may be given with other valerates when a combined chalybeate and anti-spasmodic action is desired. The dose is from 1-3 gr. (0.06-0.2 gm.). 298 TONICS. PHOSPHORUS, U. S. P. Phosphorus is a yellowish, semitransparent, non-metallic element obtained from bones. It has a waxy consistence and luster, a peculiar, garlicky odor, and a disagreeable taste. By long keeping it turns red, and occasionally black. On ex- posure it emits white fumes, which are luminous in the dark, and on longer exposure it takes fire spontaneously. It is al- most insoluble in water, soluble in 350 parts of absolute alcohol and in 50 parts of fatty oils, and readily soluble in chloroform. The dose is from 1 ] Q ^ gr. (0.00064-0.002 gm.). Preparation. Dose. Pilulse Phosphori, U. S. P. (each pill con- tains ywg g 1 "- — 0.0006 gm.) 1-3 pills. Physiologic Action. — Wegner found that when phos- phorus was given in small doses to growing animals it rendered the bones more dense, diminished the cancellous structure, and finally caused more or less obliteration of the marrow- cavity. That these changes were due to the stimulation of the bone-forming tissues, and not to the deposition of an excess of phosphates, was shown by the fact that in animals fed with phosphorus but deprived of phosphates the same hyperplasia in the bones resulted, but that the new tissue was soft and gelatinous instead of hard. Apart from these changes in the osseous system, and perhaps a slight increase in the number of red blood-cells, the effects of phosphorus in medicinal doses are not very obvious. There is considerable clinical testimony, however, to show that the drug improves the nutri- tion of other tissues, especially of the nervous system. The manner in which phosphorus is absorbed has been a matter of some dispute ; it probably enters the blood chiefly as phosphorus, absorption being facilitated by the solution of the drug in the fatty substances present in the bowel. A small part is volatilized in the alimentary canal, and probably enters the tissue in the form of vapor. Phosphorus is eliminated in minute quantities as phosphorus by the lungs and partly by the kidneys as proteid compounds, and, probably, as phosphates. Toxicology. — Toxic doses of phosphorus do not usually produce their effects for several hours. The earliest symptoms are intense abdominal pain, obstinate vomiting, thirst, a gar- licky taste in the mouth, restlessness, and prostration. The ejected material contains mucus, bile, and occasionally disinte- grated blood, and is luminous in the dark. At the end of from twenty-four to thirty-six hours the symptoms gradually PHOSPHORUS. 299- subside and the patient feels comparatively comfortable, but soon the vomiting and pain return, jaundice develops, the liver becomes enlarged and painful, the pulse grows very feeble, and not infrequently ecchymoses appear in the skin and hemorrhages occur from the mucous membranes. The urine is scanty and contains albumin, tube-casts, bile, sarcolactic acid, an increased amount of ammonia, and sometimes leucin, tyrosin, and sugar. In fatal cases death occurs generally in from a few days to two weeks, and is often preceded by deli- rium, convulsions, stupor, and coma. Occasionally, phosphorus kills within a few hours, probably through its direct depressant influence on the heart. If the patient recovers, the symptoms abate very slowly and the convalescence is tedious. The changes in the organs observed after death are attri- butable to grave disturbances of tissue-metabolism and not to the direct irritant action of the drug. The most characteristic feature is wide-spread fatty degeneration of the tissues. The latter is especially marked in the glands of the stomach and intestines, in the liver, kidneys, heart, and muscles. Ecchy- moses are found in most of the organs. Areas of complete necrosis are often observed in the stomach and liver. In sub- acute poisoning the degenerated parenchyma may be replaced in part by newly formed connective tissue. Whether the fat found in the cells of the various organs is formed in situ or is carried to them from the subcutaneous tissues is a moot question. Treatment. — If the phosphorus has been recently taken, the stomach should be washed out at once. Copper sulphate is probably the best emetic, since any excess may serve as an antidote by forming with the phosphorus insoluble phosphid of copper. A cathartic should be given to remove from the bowel any of the poison that may still be unabsorbed. All oily and fatty matters should be withheld, since they are active solvents of phosphorus. Various oxidizing agents have been employed as chemical antidotes. Potassium permangan- ate (J per cent, aqueous solution) and the solution of peroxid of hydrogen are the most useful. Old French oil of turpen- tine, which is rich in ozone, has been repeatedly recommended, but it cannot be obtained in this country, and ordinary tur- pentine is useless. Chronic Phosphorus-poisoning. — Workmen employed in match factories and who are exposed to the fumes of phos- phorus develop a symptom-complex to which Magitot has applied the name phosphorism. This condition is char- acterized by anemia, loss of flesh, a garlicky odor of the 300 TONICS. breath, chronic diarrhea, albuminuria, fragility of the bones, and, in many instances, by necrosis of the maxillary bone. Since phosphorus necrosis occurs only in workmen who have carious teeth, it is usually attributed solely to the local ac- tion of the fumes, but there are good reasons for believing that systemic infection contributes largely to its development. Thus it rarely appears, despite the existence of carious teeth, until the worker has been some time, generally many years, at his trade ; the sufferer nearly always manifests some of the symptoms of systemic saturation, and finally, Stubenrauch has demonstrated experimentally, that phosphorous fumes exert no especial action on exposed bone or periosteum. Red or amorphous phosphorus being insoluble in ordinary liquids and non-volatile is free from toxic properties. Phos- phoric acid has none of the qualities of phosphorus, and acts merely as a mild stomachic. Sodium phosphate is an agree- able laxative. The hypophosphites of calcium, sodium, and potassium are innoxious, and are employed as tonics. Sodium phosphite is extremely poisonous. Sodium pyrophosphate and sodium metaphosphate, when administered hypodermically, paralyze the central nervous system and the heart, and in slow poisoning produce fatty degeneration of the glandular organs and numerous hemorrhagic extravasations. Therapeutics. — Phosphorus is employed as a tonic in cer- tain diseases of the nervous system that are dependent upon exhaustion rather than upon organic changes. Thus, it is sometimes of service in neurasthenia, neuralgia, and impotence from sexual excesses. It has been employed in rachitis, according to Monti, since 1838, but its reputation in this disease is due largely to the very favorable reports of Kas- sowitz, in Europe, and of Jacobi, in this country. It is not unlikely that much of the benefit which has been observed in rachitic subjects while taking phosphorus has been due in reality to the cod-liver oil, simultaneously administered, and to the improvement in the diet and general hygiene. This view receives some support from the recent investigations of Zweifel, who found that phosphorus in cod-liver oil was soon con- verted, through oxidation, into phosphoric acid, and, therefore, lost its peculiar properties. Monti contends that phosphorus alone has not staid the progress of rachitis nor has it caused the slightest improvement. Phosphorus has also been employed with asserted good results in other diseases of bones, such as osteomalacia, caries, and delayed union of fractures. Administration. — As phosphorus undergoes oxidation on C A LCI I PHOSPHAS. 3OI keeping in nearly all menstrua, only freshly made preparations should be prescribed. It may be administered conveniently in the form of an elixir. R Phosphori gr. ss (0.032 gm.) ; Alcoholis absoluti f^iij (11.0 c.c) ; Olei anisi Tttiij (0.18 c.c); Glycerini f^iss (45.0 c.c); Elixiris aromatici q. s. ad f|iij (90.0 c.c). — M. Sig. Thirty min. (1.8 c.c.) equal about j^ gr. (0.0006 gm.) of phosphorus. Persons vary considerably in their susceptibility to phos- phorus, and, therefore, the initial doses should be small, espe- cially in children. Nebelthau has cited an instance in which death occurred in a well-developed child of two years after taking less than •£§ gr. (0.003 S m -) m tne course of sixty hours. Even minute doses sometimes disturb the stomach and excite unpleasant eructations. ZiTid Phosphidum (Zinc Phosphid). — This compound appears as a dark-gray, gritty powder, or as crystalline, me- tallic fragments having a faint odor and taste of phosphorus. It is insoluble in alcohol or water. The dose is from 3 ~ i gr. (0.002-0.006 gm.), in pill. Its action closely resembles that of phosphorus, and it may be used for the same purposes as the latter. Acidum Phosphorieum, U. S. P. (Phosphoric Acid). — This is a colorless liquid, composed of 85 per cent, by weight of absolute orthophosphoric acid and 1 5 per cent, of water. It has a strongly acid taste. The dose is from 3-5 min. (0.2-0.3 c.c), well diluted. Its action is somewhat like that of the dilute mineral acids, and bears no resemblance to that of phos- phorus. It may be employed to allay thirst in diabetes and febrile diseases. It has also been used to promote gastric digestio?i, but for this purpose it is inferior to hydrochloric acid. It is usually prescribed as diluted phosphoric acid (Acidum Phosphoricum Dilutum, U. S. P.), the dose of which is from 10-60 min. (0.6-4.0 c.c), in water. CALCII PHOSPHAS. (Calcium Orthophosphate ; CagfPO^.) Calcium phosphate is official as Calcii Phosphas Prcecipitatus , a white, odorless, tasteless, amorphous powder, almost insolu- ble in water. The dose is from 5-30 gr. (0.3-2.0 gm.). Preparation. Dose. Syrupus Calcii Lactophosphatis, U. S. P. (contains about 3 per cent, of the double soluble salt) 1-4 fl. dr. (4.0-15.0 c.c). 302 TONICS. Physiologic Action and Therapeutics. — The insoluble salts of calcium, of which the phosphate may be taken as a type, have no very pronounced effects upon the system. When taken internally, the greater part resists absorption and reap- pears in the stools ; a small portion, however, enters the cir- culation, and in case of any deficiency in the lime-salts of the food is appropriated by the tissues. In the absence of a deficiency in the natural supply, any excess of lime, if it does not fail altogether of absorption, is slowly excreted by the intestinal epithelium and kidneys. As food ordinarily contains more lime than the body requires, it is difficult to understand how the phosphate or hypophosphite of calcium can be of service when administered as a remedy. The difficulty, how- ever, is no greater than that which is encountered in attempt- ing to explain the undoubted efficacy of iron in chlorosis, a disease that is certainly not dependent upon a want of iron- salts in the food. Calcium phosphate has been recommended, on theoretic grounds, in rachitis and osteomalacia, but it is of very doubt- ful value. The testimony to its favorable influence on general nutrition in such diseases as tuberculosis, tertiary syphilis, and neurasthenia is more convincing, but even here it is not unlikely that much of the good attributed to the phosphate is in reality due to the remedies usually associated with it. Administration. — Calcium phosphate may be prescribed in powders or capsules. The lactophosphate, being soluble, may be given in the form of the official syrup or in an emul- sion of cod-liver oil. Calcii Glycerophosphas. — The fact that phosphorus exists in the nervous system in the form of glycerophosphoric acid has led to the introduction of the salts of this acid as substitutes for phosphates and hypophosphites. They have been used chiefly in exhaustion from overwork, in tardy con- valescence from the specific fevers, in neurasthenia, phosphaturia, and exophthalmic goiter. The dose of calcium glycerophosphate is from 2-5 gr. (0.1-0.3 g m -)> m solution or gelatin-coated pills. Sodium glycerophosphate is employed in the same dose, and may be given by the mouth or hypodermically. CALCII HYPOPHOSPHIS, U. S. P. (Calcium Hypophosphite; Ca (PH 2 2 ) 2 .) Calcium hypophosphite occurs in colorless, transparent crystals, or small, lustrous scales, of a nauseous, bitter taste. It is soluble in about 7 parts of water. The dose is from 5-30 gr. (0.3-2.0 gm.). b OLEUM MORRHU^. 303 Preparations. Dose. Syrupus Hypophosphitum, U. S. P. (cal- cium hypophosphite, 4.5 per cent. ; sodium hypophosphite, 1.5 per cent.; potassium hypophosphite, 1. 5 per cent. ; dilute hypophosphorous acid, 0.2 per cent.; spirit of lemon, sugar, and water), 1-2 fl. dr. (4.0-8.0 c.c.). Syrupus Hypophosphitum Compositus, U. S. P. (calcium hypophosphite, 3.5 per cent.; potassium hypophosphite, 1.7 per cent. ; sodium hypophosphite, 1.7 per cent. ; ferric hypophosphite, 0.2 per cent. ; manganese hypophosphite, 0.2 per cent. ; quinin, 0.1 per cent. ; strychnin, 0.0 1 per cent. ; sodium citrate, 0.37 per cent. ; dilute hypophosphorous acid, 1.5 per cent. ; sugar and water) 1-2 fl. dr. (4.O-8.O c.c). Emulsum Olei Morrhuae cum Hypophos- phitibus, U. S. P 1-8 fl. dr. (4.0-30.0 c.c). Therapeutics. — Hypophosphites may be employed in the same class of cases as that in which calcium phosphate has been recommended. OLEUM MORRHUiE, U. S. P. (Cod-liver Oil.) Cod-liver oil is a fixed oil obtained from the livers of Gadus morrhua and other species of Gadus. The shore oil, or white oil, the only variety at present used for medicinal purposes, is extracted by disintegrating the fresh livers with superheated steam, and subsequently straining the resultant pultaceous mass. It is a pale yellow, thin liquid, having a peculiar fishy odor and taste. In addition to olein, palmitin, stearin, and other fatty principles it contains traces of iodin, bromin, phos- phorus, cholesterin, trimethylamin, and, possibly, of bile-salts. The dose is from 1-4 fl. dr. (4.0-15.0 c.c). Preparations. Dose. Emulsum Olei Morrhuge, U. S. P. (50 per cent.) 1-8 fl. dr. (4.0-30.0 c.c). Emulsum Olei Morrhua? cum Hypophos- phitibus, U. S. P. (cod-liver oil, 50 per cent. ; calcium hypophosphite, I per cent. ; potassium hypophosphite, 0.5 per cent. ; sodium hypophosphite, 0.5 per cent. ; oil of gaultheria, syrup, and water) 1-8 fl. dr. (4.0-30.0 c.c). Physiologic Action and Therapeutics. — Cod-liver oil is a food rather than a medicine. It is superior to other fats, because it is more digestible and assimilable. The amount of iodin and of phosphorus present is too small for these ingredi- ents to exert any specific action. Attempts to isolate an active 304 TONICS. principle have not been attended with success. The ready- absorption of cod-liver oil has been attributed by some authorities to the presence of biliary salts ; by others, to the presence of free fatty acids, but no explanation that has yet been offered is perfectly satisfactory. In moderate doses cod- liver oil improves the general nutrition, increases the number of red blood-cells, and favors the accumulation of fat in the body. Large doses excite nausea, eructations, vomiting, and diarrhea. Cod-liver oil, provided it is well borne by the stomach, may be employed in any disease in which malnutrition is a promi- nent feature ; thus it is often of great service in tuberculosis of the lungs, bones, or lymph-glands, in rickets, tertiary syphilis, chronic rheumatism, rheumatoid arthritis, chronic bronchitis, con- valescence from the specific fevers, and secondary anemia. In the early stage of phthisis it does more good than any other medicinal agent, but it must be given cautiously and with- drawn upon the first evidence of intolerance. When symptoms of secondary infection are prominent, such as fever, sweating, and rapid wasting, it is less likely to be well borne or to do good. In conjunction with general hygienic measures, the prolonged use of cod-liver oil is also valuable in preventing the development of tuberculosis in those who, through phy- sique and heredity, have a marked predisposition to the disease. Contraindications. — High fever and gastric or intestinal irritation are the chief contraindications to its use. Administration. — Patients who at first have difficulty in taking cod-liver oil may ultimately acquire a tolerance for it if the dose be carefully adapted to their digestive powers. It is well, therefore, to begin with very small doses, even a few minims, and to increase the amount gradually as the stomach becomes accustomed to it. A single dose at bedtime may be well borne when the stomach will not tolerate it during the day. As the oil is digested in the intestine, and not in the stomach, its stay in the latter should be reduced to a minimum, and this can be accomplished by administering it two or three hours after meals. Although it is impossible to disguise com- pletely the fishy odor and taste of cod-liver oil, there are many ways in which the unpleasantness of its administration may be lessened. It may be floated on the surface of whisky or porter, care being taken to prevent it from touching the glass, and swallowed quickly; it may be taken in ketchup or in tincture of orange peel, but perhaps the best way to prescribe it is in soft capsules holding from 10-60 min. (0.6—4.0 c.c). or in a well-made emulsion. Emulsions containing 50 per AL TERA TIVES. 305 cent, of oil may be made with yolk of egg, acacia, or malt extract, and flavored with oil of bitter almond, gaultheria, or cinnamon. R Olei morrhuae, f^iv (118.0 c.c); Olei amygdalae amarae, n\, x (0.6 c.c); Acaciae, q. s. Syrupi calcii lactophosphatis, fi§ij (60.0 c.c.) ; Aquae, q. s. ad f^viij (235.0 c.c). — M. Sig. A tablespoonful twice daily, two hours after meals. The official emulsions are made with acacia and are flavored with oil of gaultheria. As a rule, children take cod-liver oil readily, and even grow to like it; but if it cannot be taken by the mouth, owing to gastric irritability, it may be given by inunction. Just before retiring, and after a warm bath, 1 or 2 drams (4.0-8.0 c.c.) of the oil should be rubbed into the skin over the chest and abdomen, and the child put to bed in a flannel night-dress. ALTERATIVES. Alteratives are agents that favorably modify general morbid processes without exerting a demonstrable influence on any particular organ. It need scarcely be said that the manner of their action is quite unknown; if it were known, these remedies could be better apportioned among other classes. The term alterative is simply applied for convenience to a group of heterogeneous drugs that experience has shown to be more or less efficacious in certain constitutional diseases, the real nature of which is very imperfectly understood. The most important members of this group are : Arsenic. Guaiac. Iodids. Sarsaparilla. Iodin. Jambul. Iodoform. Mezereum. Mercury. Calx sulphurata. Ichthyol. Uranium nitrate. Gold and sodium Gland extracts (thyroid, thymus, chlorid. and testicular extracts). Colchicum. ARSENUM. (Arsenic ; As.) Arsenic is not employed for medicinal purposes in the metallic form, but as arsenic trioxid, as a salt of arsenous acid (an arsenite), or as a salt of arsenic acid (an arsenate). 20 306 AL TERA TIVES. Preparations. Dose. Arseni Trioxidum, U. S. P -fa-fa S r - (0.001-0.003 gm.). Liquor Acidi Arsenosi, U. S. P. (contains I per cent, of arsenic trioxid and 5 per cent, of diluted hydrochloric acid) . . . 1-5 rnin. (0.06-0.3 ex.). Liquor Potassii Arsenitis, U. S. P.( Fowler's Solution : contains the equivalent of I per cent, of arsenic trioxid and 3 per cent, of compound tincture of lavender), 1-5 min. (0.06-0.3 c.c). Sodii Arsenas, U. S. P ^-\ (0.004-0.008 gm.). Sodii Arsenas Exsiccatus, U. S. P. ... fa-fa gr. (0.002-0.005 gm.). Liquor Sodii Arsenatis, U. S. P. (Pear- son's Solution ; contains I per cent, of exsiccated sodium arsenate) 1-5 min.(o.o6-o.3 c.c). Arseni Iodidum, U. S. P fa~fa g r - (0.002-0.006 gm.). Liquor Arseni et Hydrargyri Iodidi, U. S. P. (Donovan's Solution : contains I per cent, each of arsenous iodid and mercuric iodid) 1-5 min. (0.06-0.3 c.c). ARSENI TRIOXIDUM, U. S. P. (Arsenic Trioxid ; Arsenous Acid ; White Arsenic ; As 2 3 .) Arsenic trioxid occurs either as an opaque, white, amorphous powder, or as heavy, amorphous masses of a translucent, glass-like appearance. .It has neither odor nor taste. When thrown on hot coals it volatilizes without melting, and emits a strong, garlicky odor. In the presence of water it becomes arsenous acid (H 3 As0 3 ). It is soluble in from 30-80 parts of cold water, slightly soluble in alcohol, and soluble in about 5 parts of glycerin. The dose is from qq-Jo g r - (0.001-0.003 gm.). Physiologic Action. — Local Action. — On mucous mem- branes and denuded surfaces arsenic trioxid, in concentrated form, acts as a powerful and painful caustic. If it is applied over large surfaces a sufficient quantity may be absorbed to produce systemic poisoning. Circulation. — In therapeutic doses, beyond increasing slightly the pulse-rate, arsenic exerts but little influence on the circulation. Toxic doses, however, lessen the frequency of the pulse and lower the blood-pressure. The fall of blood-pressure appears to be due to depression of the heart and of the vasomotor nerves, especially of those branches dis- tributed to the blood-vessels of the abdominal organs. Blood. — In health arsenic has little or no action on the blood, but in certain forms of anemia, especially pernicious anemia, it often increases decidedly the number of erythrocytes. The view that the blood improvement is due to stimulation of the bone-marrow receives some support from the experimental researches of Stockman and Grieg, who found that arsenic in- ARSE NUM. 307 creased the vascularity of the marrow and led to a replace- ment of fat by red corpuscles. In some cases of poisoning there is marked disintegration of the red blood-cells. Nervous System. — Clinical experience indicates that in medicinal doses arsenic exerts a stimulant influence upon the nervous system. In frogs toxic doses cause a rapid paralysis, which appears to be mainly of centric origin. In man nervous phenomena occur in both acute and chronic poisoning, but they are especially pronounced in the latter. The paralysis of chronic poisoning is, in the majority of instances, the result of a polyneuritis similar to that produced by other toxic agents ; in a few cases, however, paralysis of spinal origin has been observed. Alimentary Canal. — In minute doses arsenic stimulates the appetite and favors digestion. Large doses have an irritant effect, and excite colicky pains, vomiting, and diarrhea. Effect on Metabolism. — It is generally conceded that ar- senic in therapeutic doses favorably influences nutrition, but the manner in which this is accomplished is not understood. Toxic doses have a profound effect upon tissue-metabolism. They increase proteid disintegration, augment the nitrogenous output, lessen oxidation of the tissues, and cause fatty changes in the epithelium of the alimentary canal, and, to a less extent, in the liver, heart, and kidneys. Elimination. — Arsenic passes out of the body very slowly ; most of it escapes in the urine, but traces may be detected in the other secretions. Action on Lower Organisms. — While arsenic will readily kill insects and worms, it is not very destructive to the lowest forms of animal and plant life. Toxicology. — Acute arsenical poisoning is characterized by severe abdominal pains, vomiting and purging of " rice-water " and, perhaps, bloody material, persistent thirst, oliguria, mus- cular cramps, dyspnea, cyanosis, and collapse. Death, which usually occurs in from one to three days, is often preceded by delirium, convulsions, and coma. If recovery follow, the symp- toms of acute poisoning may be slowly replaced by those of chronic poisoning. Occasionally cases are encountered in which the symptoms depart somewhat from the usual type ; thus there may be a rapid termination in collapse or coma without any preceding abdominal symptoms ; sometimes a temporary remission in the symptoms occurs about the third day, and this is followed, as in the case of phosphorus poison- ing, by jaundice and delirium ; again, there may be, in addition to the abdominal symptoms, an extensive urticarial or vesiculo- papular rash. 308 AL TERA TIVES. It is difficult to fix upon the minimum fatal dose of arsenic trioxid, since much that is ingested often escapes absorption. According to Taylor, about 2 gr. (0.13 gm.) is the minimum fatal dose for an adult ; but cases are on record in which very- large doses, even 1-2 ounces (30.0-60.0 gm.), have been swallowed without destroying life. After death from arsenic macroscopic changes are apparent in the stomach and upper bowel. The mucous membrane is swollen, congested, and more or less eroded. Microscopic ex- amination of the organs reveals fatty degeneration in the epi- thelium of the alimentary canal, and in the liver, kidneys, and muscles. The erosion of the stomach cannot be the result of a local action, since it has occurred after the hypodermic injec- tion of the poison and after its introduction through a wound, when only minute quantities could have reached the stomach. Moreover, arsenic lacks the power possessed by corrosive poisons of uniting with proteid matter to form an albuminate. The action of the drug in inducing cellular death appears to be a specific one, and in the present state of our knowledge no satisfactory explanation of it can be given. Treatment of Acute Poisoning. — The stomach should be emptied by means of the stomach-pump or by an emetic. The best chemical antidote is the recently prepared ferric hydroxid or ferric hydroxid with magnesia (see p. 293), administered while still moist, in doses of a tablespoonful or more every ten or fifteen minutes. These compounds are in themselves harm- less and act by forming insoluble arsenites. Dialyzed iron, as it liberates a certain amount of free ferric hydroxid in the stomach, is also antidotal. As in poisoning from other irri- tants, diluents, demulcents, and opiates are usually indicated. Chronic arsenical poisoning may be a sequel of acute poison- ing, may follow the prolonged use of the drug for medicinal purposes, may result from the use of foods or liquors contam- inated with arsenic, may occur from the constant inhalation of dust arising from wall-paper or other fabrics containing arsen- ical pigments, or may be acquired by workers in arsenic mines or in factories in which fumes of the metal are formed. It may be manifested by gastro-enteritis, conjunctivitis, and catarrh of the upper air-passages, anemia, peripheral neuritis, and various cutaneous lesions. Polyneuritis from the medic- inal use of arsenic is by no means infrequent. It is most commonly observed in children, to whom the drug is being given for chorea. Railton has reported 4 cases in which the paralytic phenomena did not appear until from one to three weeks after the drug had been discontinued. The recent ARSENUM. 309 endemic of chronic arsenical poisoning occurring in Manches- ter, England, in which over 4000 beer-drinkers were affected, was traced to the presence of arsenic in the glucose used for brewing. The sulphuric acid employed in making the glucose contained from 1.4 per cent, to 2.6 per cent, of arsenic trioxid, while the beer contained from \ to 3 gr. (0.016-0.2 gm.) per gallon (4.0 L.). In this endemic gastro-intestinal symptoms were not .marked, the chief phenomena being numbness and tingling in the hands and feet ; a sense of burning in the feet, and painful flushing, resembling erythromelalgia ; and certain skin-lesions, consisting of pigmentation resembling Addison's disease', herpes zoster, hyperidrosis, hyperkeratosis of the palms and soles, and pemphigoid eruptions. Besides hyperkeratosis of the hands and feet, prolonged arsenical medication may result in other lesions of the skin indicative of increased cellular proliferation. Thus it may lead to corns, horny growths, multiple warts, and, perhaps, to epithelioma. Hartzell has collected 1 1 cases of epithelioma occurring in psoriasis, and apparently due to the prolonged use of arsenic. Tolerance. — Under certain conditions, which are not well understood, the prolonged use of arsenic, instead of causing chronic poisoning, may result in the establishment of a toler- ance for the drug. In some parts of Austria it is a custom among many of the peasants to take gradually increasing doses of arsenic, under the belief that it improves the com- plexion and increases the endurance. According to Knappe, so much as 5 or 6 grains (0.3-0.4 gm.) are sometimes taken at a single dose without harm. The practice, however, even among these peasants, is not altogether free from risk, and in other countries it is the exception, rather than the rule, for the continued administration of arsenic not to be followed by untoward effects. Therapeutics. — Locally, arsenic trioxid is used success- fully as a caustic in removing from the skin circumscribed, superficial new growths, such as lupus and epithelioma, espe- cially the latter. For this purpose a paste made by adding equal parts of the trioxid and acacia to a saturated solution of cocain hydrochlorid is used. This should be spread over the diseased surface, and allowed to remain for from twenty- four to forty-eight hours, when a poultice may be applied to remove the slough. It is generally not advisable to spread the paste over a larger area than a square inch at one time. Internally, arsenic is employed empirically in a number of quite diverse pathologic conditions. After iron, it is the most 310 AL TERA TIVES. effective drug we have in anemia. In pernicious anemia Fowler's solution, although not curative, is our best remedy. When well borne, the dose should be gradually increased, so that at the end of three or four weeks the patient is taking from 10-15 min. (0.6-1.0 c.c.) or more, three times a day. Fowler's solution is also a valuable remedy in Sydenham's chorea or St. Vitus 's dance. To be effective, however, it must be given in ascending doses until symptoms of saturation appear. Neuralgia that is dependent upon anemia is often benefited by arsenic. In pulmonary tuberculosis no general tonic, with the exception of cod-liver oil, is so serviceable. The drug has a long-standing reputation as a remedy in dia- betes mellitus. While it is not nearly so efficacious as opium, it may be tried in the mild forms of the disease. It is a good alterative in chronic rheumatism, chronic gout, and rheumatoid arthritis. In bronchial asthma it is sometimes very efficient, although it is not so reliable as potassium iodid. According to Murray, it is especially useful in the asthma of children and of old emphysematous persons. Both Bramwell and Balfour have spoken in the highest terms of the prolonged use of arsenic GoQ -gV gr. — 0.0006- O.0012 gm.) in myocardial degeneration and angina pectoris. In these cases it may be combined advantageously with strychnin, and sometimes also with digitalis. In malaria it is a useful adjuvant to quinin. It probably exerts no destructive influence upon the parasite, but when employed after the subsidence of the paroxysms, it proves a valuable blood-restorer. Arsenic has been found efficacious in certain diseases of the digestive tract. It is often very useful in that obstinate affec- tion know as " geographic tongue',' in which whitish, circinate patches appear upon the tongue and creep from one part to another. In some cases of gastralgia it acts most happily. Ringer has derived great benefit from the use of Fowler's solution — a drop shortly before meals — in the morning vomit- ing of drunkards, and in cases of so-called irritative dyspepsia, in which the tongue is furred and its papillae are red and prominent. The same treatment is also highly recommended in that form of indigestion which is characterized by an uncon- trollable desire to evacuate the bowel immediately after taking food. The administration of arsenic sometimes gives very gratify- ing results in certain chronic inflammatory skin diseases of a sluggish type. It is especially useful in psoriasis, pemphigus, and chronic erythematous, squamous, and papular eczema. The ARSENUM. 311 drug is contraindicated when the inflammatory process is of an acute or active type. It is a common practice to give Fowler's solution in combination with bromids to prevent the outbreak of acne. Ewald has confirmed the observation originally made by Mabille that arsenic obviates to a great extent the unpleasant symptoms excited by thyroid medica- tion. Administration. — As persons vary considerably in their susceptibility to the action of arsenic, it is always well to begin with small doses of the drug and to increase them gradually. Pufrmess under the eyes, especially noticeable in the morning, and looseness of the bowels, with colicky pains, are the usual indications of saturation. For pills, arsenic trioxid is generally selected, and for solutions, the solution of potassium arsenite. When a very decided impression is desired, as in chorea and pernicious anemia, the best preparation to employ is Fowler's solution, and this should be prescribed by itself, so that changes in the doses can be readily made from day to day. When arsenic is prescribed for its constitutional effect, it should be given invariably after meals. When it is not tolerated by the stomach, it may be given subcutaneously in the form of sodium arsenate. The following formulae will illustrate the manner of pre- scribing the drug in combination : R Arseni trioxidi, gr. ss (0.03 gm.) ; Quininae sulphatis, gr. 1 (3.2 gm.) ; Ferri reducti, gr. xl (2.6 gm.) ; Pulveris capsici, gr. x (0.65 gm.). — M. Fiant pilulse No. xx. Sig. One after meals. ( Malaria after the arrest of the paroxysms. ) R Liquoris potassii arsenitis, fgiss (5.5 c.c); Sodii salicylates, gv (20.0 gm.) ; Glycerini, f t ^j (30.0 c.c.) ; Aquae menthae piperitae, q. s. ad. f^iv (118.0 c.c). — M. Sig. A teaspoonful in water, gradually increased to a dessertspoon- ful, after meals. {Diabetes mellitus.) Incompatibles. — Salts of iron, silver, copper, and ammo- nium, magnesia, lime, and tannic acid. Arseni Iodidum, U. S. P. — Iodid of arsenic occurs in orange-red, glossy crystals, having the odor and taste of iodin. It is soluble in water and alcohol. The dose is from 3 1 Q - 1 1 () gr. (0.002-0.006 gm.). It has been found useful in tuberculous adenitis or scrofula. Saint-Phillippe has employed it with suc- cess in the troublesome bronchitis of strumous children. He recommends 5 min. (0.3 c.c.) of a 1 per cent, solution, gradually increased to 10-15 min. (0.6-1.0 c.c), with meals. 312 ALTERATIVES. Aqueous solutions should be freshly prepared and kept in a cool place, since they are prone to decompose into arsenous and hydriodic acids. Sodii Cacodylas. — Sodium cacodylate is an organic com- pound derived from cacodylic acid or dimethyl arsenic. It is a soluble, deliquescent, tasteless solid, containing about 50 per cent, of arsenic. Like other organic compounds of arsenic it is only feebly toxic — according to Renaut, 15 gr. (1.0 gm.) injected intravenously into a rabbit does not cause death. It has been employed medicinally in the same conditions in which the inorganic preparations of arsenic have been found useful. The dose is from J— ij gr. (0.02-0.1 gm.) hypodermi- cally two or three times a day. T. R. Fraser has shown that cacodylates are inert because no dissociating influence to which thay are subjected in the tissues is able to liberate from them the active arsenic ion. He was never able by the usual tests to detect arsenic in the urine after their administration. His experiments prove what might confi- dently have been anticipated, that if arsenic is so firmly united with other bodies as to be incapable of producing toxic action, it is not capable of producing therapeutic influence. If admin- istered by the mouth, however, cacodylates may become poi- sonous by meeting with reducing agents in the alimentary canal. Murrell has reported a case of poisoning in a tuberculous patient from the administration of sodium cacodylate by the mouth in doses of 1 gr. (0.065 gm.) twice daily. The toxic symptoms appeared after the eleventh dose. Atoxyl. — This is an organic compound of arsenic acid (sodium aminophenyl arsenate) with one hydroxyl radical of the acid replaced by a molecule of anilin. It contains about 26 per cent, of arsenic. It appears as a white powder having a slightly saline taste, soluble in 6 parts of water. The dose is from \ to I gr. (0.02-0.065 gm.), hypodermically, every other day. Atoxyl acts like other arsenical compounds, but it is less irritant, and, owing to its slow decomposition, less toxic. It is capable, however, of producing poisonous effects, and Koch, Marie, Bardet, and others have reported a number of cases in which more or less serious visual disturbances occurred under its administration. It is said to have given good results in the various conditions in which arsenic generally has been found beneficial, and has been especially recommended in syphilis with marked cachexia and sleeping sickness. I4quor Arseni Brotnidi. — This preparation, which is also known as Clemens' solution, is not, as its name implies, a solu- tion of the bromid of arsenic, since the latter is decomposed in POTASS// /OD/JDUM. 313 the presence of water, but rather a solution of arsenate and bromid of potassium. It is made by boiling 73 gr. (47.3 gm.) each of arsenic trioxid and of potassium bicarbonate in 2 fl. oz. (59.14 c.c.) of water until solution is effected ; allowing to cool, adding 10 fl. oz. (295.73 c.c.) of water, then H7gr. (7.581 gm). of bromin, and finally enough water to make 16 fl. oz. (473.17 c.c). The solution represents about 1 per cent, of arsenic tri- oxid. The dose is from 1-5 min. (0.06-0.3 c.c), well diluted, after meals. It has been largely used in the treatment of diabetes mellitus, but with less success than opium, salicylic compounds, or antipyrin. Cupli Arsenis. — Arsenite of copper is a yellowish-green crystalline powder, slowly soluble in water. Under the name of Paris green or Scheele's green it is much used as an insect poison and as a pigment for paper, cotton fabrics, artificial flowers, etc. Cases of poisoning from this salt of copper have been of frequent occurrence. The antidotes are the same as those to arsenic trioxid. The therapeutic dose is from -3-g-g— yj-g- gr. (0.0002-0.00064 gm.), well diluted. It has been very highly recommended as an intestinal antiseptic in the diarrhea of childhood, when the stools are copious, green, and offensive. POTASSII IODIDUM, U. S. P. (Potassium Iodide, KI.) Potassium iodid occurs as colorless, transparent or translu- cent crystals, or as a white granular powder, having a pun- gent, saline taste. It is soluble in 0.7 part of water, 2.5 parts of glycerin, and 12 parts of alcohol. The usual dose is from 5-10 gr. (0.3-0.65 gm.), well diluted, thrice daily; but in syphilis often three or four times this amount may be given with advantage. Preparation. Unguentum Potassii Iodidi, U. S. P. (contains 10 per cent, of potassium iodid and 0.6 per cent, of potassium carbonate). Physiologic Action. — In health a single, moderate dose of potassium iodid produces no demonstrable effects beyond a slight increase in the secretion of urine and, perhaps, some disturbance of the stomach. The drug is rapidly absorbed from all parts of the digestive tract, and reappears in the secre- tions in less than fifteen minutes after its ingestion. The larger portion is eliminated through the kidneys, but small quantities escape in the saliva, tears, milk, and perspiration. It is likely that a small portion is retained for a time in the body, and that its continuous administration may result in accumulation. 314 AL TERA TIVES. Large doses of potassium iodid cause burning in the stomach, nausea, vomiting, and diarrhea. The continuous use of the drug is usually followed, sooner or later, by a group of symp- toms known as iodism. This condition has been attributed to the irritant effects of free iodin, into which a portion of the iodid appears to be converted. Its manifestations are most commonly associated with the mucous membrane of the res- piratory tract and with the skin, and consist of frontal head- ache, lacrimation, running at the nose, sneezing, soreness of the throat, an increased flow of saliva, and, later, of a generalized acneiform eruption on the skin. More rarely the eruption is of an erythematous, purpuric, or bullous character. Parotitis and intense dyspnea from inflammatory edema of the larynx have occasionally been observed. In some instances symptoms suggesting Graves' disease have developed, such as tremors, car- diac palpitation, sweating, and loss of weight. It is not improb- able that the last-named symptoms owe their origin to an in- fluence exerted by the iodid on the thyroid gland. Profound cachexia, atrophy of the mammae or testicles, paralysis, and blind- ness have also been reported as occurring from the prolonged use of iodids. The amount of the drug required to induce iodism varies considerably in different subjects. Daily doses of from 200-300 gr. (13.0-20.0 gm.) are sometimes well borne, and, on the other hand, doses of from 2-3 gr. (o. 1 3-0.2 gm.) a day may soon excite intense discomfort. Russell has reported a case in which 5 doses of 4 min. (0.25 c.c.) of the syrup of ferrous iodid with 2 gr. (0.13 gm.) of potassium iodid, over a period of three days, caused acute iodism with fatal termination, in a man of sixty-eight years, suffering from rheumatoid arthritis. Patients with chronic Bright's disease are often extremely intolerant. Syphilis does not always confer immunity. Therapeutics. — Potassium iodid is of value in a variety of morbid conditions, but the study of its action on healthy subjects has thus far failed to throw much light upon the manner in which its good effects are accomplished. Its best effects are observed in syphilis, in which disease its efficacy is equal to that of mercury. In the tertiary period it is more valuable than mercury, and in the late secondary period it is an excellent adjuvant. It should be given in ascending doses until improvement follows or symptoms of iodism appear. To secure permanent results, the treatment must be continued for six months or a year. In parasyphilitic affections — loco- motor ataxia, paretic dementia, and arteriosclerosis — the iodid should always be tried, though, of course, no good can accrue from its use if there has been much destruction of tissue. POTASSII IODIDUM. 315 Various opinions are held as to the value of potassium iodid in chronic interstitial inflammations, like cirrhosis of the liver, chronic interstitial ?iephritis } and sclerosis of the spinal cord, when a syphilitic origin can be excluded. The author is of the opinion that though the drug is of doubtful service, it ought to be tried. Only small doses, however, should be given, and these should be withdrawn on the slightest evidence of in- tolerance. In subacute and chronic rheumatism and in chronic gout it sometimes proves beneficial. It is generally believed that it aids in the absorption of the effusion in serous pericar- ditis and pleurisy. It is the most reliable remedy that we pos- sess in bronchial asthma to prevent the return of the parox- ysms. In chronic bronchitis, when the sputum is composed of thick, viscid mucus, it may be combined advantageously with expectorants. In doses of from 10-20 gr. (0.65-1.3 gm.) thrice daily it is very beneficial in aortic aneurysm, ; even if it does not retard the progress of the disease, it nearly always lessens the pain. It is said to act by lessening the viscosity of the blood, but this is doubtful. It certainly does not lower the blood-pressure. In angina pectoris no remedy with the exception of the nitrites is so useful in preventing recurrence of the attacks. To be effectual it should be given in daily doses of from 30-45 gr. (2.0-3.0 gm.) for several months. According to Osier, the patients who stand the treatment well are the robust, middle- aged men, in whom the angina is the sole symptom. In chronic metallic poisoning, especially from lead and mer- cury, potassium iodid is apparently efficacious. In large doses continued over long periods of time it has given very good results in many cases of actinomycosis in man. Administration. — Individual susceptibility to the iodids varies remarkably and idiosyncrasies are frequently encoun- tered. Children generally bear the drug much better than adults. The initial dose should always be small, and the amount gradually increased as the tolerance of the patient permits. No drug is of much value in preventing iodism when the tendency to it is pronounced, but the tincture of bella- donna (3-5 min. — 0.2-0.3 c.c.) will sometimes relieve the coryza, and Fowler's solution (1-2 min. — 0.06-0.12 c.c), the acne and indigestion. Iodids should always be given after meals and well diluted. The unpleasant taste can be disguised with compound syrup of sarsaparilla. A convenient method of prescribing potassium iodid is in the form of a saturated aque- ous solution, so prepared that 1 min. (0.06 c.c.) will contain 1 gr. (0.065 gm.) of the salt. As prescribing the iodid and 316 ALTERATIVES. water, ounce for ounce, results in a solution much weaker than the one indicated, Hynson suggests the following plan : Dissolve 480 gr. (31.1 gm.) of the salt in 5 J dr. (20.34 c.c.) of hot water, and then make up the solution to 8 dr. (29.57 c.c.) with water. This results in a solution containing 1 gr. (0.065 gm.) to a minim (0.06 c.c). A drop from a medicine dropper will contain a little less than 1 gr. (0.065 gm.). If taken in milk, most patients do not find the solution disagreeable. When not tolerated by the stomach, potassium iodid may be given as an enema in milk. Incompatibles. — Mineral acids and salts, alkaloids, and spirit of nitrous ether. Potassium iodid is often added in excess to solutions of corrosive sublimate to form the soluble double iodid of mercury and potassium. SODII IODIDUM, U. S. P. (Sodium Iodid; Nal.) Sodium iodid occurs in colorless, cubical crystals or white crystalline powder, of a bitter, saline taste. On exposure to moist air it deliquesces and becomes sodium carbonate and free iodin. It is soluble in 0.5 part of water and in 3 parts of alcohol. The dose is from 5-20 gr. (0.3-1.3 gm.) or more, well diluted. It has the same therapeutic value as the potas- sium salt, but it is sometimes better borne by the stomach. AMMONII IODIDUM, U. S. P. (Ammonium Iodid ; NHJ.) Ammonium iodid occurs in minute colorless, cubical crystals or white granular powder, of sharp, saline taste. On exposure it attracts moisture from the air, and becomes yellowish-brown from the loss of ammonia and the liberation of iodin. It is soluble in 0.6 part of water and in 9 parts of alcohol. The dose is from 3-15 gr. (0.2-1.0 gm.) or more, well diluted. Excepting that it is somewhat more irritating to the stomach it has the same properties as potassium iodid. STRONTII IODIDUM, U. S. P. (Strontium Iodid ; Srl 2 -f 6H 2 0.) Strontium iodid occurs in colorless or faintly yellow, hex- agonal plates, deliquescent, and of bitterish, saline taste. It is soluble in 0.5 part of water. The dose is from 5-20 gr. (. ^ 1.3 gm.) or more, well diluted. While less irritating and less prone to induce iodism than potassium iodid, it does not seem to be so powerful as the latter salt. IODUM. 317 PLUMBI IODIDUM, U. S. P. (Leadlodid; Pbl 2 .) Lead iodid is a heavy, bright yellow powder, odorless and tasteless, and permanent in the air. It is almost insoluble in water. The dose is from J— 3 gr. (0.03-0.2 gm.). Preparation. Unguentum Plumbi Iodidi (10 per cent.). Iodid of lead is rarely used internally. Externally the oint- ment makes an excellent resolvent application for tuberculous lymphatic glands and other forms of nonsuppurative adenitis. It should be applied very thoroughly and with gentle friction. ACIDUM HYDRIODICUM. (Hydriodic Acid; HI.) Hydriodic acid is official as diluted hydriodic acid {Acidum Hydriodicum Dilutum, U. S. P.), which contains 10 per cent, by weight of the absolute acid, and as the syrup of hydriodic acid (Syrupus Acidi Hydriodici, U. S. P.), which contains 1 per cent, by weight of the absolute acid. The action of these prep- arations is feeble, but resembles that of the iodids. The dose of the diluted acid is from 5-10 min. (0.3-O.6 c.c.), and of the syrup \-2 fl. dr. (2.0-8.0 c.c). IODUM, U. S. P. (Iodine ; I.) Iodin is a non-metallic element obtained chiefly from the ashes of seaweed. It occurs in heavy, bluish-black, friable crystals, having a metallic luster, a peculiar odor, and a sharp, acrid taste. On heating it emits a violet-colored vapor. It is soluble in 5000 parts of water, in 10 parts of alcohol, and freely soluble in ether, chloroform, and solutions of potassium iodid. Preparations. Dose. Tinctura Iodi, U. S. P. (7 per cent.) 1-5 min. (0.06-0.3 c - c -)- Liquor Iodi Compositus, U. S. P. (Lugol's solu- tion : 5 per cent, of iodin in a 10 per cent, solution of potassium iodid) I-IO min. (0.06— 0.6 c.c. ). Unguentum Iodi, U. S. P. (4 per cent, of iodin and 4 per cent, of potassium iodid). Physiologic Action. — When applied to the skin, iodin stains it a yellowish-brown color and causes burning and itch- ing. Strong solutions produce vesication. Mucous mem- branes are especially sensitive to its irritant action. Injections beneath the skin or into serous .sacs excite intense pain and 3 1 8 AL TERA TIVES. severe inflammatory reaction. When taken internally, it is rapidly absorbed in the form of iodids and soon reappears in all the secretions of the body. The bulk of it is eliminated in the urine, also in the form of iodids. In medicinal doses iodin exerts the same influence as potassium iodid, and if given con- tinuously, induces all the phenomena of iodism (p. 314). Single large doses produce gastro-enteritis, respiratory failure, and collapse. Anuria and albuminuria have also been observed. Cases of fatal poisoning have been reported from its injection into large cysts and also from its too free use externally. The treatment of acute iodin-poisoning consists in evacuating the stomach, administering starch or starchy foods (flour, arrow- root) as antidotes, and maintaining the respiration and circula- tion by hypodermic injections of alcohol, strychnin, digitalis, and ammonia. Therapeutics. — Iodin is a useful counterirritant in con- ditions requiring a mild but persistent effect. The tincture may be applied externally in pleurisy, bronchitis, laryngitis, synovitis, arthritis, neuritis, muscular rheumatism, and similar inflammatory affections. It is best applied by means of a camel's-hair brush, one or two coats being painted over the part at intervals of a day or two. For children it should be diluted with 2 or 3 parts of alcohol. If the application proves too painful, the iodin should be removed with dilute alcohol, or, better, with a solution of potassium iodid, and the part dressed with starch jelly. Preparations of iodin are very efficacious in bringing about resolution in various forms of adenitis provided they are applied early and before suppuration has commenced. A broad ring may be painted with the tincture around the swelling, or the ointment may be thoroughly rubbed into it. A better plan, however, and one less likely to produce painful dermatitis, is to rub in a mixture of equal parts of the ointments of bella- donna and of lead iodid, and then to apply firm continuous pressure by means of a pad and a bandage. Ganglion, hydrocele, housemaid's knee, and spinal meningo- cele are often successfully treated by evacuating the fluid and then injecting tincture of iodin into the sac. Iodin was formerly much used, both internally and externally, in the treatment of simple goiter , hut thyroid extract has been found more efficacious. Injections of tincture of iodin are sometimes of value in reduc- ing cystic goiter. From 3-5 min. (0.2-0.3 c.c.) should be in- jected into different parts of the tumor at intervals of three or four days. Local applications of iodin have long been held in high repute in certain chronic catarrhal processes attended by IODOFORMUM. 319 glandular hypertrophy, such as rhinitis, pharyngitis, and endo- metritis. In chilblain an application of tincture of iodin and glycerin, equal parts, acts very favorably. Iodin has been used inter- nally in the form of Lugol's solution in syphilis, tuberculous adenitis, and goiter, but on account of its irritant properties it is far less serviceable than the iodids. Various attempts have been made to lessen the irritant effects of iodin by combining it with albumin or fat. The preparation known as iodipin represents, perhaps, the most successful of these attempts. It is an addition-product of iodin (10 per cent. or 25 per cent.) and oil of sesame, which, according to Win- ternitz, is not decomposed in the stomach, but in the intestine. The 10 per cent, preparation is administered by the mouth in doses of J— 2 fl. dr. (2.0-8.0 c.c). It is generally well borne, but its oily taste frequently proves objectionable. The 25 per cent, iodipin is used for subcutaneous injection, about J-i fl. dr. (2.0-4.O c.c), slightly warmed, being injected daily between the skin and muscle of the gluteal region. Incompatibles. — Alkaloids, mineral salts, ammonia, car- bonates, starch, and mucilage of acacia. It acts violently upon turpentine and many other volatile oils. Tincture of iodin is also incompatible with aqueous preparations. In the so-called " colorless solutions of iodin " the iodin is replaced by iodids. IODOFORMUM, U. S. P. (Iodoform; CHI,.) Iodoform, or tri-iodid of methane, is methyl with 3 atoms of hydrogen displaced by 3 of iodin. It is made by heating in a closed vessel iodin, alcohol, sodium hydrate, and water. It occurs in small, yellow, hexagonal crystals, having a peculiar penetrating odor, and a sweetish, iodin-like taste. It is freely soluble in ether, chloroform, and oils, soluble in about 47 parts of alcohol, and very feebly soluble in water. It contains more than 95 per cent, of iodin. The dose is from 1-3 gr. (0.06- 0.2 gm.) in pill. Preparation. Unguentum Iodoformi, U. S. P. (10 per cent.). Physiologic Action. — Upon mucous membrane and raw surfaces, especially the latter, iodoform acts as a mild anes- thetic. It is readily absorbed from wounded surfaces, partly as iodin, which it liberates in the presence of moist organic matter, partly as albuminous compounds of iodin, and partly, probably, as iodoform. Shortly after absorption iodin appears 320 ALTERATIVES. in all the secretions ; elimination, however, is mainly effected through the kidneys, which slowly excrete the drug in the form of iodids. When absorbed too freely it induces an intoxication, which not infrequently proves fatal. The symptoms of poison- ing somewhat resemble those of cerebral meningitis, and include malaise, headache, mental depression, contraction of the pupils, the taste of iodoform in the mouth, nausea and vomiting, a very rapid pulse, delirium with hallucinations, stupor, and coma. In some cases there has been, in addition, high fever, and in others, a diffuse erythematous rash. Postmortem examination shows fatty degeneration of the organs and sometimes conges- tion of the cerebral meninges. As neither iodin nor iodids in overdoses cause cerebral symptoms, it is probable that the latter result from the action of iodoform itself. Old, anemic patients, especially sufferers from Bright's disease, are more readily poisoned than the young and robust. Although the favorable action of iodoform on infected wounds can no longer be disputed, the manner of its operation is still obscure. It has little or no germicidal power, but it may act by retarding germ-growth through the iodin which it liberates, by inhibiting serous exudation and thus depriving the organisms of nourishment, or by neutralizing the toxins formed by bacteria. In some persons the local application of iodoform proves irritating, and gives rise to a severe pustular or erythematous eruption. Treatment of Poisoning. — The indications are to suspend the applications, to sustain the strength of the patient, and to favor elimination of the drug by means of subcutaneous injections of normal salt solution and the administration of alkaline diuretics. Therapeutics. — Iodoform is extensively employed as a local application in infected wounds. In various ulcers — syphil- itic, chancroidal, and tuberculous — it is very efficient. In the form of iodoform gauze it makes an excellent packing for deep wounds, sinuses, ftstidce, and the rectal, vaginal, and nasal cav- ities. Cold abscesses and tuberculous joints are often successfully treated by injecting into them, once a week, iodoform (10 per cent.) in sterile olive oil or glycerin or iodoform (5 per cent.) in ether, to the amount of \- 3 fl. oz. (15.0-90.0 c.c). The iodoform should always be sterilized by soaking it for several days in a solution of 1 : 1000 of corrosive sublimate and then thoroughly washing in sterilized water. As a local analgesic it is particularly useful in relieving the pain and dysphagia of tuberculous laryngitis, in which affection IOD O FOR MUM. 3 2 1 it may be employed by insufflation, either in pure form (2-3 gr. — O.13-O.2 gm.) or mixed with morphin (yV~rV S r - — 0.004- 0.005 g m 0- Suppositories of iodoform (3 gr. — 0.2 gm.) are of service in pai?iful hemorrhoids and in fissure of the anus. Semmola, Dreschfeld, Foxwell, and others have spoken very highly of the internal use of iodoform (6-12 gr. — 0.4-0.8 gm. daily) in pulmonary tuberculosis, but the treatment has gone out of vogue. While many agents have been recom* mended for disguising the disagreeable odor of iodoform, none has proved very successful ; the best, however, are the volatile oils, such as bergamot, fennel, anise, and cumarin, the odorous principle of Tonka bean. IODOLUM, U. S. P. (Iodol; Tetra-iodo-pyrrol ; C 4 I 4 NH.) Iodol is prepared by acting upon pyrrol, a principle obtained from bone oil with iodin. It contains a little less than 90 per cent, of iodin, and appears as a yellowish, crystalline powder, free from odor and taste. It is almost insoluble in water, but it is freely soluble in alcohol, ether, and oils. It is used as a substitute for iodoform. Though much more costly than the latter, it has a decided advantage in being odorless. THYMOLIS IODIDUM, U. S. P. (Thymol Iodid ; Di-thymol-di-iodid ; Aristol; C 20 H 24 O 2 I 2 .) Thymol iodid, or aristol, is obtained by acting upon thymol in alkaline solution with iodin dissolved in potassium iodid. It contains about 45 per cent, of iodin, and appears as a brown- ish-red powder, tasteless and almost odorless. It is readily soluble in ether and oils, but it is insoluble in water. It is decomposed by heat, light, acids, alkalis, alcohol, and corro- sive sublimate. It is employed as a substitute for iodoform. While it has advantages in being odorless and less toxic than iodoform, it is more unstable, more costly, and less effective. It may be applied pure or dissolved in ether or oil. EUROPHEN. (Di-isobutyl-ortho-cresol-iodid ; C^H^CXJ. ) Europhen is obtained by precipitating an alkaline solution of isobutyl-ortho-cresol with a solution of iodin in potassium iodid. It contains 28 per cent, of iodin, and appears as a very bulky, yellow, amorphous powder, of an aromatic odor. It is insoluble in water and glycerin, but freely soluble in alcohol, ether, and oils. It is a good substitute for iodoform. 21 322 AL TERA TIVES. NOSOPHEN. ( Tetra-iodo-phenol-phthalein ; ( C 6 H 2 I 2 OH ) 2 C 8 H 4 2 . ) Nosophen is obtained by the action of iodin on a solution of phenol-phthalein. It is a pale yellow, inodorous, and taste- less powder. It contains 60 per cent, of iodin. With bases it forms salts, the most important of which is the sodium salt (antinosiri). It differs from iodoform in being an active anti- septic and in not yielding its iodin to the tissues. HYDRARGYRUM, U. S. P. ( Mercury ; Quicksilver ; Hg.) Mercury is a heavy, liquid metal, of a silvery luster, and without odor or taste. Physiologic Action. — When small doses of an unirritating preparation of mercury are given continuously for a certain length of time, the first effects are observed in the mouth. There are increased flow of saliva, fetor of the breath, soreness of the teeth when the jaws are brought forcibly together, and redness of the gums near the insertion of the teeth. If the drug is not withdrawn, salivation becomes excessive, the gums become swollen and spongy, the teeth loosen and fall out, the tongue and parotid glands enlarge, — the former sometimes to such an extent that it protrudes from the mouth, — and finally the soft tissues become ulcerated and the bones necrosed. The term ptyalism is applied to this group of symptoms. At the same time the general health is more or less affected. The patient becomes pale and loses flesh. Fever, chilliness, thirst, anorexia, nausea, vomiting, and purging may appear. The mercuric salts are more irritant and poisonous than the mercurous salts. The ingestion of a large dose of one of the former (corrosive sublimate) is speedily followed by intense burning in the esophagus, stomach, and abdomen, vomiting and purging of mucous and bloody material, anuria, or ischuria with albuminous urine, and profound collapse. Subsequently, if the patient survive the corrosive effects of the drug, ptyalism may develop from the absorption of the metal into the circula- tion. After death from acute mercury poisoning the mucous membrane of the alimentary canal is intensely inflamed and often deeply eroded. A diphtheric condition is sometimes observed. The kidneys are peculiarly affected. In addition to the evidences of acute parenchymatous degeneration, deposits of lime are found in the uriniferous tubules, especially the con- voluted ones. These chalky deposits, while not pathog- nomonic of mercurial poisoning, are very suggestive of it. Chronic mercurial poisoning is most frequently met with in HYDRARG YR UM. 323 workmen who handle the metal or who are exposed to its fumes. Thus it occurs in makers of thermometers, mirrors, and scientific instruments. Occasionally it is induced by the prolonged use of mercury as a medicine. Its chief manifesta- tions are anemia, loss of flesh and strength, mental impair- ment, tremors similar to those of multiple sclerosis, motor palsies without atrophy of the muscles, gastro-intestinal dis- turbances, stomatitis, and salivation. The form in which mercury is absorbed has not been defi- nitely determined, but it is probable that the soluble prep- arations, at least, enter the circulation in the form of an albuminate. The metal is slowly eliminated through all the emunctories, but especially through the kidneys and bowel. In medicinal doses the insoluble preparations of mercury act as cathartics (see p. 209), producing copious, loose stools without much griping. They also increase the flow of urine (see p. 233), probably by directly stimulating the renal epi- thelium. It is generally assumed that they stimulate also the hepatic cells, and thus increase the flow of bile, but recent investigations have shown that they have no such action. Mercurials, especially when locally applied, have a decided influence upon inflammatory exudations of a serous or fibrinous character, often aiding materially in their solution and reab- sorption. That they have power to prevent or to lessen the out- pouring of inflammatory material is very doubtful. There is reason for believing that the bichlorid in minute doses { ^q $ gr. — 0.0006-0.001 gm.) causes an increase in the number of red blood-corpuscles, when the latter have been reduced from overwork, acute disease, or hemorrhage. Soluble forms of mercury, owing to the avidity with which they unite with pro- teids, are very destructive to bacteria and other low forms of life. Finally, the drug exerts a specific influence in syphilis, but the manner of its action is unknown. Untoward Effects. — Certain persons are exceedingly sus- ceptible to the influence of mercury. A dose of less than a grain (0.065 gm.) of calomel has been known to excite severe stomatitis, persisting for several weeks. An erythematous or eczematous rash occasionally follows its administration by the mouth or its application to the skin. Calomel should not be applied to mucous membranes or be taken internally while the patient is under the influence of potassium iodid, since the latter is eliminated in all secretions and readily forms with mercurous compounds the irritant mercuric iodid. Treatment of Poisoning. — Ptyalisin. — The administra- tion of mercury should be suspended as soon as the slightest tenderness of the gums manifests itself. The mouth should be 3 H AL TERA TIVES. frequently rinsed with a saturated solution of potassium chlo- rate. In severe cases the affected parts may be painted with slightly diluted sulphurous acid or with a saturated solution of iodoform in ether. To check the excessive flow of saliva, atropin (yj-g- gr. — 0.0005 gm.) may be given once or twice a day. Morphin may be required at night to relieve pain and to secure sleep. Potassium iodid is recommended to aid in the elimination of the mercury. Tonics may be needed to combat the anemia and exhaustion. Acute Poisoning. — After evacuating the stomach, egg- albumen should be administered freely as an antidote. Opium is often required to allay the pain. Chronic Poisoning 1 . — The patient should be removed from the influence of the metal. Potassium iodid should be given to aid the elimination of the poison, and tonics to overcome the cachexia. Baths, massage, and electricity are useful adjuvants. Therapeutics. — Mercury is used as an antisyphilitic, a germicide, a cathartic, a diuretic, and an absorbent. Antisyphilitic. — Mercurials and iodids are the remedies relied upon to combat syphilis. Mercury should be given as soon as the diagnosis can be made with certainty, and con- tinued throughout the secondary stage. In the tertiary stage iodids are generally more serviceable, but mercury is not with- out effect, and a combination of the two drugs is often em- ployed with advantage. When very prompt effects are neces- sary, mercury should be given the preference. No matter which preparation of the metal is selected it should be given in ascending doses until the limit of tolerance is reached, when the dose should be cut down one-third or one-half, and this amount continued for a year or a year and a half. At the end of this time an iodid should be added, and the combination continued for about another year. The preparations of mer- cury most frequently prescribed in syphilis are the protiodid, biniodid, bichlorid, and mercury with chalk. Germicide. — The soluble preparations of mercury, although among the most powerful germicides known, have certain drawbacks. Thus they are highly toxic, they are irritating to the tissues, they are destructive to metal instruments, and in the presence of albuminous matters they are readily converted into insoluble and inert albuminates. Notwithstanding these drawbacks they are the most popular germicides for general surgical work. Of the soluble salts, the bichlorid is usually chosen. Cathartic. — Certain insoluble preparations of mercury — calomel, blue mass, mercury with chalk — have just enough irritant action on the bowel to induce catharsis. They are not HYDRARG YR UM. 325 suitable remedies for habitual constipation, but on account of their thorough and agreeable action they are well adapted for unloading the bowel in dyspeptic diarrhea and in the begin- ning of acute infectious diseases. Diuretic. — Mercury in the form of calomel or blue mass is an active diuretic, and one that is well suited for carrying off dropsical effusions resulting from cardiac or hepatic disease. Absorbent. — Ointments of mercury are very efficacious in promoting the absorption of the exudation thrown out in cer- tain subacute and chronic inflammations. They are exten- sively employed for this purpose in synovitis, thecitis, arthritis, adenitis, and orchitis. It need scarcely be said that they are of no value in purulent inflammation. Administration. — Mercurial preparations may be given by the mouth, by inunction, by subcutaneous injection, or by fumigation. By the Mouth. — This is usually the best method of admin- istration when mercury is employed for its constitutional effects. Blue mass, mercury with chalk, mercurous chlorid (calomel), mercuric chlorid (corrosive sublimate), mercurous iodid, and mercuric iodid, are the compounds most frequently chosen for exhibition by the mouth. The insoluble prepara- tions are generally prescribed in pills or tablets. Corrosive sublimate may be given in solution or in pills or tablets. The biniodid is soluble in a solution of potassium iodid. By Inunction. — This method of administering mercury is useful when the stomach is irritable or when it is deemed desirable to hasten mercurialization. The method has disad- vantages in being uncleanly, troublesome, and uncertain as to dosage. About 1 dr. (4.0 gm.) of blue ointment may be rubbed into the groins, axillae, or inner surface of the thighs and arms once a day. In order to avoid local irritation a different region should be selected each day. For infants an ointment may be used consisting of I part of mercurial oint- ment and from 6 to 8 parts of lard. A piece of this the size of a hickory-nut may be spread every day upon a flannel binder which is worn around the abdomen. By Subcutaneous Injection. — Mercury may be given hypo- dermically in syphilis when a very rapid impression is neces- sary, or when other modes of administration have proved un- successful. This method is not suitable for ordinary cases. The injections are painful and are not unattended with danger. Local complications — induration, abscess, sloughing — are lia- ble to occur, and grave ptyalism may develop, especially in patients with chronic nephritis. Soluble preparations only should be employed. Insoluble preparations may accumu- 326 ALTERA TIVES. late in the tissues for a time, and later give rise to severe constitutional symptoms. The best salts for hypodermic use are the bichlorid and succinimid. From 20 to 30 daily injections should be made deep into the back or buttock. The initial dose of the bichlorid should not exceed \ gr. (0.008 gm.), and this amount should be gradually increased to a maximum of \ gr. (0.016 gm.). The injections should be given through a platino-iridium needle which has been pre- viously sterilized. By Fumigation. — This method is sometimes employed in syphilis instead of inunction, when the stomach is intolerant. It is especially useful when the cutaneous lesions prove obsti- nate. The mercurial salt, preferably calomel, of which about 20 gr. (1.3 gm.) are used, may be volatilized from a tin plate suspended over a spirit-lamp. The latter is placed under a stool or cane-seated chair, upon which is seated the patient, disrobed and surrounded by a blanket fastened to the neck. In about fifteen or twenty minutes the calomel is volatilized and deposited on the skin as a fine dust. The baths should be given just before retiring, and the sublimated mercury should be allowed to remain on the skin until the next morning. The treatment may be continued until slight tenderness of the gums develops. Blue Mass (Massa Hydrargyri, U. S. P.). — This is a tritu- rate of metallic mercury with honey of rose, glycerin, licorice, and althaea, containing 33 per cent, of the metal. The dose is from \-\o gr. (0.03-0.6 gm.). It is employed as a cathartic and diuretic. In the condition known as "biliousness" no treatment is so successful as the administration of a blue pill (5 g r - — °-3 g m -)> followed in the morning by Epsom salts or a Seidlitz powder. In the beginning of acute febrile diseases and dyspeptic diarrhea blue mass is an excellent cathartic for un- loading the bowel without inducing irritation. In combina- tion with powdered digitalis and squill it is an efficient diu- retic in the dropsy of chronic heart and liver disease. Mercury with Chalk (Hydrargyrum cum Creta, U. S. P.). — This is a light-gray, damp powder, without odor, and of a sweetish taste. It contains 38 per cent, of mercury intimately mixed with chalk, honey, and water. The dose is from ^-10 gr. (0.03-0.6 gm.). It is used in the same class of cases as blue mass. It is particularly serviceable in the diarrhea of childre7i when the tongue is heavily coated, the breath fetid, and the stools are greenish or clay-colored. Hutchinson highly recommends mercury with chalk, in doses of from 1-4 gr. (0.065-0.26 gm.), thrice daily, as a convenient and efficient form in which to administer mercury in syphilis. In HYDRARGYRUM. $2? congenital syphilis from J-to I gr. (0.016-0.065 gm.) may be given three times a day. Ointments of Mercury. — The U. S. Pharmacopoeia of 1900 recognizes two ointments : Mercurial ointment (Unguen- tum Hydrargyri) and blue ointment {Unguentum Hydrargyri Dilutum). Mercurial ointment contains 50 per cent, of metallic mercury and 2 per cent, of oleate of mercury, 25 per cent, of lard, and 23 per cent, of suet. Blue ointment contains 6j per cent, of mercurial ointment (33 per cent, of metallic mercury) and 33 per cent, of petrolatum. These preparations are em^ ployed as antisyphilitics, absorbents, and parasiticides. In syphilis they are administered by inunction. In synovitis, bur- sitis, rheumatic arthritis, glandular enlargements, and syphilitic nodes they are valuable as absorbents. When the swelling is painful, an equal amount of belladonna ointment may be added for its sedative effect. In subacute rheumatism the local appli- cation to the affected joints of an ointment containing mercury and salicylic acid is often efficacious. U Acidi salicylici, gr. xxx (2.0 gm.) ; Olei terebinthinse, f^iiss (10.0 c.c.) ; Adipis lanae hydrosi, Sss (15.0 gm.) ; Unguenti hydrargyri, gj (30.0 gm.). M. Sig. Apply with gentle friction night and morning. In pediculosis pubis the parasites are quickly destroyed by rubbing into the affected parts a small amount of blue oint- ment. Mercurial Plaster (Emplastrum Hydrargyri, U. S. P.). — This is a plaster containing 30 per cent, of metallic mercury, 1 per cent, of oleate of mercury, 10 per cent, of hydrous wool-fat, and 59 per cent, of lead-plaster. It is employed as an absorb- ent in chronic inflammatory swellings, glandular enlargements, syphilitic nodes, etc., but is far less efficient than the ointment. HYDRARGYRI CHLORIDUM CORROSIVUM, U. S. P. (Mercuric Chlorid; Corrosive Sublimate ; Bichlorid of Mercury ; HgCl 2 .) Mercuric chlorid appears in the form of colorless, odorless crystals, having an acrid, metallic taste. It is soluble in 13 parts of water and in 3 parts of alcohol. The dose is from rk-TJ g r - (0.0006-0.005 gm.). Therapeutics. — Corrosive sublimate is employed chiefly as a germicide, an antisyphilitic, and a tonic. Germicide. — It is an energetic germicide, capable of destroy- ing most bacteria even in solutions of 1 : 20,000, and their spores in solutions of 1 : 10,000. Some micro-organisms, how- ever, like the bacillus of anthrax, are much less susceptible to 328 ALTERATIVES. its action. In the presence of hydrogen sulphid it is con- verted into an insoluble and inert sulphid of mercury ; with albuminous matter it forms an impermeable albuminate, which prevents its further penetration ; it has a corroding action on metal; it is irritating to the tissues, and when applied too freely to wounds or mucous membranes, it may be absorbed in sufficient quantity to induce poisoning. Notwithstanding these drawbacks, most surgeons accord corrosive sublimate the first rank among germicides for use upon the skin of the patient and the hands of the operator, and for irrigating in- fected wounds and cavities. On account of its irritant proper- ties it should not be used on serous membranes. For the patient's skin and surgeon's hands a solution of from I : iooo to I : 500 should be employed ; for large wounds and cavities, 1 : 10,000 to 1 : 5000; for small wounds, 1 : 2000; for irrigating the bladder and vagina, 1 : 20,000 to 1 15000; for irrigating the urethra, 1 : 40,000 to 1 : 20,000 ; and for irrigating the conjunctiva, 1 : 5000. Tartaric or citric acid may be advan- tageously combined with bichlorid solutions to prevent the mercuric salt from forming an insoluble albuminate with the albuminous matter of the tissues. Compressed tablets, each containing j\ gr. (0.48 gm.) of the salt with tartaric acid, are in common use. One of these added to a pint of water makes a solution of 1 : 1000. Ordinary water, on account of the lime which it contains, partially precipitates corrosive sublimate in the form of an oxid of mercury. This precipitation, however, can be prevented by adding common salt to the water. Bi- chlorid solutions cannot be used for sterilizing metal instru- ments. As a household disinfectant mercuric chlorid has several disadvantages. It is very poisonous ; it has a corrod- ing action on metals ; it becomes ineffective by contact with albuminous matters ; and it renders indelible any stains of feces or blood that may be on clothing. Solutions of from 1 : 5000 to I : 1000, however, are serviceable for scrubbing floors, wood-work, and bare walls. It is not a suitable disin- fectant for sputum, feces, or other albuminous matters. As a parasiticide, corrosive sublimate is a useful remedy in pediculosis pubis and ringworm. In these affections it may be employed in the form of a lotion in the strength of from 2—4 gr. (0.13-0.26 gm.) to the ounce (30.0 c.c.) of water, or, better, tincture of benzoin. The following solution, recommended by Jacobi, may be used as a local remedy in diphtheria : R Hydrargyri chloridi corrosivi, gr. i\ (0.08 gm.) ; Sodii chloridi, gr. xl (2.6 gm.) ; Aquae, Oj (0.5 L.). M. HYDRAR G YR UM. 3 29 In nasal diphtheria this solution should be warmed and poured into the nares or from a nasal cup several times a day. Before the introduction of antitoxin, mercury, in the form of calomel or of corrosive sublimate, was extensively used internally in the treatment of diphtheria. It seems to have some value in this affection, but the manner of its action is unknown. Children bear the drug remarkably well, and ■£§ gr. (0.0015 gm.) of corrosive sublimate, gradually increased to -^5- gr. (0.003 g m -)> ma y be given every three or four hours to a child of five years. Compresses wrung out of bichlorid solutions (1 : 5000) are useful in erysipelas and in small-pox. Antisyphilitic. — Corrosive sublimate, though somewhat more irritant than the protiodid, is a reliable salt of mercury for use in syphilis. It may be administered either in pill or in solution. One-twentieth of a grain (0.003 g m -)> gradually in- creased to y 1 ^ gr. (0.005 g m -)> ma y b e gi yen three times a day after meals. The addition of a small amount of opium will usually serve to allay any gastric or intestinal irritation. In the late secondary period the bichlorid may be prescribed with potassium iodid, as in the following formula : R Hydrargyri chloridi corrosivi, gr. iss-ij (0.1-0.13 gm.) ; Potassii iodidi, ?>i v - v j ( I 5-°- 2 3-° gP 1 -) » Syrupi sarsaparillae compositi, f^iss (45.0 c.c); Aquae, q. s. ad f 3HJ (90.O c.c). M. Sig. A teaspoonful in water after meals. Corrosive sublimate is one of the best salts of mercury for hypodermic use. Sodium chlorid should be added to the solution to prevent the formation in the tissues of an insoluble albuminate. R Hydrargyri chloridi corrosivi, gr. vj (0.4 gm.) ; Sodii chloridi, gr. xl (2.6 gm.) ; Aquas destillatse, f§j (30.0 c.c). M. Sig. Inject 5-20 min. (0.3-1.2 c.c.) daily. Tonic. — Mercuric chlorid, in doses of 1 ^ 6 - ^ gr. (0.0006- O.OO I gm.), is sometimes useful as an adjuvant to iron in sec- ondary anemia. Incompatibles. — Corrosive sublimate has a wide range of incompatibilities. The most common substances precipitated by it are tannic acid, alkaline carbonates, albumin, iodids, silver nitrate, and solutions of lime. With potassium iodid it forms mercuric iodid, but if the potassium salt is present in excess, a colorless solution of the double iodid of mercury and 330 ALTERA TIVES. potassium at once results, so that a combination of the two drugs is perfectly admissible. Yellow wash (lotio flava) is made by adding 24 gr. (1.6 gm.) of mercuric chlorid to 16 ounces (474.0 c.c.) of lime- water. Yellow mercuric oxid is precipitated and calcium chlorid remains in solution. It is sometimes employed as a stimulating dressing in the treatment of phagedenic venereal sores. HYDRARGYRI CHLORIDUM MITE, U. S. P. (Mild Mercurous Chlorid ; Calomel ; HgCl.) Calomel is a white, odorless, tasteless powder, insoluble in all ordinary menstrua. The dose is from -rV" 10 S r - (0.0065- O.65 gm.). Preparation. Dose. Pilulae Catharticae Composite, U. S. P. (contains I gr. — 0.06 gm.) 1-3 pills. Therapeutics. — Calomel is used internally as a cathartic (see p. 209), as a diuretic (see p. 232), as an antiphlogistic, and as an antisyphilitic. Externally it is employed as a stimulant, desiccant, and antiseptic. External Use. — Zinc ointment to which calomel (5-15 gr. to the ounce — 0.4-1.0 gm.) has been added makes an excel- lent application in subacute and chronic eczema. A dusting- powder composed of equal parts of calomel and zinc oxid is effective in venereal warts. Calomel is also efficacious in cor- neal idcers and phlyctenular conjunctivitis when there is not much ciliary irritation. It should be flicked into the eye by gently tapping a cameFs-hair brush loaded with the powder. Antiphlogistic. — Some practitioners believe that calomel is of service in limiting fibrinous exudation in inflammatory dis- eases of the serous membranes. For this purpose it has been much used in pleurisy, meningitis, iritis, and pericarditis, but its beneficial effects are very doubtful. Antisyphilitic. — Calomel has been used internally to com- bat syphilis, but the protiodid and the bichlorid are deci- dedly preferable, since they do not induce salivation so quickly. It is a suitable preparation, however, for volatiliza- tion when the patient is to be treated by fumigation. Some surgeons have recommended deep injections of oily mixtures of calomel in syphilis, but grave symptoms have occasionally resulted from its use in this way. Incompatibles. — Calomel is incompatible with hydro- HYDRARG YR UM. 3 3 1 chloric acid, chlorates, chlorids, iodids, bromids, and lime- water. With hydrocyanic acid and potassium cyanid it forms the highly poisonous bicyanid of mercury. Mixtures of calo- mel and iodoform turn red from the formation of mercuric iodid. Black wash (lotio nigra) is made by adding 1 dr. (4.0 gm.) of calomel to 1 pint (0.5 L.) of lime-water. Black mer- curous oxid is precipitated and calcium chlorid remains in solution. It is sometimes employed as a stimulating applica- tion in venereal sores. It is often very useful in rhus poisoning and acute eczema, when dabbed on the parts, allowed to dry, and followed by an application of zinc ointment. HYDRARGYRI IODIDUM RUBRUM, U. S. P. (Red Mercuric Iodid ; Biniodid of Mercury ; Hgl 2 .) Red iodid of mercury is a bright-red, amorphous powder, free from odor and taste. It is almost insoluble in water, soluble in 116 parts of alcohol, and freely soluble in solutions of potassium iodid. The dose is from -fa-lfe S r - (0-0012-0.005 gm.). Preparation. Dose. Liquor Arseni et Hydrargyri Iodidi, U. S. P. (Donovan's solution : I per cent, of each iodid) 1-5 min. (0.06-0.3 c.c). Therapeutics. — In its effect and strength the biniodid of mercury resembles the bichlorid. In the late secondary stage of syphilis it is often of value when given in a solution of potas- sium iodid, as in the following formula : R Hydrargyri iodidi rubri, gr. j (0.065 g m -) '■> Potassii iodidi, ,^ij-i v (8.0-15.0 gm.) ; Aquae, f^ij (60.0 c.c.) ; Syrupi sarsaparillae compositi, q. s. ad f^iv (120.0 c.c). M. Sig. A dessertspoonful in water after meals. Donovan's solution is used internally as an alterative in chronic rheumatism, tuberculous adenitis, and tertiary syphilis. HYDRARGYRI IODIDUM FLAVUM, U. S. P. (Yellow Mercurous Iodid ; Protiodid of Mercury ; Green Iodid of Mercury ; HgL) Protiodid of mercury is a yellow, amorphous, insoluble pow- der, free from odor and taste. The dose is from T V~ 2 S r - (0.006-0.03 gm.). Therapeutics. — The protiodid of mercury is far less irri- tant than the biniodid. Ordinarily, it is the best preparation 3 3 2 AL TERA TI VES. for use in syphilis. It should be given in pills to which a little opium may be added if it excite colic or diarrhea. HYDRARGYRI NITRAS. (Mercuric Nitrate ; Hg(N0 3 ) 2 .) Mercuric nitrate is official in two forms : Liquor Hydrargyri Nitratis, U. S. P. (contains 60 per cent, of mercuric nitrate and 11 per cent, of free nitric acid). Unguentum Hydrargyri Nitratis, U. S. P. (citrine ointment : contains 7 per cent, of mercuric nitrate). Therapeutics. — The solution of mercuric nitrate is a pow- erful caustic. It is extensively employed for the cauterization of mucous patches and sloughing venereal sores. The danger of inducing salivation from using it too freely must be borne in mind. Citrine ointment, more or less diluted, may be used as a stimulant application in indolent ulcers and chronic eczema. Diluted with 8 parts of petrolatum it makes an efficient appli- cation for granulating venereal ulcers. HYDRARGYRUM AMMONIATUM, U. S. P. (Ammoniated Mercury; Mercuric Ammonium Chlorid; White Precipitate; NH 2 HgCl.) Ammoniated mercury is made by the action of ammonia on corrosive sublimate, and appears as a white, insoluble powder, free from odor and taste. Preparation. Unguentum Hydrargyri Ammoniati. U. S. P. (10 per cent.). Therapeutics. — Ammoniated mercury is employed exter- nally, in the form of the ointment, as a stimulant and as a parasiticide. It is often serviceable in chronic eczema, psoriasis, and ringworm. The official ointment, however, is too strong for ordinary use, a strength of from 20-30 gr. (1.3-2.0 gm.) to the ounce (30.0 gm.) being quite sufficient. HYDRARGYRI CYANIDUM. (Mercuric Cyanid ; Hg(CN) 2 .) Mercuric cyanid occurs in the form of colorless, prismatic crystals, odorless, and of a bitter, metallic taste. It is freely soluble in water and alcohol. The dose is from ? V~ru" S r - (0.0016-0.006 gm.). Its action, though less irritant, resembles that of the bi- chlorid. It has been used as a substitute for the latter in sur- gical practice and also in the hypodermic treatment of syphilis. HYDRAR G YR UM. 333 HYDRARGYRI OXIDUM. (Mercuric Oxid; HgO.) Mercuric oxid occurs in two forms : Yellow oxid {Hy- drargyri Oxidum Flavum, U. S. P.) and red oxid (Hydrargyri Oxidum Rubrum, U. S. P.). Both are heavy, permanent, in- soluble powders, odorless, and of a somewhat metallic taste. The yellow oxid is an impalpable powder ; the red oxid is more or less crystalline. They are not used internally. Preparations. Unguentum Hydrargyri Oxidi Flavi, U. S. P. (10 per cent.). Unguentum Hydrargyri Oxidi Rubri, U. S. P. (10 per cent.). Oleatum Hydrargyri, U. S. P. (25 per cent, of yellow oxid). Therapeutics. — The oxids of mercury are used externally for their stimulant and alterative effects. In certain chronic in- flammatory diseases of the eye — phlyctenular conjunctivitis, keratitis, and blepharitis marginalis, an ointment of the yellow oxid is often very useful. In the last affection it is particularly efficacious when applied at night to the margins of the lids in the strength of 1 gr. of the oxid (0.06 gm.) to 1 dr. (4.0 gm.) of vaselin. In chronic eczema an ointment containing from 10-20 gr. (0.6-1.3 gm.) to the ounce (30.0 gm.) is sometimes serviceable. In the form of a dusting-powder the oxids of mercury have also been used in chancroidal and syphilitic sores. In chronic adenitis and other indolent inflammatory in- durations one of the official ointments or the oleate may be employed for its sorbefacient effect. The red oxid may be used in the same class of cases as the yellow oxid, but it is less satisfactory on account of its crys- talline character. HYDRARGYRI SUBSULPHAS FLAVUS. (Yellow Mercuric Sulphate ; Turpeth Mineral; Hg(HgO) 2 S0 4 .) Yellow mercuric sulphate is a lemon-yellow, odorless, and tasteless powder, sparingly soluble in water. The dose is from 2-3 gr. (0.1-0.2 gm.), repeated once. Therapeutics. — This preparation of mercury was formerly much used as an emetic in croup, but it has been largely re- placed by less poisonous and less irritant drugs. HYDRARGYRI SALICYLAS. (Basic Mercuric wSalicylate, HgC 7 H 4 3 .) Mercuric salicylate is a white amorphous powder, without odor or taste. It is insoluble in water or alcohol, but readily so in water containing sodium chlorid. It has been especially 334 AL TERA TIVES. recommended for intramuscular administration in syphilis, liquid paraffin or almond oil (i in 10) being used as a vehicle. The dose is from |to I gr. (0.02-0.065 gm.). R Hydrargyri salicylates, gr. xv (i.o ex.); Petrolati liquidi, f^iiss (10.0 ex. ). M. Sig. From 3-10 min. (0.12-0.6 ex.), intramuscularly, once a week or every ten days. HYDRARGYRI SUCCINIMIDUM. (Mercuric Succinimid, HgC 8 H g 4 N 2 .) Mercuric succinimid is a white crystalline powder, soluble in 75 parts of cold water and in 300 parts of alcohol. It is com- paratively non-irritant and does not precipitate albumin. The dose, by the mouth, is from \-\ gr. (0.0 1 -0.0 15 gm.). Mercuric succinimid has been used chiefly by hypodermic injection in the treatment of syphilis, from 8-15 minims (0.5-1.0 c.c.) of a 2.5 per cent, solution being given daily or every other day. Recently it has been highly recommended by B. L. Wright in pulmonary tuberculosis, injections being given every other day (£ gr.-0.013 gm.) for two months and followed by a course (two weeks) of potassium iodid. ICHTHYOL. (Ammonium Sulpho-ichthyolate.) Ichthyol is the ammonium salt of ichthyol sulphonic acid. The latter is the product of the action of sulphuric acid on an oily substance obtained by the destructive distillation of a bituminous mineral rich in fossil fish, found in the Tyrol. It is a thick, reddish-brown liquid, having a bituminous odor and taste. It is soluble in water and in a mixture of alcohol and ether, miscible with oils and glycerin in all proportions, and almost insoluble in strong alcohol or ether. It contains nearly 15 per cent, of sulphur, and to this ingredient its therapeutic properties, no doubt, are largely due. The dose is from 2-10 gr. (0.13-0.65 gm.), in capsules or pills. Physiologic Action. — When applied to the skin in con- centrated form, ichthyol produces slight redness and burning. Its absorption through the unbroken skin is readily effected if gentle friction be used in the application. The efficacy of the drug in many inflammatory diseases of the skin and mu- cous membranes has been attributed to a constricting action on the vessels and to an alterative influence on the deeper tissues, especially the glandular cells. Fessler, Abel, Neisser, and others have shown, also, that it possesses decided bacter- icidal properties. According to Neisser, even in solutions so ICHTHYOL. 335 dilute as I per cent, it is rapidly destructive to gonococci. In- ternally, large doses cause eructations, nausea, vomiting, and diarrhea. Therapeutics. — Ichthyol is very largely employed exter- nally as an antiseptic and alterative. In the form of an oint- ment it is decidedly useful in reducing inflammatory swelling in glands and joints. The best vehicle is lanolin, and the strength of the application may vary from 25 to 50 per cent. It is of some value as a local remedy in erysipelas, and in this disease it may be combined with blue ointment, as in the fol- lowing formula, so highly extolled by Roswell Park : R Ichthyol, gr. xxx-xl (2.0-2.6 gm.) ; Resorcinolis, ^ss (2.0 gm.) ; Unguenti hydrargyri, £iv (15.5 gm.) ; Adipis lanae hydrosi, gv (20.0 gm.). — M. It is said to be useful, either as a lotion or an ointment (10 to 20 per cent), in certain diseases of the skin, especially acne, vesic- ular and sqjiamous eczema, pruritus, and urticaria. It is some- times of service in bruises, sprai?is, and chilblains. Tampons saturated with ichthyol and glycerin (1 to 20 or 1 to 10) are sometimes remarkably beneficial in oophoritis, perimetritis, en- dometritis, cervical catarrh, and go?iorrheal vaginitis. In atro- phic rhinitis no remedy is so efficacious as ichthyol in relieving the disagreeable symptoms. After the nares have been thor- oughly cleansed, pledgets of cotton soaked in an aqueous solution (20 to 50 per cent.) should be inserted and allowed to remain for a period of from fifteen to twenty minutes, or in bad cases the drug may be applied pure by means of a probe armed with cotton. The chief drawback to the use of ichthyol externally is its unpleasant, bituminous odor ; this can be disguised in a meas- ure by the addition of oil of bergamot (1 140). Ichthyol has been used internally in a variety of diseases, particularly tuberculosis and rheumatism, but the testimony to its efficacy is not convincing. Incompatibles. — Acids, alkalis, and alkaloidal salts. Ichthalbin. — This preparation is a combination of ich- thyol and albumin, appearing as a brownish powder, odorless, and nearly tasteless. The dose is from 5—10 gr. (0.33-0.65 gm.). It has been thoroughly exploited as a substitute for ichthyol, both for internal and external use. Icnthoform is a condensation product of ichthyol and formaldehyd. It has been recommended as a substitute for iodoform ; but notwithstanding its freedom from odor it is less satisfactory than the older remedy. Ichthargan is a compound of ichthyol and silver, contain- 3 3^ AL TERA TIVES. ing 30 per cent, of metallic silver in organic chemical combi- nation. It is a brown, amorphous powder, with a faint odor of chocolate. It is freely soluble in water, diluted alcohol, and glycerin. It has been used with asserted good results in gonorrhea, injections of a 1 : 10,000 to a 1 : 1000 solution being made three or four times daily. Thiol. — This is a synthetic product obtained by the action of sulphur and sulphuric acid upon hydrocarbon as formed by the destructive distillation of peat. It was introduced as a substitute for ichthyol, but it has not proved a very formida- ble rival. AURI ET SODII CHLORIDUM, U. S. P. (Gold and Sodium Chlorid; AuCl 3 + NaCl.) The gold and sodium chlorid of the Pharmacopeia is a mix- ture of equal parts, by weight, of dry gold chlorid and sodium chlorid. It is an orange-yellow powder, slightly deliquescent, of a saline and metallic taste. It is freely soluble in water. The dose is from 2 1 o" , l g r - (0.003-0.016 gm.), in pill. Physiologic Action and Therapeutics. — Gold and sodium chlorid is supposed to act as an alterative and a tonic. Large doses have an irritant action and excite gastro-enteritis. It has been recommended in a number of diseases, especially in diabetes, hysteria, neurasthenia, tertiary syphilis, chronic alco- holism, and sclerosis of the spinal cord, but it is of very doubt- ful value. COLCHICUM. (Meadow Saffron.) Colchicum is the corm and seed of Colchicum autumnale, a bulbous perennial growing in Southern Europe and Northern Africa. The corm is official as Colchici cormus, and the seed as Colchici semen. The active principle of the drug is the alka- loid, colchicin (Colchicina, U. S. P.), which is a whitish, amor- phous or crystalline powder, of a saffron odor and bitter taste, and is readily soluble in water and alcohol. The dose of colchicin is from 1 | - 3 1 gr. (0.0004-0.002 gm.). Preparations. Dose. Extractum Colchici Cormi, U. S. P £-2 gr. (0.03-0.13 gm. ). Fluidextractum Colchici Seminis, U. S. P. . . 2-5 min. (0.1-0.3 c.c. ). Tinctura Colchici Seminis, U. S. P 10-30 min. (0.6-2.0 c.c). Vinum Colchici Seminis, U. S. P 10-30 min. (0.6-2.0 c.c). Physiologic Action. — In warm-blooded animals large doses of colchicum or of its alkaloid excite severe abdominal pains, nausea, vomiting, and diarrhea. The discharges are at first serous, but later they may become mucous and even colchicum. 337 bloody. These symptoms are followed by progressive motor paralysis, enfeeblement of the circulation, collapse, and finally by death from asphyxia. Postmortem examination usually reveals pronounced in- flammatory lesions in the alimentary canal. In some instances, however, no morbid changes have been observed. Fatal poi- soning has occurred from the ingestion of less than 3 dr. (11.0 c.c.) of the wine of the root (U. S. P. 1890), and of less than \ gr. (0.03 gm.) of colchicin. The gastro-intestinal features of the poisoning are probably due to the direct irritant action of the drug, although Jacobj attributes them to increased irritability of the motor nerves of the bowel, in consequence of which the muscular coat responds too vigorously to the ordinary stimuli. The paralysis, accord- ing to Rossbach, results from depression of the central ner- vous system. Upon the circulation colchicum appears to have no direct influence. Both the water and the solids of the urine are somewhat increased after moderate doses of the drug, but large doses may be followed by suppression. Treatment of Poisoning. — The stomach should be evac- uated as speedily as possible. Albumin and other demulcents are useful in allaying irritation and in preventing further in- jury to the mucous membrane. Tannic acid is of no value as an antidote. Morphin may be given hypodermically to re- lieve pain and to inhibit peristalsis. The usual measures will be required to combat the collapse. Therapeutics. — The only disease in which colchicum is of value is gout. The good and bad effects of the drug in chronic joint affections seem to have been known as early as the sixth century of the Christian era. For many years it was neglected by regular practitioners, although it still served as the basis of many celebrated nostrums. Later the studies of Halford, Watson, and Garrod reestablished it in the confidence of the profession. The way in which gouty inflammation is affected by colchicum is not understood, and cannot be, until our knowledge of the pathology of the disease becomes more complete. The drug is most potent in acute gout, the pain and swelling of which it relieves as if by magic ; it is less effi- cacious in the chronic manifestations of the disease. In the different forms of rheumatism it is useless. Administration. — As colchicum is powerful for harm as well as for good, considerable care should be exercised in its administration. Only small doses should be employed, and these should be withdrawn or considerably reduced so soon as the pain has been relieved. Large doses, even if they do 22 338 AL TERA TIVES. not excite irritation of the stomach or purging, may, by sup- pressing the local manifestations too abruptly, cause the grave visceral disturbances to which the term retrocedent gout has been applied. The wine and the tincture are reliable prepara- tions ; they should be taken, well diluted, after food. Alkalis are useful adjuvants, and may be combined with the colchicum, as in the following formula : R Potassii bicarbonatis, ^ij (8.0 gm.) ; Vini colchici seminis, fgiiss (10.0 c.c.) ; Aqua menthas piperitse, q. s. ad f ^iv (120.0 c.c). — M. Sig. A tablespoonful in a wineglassful of water thrice daily, after meals. Colchicin is a convenient form for administering in pills or capsules. GUAIACUM, U. S. P. (Guaiac.) Guaiac is the resin of Guaiacum officinale (Lignum Vitae), a large tree growing in the West Indies and South America. It appears as irregular masses, of a reddish-brown color, turning greenish-brown on exposure, and has an aromatic odor and an acrid taste. It is soluble in alcohol and in alkaline fluids, but is insoluble in water. Alcoholic solutions turn blue on the addition of oxidizing agents. It contains several resinous acids and aromatic oils and gums. The dose is from 5-30 gr. (0.3-2.0 gm.). Preparations. Dose. Tinctura Guaiaci, U. S. P. (20 per cent, of the resin) \-\ fl. dr. (2.0-4.0 c.c). Tinctura Guaiaci Ammoniata, U. S. P. (20 per cent, of the resin in aromatic spirit of ammonia) ^-1 fl. dr. (2.0-4.0 c.c). Therapeutics. — Guaiac possesses considerable power,, though less than colchicum, in relieving gouty inflammation. It is especially efficacious in the subacute and chronic forms of the disease. In acute gout it may be substituted advan- tageously for colchicum so soon as the pain has subsided. According to Garrod, when it is taken in the intervals of gouty attacks it is very effective in averting their recurrence. The drug is quite innocuous, and may be taken for indefinite periods without inducing untoward effects. It is also used in tonsillitis and chronic rheumatism. Administration. — The tinctures are reliable preparations, but as they have a very disagreeable taste, they should be given in the form of an emulsion. The resin itself may be given in cachets or in an emulsion. SARSAPARILLA— JAMBUL. 339 R Guaiaci, ^iisss (io.o gm.) ; Acaciae, q. s. Syrupi, f^iv (15.0 c.c); Aquae cinnamomi, q. s. ad f^iv (120.0 c.c). Misce et fiat emulsum. Sig. A dessertspoonful in water after meals. Incompatibles. — Mineral acids and spirit of nitrous ether. Water is incompatible with the tinctures. SARSAPARILLA, U. S. P. Sarsaparilla is the root oiSmilax medica and of other species of Smilax, large perennial climbers growing in swampy places in tropical America. It contains a volatile oil, resin, and sev- eral saponins. Preparations. Dose. Fluidextractum Sarsaparillse, U. S. P. . . . £-2 fl. dr. (2.0-8.0 c.c). Fluidextractum Sarsaparillas Compositum, U. S. P. (sarsaparilla, 75 parts ; glycyrrhiza, 1 2 parts; sassafras, 10 parts; mezereum, 3 parts; glycerin, 10 parts; diluted alcohol to make 100 parts) 5-2 fl. dr. (2.O-8.O C.C.). Syrupus Sarsaparillae Compositus, U. S. P. (fl. ext. sarsaparilla, 20 parts ; fl. ext. gly- cyrrhiza, 1.5 parts; fl. ext. senna, 1.5 parts ; sugar, 65 parts ; oil of sassafras, oil of gaultheria, and oil of anise, of each, 0.02 part ; water to make 100 parts) .... 1-4 fl. dr. (4.0-15.0 c.c). Therapeutics. — The action of sarsaparilla is very feeble. It has been used as an alterative in syphilis and tuberculosis, but it is without value. It is chiefly useful as a vehicle to disguise the taste of unpalatable drugs, particularly potassium iodid. JAMBUL. (Java Plum.) Jambul is the root and seeds of Eugenia jambolana, a large tree growing in the East Indies. The active constituent of the drug has not been determined. The seeds are more pow- erful than the root, and may be given powdered in doses of from 5-20 gr. (0.3-1.3 gm.), in capsules. Preparation. Dose. Fluidextractum Jambul 10-30 min. (0.6-2.0 c.c). Therapeutics. — Jambul has been used solely as a remedy in diabetes mellitus, for which it was originally recommended by Banatvala, of Madras. Binz found that it materially les- sened the excretion of sugar in phloridzin diabetes, but Min- kowski found it absolutely useless in experimental pancreatic 340 AL TERA TIVES. diabetes. Clinically, we have derived some benefit from it in a few cases of a mild type. Large doses sometimes lessen the glycosuria, but increase the quantity of urine. Von Noor- den, in a study of 600 cases of diabetes, concludes that while jambul has no very marked action on the elimination of sugar, it is a good adjuvant to dietetic and hygienic procedures. MEZEREUM, U. S. P. (Mezereon.) Mezereum is the bark of Daphne Mezereum and of other species oi Daphne, small shrubs growing in mountainous dis- tricts in Europe and Asia. It contains a bitter glucosid and an irritant volatile oil. Preparations. Fluidextractum Mezerei, U. S. P. Fluidextractum Sarsaparillge Compositum, U. S. P. (3 per cent, of mezereum). Therapeutics. — Mezereum is an active irritant, and when applied to the skin it causes vesication. Large doses of the fluid extract taken internally produce severe abdominal pain, followed by vomiting and purging. It has been recommended as an alterative in chronic rheumatism, syphilis, and various skin diseases, but its utility has never been satisfactorily demon- strated. Except in the form of the compound, fluid extract of sarsaparilla is never prescribed internally. Externally the fluid extract has been used as an irritant application for indo- le tit ulcers. CALX SULPHURATA, U. S. P. (Sulphurated Lime; Crude Calcium Sulphid.) Sulphurated lime is a mixture containing at least 60 per cent, of calcium monosulphid, together with calcium sulphate and varying proportions of carbon. It is a pale gray powder, having a nauseous, alkaline taste and a faint odor of hydrogen sulphid. It is slightly soluble in water and insoluble in alco- hol. On exposure to air it is gradually decomposed. The dose is from ^ \ gr. (0.006-0.03 gm.), in pills, capsules, or powders. Therapeutics. — As was first pointed out by Ringer, sul- phurated lime possesses some power of preventing and arrest- ing suppuration. It has been found especially useful in piistu- lar acne, boils, and carbuncles. In follicidar tonsillitis and in quinsy, doses of -^ gr. (0.003 gm.) every hour sometimes yield excellent results. It is better to give small doses at short in- tervals than large doses infrequently, since the latter are more prone to derange digestion and to cause disagreeable eructa- GLAND ULyE THYROIDEsE SICCM. 34 1 tions of sulphureted hydrogen. As the drug deteriorates on keeping, only fresh preparations should be used. As a local remedy, in the form of Vleminckx's solution, it is often very efficacious in acne rosacea. R Cakis, ^ss (15.5 gm.) ; Sulphuris sublimati, ?j (31.1 gm.); Aquae, f^x (296.0 c.c). Coque ad f^vj (177.5 c.c), deinde filtra. Sig. Dilute with 10 parts of water and apply to the affected parte. URANII NITRAS. (Uranium Nitrate ; Uranyl Nitrate ; U0 2 (N0 3 ) 2 4- 6H 2 0.) Uranium nitrate occurs as light-yellow, rhombic prisms, soluble in water, alcohol, and ether. The dose is \ gr. (0.03 gm.), gradually increased to 5 gr. (0.3 gm.) or more, freely diluted with water, after meals. Therapeutics. — In large doses uranium salts act as irri- tant poisons, producing gastro-enteritis and nephritis. More- over, they affect the oxyhemoglobin of the blood in such a way that its oxygenating power is much reduced. This action on the blood may be responsible for the glycosuria, which, according to Leconte, results from the prolonged use of uranium compounds. West, Morrison, Duncan, and others have observed im- provement in cases of diabetes mellitus from the use of uranium nitrate in doses of from 5-20 gr. (0.3-1.3 gm.) two or three times a day. In general, however, the drug has proved dis- appointing. It certainly has no specific influence on the dis- ease, and whatever action it may have in lessening the excre- tion of sugar probably depends, as Symonds suggests, on its effect in retarding the digestion of starches. GLANDULE THYROIDE^ SICCj®, U. S. P. (Desiccated Thyroid Glands ; Thyroid Extract. ) The profession is largely indebted to the observations of Kocher and to the experimental researches of Horsley for the treatment of myxedema and allied conditions by the adminis- tration of thyroid gland. Kocher found that complete removal of the thyroid gland was followed in many instances by the appearance of a peculiar cachexia, the symptoms of which were almost identical with those of myxedema. Horsley showed that thyroidectomy in monkeys induced a similar con- dition. Schiff proved that the bad effects of thyroidectomy in animals could be averted by transplanting the gland in the peritoneum or subcutaneous tissue, and thereupon Horsley 342 ALTERATIVES. suggested this treatment for myxedematous conditions in man. Murray, in 1 891, found that transplantation of the gland was unnecessary, as the same results could be secured from hypodermic injections of thyroid juice, and a little later Mackenzie demonstrated that thyroid feeding was equally efficacious. According to Baumann, the active constituent of the thyroid gland is iodothyrin, a non-proteid compound containing from 5 to 10 per cent, of iodin. This substance is localized in the colloid matter, and is probably secreted by the gland in asso- ciation with an iodin proteid, the two forming the thyreoglobu- lin of Oswald. Physiologic Action. — Large doses of thyroid extract frequently, but not invariably, produce a train of symptoms to which the term thyroidism has been applied. The most com- mon manifestations of this intoxication are restlessness, in- somnia, headache, palpitation of the heart, weakness of the circulation, anorexia, nausea, elevation of temperature, free perspiration, shortness of breath, tremors and twitchings of the limbs, prostration, and progressive loss of flesh. It will be observed that these symptoms are not unlike those of ex- ophthalmic goiter, and to make the resemblance more com- plete, swelling of the thyroid gland and exophthalmos have occurred in a few instances. Coppez has reported 5 cases of optic neuritis from the continued use of large doses. In man, the most constant effect of thyroid extract in medici- nal doses is increased oxidation, in consequence of which a considerable reduction in the body-weight occurs. Both the proteids and the fats suffer disintegration, but, according to Vendelstadt, only one-sixth of the loss of weight can be attrib- uted to the destruction of nitrogenous compounds, the rest being due to oxidation of fats and to increased excretion of water. The excessive catabolism of proteids is made evident by the increased excretion in the urine of nitrogen and of phos- phorus ; the more rapid comoustion of fats, by the increased elimination of carbon dioxid and the greater demand for oxygen. In excess, thyroid extract frequently increases the rate of the pulse and lowers the arterial pressure. The manner in which these effects on the circulation are produced is not known. The hurried respiration observed in thyroidism may be due to the increased demand for oxygen. Even in mod- erate doses the drug usually increases the quantity of urine, and in large doses it may induce albuminuria and glycosuria. Elimination. — Iodothyrin must be decomposed in the body, at least to some extent, since after its administration iodin appears in the urine. Hutchinson found this element GLANDULE THYROIDEJE SICC^. 343 in the urine of a dog three hours after the administration of 15 gr. (1 gm.) of colloid matter. That a part of the active constituent resists destruction in the body and escapes through avenues other than the kidneys is evidenced by the fact that an infant may acquire thyroidism through the mother's milk. Therapeutics. — The diseases in which thyroid extract is most efficacious are cretinism and myxedema of the adult. In cretinism the results are often truly remarkable, especially when the treatment is instituted early. " Within six weeks," as Osier writes, " a poor, feeble-minded, toad-like caricature of humanity may be restored to mental and bodily health." In both affections the remedy must be continued throughout life, otherwise relapses occur. After the symptoms have been re- lieved, a weekly or biweekly dose may be all that is necessary to maintain normal metabolism. Thyroid extract sometimes proves efficacious, also, in infantilism, and in certain other con- ditions on the borderland of myxedema, in which imperfect mental and physical development is a prominent feature. Considerable success has attended the use of the drug in simple goiter, especially in that form met with in adolescents. No effect, of course, can be expected from the treatment in the old cystic goiters of adults. In exophthalmic goiter thy- roid feeding is either useless or harmful. The loss of flesh following the administration of thyroid extract suggested its use in obesity. Ebstein believes that the treatment is not a rational one, since the drug causes a waste of the body-proteids as well as of the fats. The nitrogen loss can be controlled in a measure, however, by increasing the amount of proteids in the food, so that it does not become an insurmountable objection to the treatment. In some cases of obesity the remedy proves entirely satisfactory and is not followed by any unpleasant consequences. It is most effective in the cases which bear a certain resemblance to myxedema, in which the skin is pale and the tissues are soft and flabby. Unfortunately, many patients rapidly acquire a tolerance for the drug, and for this reason relapses are common. In certain skin diseases, such as psoriasis and ichthyosis, thy- roid extract is occasionally serviceable, but in the majority of cases it proves disappointing. In inoperable cancer it is often useful as a palliative remedy in relieving pain, dispelling dis- agreeable odor, and retarding ulceration. The drug seems to have a special influence on the uterus. There is consider- able testimony as to its efficacy in metrorrhagia from various causes, and some authorities go so far as to claim for it the power of reducing the size of uterine fibroids. Montgomery has found it useful in sterility dependent upon obesity. 344 ALTERATIVES. The hope that thyroid extract might prove valuable in cer- tain forms of insanity has not been realized. While some observers, notably Mabon and Babcock and Easterbrook, have found it useful in acute melancholia, acute mania, puerperal and climacteric insanities, and stuporous states, the testimony of most alienists has been unfavorable. Administration. — As persons vary considerably in their susceptibility to thyroid preparations, it is always advisable to begin with small doses and gradually to increase them. As a rule, it is better to give small doses frequently than large doses at long intervals. Treatment should be suspended, at least temporarily, on the very first appearance of untoward symptoms. Mabille and Ewald have shown that the drug is much better received when combined with small doses of arsenic. Individuals with tuberculosis, Bright's disease, and cardiac insufficiency are generally intolerant to thyroid medi- cation. Thyroid gland may be given in the form of the fresh glands of the sheep, the dried glands (Glandulae Thyroideae Siccse), the glycerin extract (Liquor Thyroidei, B. P.), or iodothyrin. The fresh glands may be given raw or slightly cooked in doses of from \- \ of a gland a day. The dried glands and the glycerin extract, however, are far more convenient and are just as potent. Dry thyroid is a light, dull-brown powder, with a meat-like odor and taste. On exposure to air and moisture it is liable to decompose. The dose is from 1-5 gr. (0.06-0.3 gm.) three times a day. The glycerin extract is a pinkish turbid fluid, without putrescent odor. One hundred min. (6.0 c.c.) equal one fresh gland. The dose is from 5-15 min. (0.3-1.0 c.c). Tablets of iodothyrin triturated with milk- sugar are on the market, and may be given in doses of from 2-10 gr. (0.13-0.6 gm.) thrice daily. GLANDULA THYMUS. (Thymus Gland.) The persistence of the thymus in the majority of cases of exophthalmic goiter suggested the possibility of an antagonism between this gland and the thyroid. Reasoning from this pre- mise, many have employed thymus preparations in the treat- ment of Graves's disease. Kinnicutt, in 1897, collected 62 cases treated with the gland. Of these, 36 cases showed improve- ment; 25 were unimproved or showed aggravation of the symptoms. Of 20 cases treated by Mackenzie, 1 died, in 6 no improvement was observed, and in 1 3 there was some improve- ment. In none of the cases, however, was the effect so de- HYPOPHYSIS CEREBRI— TESTIS AND OVARIUM. 345 cided as to justify the conclusion that the thymus has any great therapeutic activity. Mendel, Mettenheimer, and others claim to have had good results from the use of thymus prepa- rations in rickets. They base the treatment on Friedleben's observation that the thymus gland is often atrophied in rachitic children, and on Mendel's observation that removal of the thymus in dogs induces symptoms resembling rachitis. The dose of the dried gland is from 10-15 gr. (0.6-1.0 gm.) or more three or four times a day. HYPOPHYSIS CEREBRI. (Pituitary Body.) Schaefer and Vincent have demonstrated the existence of two substances in the infundibular part of the pituitary body, one producing a rise and the other a fall of blood-pressure. They distinguish them as the pressor and depressor substances respectively, the former being insoluble in alcohol and ether, while the latter is soluble in both of these fluids. The pressor substance, the more active of the two, when given hypoder- mically, stimulates the heart and constricts the arterioles, in consequence of which it raises the blood-pressure, slows the pulse, and increases the quantity of urine. The almost constant finding of lesions of the hypophysis in acromegaly suggested the use of pituitary extract in the treat- ment of this disease. Of 20 cases so treated collected by Hins- dale, 9 showed some improvement in the subjective symptoms. The dose of the dried extract is from 3-5 gr. (0.2-0.3 gm.) three times a day. TESTIS AND OVARIUM. In 1889 Brown-Sequard announced that he had personally experienced remarkable rejuvenating effects from injections of the extract of the testicle of rabbits. Emanating from such a high authority, this announcement led rapidly to the use of orchitic extracts, not only in senility, but in impotence, neuras- thenia, hysteria, locomotor ataxia, and many other affections of the nervous system. More or less favorable results of this treatment have been reported, but in no instance has the good achieved been so decided as to convince a judicious observer that it was not due to mental suggestion rather than to the physiologic activity of the drug itself. So few have been con- vinced of the efficacy of the remedy that it has already been practically abandoned. Upon the assumption that the ovary is a secreting gland, its substance has been recommended in a variety of conditions connected with menstruation, especially for the relief of the 346 ANTIPYRETICS OR FEBRIFUGES. distressing symptoms attending the premature or artificial meno- pause. The results of its use, however, have not been very satisfactory ; moreover, there is no good reason for believing that the ovary has any other function than that of ovulation. ANTIPYRETICS OR FEBRIFUGES. The body derives its heat mainly from the oxidation of food- stuffs and from various mechanical movements, and loses it mainly by radiation and conduction from the skin and by the evaporation of water from the skin and lungs. Normally, heat-production and heat-dissipation are so evenly balanced that a mean temperature of 98.6 F. in the axilla is maintained, notwithstanding considerable variations in the surrounding temperature. The balance between income and expenditure is secured through the operation of a regulating mechanism located in the central nervous system. Antipyretics are drugs that lower temperature when it is abnormally high. They exert but little influence upon the normal temperature. Some of them, like acetanilid, phena- cetin, and antipyrin, act directly on the heat-regulating centers in such a way that the standard of temperature is brought to a lower level, where it is maintained for a limited period ; some, like alcohol, through their influence on the circulation, increase the dissipation of heat ; while others, like quinin, lessen the production of heat by retarding oxidation. Diaphoretics lower temperature by increasing the loss of heat due to the evaporation of sweat. Cold applications increase the heat-loss by conduction. Indication. — Antipyretics are employed to lower temper- ature in febrile states. They are indicated, however, only when the temperature is sufficiently high as to be in itself a source of actual danger or of considerable discomfort to the patient. When used repeatedly at short intervals, they are all more or less depressing. On the other hand, cold bathing has a stimulant as well as an antipyretic effect, and for this reason, when it can be carried out satisfactorily, it is always preferable to the use of drugs. The most important antipyretics are : Acetanilid, ""l Quinin. Antipyrin, ^ , . , . . • Guaiacol. Phenicetin, \ Coal - tar ^pyretics. Aconfe Phenocoll, J ACETANIL1DUM. 347 Salicylic acid, carbolic acid, and resorcin also lower temper- ature in febrile states, but they are no longer used for this purpose. ACETANILIDUM, U. S. P. (Acetanilid ; Antifebrin; C 6 H 5 NH.C 2 H 3 0.) Acetanilid is a derivative of anilin, an atom of hydrogen in the latter being replaced by the acetic acid radical acetyl. It is a white, shining, crystalline powder, odorless, and of a faintly burning taste. It is soluble in 179 parts of water, in 2.5 parts of alcohol, and in 12 parts of ether. The dose is from 3-10 gr. (0.2-0.65 gm.). Preparation. Dose. Pulvis Acetanilidi Compositus, U. S. P. (acet- anilid, 70 parts ; caffein, 10 parts and so- dium bicarbonate, 20 parts) 5 -I 5 g r - (0-3- 1 - gm.). Physiologic Action. — In health, single, moderate doses (5-10 gr. — 0.3-0.65 gm.) of acetanilid produce no perceptible effect. In fever, however, they induce a marked fall in tem- perature, which usually begins within two or three hours, and lasts a variable time, generally four or five hours. The fall in temperature is often associated with free perspiration. The antipyretic action of the drug has not been satisfactorily ex- plained, but it appears to be the result of a direct influence exerted on the heat-regulating centers, in consequence of which the cutaneous vessels are dilated and the heat-dissipa- tion is increased. Circulation. — In ordinary doses acetanilid has no pro- nounced action on the circulation, a slight quickening of the pulse, however, is sometimes observed, which is probably the result of the direct action of the drug on the cardiac muscle. Blood. — After large doses the blood becomes of a choco- late color, owing to the production of methemoglobin. The corpuscles themselves, however, do not suffer disintegration unless the dose has been very large. Respiration. — The drug seems to have no direct action on respiration. In poisoning there is marked dyspnea, but this is probably due to the changes induced in the red blood-cells. Nervous System. — Our knowledge of the action of acetan- ilid on the nervous system is very vague. The fact that the drug relieves headache and neuralgic pain without affecting 348 ANTIPYRETICS OR FEBRIFUGES. movement or consciousness shows that it has a special affinity for the sensory neurons, but as in large doses it induces more or less somnolence and paresis, it must affect also, though to a less extent, other portions of the nervous apparatus than the sensorium. Locally, on mucous membranes and raw surfaces it exerts an analgesic effect by depressing the peripheral sen- sory nerves. Bokai and others assert that in frogs it para- lyzes the motor nerve-endings also when directly applied. In animals, poisonous doses may excite convulsions, and these appear to be sometimes of spinal and sometimes of cere- bral origin. Metabolism. — The testimony as to the action of acetanilid upon nitrogenous elimination is so contradictory as to justify the conclusion that the drug has but little influence one way or the other upon tissue-metabolism. Absorption and Elimination. — Acetanilid is absorbed and eliminated with great rapidity. It is largely oxidized in the organism, and appears in the urine as the sulphate and glyco- uronate of paramidophenol. Action on Lower Organisms. — It has some power in in- hibiting the growth of bacteria, but its germicidal powers are feeble. Toxicology. — The chief symptoms of acetanilid poisoning are marked cyanosis, feeble breathing, extreme weakness of the circulation, free perspiration, dilatation of the pupils, and collapse. Treatment consists in maintaining the temperature of the body by means of external heat and in supporting the respiration and circulation by the liberal use of such drugs as strychnin, ammonia, and atropin. Artificial respiration and oxygen inhalations are useful in combatting the cyanosis. Untoward Effects. — Idiosyncrasies to acetanilid are not uncommon. Some persons are so susceptible to its action that cyanosis and collapse follow the administration of the drug even in small doses. Summers has reported an instance in which 4 grains, repeated in thirty minutes, caused cyanosis, partial loss of consciousness, and grave collapse in a healthy patient, who had many times previously taken the drug in much larger doses without ill effects. Fortunately, in the vast majority of such cases recovery follows under appropriate treatment. Papular and erythema- tous rashes are occasionally induced by acetanilid, but not so frequently as by antipyrin. Therapeutics. — Moderate doses of acetanilid (5 gr. — 0.3 gm.) are sometimes useful in controlling the temperature in ACETANILIDUM. 349 such diseases as typhoid fever, scarlet fever, and erysipelas. Nothing, however, is to be gained from the use of antipyretic drugs in these diseases when the temperature is not above 103 ° F. or 103.5 ° F., and is not causing much inconvenience to the patient. They should be employed only when the tem- perature itself is exciting considerable discomfort or when it is so high as to exert a baleful influence upon the nutrition of the vital organs ; even then, hydrotherapy, on account of its stim- ulant effects, is always preferable if it can be satisfactorily car- ried out and is not precluded by some special feature of the case. In tuberculosis and other adynamic diseases coal-tar anti- pyretics, if used at all, must be used with the utmost caution. Acetanilid and its congeners, judiciously employed, are of great value in relieving certain forms of pain, particularly head- ache, neuralgia, migraine, the pai?is of influenza, and even the nerve-storms of locomotor ataxia, but they have little or no in- fluence upon the pain of acute inflammation, of traumatism, or of morbid growths. Acetanilid has been recommended as a depressomotor in epilepsy, chorea, and whooping-cough, but for this purpose it has been employed much less extensively than antipyrin. Externally, it has been frequently substituted for iodoform in the treatment of wounds, burns, ulcers, and chancroidal sores. Its advantages are its inexpensiveness and freedom from odor. It must be employed with some caution, as it may be absorbed in sufficient quantity to produce toxic symptoms. This use of the drug appears to be decidedly dangerous in young chil- dren, no less than 20 cases of poisoning from it in infants having been reported within recent years. Administration. — It may be administered in powders, capsules, tablets, or pills. When a prompt effect is desired, it should be given in solution, alcohol being used as a solvent before the diluent is added. Incompatibles. — With alkaline bromids and iodids, in aqueous solution, it forms insoluble compounds. When tritu- rated with antipyrin, chloral, thymol, or resorcin, it forms a semiliquid mass. When added to spirit of nitrous ether, the solution after a time turns yellow and then red. Bxalgin or methyl-acetanilid is also a derivative of anilin. It has no advantages over acetanilid, which it resem- bles very closely in its action. It has been used more as an analgesic than as an antipyretic. The dose is from 3-10 gr. (0.2-O.6 gm.). 350 ANTIPYRETICS OR FEBRIFUGES. ANTIPYRINA, U. S. P. (Antipyrin; Phenazon; Phenyl-dimethyl-pyrazolon ; C 6 H 5 (CH 3 ) 2 C3HN a O.) Antipyrin is a synthetic base obtained by acting on phenyl- hydrazin (an anilin derivative) with diacetic ether, and then methylating the resulting monoethyl compound. It occurs in white, crystalline scales, odorless, and of a somewhat bitter taste. It is freely soluble in water, alcohol, and chloroform. The dose is from 3—15 gr. (0.2—1.0 gm.). Physiologic Action. — The action of antipyrin, so far as it is definitely known, closely resembles that of acetanilid. It is probably a little less toxic than acetanilid, although it is more prone than the latter to cause papular or erythematous skin eruptions. It is absorbed and eliminated very rapidly, most of it escaping un decomposed through the kidneys. Therapeutics. — Antipyrin is employed internally for the same purposes as acetanilid. Both are used to lower temper- ature in fever and to relieve pains of a neuralgic character. While the two drugs are equally efficacious, one sometimes succeeds where the other fails. Antipyrin has been used to a considerable extent as an antispasmodic. The diseases in which it is has acquired the most reputation in this respect are epilepsy and whooping- cough. In epilepsy it sometimes renders excellent service as an adjuvant to the bromids. From 10-15 gr. (0.6-1.0 gm.) a day may be given for three or four weeks, and then discontinued for two or three weeks before being resumed. The drug should be withdrawn at once, however, if cyanosis appear. In whooping-cough no remedy is so generally useful in con- trolling the paroxysms as antipyrin. It may be given by itself or in combination with a bromid, as in the following formula : R Antipyrinse, gr. 1 (3.2 gm.) ; Sodii bromidi, giss (6.0 gm.) ; Glycerini, f|ss (15.O c.c.) ; Aquae menthse piperita, q. s. ad f Jiij (90.0 c.c). M. Sig. A teaspoonful in water every three hours for a child of three years. Antipyrin is of some value in diabetes mellitus } but the manner of its action is unknown. Locally it has been recom- mended as an analgesic and as a hemostatic. As an analgesic it has been used with more or less success in relieving the pain of cancerous ulcers. Deep injections of a 50 per cent, solution have been employed also in lumbago and in sciatica y A CE TPHENE TIDINUM. 3 5 I but they are painful and liable to cause abscesses. As a hemostatic it sometimes is effective in arresting hemorrhage from small vessels ; thus solutions of from 5 to 10 per cent, have been found satisfactory in checking epistaxis and in controlling the capillary oozing after operations. In some persons its application in any strength proves irritating. Administration. — Antipyrin may be given by the mouth in the form of powders or capsules, but on account of its ready solubility it is perhaps best ordered in some aromatic water. In exceptional cases it may be administered hypoder- mically or by the rectum. Incompatibles. — On account of its basic properties anti- pyrin has a wide range of incompatibility. It is incompatible with iron salts, calomel, corrosive sublimate, iodin, iodids, ben- zoates, carbolic acid, ammonia water, sodium bicarbonate, nitrites, and all preparations containing tannic acid. When triturated with chloral, butyl-chloral, sodium salicylate, ortho- form, or beta-naphthol, it forms a semiliquid mass. When added to spirit of nitrous ether a green color results from the formation of iso-nitroso-antipyrin. ACETPHENETIDINUM, U. S. P. (Acetphenetidin ; Phenacetin ; C 6 H 4 .OC 2 H 5 .NHC 2 H 3 0.) Acetphenetidin, or phenacetin, is obtained by acting on para- phenetidin (an anilin derivative) with glacial acetic acid. In the reaction that takes place an atom of hydrogen in para- phenetidin is replaced by the acetic acid radicle, acetyl. It forms colorless, tasteless, inodorous scales, soluble in alcohol and in glycerin, but only sparingly so in cold water. The dose is from 5-10 gr. (0.3-0.65 gm.). Physiologic Action and Therapeutics. — The studies that have been made upon the action of phenacetin indicate that it exerts much the same influence as acetanilid and anti- pyrin, save that it is less toxic than either of these drugs. On the whole, it is the most satisfactory of the coal-tar antipy- retics, and when used in moderate doses, it is rarely followed by cyanosis, collapse, cutaneous eruptions, or other untoward effects. It may be employed with advantage as an antipyretic and analgesic in the same class of cases as that in which ace- tanilid has been found to be useful. Administration. — It may be given in pills, capsules, pow- ders, or tablets. 352 ANTIPYRETICS OR FEBRIFUGES. Incompatibles. — Salicylic acid, iodin, carbolic acid, chloral hydrate, and oxidizing agents. I/actophenin. — This compound is closely allied to phenac- etin in that it is para-phenetidin with an atom of hydrogen replaced by the lactic acid radicle, lactyl, instead of by the acetic acid radicle, acetyl. In addition to being an antipyretic and analgesic it has some power as a somnifacient. The dose is from 5-15 gr. (0.3-1.0 gm.). Phenocoll Hydro chlorid. — This phenetidin derivative represents an attempt to produce a soluble phenacetin. Chem- ically, it is glycocoll para-phenetidin hydrochlorid. It is a white, crystalline powder, soluble in about 16 parts of water. It is readily decomposed by alkalis and alkaline carbonates. The dose is from 5-15 gr. (0.3-1.0 gm.). As an antipyretic and analgesic it appears to be a safe and an effective substitute for acetanilid and antipyrin. It has been used also in rheuma- tism and in malarial fever, but with very indifferent success. Apolysin, Citrophen, and Kryofin. — These compounds, all phenetidin derivatives, have been introduced as rivals of phenacetin. Apolysin differs from phenacetin in containing a citric acid radicle instead of an acetic acid radicle. Citrophen differs from apolysin in containing 3 phenetidin groups instead of 1 to the molecule of citric acid. Kryofin differs from phenac- etin in containing a methyl-glycollic acid radicle instead of an acetic acid radicle. The dose of any one of these com- pounds is from 5-15 gr. (0.3-1.0 gm.). OTHER ANTIPYRETICS, Quinin (seep. 416).— In health the bodily temperature is not appreciably lowered by quinin unless the dose be exces- sive, but in febrile states the drug usually exerts a marked antipyretic influence when given in doses of from 20 to 30 gr. (1.3-2.0 gm.). This effect on the temperature cannot be attributed to an action on the heat-regulating centers, since it occurs after section of the spinal cord ; it appears to be due rather to an interference with metabolism, in consequence of which there is a decrease in the production of heat. The best results are obtained by giving the drug in one large dose a few hours before a natural remission is expected to occur. As a matter of fact, however, quinin is rarely used as an antipyretic at the present time. When it is deemed necessary to lower the temperature by means of drugs, the coal-tar derivatives, on account of the certainty and prompt- ness of their action, the ease with which thev can be admin- ASTRINGENTS. 353 istered, and their power to relieve headache and other pains incident to fever, are preferable to quinin, which lacks these advantages, and which, moreover, often disturbs the stomach. Guaiacol (see p. 286). — In febrile diseases guaiacol, applied to the skin, acts as a prompt and powerful antipyretic. To secure the desired effect about 30 min. (2.0 c.c.) should be slowly rubbed into the skin of the abdomen with a camel's- hair brush, and the part subsequently covered with a piece of waxed paper to prevent evaporation. The absorption of the drug, which usually occurs in a few minutes, is followed by a gradual fall of temperature, the lowest point being reached about three hours after the application. The reduction of temperature is associated with profuse perspiration, and is followed shortly by a rapid return of the fever, with marked chilliness. The applications, especially if made repeatedly, often cause considerable depression, and for this reason guaia- col cannot be recommended as an antipyretic, except for occa- sional use. Aconite (see p. 60). — Compared with the coal-tar deriva- tives, aconite is but a feeble antipyretic. It lowers tempera- ture probably through a central action, but this has not been definitely established. On account of its sedative influence on the circulation it is a useful febrifuge in acute inflammatory con- ditions and in the febrile diseases of childhood when the pulse is rapid and strong. It is contraindicated in asthenic fevers. The best results are obtained by giving the tincture in small doses at frequent intervals. Spirit of nitrous ether and the solution of ammonium acetate are useful synergists. ASTRINGENTS. Astringents are substances which, by their direct action, cause contraction or condensation of the tissues. Their influ- ence is most marked upon raw surfaces and mucous mem- branes. Many of them have also the property of diminishing or arresting glandular secretion, and this they accomplish not so much by constricting the blood-vessels of the part as by affecting the secreting cells directly. While their action is probably due in part simply to shrinking of the protoplasm, it is undoubtedly chiefly due to precipitation or to coagulation of the albumin of the cells. Astringents are divided into two classes, vegetable and min- eral. The former owe their efficacy to the presence of tannic 23 354 ASTRINGENTS. acid. There are but few astringents that are not also irritants, especially if employed in concentrated form. Some of the metallic salts are more irritant and caustic in their action than they are astringent. This is due in one instance to the irritant properties of the acid liberated by the union of the metal with the albumin of the cells ; in another instance to the intensely toxic nature of the metal itself; and instill another instance to the permeable texture of the coagulum that is formed by the first application of the salt. Among the mineral astringents, the insoluble salts of bis- muth, zinc oxid, and lead acetate have more of a sedative than an irritant action. The chief vegetable astringents are : Tannic acid. Gambir. Gallic acid. Geranium. Galls. Hematoxylon. Kino. Sumac. Krameria. Oak bark. Hamamelis. The chief mineral astringents are : Alum. Zinc oxid. Lead acetate. Silver nitrate. Copper sulphate. Bismuth subnitrate. Zinc sulphate. Bismuth subcarbonate. Calcium carbonate. Iron salts (see p. 289) and weak solutions of mineral acids, especially sulphuric acid (see p. 448), also have an astringent action. Indications. — The very mild astringents, like bismuth subnitrate and zinc oxid, are useful as protectives in acute superficial inflammations ; the more active ones, like the tannic acid compounds and zinc sulphate, are employed to lessen the excessive secretion often remaining as a sequel of acute in- flammation of mucous membranes. Some astringents, like alum and tannic acid, are also used to check hemorrhage, their styptic properties depending upon their power to coagu- late the albumin of the blood. ACIDUM TANNICUM, U. S. P. (Tannic Acid ; Tannin; Gallotannic Acid ; HC u H g 9 .) Tannic acid is the active constituent of all the vegetable astringents. It is derived from the nutgall, which contains ACIDUM TANNIC 'UM. 355 from 30 to 60 per cent, of it. The pure acid is a light-yellow- ish, amorphous powder, almost odorless, and of a strongly astringent taste. It is soluble in about 0.34 part of water, in 0.23 part of alcohol, and in 1 part of glycerin. The dose is from 3-10 gr. (0.2-0.6 gm.). Preparations. Collodium Stypticum, U. S. P. (20 per cent.). Glyceritum Acidi Tannici, U. S. P. (20 per cent.). Unguentum Acidi Tannici, U. S. P. (20 per cent.). Trochisci Acidi Tannici, U. S. P. (l gr.— 0.06 gm. — in each). Physiologic Action. — When applied to raw surfaces tannic acid precipitates the albumin of the superficial cells and causes condensation of the tissues. At the same time it lessens the sensibility of the peripheral nerves. On mucous mem- branes it acts in a similar manner, but more decidedly, and in addition dries up secretion by combining with the proteids of the glandular cells. Whether or not it constricts the blood- vessels with which it comes in contact is a mooted question. It coagulates blood, and thus serves as a local styptic. It is said also to inhibit the diapedesis of the leukocytes. When taken internally, the acids of the gastric juice prevent it from form- ing a permanent union with any proteids that may be present, so that it is free to act as an astringent in both the stomach and bowel. In moderate doses it impairs digestion and causes constipation ; in very large doses it acts as an irritant and ex- cites vomiting and diarrhea. In the intestine, tannic acid is transformed into gallic acid, and in this form a certain amount is absorbed and is subse- quently eliminated in the urine. Therapeutics. — Locally, tannic acid is much used to check excessive secretion and to impart tone to relaxed mu- cous membranes. In subacute and chronic laryngitis and pharyngitis a solution of from 1-5 gr. (0.06-0.3 gm.) to the ounce (30.0 c.c.) makes a useful spray. Some surgeons have found injections of the glycerite, more or less diluted, efficacious in subacute and chronic urethritis. The same preparation is frequently beneficial in chronic vaginitis, leukorrhea, erosion of the uterine cervix, and chronic cervical endometritis. Lotions and dusting-powders containing tannin sometimes act favor- ably in hyperidrosis of the feet. When it can be brought in direct contact with a bleeding surface tannic acid is a reliable hemostatic. In epistaxis strips of lint spread with vaselin and tannic acid make an excellent tampon. In hematemesis or enterorrhagia the drug may be given in full doses by the mouth. As it is absorbed in the form of gallic acid, which has no styptic power, it is valueless 356 AS TR INGE NTS. as an internal remedy in hemorrhages outside of the aliment- ary canal. As it forms more or less insoluble tannates with tartar emetic and the vegetable alkaloids, it may be employed as a chemical antidote in poisoning by one of these drugs. Can- tani and others have spoken highly of enteroclysis with a hot tannic acid solution (2 per cent.) in Asiatic cholera. Administration. — When its action is desired in the stom- ach, tannin should be given in powder ; if the intestine is to be reached, it should be given in pill. Incompatibles. — Alkaloids, gelatin, lime-water, tartar emetic, and the salts of iron, silver, lead, and copper. When tannic acid is triturated with potassium chlorate the mixture explodes with great violence; hence, when these two drugs are to be combined in solution, they should be dissolved sepa- rately before being brought together. Tannalbin, Tannigen, and Tannoform. — In the last few years several attempts have been made to enhance the therapeutic value of tannic acid as an intestinal astringent by converting it into compounds that will pass through the stom- ach unchanged and will be decomposed in the intestine, set- ting free the acid. The most important of these new com- pounds are tannalbin, tannigen, and tannoform. Tannalbin is a light-brown, odorless and tasteless powder, containing about 50 per cent, of tannin. It is prepared by subjecting tannin albuminate to dry heat for a considerable time. The dose for adults is from I5~20gr. (1. 0-1.3 gm.), in powders or cachets ; for children, from 5-15 gr. (0.3-1.0 gm.), in some mucilaginous vehicle or in powders. Tannigen is an acetic ester of tannic acid, and appears as a yellowish, odorless, almost tasteless, hygroscopic powder, in- soluble in water. As in the case of tannalbin, its astringent properties are not manifested until it reaches the bowel, where its decomposition is effected. It may be given in the same dose as tannalbin. Experience in the use of these two remedies warrants the opinion that they may be used interchangeably ; that they are free from irritant properties, even when administered in large amounts ; and that they have a definite, if but limited, field of usefulness in the treatment of acute intestinal catarrh. The chief indication for their employment is the continuation of profuse and watery discharges after the cause of the inflam- mation has been completely removed. In chronic diarrhea and in dysentery they usually prove disappointing, and in tuberculous enteritis, of course, no favorable results from them are to be expected. ACIDUM GALLICUM—GALLA. 357 Tannoform is a combination of tannic acid and formaldehyd. It appears as a pale-pink powder, insoluble in water. It escapes decomposition in the stomach, but in the intestine is slowly broken up, yielding free tannin and formaldehyd. The dose for an adult is from 3-5 gr. (0.2-0.3 gm.) ; for a child, 1-3 gr. (0.06-0.2 gm.). It has been recommended in intestinal catarrh, but it is most too irritating for internal use. As an external remedy, however, it is not without value. A mixture of tannoform 1 part and Venetian talc 2 parts often acts very favorably in excessive sweating of the feet, especially when there is more or less maceration of the tissues. ACIDUM GALLICUM, U. S. P. (Gallic acid; HC 7 H 6 5 + H 2 0.) Gallic acid is the hydrid of tannic acid, from which it is usually prepared by boiling with dilute sulphuric acid. It occurs in white or pale-fawn colored, silky needles, odorless, of an astringent or slightly acidulous taste, and permanent in the air. It is soluble in 84 parts of water, in 4 parts of alco- hol, and in 12 parts of glycerin. It differs from tannic acid in not precipitating gelatin, albumin, or alkaloids. The dose is from 5-20 gr. (0.3-1.3 gm.) in powders or capsules. Physiologic Action and Therapeutics. — Locally, gal- lic acid is a very feeble astringent, but as it does not coagu- late blood, it cannot be recommended as a styptic. When taken internally, it is absorbed into the blood and is eliminated unchanged in the urine. It has an undeserved reputation as a remote astringent in checking hemorrhages from parts that can be reached only through the circulation, in controlling night-sweats, and in diminishing the excessive secretion of urine in diabetes insipidus. Incompatibles. — Ferric salts, tartar emetic, lead acetate, silver nitrate, and spirit of nitrous ether. GALLA, U. S. P. (Nutgall; Gall.) Galls are excrescences produced by the stings and deposited ova of an insect in the bark or leaves of a plant. The official galls are caused by a species of cynips, which deposits its eggs in the tender shoots of Quercus infectoria y an oak growing in the countries bordering on the Mediterranean. Their thera- peutic activities depend upon tannic acid, of which they contain from 30 to 60 per cent. Preparations. Dose. Tinctura Gallse, U. S. P \-2 fl. dr. (2.0-8.0 c.c). Unguentum Gallse, U. S. P. (20 per cent.). 35^ ASTRINGENTS. Therapeutics. — Neither galls themselves nor the tincture are at the present time used internally. Nutgall ointment with equal parts of stramonium ointment is a time-honored remedy in painful hemorrhoids. KINO, U. S. P., KRAMERIA, U. S. P., AND GAMBIR, U. S. P. Kino is the inspissated juice of Pterocarpus Marsupium, a large tree growing in the East Indies. The dose of the pow- dered drug is from 5-30 gr. (0.3-2.0 gm.). Preparation. Dose. Tinctura Kino, U. S. P \-2 fl. dr. (2.0-8.0 c.c). Krameria, or rhatany, is the root of Krameria triandra, a low shrub growing on the mountains of Peru and Bolivia. Preparations. Dose. Tinctura Krameriae, U. S. P \-2 fl. dr. (2.0-8.0 c.c). Syrupus Krameriae, U. S. P. (contains 45 per cent, by volume of the fluid extract) . 1-2 fl. dr. (4.0-8.0 c.c). Fluidextractum Krameriae, U. S. P. ... 5-30 min. (0.3-2.0 c.c). Extractum Krameriae, U. S. P 5-10 gr. (0.3-0.6 gm.). Trochisci Krameriae, U. S. P. (each con- tains about I gr. — 0.06 gm. — of the ex- tract). Gambir is an extract prepared from the leaves and twigs of Ourouparia Gambir, a climbing plant of the East Indies. It was introduced into the Pharmacopeia to take the place of catechu (U. S. P. 1 890), as the wood from which the latter is extracted is difficult to obtain. Preparations. Dose. Tinctura Gambir Compositae, U. S. P. (5 per cent., with Saigon cinnamon 2.5 per cent.) \-2 fl. dr. (2.0-8.0 c.c). Trochisci Gambir, U. S. P. (each contains about I gr. — 0.06 gm.). Therapeutics. — All these drugs contain large amounts of tannic acid, to which their astringent properties are due. They are sometimes employed to check excessive secretion in acute diarrhea. They should never be given, however, until the bowel has been thoroughly cleared of irritant material. They are often prescribed with chalk and opium, as in the following formula : R Cretae praeparatae, gij (8.0 gm.) ; Tinctura? opii deodorati, ll^xx (1.3 c.c); Tincturae krameriae, f^ij(S.occ); Acaciae, q. s. ; Aquae cinnamomi, q. s. ad f ^iij (90.0 c.c). M. Sig. A teaspoonful every two or three hours for a child of two years. GERANIUM— RHUS GLABRA. 359 Troches of krameria or of gambir are useful in relaxed sore throat, GERANIUM, U. S. P. (Cranesbill.) Geranium is the rhizome of Geranium maculatum, a peren- nial herb growing in the woody places of North America. It contains from 10 to 28 per cent, of tannic acid. Preparation. Dose. Fluidextractum Geranii, U. S. P ^-1 fl. dr. (2.0-4.0 c.c). Therapeutics. — Geranium is the therapeutic equivalent of kino, krameria, and gambir, for which it may be substituted with advantage on account of its less disagreeable taste. HiEMATOXYLON, U. S. P. (Hematoxylon ; Logwood.) Hematoxylon is the heart-wood of Hcematoxylon campechia- num, a small tree growing in Central America and the West Indies. Its chief constituents are tannin and a crystalline color- ing principle, hematoxylin. Preparation. Dose. Extractum Haematoxyli, U. S. P 5 _ 3° g 1 "- (0.3-2.0 gm.). Therapeutics. — Logwood is used chiefly as an astringent in the diarrhea of young children. It is less active than kino, krameria, or gambir, but more agreeable on account of its sweetish taste. It has a disadvantage in staining the diapers a blood-red color. Hematoxylin is not used medicinally, but it is extensively used for its tinctorial properties in preparing tissues for microscopic study. RHUS GLABRA, U. S. P. (Sumac.) Sumac is the fruit of Rhus glabra, a shrub growing in waste places in North America. It contains, in addition to tannic acid, several acid mallates. Preparation. Fluidextractum Rhois Glabrae, U. S. P. Therapeutics. — Sumac is never used internally, but the fluid extract, diluted with from 6 to 8 parts water, makes an ex- cellent mouth-wash or gargle in mercurial stomatitis and in acute pharyngitis, especially if a small amount of potassium chlorate be added, as in the following formula : 360 ASTRINGENTS. R Potassii chloratis, £j (4.0 gra.) ; Fluidextracti rhois glabrae, f Jy (30.0 c. c. ) ; Aquae, q. s. ad f gviij (250.0 c. c). — M. Sig. Use as a gargle. QUERCUS, U. S. P. (Quercus Alba; White Oak.) Quercus is the bark of Quercus alba, a large tree growing in North America east of the Mississippi. It contains from 5 to 10 per cent, of tannin and a bitter principle, quercin. Therapeutics. — In the form of a decoction (1 oz. : 1 pint — 30.0 gm. : 0.5 L.) it is occasionally used as a gargle in sore throat or as an injection in leukorrhea. HAMAMELIS. (Witch-hazel.) Hamamelis is official as the bark (Hamamelidis Cortex) and the dried leaves (Hamamelidis Folia) of Hamamelis vir- giniana, a shrub widely distributed throughout North America. It contains a volatile oil, a small amount of tannin, and a bitter principle. Preparations. Dose. Fluidextractum Hamamelidis Foliorum, U. S. P. %-l fl. dr. (2.0-4.0 c.c). Aqua Hamamelidis, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). Physiologic Action and Therapeutics. — Although ex- aminations of witch-hazel have not revealed the presence of any very active ingredient, the drug is credited with consider- able power as an astringent, a hemostatic, and a sedative. Dujardin-Beaumetz was of the opinion that it exerted a tonic influence upon the muscular coats of the blood-vessels, but the investigations of Guy and of Wood indicate that it has no such action. According to Ringer, large doses sometimes cause severe headache. Hamamelis water has a popular reputation as a topical remedy for sprains, bruises , and small wounds. As an injec- tion or lotion it makes a very soothing application in painful hemorrhoids. Diluted with water, 1 part to 3, it is used with benefit as a spray in acute coryza. Both the water and the fluid extract have been used internally in various hemorrhages with asserted good results. A LUMEN. 361 ALUMEN, U. S. P. (Alum; Potassium Alum; Aluminum and Potassium Sulphate; A1K(S0 4 ) 3 + I2H 2 0.) The alum of the United States Pharmacopeia is a double sulphate of aluminum and potassium. In the British Phar- macopeia both this salt and the double sulphate of aluminum and ammonium are official. These compounds are of equal value. Potassium alum occurs in large, colorless, octahedral crystals, odorless, and of a sweetish and strongly astringent taste. It is freely soluble in water and in warm glycerin, but it is insoluble in alcohol. The usual dose is from 5-15 gr. (0.3-1.0 gm.), but as an emetic from 1-2 dr. (4.0-8.0 gm.) may be given. Preparation. Alumen Exsiccatum, U. S. P. (dried or burnt alum). Physiologic Action. — When applied to the broken skin or to mucous membranes, alum acts as a powerful astringent, precipitating the albumin of the superficial cells, coagulating the fluids, and contracting the tissues. When used too freely or in the form of dried alum, it acts as an irritant. It forms a firm coagulum with blood, and thus tends to arrest hemor- rhage. Taken internally in small doses it has an astringent effect and causes constipation. Large doses usually excite vomiting, but if retained, they induce gastro-enteritis. Therapeutics. — Alum may be used as a local styptic in arresting hemorrhages from small wounds. A solution of from \- 1 dr. (2.0-4.0 gm.) to the pint (0.5 L.) is sometimes effica- cious in leukorrhea. Insufflations of dried alum (1 : 20 of starch) or sprays of a weak solution — 5-10 gr. (0.3-0.6 gm.) to the ounce (30.0 c.c.) — are sometimes of service in subacute and chronic pJiaryngitis and laryngitis, especially when there is much mucous secretion. Its prolonged use in the mouth is contraindicated on account of its destructive action on the teeth. Lotions of alum and diluted alcohol are sometimes employed in hyperidrosis. Dried alum has long been used as a mild caustic for destroying exuberant granulations. Internally alum is no longer in use as an astringent. It is, however, a safe but somewhat uncertain emetic, and may be given to children in doses of a teaspoonful of the powdered drug in syrup, repeated once or twice if vomiting does not follow. Incompatibles. — Alkalis and their carbonates, lead ace- tate, mercury, iron salts, and tannic acid. 362 ASTRINGENTS. PLUMBUM. (Lead; Pb.) Metallic lead is obtained from a native sulphid and is not official ; the following preparations, however, are recognized by the United States Pharmacopeia: Acetate, subacetate, oxid, nitrate, and iodid. Physiologic Action. — Upon the skin soluble lead-salts have little or no effect, but when applied to denuded surfaces or to mucous membranes, they act as astringents, combining with the albumin of the cells and fluids to form a delicate but impervious coagulum. Unless applied in concentrated form they exert, with the exception of the nitrate, a sedative rather than a corrosive action. Taken internally, single, moderate doses of lead acetate have no action outside of the alimentary canal. They leave a sweetish, metallic taste in the mouth, with a feeling of dryness, and, owing to their astringent effects, they tend to cause con- stipation. Most of the drug escapes absorption and is dis- charged in the stools in the form of a sulphid. In very large doses lead acetate acts as an irritant poison and excites pain in the stomach, nausea and vomiting, great thirst, diarrhea, or, more rarely, constipation, and collapse. Death is often pre- ceded by coma and convulsions. The form in which lead is absorbed is not definitely known, but it is presumed that it circulates as an albuminate. It is eliminated in the urine, bile, intestinal secretions, saliva, and milk, and probably, also, in the sweat. Ordinarily its excretion is effected rather slowly, so that its continuous absorption, even in small quantities, is liable to lead to an accumulation of the metal in the tissues. Chronic I^ead-poisoning or Plumbism. — This con- dition may be brought about by the too prolonged use of the salts of lead for medicinal purposes, but it is much more fre- quently induced in workmen who are exposed to the fumes or dust of lead, or who handle the metal or paints containing it. It may follow, also, the accidental introduction of lead into the system through drinking-water, articles of food, hair-dyes, and cosmetics. Hard waters may be stored in cisterns lined with lead or may be conveyed through lead pipes without harm resulting, since they soon deposit on the metal an insoluble coating of lead sulphate ; on the other hand, soft waters, especially those containing considerable quantities of carbon dioxid, have a dangerous lead-dissolving action. Symptoms of Chronic Poisoning-. — The most common PLUMBUM. 363 symptom is colic (colica pictonum). This condition consists in paroxysms of severe abdominal pain, with retraction and rigidity of the abdominal muscles and obstinate constipation, although rarely there may be diarrhea. During the attacks there is often a marked increase in the arterial tension and slowing of the pulse. A characteristic feature of plumbism is the blue line on the edge of the gums near the insertion of the teeth. This discoloration is due to the deposit of lead sulphid formed from the sulphureted hydrogen evolved in the decom- position of particles of food. Perfect cleanliness of the teeth may prevent its appearance. Lead palsy is of common occur- rence. It usually attacks the muscles supplied by the mus- culospiral nerve, — the extensors of the fingers and of the wrist, — causing the so-called " wrist drop." The affected mus- cles ultimately atrophy and yield the reactions of degenera- tion. Occasionally other muscles are involved, such as the extensors of the legs, the recti of the eye, and the adductors of the larynx. Lead-paralysis usually results from peripheral neuritis ; in some instances, however, there appears to be also degeneration of the ganglionic cells of the spinal cord, but whether this is primary or is secondary to the neuritis has not been determined. Anemia is rarely absent. Both the hemoglobin and the number of red cells are decreased, and, moreover, as Grawitz has shown, the red cells usually contain numerous basophilic granules. Cerebral symptoms (encephalopathia saturnina) occasionally occur. They include persistent headache, epileptiform con- vulsions, delirium, optic neuritis, stupor, and coma. A symp- tom-complex resembling paretic dementia has also been de- scribed. In some instances the cerebral symptoms are simply expressions of uremia, but in others they are the consequence, without doubt, of the toxic action of the lead itself. McCarthy has observed in dogs poisoned by lead degeneration of the ganglion-cells, increase in the gliar elements, and marked endarteritis. Finally, workers in lead are especially prone to chronic nephritis with arteriosclerosis and to gouty arthritis. Treatment of Lead-Poisoning-. — Acute Poisoning. — The stomach should be emptied by means of the stomach-pump, unless vomiting has rendered this procedure unnecessary. A soluble sulphate (Epsom or Glauber's salt) is a chemical anti- dote, forming with the lead an insoluble sulphate ; it should be given in excess, so that a purgative effect may also be secured. The resulting gastro-enteritis should be treated by 364 ASTRINGENTS. the application of warm fomentations and by the administra- tion of opium and demulcent drinks. Chronic Poisoning. — Much may be done to prevent plumb- ism in lead-work establishments. Absolute cleanliness, espe- cially of the hands and nails, is of the utmost importance. Fans and suitable means of ventilation should be provided wherever dust is generated. Respirators should be worn by persons employed in dry processes. No food should be eaten in any part of the works. Curative treatment consists in eliminating the poison and in relieving the immediate symptoms. Potassium iodid, in doses of from 5-15 gr. (0.3-1.0 gm.) thrice daily, is employed to meet the first indication. Sulphur baths are also recommended. They are prepared by mixing in a wooden tub 3 or 4 oz. (90.0-125.0 gm.) of potassium sulphuret with about 20 gallons (75.0 L.) of water. Constipation should be relieved by saline cathartics, preferably by Epsom salts, or, if necessary, by elate- rium. Colic will require hot applications and hypodermic injections of morphin and atropin. For the paralysis, massage, electricity, and strychnin should be used. PLUMBI ACETAS, U. S. P. (Lead Acetate; Sugar of Lead; Pb (C,H 3 2 ) 2 + 3H 2 0.) Lead acetate occurs in heavy, colorless, efflorescent, pris- matic crystals or crystalline masses, having a sweetish, metallic taste, and a faintly acetous odor. It is soluble in 2 parts of water and in 30 parts of alcohol. The dose is from 1-4 gr. (0.065-0.26 gm.) in pills. Therapeutics. — Internally, pills of lead acetate and opium are sometimes useful in controlling subacute and chronic diar- rhea. Solutions of from 1-5 gr. (0.06-0.3 gm.) to the ounce (30.0 c.c), employed as injections, are of service in the station- ary stage of gonorrhea. The well-known " lead-water and laudanum " is usually made of the subacetate of lead, but the acetate may be sub- stituted with advantage, as in the following formula : R Plumbi acetatis, gj (4.0 gm.) ; Tincturae opii, f ,^j (3°-° c.c.) ; Aquae, q. s. ad f 3viij (236.0 c.c). — M. Although the ingredients in this combination are chemically incompatible, the mixture makes a useful sedative applica- tion in bruises, sprains, superficial inflammation, and erysipelas. PLUMBUM. 365 Incompatibles. — Acids, alkalis, sulphates, carbonates, chlorids, and tannin. PLUMBI SUBACETAS. (Lead Subacetate ; Pb 3 (C 2 H 3 2 ) 2 .) The subacetate of lead is so unstable that it is employed only in solution. Preparations. Liquor Plumbi Subacetatis, U. S. P. (Goulard's extract: contains 25 per cent, of lead subacetate) . Liquor Plumbi Subacetatis Dilutus, U. S. P. (lead-water : contains I per cent, of lead subacetate). Ceratum Plumbi Subacetatis, U. S. P. (Goulard's cerate : contains 20 parts each of the solution of lead subacetate, wool-fat, and paraffin ; 38 parts of white petrolatum, and 2 parts of camphor. Therapeutics. — The solution of the subacetate of lead, diluted with 3 or 4 parts of water, is employed as a sedative lotion in acute eczema, rhus poisoning, and erysipelas. The official diluted solution is too weak to be of much service, although it is often used in preparing " lead-water and lauda- num " (2 parts of lead- water to 1 part of laudanum). The cerate is occasionally used as an application for chapped hands. OLEATUM PLUMBI. (Oleate of Lead ; Pb2C, 8 H 33 2 . ) Oleate of lead is official as lead-plaster {Emplastrum Plumbi), which is prepared by stirring together hot solutions of lead acetate and soap. Lead plaster makes a useful protective dressing for superficial ulcers and bed-sores. An ointment com- posed of equal parts of lead-plaster and of vaselin makes an efficacious application in subacute eczema and hyperidrosis. In the latter affection, after the parts have been cleaned and dried, the ointment should be applied on strips of muslin, and renewed twice daily for two or three weeks, instructions being given to avoid washing the feet in water during the progress of the treatment. Lead-plaster also enters into diachylon ointment (Unguentum Diachylon, U. S. P.) and into all of the official plasters. PLUMBI NITRAS, U. S. P. (Lead Nitrate ; Pb(N0 3 ) 2 .) Lead nitrate occurs in white, translucent, octahedral crystals, odorless, and of a sweetish, astringent, and metallic taste. It is soluble in 2 parts of water. 366 ASTRINGENTS. Therapeutics. — At the present time lead nitrate is em- ployed only as a caustic in the treatment of onychia. It is usually applied as a powder. PLUMBI IODIDUM, U. S. P. (Lead Iodid; Pbl,.) Lead iodid is a heavy, bright yellow powder, odorless and sparingly soluble in water and in alcohol. It owes its activity more to the iodin element than to the lead, and is used only as a local absorbent (see p. 317). PLUMBI OXIDUM, U. S. P. (LeadOxid; Litharge; PbO.) Lead oxid is a heavy, reddish-yellow powder, odorless and tasteless, and insoluble in ordinary menstrua. It is rarely employed except in preparing the solution of lead subacetate {Liquor Plumhi Subacetatis, U. S. P.). CUPRI SULPHAS, U. S. P. (Copper Sulphate; Blue Vitriol; CuS0 4 -f- 5H 2 0.) Copper sulphate occurs in large, transparent, deep-blue crystals, odorless, and of a nauseous, metallic taste. It is solu- ble in 2.2 parts of water and in 400 parts of alcohol. The dose as an astringent is from J-i gr. (0.016-0.06 gm.) ; as an emetic, 5-10 gn (0.3-0.6 gm.). Physiologic Action. — Upon mucous membranes and raw surfaces copper sulphate in dilute form acts as an astringent ; in concentrated forms it acts as a mild caustic. Taken internally in large doses it causes emesis by its direct irritant action on the stomach. Toxicology. — Acute copper-poisoning is characterized by severe abdominal pain, a metallic taste in the mouth, and violent vomiting and purging, the ejecta often being mucous and bloody. Death may be preceded by delirium, convulsions, and coma. The bluish or greenish color of the vomit may serve to distinguish it from poisoning by other irritants. After death the gastro-intestinal tract is found to be intensely in- flamed, and sometimes ulcerated. Unless death occurs quite promptly, there may be found also fatty changes in the liver and kidneys. Treatment. — The antidotes are potassium ferrocyanid, magnesia, sodium carbonate, and soap. Demulcents like milk and eggs should be given freely. Opium will be required to relieve the pain. ZINCUM. 367 Chronic copper-poisoning is of doubtful occurrence; it is said to occasion gastro-intestinal disturbances, cachexia, a green line on the gums, and a greenish discoloration of the hair. Therapeutics. — Copper sulphate is a prompt and power- ful emetic, but it is most too irritant for ordinary use. When administered once without effect it is best not to repeat the dose. In phosphorus poisoning it is useful not only as an emetic, but also as an antidote, since it forms on the phos- phorus an insoluble coating. In indolent ulcers, ulcerative stomatitis, chronic granular con- junctivitis (trachoma), light applications of the solid crystal are often very useful for their stimulant effects. In gonorrhea, after the acute symptoms have subsided, an injection contain- ing 2 gr. (0.13 gm.) to the ounce (30.0 c.c), gradually increased in strength, is quite efficacious. Internally, in pill form combined with opium, it is some- times of service in obstinate chronic diarrhea. ZINCUM, U.S. P. (Zinc; Zn.) Metallic zinc is official in the form of thin sheets, or in irregular granulated pieces, or molded into thin pencils, or in a state of fine powder. The metal itself is not used medi- cinally. ZINCI SULPHAS, U. S. P. (Zinc Sulphate; White Vitriol; ZnS0 4 -f- 7H 2 0.) Zinc sulphate occurs in colorless, transparent, rhombic crys- tals, odorless, and of an astringent metallic taste. It is soluble in 0.53 part of water and in 3 parts of glycerin, and is insoluble in alcohol. The dose as an astringent is from J— 3 gr. (0.03- 0.2 gm.); as an emetic, 10-30 gr. (0.6-2.0 gm.). Physiologic Action. — In weak solution zinc sulphate exerts an astringent effect ; in concentrated solution, an irritant or caustic effect. Administered by the mouth, large doses (20 gr. — 1.3 gm.) excite emesis through their action on the stomach. Toxic doses induce severe gastro-enteritis. The treatment of poisoning consists in the free exhibition of alkalis or their carbonates, and of demulcents like eggs and milk. 368 ASTRINGENTS. Therapeutics. — A solution containing \ gr. (0.03 gm.) gradually increased to 5 or 6 gr. (0.3-0.4 gm.) to the ounce (30.0 c.c.) makes an excellent injection in gonorrhea after the sub- sidence of acute symptoms. Weak solutions are sometimes of service in leukorrhea. R Zinci sulphatis, Aluminis, aa ^iss (5.8 gm.) ; Glycerini, f^vj (180.0 c.c.). — M. Sig. Add a tablespoonful to a quart of hot water, and use as an injection. A solution of from 1-2 gr. (0.06-0.1 gm.) to the ounce (30.0 c.c.) is a favorite collyrium in the later stages of simple conjunc- tivitis. Internally, zinc sulphate is used as an emetic (see p. 167), and very rarely as an astringent in chronic diarrhea. Incompatibles. — Alkalis and their carbonates, vegetable astringents, lead acetate, silver nitrate, and lime-water. ZINCI ACETAS, U. S. P. (Zinc Acetate; Zn (C 2 H 3 2 ) 2 + 2H 2 0.) Zinc acetate occurs in thin, colorless, six-sided plates, of a pearly luster, an acetous odor, and an astringent, metallic taste. It is soluble in 2.5 parts of water and in 36 parts of alcohol. It is used as an astringent for the same purposes as zinc sulphate. ZINCI OXIDUM, U. S. P. (Zinc Oxid; ZnO.) Zinc oxid is an amorphous white powder, free from odor and taste, and insoluble in water and in alcohol. The dose is from 1-5 gr. (0.06-0.3 gm.) in pill. Preparation. Unguentum Zinci Oxidi, U. S. P. (contains 20 per cent, of zinc oxid). Therapeutics. — The ointment of zinc oxid is extensively used as a slightly astringent and protective dressing for burns, acute ulcers , and acute inflammatory skin diseases. Dusting- powders containing zinc oxid, starch, and Venetian talc, in various proportions, are very serviceable in vesicular eczema and in erythema intertrigo. R Zinci oxidi, Talci purificati, aa £j (4.0 gm.) ; Pulveris amyli, £ij (8.0 gm.). — M. ARGENTUM. 369 Internally, zinc oxid has been employed as an antispasmodic and an antihydrotic, but it is useless for either of these pur- poses. ZINCI CARBONAS. (Zinc Carbonate; 2ZnC0 3 . 3Zn(OH) 2 .) Zinc carbonate is official in the form of precipitated zinc car- bonate {Zinci Carbo?ias Prcecipitatus, U. S. P.), which is an impalpable white powder, of variable composition, odorless and tasteless, and insoluble in ordinary menstrua. An impure precipitated carbonate of zinc, known as calamin, was formerly official (i860). Therapeutics. — Zinc carbonate resembles zinc oxid in appearance and in therapeutic properties. It is chiefly employed as a sedative and protective application in acute inflammatory affections of the skin, such as eczema, erythema intertrigo, and dermatitis venenata. It is often combined with zinc oxid, as in the following formula : R Zinci carbonatis prsecipitati, Zinci oxidi, aa £iiss (10.0 gm.) ; Glycerini, fsjj (4.0 c.c.) ; Liquoris calcis, f^ij (60.0 c.c.) ; Aquae rosae, q. s. ad f'^vj (178.0 c.c). — M. ZINCI CHLORIDUM, U. S. P. (Zinc Chlorid; ZnCl,.) Zinc chlorid occurs in white, granular powder or porcelain- like masses, or molded pencils, very deliquescent, odorless, and of a caustic metallic taste. It is freely soluble in water and in alcohol. Preparation. Liquor Zinci Chloridi, U. S. P. (50 per cent, by weight of zinc chlorid). Therapeutics. — Zinc chlorid is the least astringent and the most caustic of the zinc salts. At present it is rarely employed except as an escharotic in removing superficial epitheliomata. Its action is rather slow, and is attended with severe pain. It is best applied in the form of a paste, which may be made by mixing 1 part of zinc chlorid and 3 parts of flour with a satu- rated solution of cocain hydrochlorid. The solution of zinc chlorid has an unmerited reputation as a disinfectant. ARGENTUM. (Silver; Ag.) The following preparations of silver are official: Silver cyanid (Argenti Cyanidum, U. S. P.), silver nitrate {Argenti 24 370 ASTRINGENTS. Nitras, U. S. P.), and silver oxid (Argenti Oxidutn, U. S. P.). Of these, the only one of any importance is silver nitrate. ARGENTI NITRAS, U. S. P. (Silver Nitrate ; Lunar Caustic ; AgN0 3 .) Silver nitrate occurs in colorless, transparent, tabular, rhom- bic crystals, odorless, of a caustic metallic taste, and soluble in 0.54 part of water and in 4 parts of alcohol. It turns dark on exposure to light. The dose is from -J— J gr. (0.01-0.03 gm.). Preparations. Argenti Nitras Fusus, U. S. P. (silver nitrate molded into hard, white cones or pencils). Argenti Nitras Mitigatus, U. S. P. (mitigated caustic ; molded cones or pencils of silver nitrate and potassium nitrate, containing about 33 per cent, of the former). Physiologic Action. — When applied undiluted to the skin, silver nitrate acts as a superficial escharotic, producing a white slough which subsequently turns black on exposure to light. Upon mucous membranes and raw surfaces it acts in dilute form as an unirritating astringent, precipitating the albumin of the cells with which it comes in contact, and con- tracting the blood-vessels ; in concentrated form it acts as a caustic, coating the part with a white pellicle of silver albumi- nate. Its corrosive action, however, never extends very deeply on account of the impenetrable nature of the coagulum that is at once formed. Silver nitrate is an active germicide, solutions of 1 : 2500 destroying the organisms of diphtheria, cholera, glanders, and typhoid fever in two hours. When taken internally in medicinal doses, it exerts no other influence than that of an astringent and an antiseptic. Being so readily precipitated by chlorids, proteids, and acids, its astringent action is chiefly expended on the mucous membrane of the stomach. The bulk of it escapes absorption, but that a small percentage enters the circulation is evident from the fact that the prolonged use of the drug is followed by a deposit of silver in the skin and internal organs. Very little is known concerning its elimination ; it is supposed to be excreted slowly and imperfectly in the urine. Toxicology. — In large doses silver nitrate acts as an irritant poison, producing intense abdominal pain, persistent vomiting and purging, and collapse. White or blackish patches may be present on the lips and mucous membrane of the ARGENTUM. 371 mouth. Death is sometimes preceded by delirium, convul- sions, and coma. Treatment. — Common salt is the best antidote. It forms with the poison an insoluble and inert chlorid of silver. De- mulcents should also be used freely. Argyria. — The long-continued use of silver nitrate, either internally or locally, may result in the permanent deposition of dark granules of metallic silver in various tissues of the body. This pigmentation is known as argyria. Clinically, its chief manifestation is a peculiar, bluish-gray discoloration of the skin and mucous membranes. In the majority of cases there is no impairment of the general health. It is incurable. Therapeutics. — At the present time silver nitrate is chiefly used for its action on inflamed mucous membranes and ulcerated surfaces. In chronic ulcers a solution of from 10 to 40 grains to the ounce (0.6-2.6 gm. to 30.0 c.c.) or the solid stick may be employed as a stimulant application. Silver nitrate is perhaps the best caustic for removing exuberant or superfluous granula- tions. Its employment in poisoned wounds, especially in the punctured variety, and in those resulting from the bites of rabid animals, is to be condemned on account of its superficial action and the premature closure of the orifice. A strong solution (30 gr. to 1 oz. — 2.0 gm. to 30.0 c.c.) will sometimes abort a felon if applied early. In acute epididymitis counter- irritation may be secured by drawing a pencil of lunar caustic several times over the posterior surface of the scrotum, but this treatment is less efficacious than the application of guaia- col (p. 286). The treatment of erysipelas by local applications of silver nitrate, so highly recommended by Higginbottom, has few advocates at the present time. In simple conjunctivitis, when the discharge has become mucopurulent, the membrane may be painted with a solution containing from 3 to 5 grains to the ounce (0.2-0.3 to 30.0 c.c). In purulent ophthalmia and ophthalmia neonatorum the con- junctiva, after being thoroughly cleansed, may be touched with a 10-grain solution (0.65 gm. to 30.0 c.c). Crede's prophylactic treatment, which consists in the instillation of 2 drops of a 2 per cent, solution into the eyes of the new-born child when gonorrhea in the mother is suspected, has given excellent results. It must be remembered that the long-continued use of collyria containing silver nitrate may be followed by perma- nent discoloration of the conjunctiva. Copious irrigation of the urethra with hot solutions of silver nitrate (1 : 10,000) has been found serviceable in both acute and 372 ASTRINGENTS. subacute gonorrhea. Excellent results are obtained in chronic cystitis by washing out the bladder first with distilled water and then with a solution of silver nitrate (i : 8000). Solutions varying in strength from 10 to 60 grains to the ounce (0.6-4.0 gm. to 30.0 c.c.) are extensively employed in the treatment of chronic stomatitis, chronic pharyngitis, and chronic laryngitis. Light touches of the solid stick act very favorably upon mucous patches. In chronic dysentery great benefit often follows the use of copious injections into the bowel of solutions of silver nitrate (10-30 grains to the pint — 0.65-2.0 gm. to 0.5 L.). These in- jections should be given two or three times a week, the fluid being introduced very slowly through a tube passed well up into the bowel. At first the amount injected should not ex- ceed 2 pints (1.0 L.), but later 4 or 5 pints (2.0-2.5 L.) may be employed with advantage. Internally, silver nitrate is employed chiefly for its local action on the gastro-intestinal tract In chronic gastric catarrh and in ulcer of the sto?nach no remedy, with the exception of bismuth subnitrate, is so generally useful. In obstinate catarrh of the stomach, especially when there is supersecretion or marked hyperesthesia of the mucous membrane, douching the stomach once or twice a week, first with a solution of silver nitrate (1:5000 to 1 : 2000) and then with plain water, is a valuable method of treatment. About a pint (0.5 L.) of the solution should be introduced through the douche at each operation. Silver nitrate is also used in acute and chronic en- teritis, but with less benefit than in inflammatory diseases of the stomach. The treatment of epilepsy, locomotor ataxia, and chorea by the administration of the salts of silver possesses little more than a historic interest. Administration. — In affections of the stomach silver nit- rate should be given in pill form, half an hour before meals. Powdered opium or extract of hyoscyamus may be used as an excipient. When intended to act in the bowel, it should be given in keratin-coated pills. The administration of silver should not be continued for a longer period than six or eight weeks without interrupting the treatment for a like period. Incompatibles. — Organic matter, bromids, chlorids, iodids, cyanids, sulphids, carbonates, phosphates, arsenites, and hydro- chloric acid. With creasote it is explosive. Organic Silver Salts and Soluble Silver. — Many at- tempts have been made recently to produce compounds of sil- ARGENTUM. 373 ver that will not precipitate albumins and chlorids, and yet will retain the germicidal properties of the metal. The most im- portant compounds of this class thus far introduced are argen- tamin, silver lactate (actol), silver citrate (itrol), protargol, ar- gyrol, and largin. In addition to these, Crede has also sug- gested a soluble allotropic form of silver (argentum solubile). The therapeutic value of these preparations has not yet been definitely determined. Argentamin. — This is a solution of silver nitrate (10 per cent.) in an aqueous solution of ethylendiamin (10 per cent.), the purpose of the ethylendiamin being to prevent the precipitation of the salt by albumins and chlorids. Like other silver preparations, it is decomposed by light. It has been used chiefly in gonorrhea and in conjunctivitis ; in the former, in solutions of from I : 2000 to 1 : 100, and in the latter, in solutions of from 3 to 5 per cent. In the eye its action is somewhat irritating. Silver Lactate (Actol). — This is a white powder, free from odor and taste, and soluble in about 20 parts of water. It is a powerful germicide, solutions of 1 : 1000 destroying most micro- organisms within five minutes. Solutions of from 1 : 1000 to I : 500 have been employed for injection in gonorrhea, but they have proved very irritating. Silver Citrate (Itrol). — This salt resembles the lactate in appearance, but as it is almost insoluble in water, it is much less irritating. It has been used as an antiseptic dusting- powder for wounds, and in solution (1 : 5000) as a disinfectant for instruments and the skin. Protargol. — This is a proteid compound of silver containing about 8 per cent, of metallic silver. It is a fawn-colored powder, freely soluble in water. It is an energetic germicide and comparatively free from irritant properties. It has been used quite extensively and with good results in purulent con- junctivitis (1 to 10 per cent, solution), in gonorrhea (0.25 per cent, solution gradually increased to 2 per cent.), and in sup- purative middle-ear disease (3 to 5 per cent, solutions). Argyrol (Silver Vitellin). — This is a compound of silver and a vegetable proteid containing 30 per cent, of metallic silver. Its high percentage of silver (nearly four times that of protargol), extreme solubility, and comparative freedom from irritant properties make it one of the most serviceable of the organic silver compounds. In solutions of from 5 to 25 per cent, it has been used with considerable success in both acute and chronic gonorrheal infections, purulent conjunctivitis, and suppurative affections of the ear, nose, and throat. Largin. — This is also a proteid compound of silver. It is 374 ASTRINGENTS, a grayish powder, freely soluble in water, containing about 1 1 per cent, of metallic silver. It has been used with asserted good results in gonorrhea (0.5 to 1.5 per cent, solution) and in purulent ophthalmia (1 to 10 per cent, solution). Soluble or Colloidal Silver (Argentum Colloidale, Collar- gol). — This is an allotropic form of silver, occurring in heavy, greenish-black particles, readily soluble in water, forming a reddish-brown solution. It is most commonly used in the form of a 15 per cent, ointment, known as Crede's ointment, which has been found of service as a local remedy in such con- ditions as e?ysipelas, lymphadenitis, septic phlebitis, and go?wr- rheal arthritis. With the view of producing a constitutional impression, daily inunctions of the ointment (45 gr. — 3.0 gm.) have also been employed in various septic processes, but this method of using the drug is not very promising. BISMUTHUM. (Bismuth; Bi.) The following preparations of bismuth are official : Bismuth subnitrate {Bismuthi Subnitras, U. S. P.), bismuth subcarbonate (Bismuthi Subcarbo?ias } U. S. P.), bismuth subgallate {Bismuthi Subgallas), bismuth subsalicylate {Bismuthi Subsalicylas), bis- muth citrate {Bismuthi Citras, U. S. P.), and bismuth ammo- nium nitrate {Bismuthi et Ammonii Citras, U. S. P.). As the bismuth preparations are useful largely on account of their insolubility, the soluble salts — bismuth citrate and bismuth and ammonium citrate — seem to be superfluous. Among compounds oi bismuth which are in use, but which are not official, may be mentioned tribromphenol-bismuth (xeroform), and betanaphthol-bismuth (orphol). These will be considered in the section devoted to Germicides and Antiseptics (p. 383). BISMUTHI SUBNITRAS, U. S. P. (Bismuth Subnitrate; BiON0 3 -(-H 2 0(?).) Bismuth subnitrate is a heavy white powder, of a somewhat varying composition, odorless, almost tasteless, and permanent in the air. It is insoluble in water and in alcohol. The dose is from 5-40 gr. (0.3-2.6 gm.). Physiologic Action. — When taken internally, even in very large doses, the effects of bismuth subnitrate are confined to the mucous membrane of the alimentary canal, its action being that of a feeble astringent and protective. Since traces of the metal have been found in the urine there must be some absorption, but the amount of the drug entering the blood is undoubtedly too small to exert any special influence. Worden, Sailer, and Pancoast have reported six cases in which BISMUTHUM. 375 alarming symptoms were observed after 2 to 4 ounces (60.O- 120.0 gm.) of perfectly pure bismuth subnitrate had been given for diagnostic purposes. It is suggested, however, that the symptoms were due to the formation of nitrites in the intestines, as they were quite unlike those produced by heavy metals. The characteristic black stools following the administration of the drug are attributed to its partial conversion into a sulphid in the intestine. The breath of patients taking bismuth some- times acquires a peculiar garlicky odor ; this is due, as Reisert has demonstrated, to the minute tellurium impurities often present in commercial bismuth compounds. Upon the unbroken skin bismuth subnitrate acts simply as a protective, but on raw surfaces it acts also as an astringent and antiseptic. Absorption takes place rather readily from denuded parts, and poisoning may occur if the drug be applied too freely. The symptoms of bismuth poisoning are saliva- tion, stomatitis, dysphagia, a black discoloration of the mucous membrane of the mouth, ulceration of the throat, diarrhea, and albuminuria. Therapeutics. — No drug is so generally useful as bismuth subnitrate in allaying gastric irritation from various causes. It is a standard remedy in both acute and chronic gastric catarrh and in gastric ulcer. In the latter affection excellent results are often obtained by giving a single daily dose of from 1-2 dr. (4.0-8.0 gm.) in the morning, on an empty stomach, and then having the patient assume various positions — on the back, on the right, and on the left side, remaining in each position for five or ten minutes. In many cases of ulcer an alkali, such as sodium bicarbonate or magnesia, may be added with advantage. Even in gastric cancer the drug sometimes affords temporary relief. It is of much service in gastralgia dependent upon ex- cessive acidity of the stomach. Vomiting the result of gastric irritation generally yields to it. It is especially efficacious as an antiemetic when conjoined with diluted hydrocyanic acid. In catarrhal diarrhea, after the intestine has been thoroughly emptied, bismuth subnitrate is invaluable as a protective and an astringent. In these cases it may be combined advantageously with morphin and an antiseptic, as in the following formula : R Morphinae sulphatis, gr. j (0.06 gm.) ; Salol, gr. xxx (2.0 gm.); Bismuthi subnitratis, ^vj (24.0 gm.). M. Fiant chartulae No. xv. Sig. One every three hours. Topically, bismuth subnitrate, alone or with starch, may be used as a dusting-powder in acute erythema and in intertrigo. In the form of a paste made with glycerin and water it has 376 ASTRINGENTS. been employed rather extensively also as a protective dressing for burns ; in a number of instances, however, such applica- tions have been followed by poisoning. In the second stage of gonorrhea injections of bismuth subnitrate, 15 gr. (1.0 gm.) to the ounce (30.0 c.c.) of glycerin and water, have a favorable action. In acute coryza a snuff composed of bismuth subnitrate, gum acacia, and a little morphin sometimes affords relief. Administration. — It is usually prescribed in powders or in capsules. Very large doses, however, may be given con- veniently in water, the mixture being well shaken before each administration. Alkaline bicarbonates and sodium hyposul- phite are incompatible with such mixtures. In affections of the stomach the drug should be taken half an hour before meals. BISMUTHI SUBCARBONAS, U. S. P. (Bismuth Subcarbonate ; (BiO) 2 C0 3 -f H 2 (?).) Bismuth subcarbonate closely resembles bismuth subnitrate in its physical properties and action. Its uses and dose are the same as those of the subnitrate. When an enormous dose of a bismuth salt is required, as in the skiagraphic examination of the stomach and intestines, the subcarbonate should be selected in preference to the subnitrate, as being less likely to cause ill-effects -from decomposition. BISMUTHI SUBGALLAS. (Bismuth Subgallate; Dermatol; C6H 2 (OH) 3 C0 2 Bi(OH) r ) Bismuth subgallate is a fine, yellowish-white powder, odor- less and tasteless, permanent, and insoluble in ordinary sol- vents. It should contain not less than 52 per cent, nor more than 57 per cent., of bismuth oxid. The dose is from 5-30 gr. (0.3-2.0 gm.). Therapeutics. — Bismuth subgallate has been employed somewhat extensively as a protective and an astringent appli- cations for burns and moist eczema. It does not appear, how- ever, to have been less harmful than other bismuth compounds when used externally. Internally it has been used instead of the subnitrate in catarrhal affections of the stomach and intestine^ but it has no advantages over the official preparation. BISMUTHI SUBSALICYLAS, U. S. P. (Bismuth Subsalicylate ; Bi(C r H s 3 ) 8 Bi 3 3 .) Bismuth subsalicylate is a white amorphous or crystalline powder, odorless and tasteless, and insoluble in water. It is used chiefly as an intestinal antiseptic and astringent in diarrhea. The dose is from 5-20 gr. (0.3-1.3 gm.). HEMOSTA TICS. 377 CALCII CARBONAS. (Calcium Carbonate; Chalk ; CaC0 3 .) Chalk is official in two forms : Precipitated calcium carbon- ate {Calcii Carbonas Prcecipitatus, U. S. P.) and prepared chalk {Creta Prceparata, U. S. P.). The dose of either preparation is from 10-40 gr. (0.65-2.3 gm.) or more. Preparations. Dose. Pulvis Cretse Compositus, U. S. P. (prepared chalk, 30; acacia, 20; sugar, 50) . . . 5-40 gr. (0.3-2.3 gm.). Mistura Cretse, U. S. P. (compound chalk powder, 20; cinnamon water, 40; water, q. s. 100) 1-4 fl. dr. (4.0-15.0 c.c). Hydrargyrum cum Creta, U. S. P. (57 per per cent, of chalk) \~ l ° g 1 - (0.03-0.6 gm.). Therapeutics. — Chalk is a mild astringent and antacid, free from irritant properties. It may be employed in acute inflammatory diarrhea in the same manner as bismuth sub- nitrate. It is an excellent antacid when acidity of the stomach is associated with relaxation of the bowels. It may be pre- scribed as an antidote in poisoning by a mineral acid or by oxalic acid. Externally, it is used as a dusting-powder in erythematous eczema and intertrigo. It is particularly useful in the chafing of the genitalia and buttocks of young children from irritation by urine. It enters into the composition of most tooth-powders. HEMOSTATICS. Hemostatics are agents that arrest hemorrhage. They all act in accordance with the methods pursued by nature in spontaneously closing a bleeding vessel. If an artery be divided, it shrinks within its sheath, the contiguous structures fall in upon the bleeding orifice, and if the hemorrhage be copious, the force of the circulation diminishes and the coagula- bility of the blood increases. The choice of the hemostatic will largely depend upon the seat of the hemorrhage — that is, whether it is in an accessible or in an inaccessible region, and upon its source — that is, whether it is of capillary, of venous, or of arterial origin. Hemorrhage from a large vessel in an accessible region should always be controlled by mechanical means — that is, by ligature, torsion, pressure, acupressure, or cauterization. Many parts formerly considered inaccessible are 378 HEMOSTA TICS. no longer so regarded, and to-day surgical aid is sometimes wisely invoked to arrest excessive bleeding from such organs as the stomach and bowel, and even the brain. Small external hemorrhages, especially capillary oozing, are often satisfactorily controlled by the direct application of agents that contract the vessels or that coagulate the albumin of the blood. The most potent local vasoconstrictors are cold, in the form of water or of ice, and adrenalin ; and the most powerful styptics are ferric subsulphate, ferric chlorid, alum y and tannic acid. Three classes of drugs have been recommended to control hemorrhage in organs that must be reached through the cir- culation. The first includes drugs like tannic acid and certain mineral salts, which have been found useful as local styptics or astringents ; the second, drugs like ergot, which cause vaso- constriction by stimulating the vasomotor centers or by acting directly on the muscular walls of the vessels ; and the third, drugs like gelatin and calcium chlorid, which are thought to increase the natural coagulability of the blood. There is no reason to believe that tannic acid exerts any in- fluence as a hemostatic outside of the alimentary canal, since it enters the blood in such a form {gallic acid) that it loses its styptic and astringent properties. As regards the mineral astringents, it is exceedingly doubtful whether any one of them can enter the circulation in sufficient quantity to exert a favor- able influence upon a hemorrhage in a territory remote from the point of absorption. Owing to its power of causing con- traction of the unstriped muscle of the uterus, ergot is unques- tionably of value in controlling certain forms of metrorrhagia, but the testimony to its efficacy in other internal hemorrhages, such as hemoptysis and hematuria, is not convincing. Grant- ing that it has the power of causing vasoconstriction through a central influence, it is unreasonable to suppose that its effects are limited to the vessel concerned in the bleeding, and if such be not the case, it should tend to do harm rather than good, since a universal narrowing of the blood-paths and a conse- quent rise in the blood-pressure must favor the escape of blood and also hinder the formation of an occluding thrombus. Like ergot, hydrastinin and cotarnin also act as vasoconstrictors. While clinical experience has shown them to be of value in some forms of metrorrhagia, it is doubtful whether they are of any avail in bleeding from other organs. Gelatin and calcium chlorid have recently been recommended as internal hemo- statics on the ground that they increase the normal coagula- bility of the blood. The former appears to be more reliable HYDRASTIS. 379 than the latter, but sufficient time has not yet elapsed to allow of any decided opinion of its efficacy. In the treatment of internal hemorrhage absolute rest of body and mind is essential. An ice-bag may be applied over the seat of the bleeding. Opium is of great value ; it not only exerts a calmative effect, but it also serves to control involun- tary movements, such as cough and peristalsis. For the pur- pose of lowering the blood-pressure a ligature may be applied to a leg or an arm. For the profound anemia which accom- panies or follows profuse hemorrhage normal salt solution may be given subcutaneously. The only drugs employed as hemostatics which have not been considered in other sections are hydrastis, cotarnin, gela- tin, and calcium chlorid. HYDRASTIS, U. S. P. (Golden Seal.) Hydrastis is the rhizome and root of hydrastis canadensis, a perennial herb growing in the woods of North America east of the Mississippi. It contains hydrastin, berberin, and canadin. Of these hydrastin is official as Hydrastina. By oxidizing hydrastin with potassium permanganate the artificial alkaloid hydrastinin is obtained, which is official as Hydrastinince Hydro- chloridum. The dose of crystalline hydrastin is from \-\ gr. (0.01-0.03 gm.); of hydrastinin hydrochlorid, from J-i gr. (0.016-0.06 gm.). Preparations. Dose. Fluidextractum Hydrastis, U. S. P £-1 fl. dr. (2.0-4.0 c.c). Tinctura Hydrastis, U. S. P J-2 fl. dr. (2.0-8.0 c.c). Glyceritum Hydrastis, U. S. P £-2 fl. dr. (2.0-8.0 c.c). Physiologic Action. — Hydrastis owes its activities largely to the presence of the alkaloid hydrastin. The latter is first an excitant and then a paralyzant of the spinal cord, conse- quently toxic doses are followed first by tetanic convulsions and later by motor paralysis. Large doses primarily raise the blood-pressure by stimulating the vasomotor centers and thus constricting the arterioles ; secondarily, they lower the blood- pressure by depressing the vasomotor centers and the heart. Hydrastin probably increases peristalsis and induces uterine contractions, although its power to do the latter has been denied by some authorities. Finally, the drug, when locally applied, seems to exert a favorable influence on chronic catarrhal inflammations, but the manner of its action is not understood. Hydrastinin in very large doses is a powerful paralyzant to 3 So HEMOSTA TICS, the motor centers of the brain and spinal cord. The paralysis is apparently not preceded, as in the case of hydrastin, by a stage of motor excitation. Like hydrastin, it raises the arterial pressure, but its action in this respect differs from that of hydrastin in being more pronounced and more lasting and in not being followed secondarily by circulatory depression. The rise in the arterial pressure is due in part to stimulation of the vasomotor centers, and in part, also, according to some authors, to stimulation of the heart and of the muscular coats of the arterioles. Whether or not hydrastinin can induce uterine contractions is a moot question, but the trend of experimental evidence favors the view that it does possess ecbolic properties and is capable, in sufficient dose, of causing abortion. Therapeutics. — Hydrastis is a useful local remedy in cer- tain catarrhal affections. In leukorrhea, injections of the fluid extract, 2 fluidrams (8.0 c.c.) to the pint (0.5 L.) of hot water, are often beneficial. In the catarrhal stage of gonorrhea injec- tions of hydrastinin hydrochlorid, 1-5 gr. (0.06-0.3 gm.) to the ounce (30.0 c.c), have been used with excellent results. The same preparation, in doses of from y^— J gr. (0.005-0.01 gm.),has also been highly recommended as an internal remedy in chronic gastric catarrh, especially when there is muscular atony. Both hydrastinin and hydrastin have been largely used in- ternally as uterine hemostatics. They are particularly effi- cacious in menorrhagia or metrorrhagia dependent upon con- stitutional disorders, endometritis, or disease of the adnexa. Hydrastin cannot be used externally owing to its insolu- bility. COTARNIN^E HYDROCHLORID. (Stypticin.) Cotarnin is an artificial alkaloid closely allied to hydrastinin in its chemical composition, and obtained by the oxidation of the opium alkaloid, narcotin. It appears in the form of yellow crystals of a bitter taste, and freely soluble in water. The dose is from f-3 gr. (0.3-0.2 gm.), three or four times a day. It may be administered by the mouth or subcutaneously. Its action resembles that of hydrastinin, but is less rapid. It has been found useful as a hemostatic in uterine hemon'hages not accompanied by gross lesion of the uterine mucous membrane. GELATINUM, U. S. P. (Gelatin.) Gelatin is the air-dried product of the action of boiling water on gelatinous animal tissues, such as skin, tendons, liga- ments, and bones. It occurs in brittle, transparent sheets or shreds, without odor or taste. It is insoluble in cold water, GELATINUM. 38 1 but freely so in hot water, and if the solution contain more than 2 per cent., it solidifies on cooling. Solutions heated above a temperature of 230 F. (no° C), however, remain permanently liquid. Physiologic Action. — In 1896 Dastre and Floresco demonstrated that blood drawn from a dog into which a 5 per cent, solution of gelatin had been injected intravenously solidi- fied almost immediately, and further that the same result could be secured by adding gelatin to the blood outside of the body. That the solidification was due to clotting and not merely to jellifying was evident from the fact that it occurred at a tem- perature (3 8° C.) at which a 5 per cent, solution of gelatin will not jellify, and, moreover, that it occurred also with solutions containing a percentage of gelatin much under that which is necessary for jellying — that is, under 2 per cent. These ob- servers also showed that gelatin could offset the anticoagulant action of peptones, but not of concentrated saline solutions or of substances which decalcify the blood, like oxalic acid. In 1898 Lancereaux and Paulesco found that subcutaneous in- jections of gelatin were quite as efficient in increasing the coagulability of the blood as intravenous injections. Whether or not its power is affected by digestion has not been defi- nitely determined, although a number of practitioners have attributed good results in hemorrhage to its administration by the mouth or rectum. No satisfactory explanation has yet been offered of the action of gelatin in promoting the coagula- bility of the blood. Therapeutics. — Carnot appears to have been the first to bring gelatin prominently forward as a hemostatic ; although, according to Miwa, it has been used for this purpose for many centuries in Oriental countries. Considerable testimony has already accumulated as to its efficacy in hemorrhages from both external and internal parts. As a local remedy it has been used with success in epistaxis, metrorrhagia, bleeding front hemorrhoids, and in oozing from wounds. As an internal hemo- static it has apparently rendered service in hemoptysis, hema- turia, and enter orrhagia. It has been found efficacious also in hemophilia, purpura hemorrhagica, and melcena neonatorum. For bleeding in accessible parts a 10 per cent, solution may be applied on tampons. The solution should be sterilized and should have added to it a small quantity of carbolic acid to prevent de- composition. The dose for subcutaneous administration is from 15—45 % x > (1.0-3.0 gm.), in the form of a 5 or 10 per cent, solu- tion, once or twice a day. The best vehicle is normal salt solution. A 10 per cent, solution may be prepared by dissolv- ing 1 J ounces (50.0 gm.) of gelatin and 35 gr. (2.5 gm.) of 382 HEMOSTA TICS. salt in a pint (0.5 L.) of hot distilled water. After the mixture has been allowed to cool, the white of an egg should be stirred in, and the whole brought quickly to the boiling-point. The mixture should next be filtered first through gauze and then through paper. Finally, it should be poured into small flasks and sterilized in a steam sterilizer, fifteen or twenty minutes, once daily, for three days. Prepared in this way the mixture will keep for several weeks. When required, it should be liquefied by standing the flask in hot water, and then injected to the amount of from 3 to 5 fluidrams (10.0-20.0 c.c.) into the thigh or under the breast, using for the purpose a perfectly sterile syringe. When the fluid is free from turbidity, the in- jections are not painful. It is exceedingly important that the solution should be absolutely sterile, since commercial gelatin not infrequently contains tetanus bacilli. Several cases of tetanus developing after gelatin injections have recently been reported. Acute nephritis is regarded by some authorities as a contraindication to the employment of gelatin subcutaneously. When administered by the mouth, it may be given in doses of from 1-8 dr. (4.0-30.0 gm.) or more daily. The treatment of aortic aneurysms by subcutaneous injec- tions of gelatin, first recommended by Lancereaux, although it seemed promising, has not proved very satisfactory. It is followed, however, in a certain proportion of cases by a tem- porary amelioration of the symptoms. It is credited with hav- ing caused embolism in one or two instances. Gelatin makes a good protective dressing for indolent leg ulcers, especially when they are accompanied by chronic eczema. It may be employed in the form of Unna's dressing : JJ Zinci oxidi, Gelatini, aa 3J (4.0 gm.); Glycerini, Aquae, aa fj^iv (120.0 c.c). M. Sig. After the ulcer has been thoroughly cleansed and disinfected, coat the eczematous regions with Lassar's paste (starch and zinc oxid, of each, 2 parts; vaselin, 4 parts), dust the ulcer with iodoform, and cover it with cotton. Then paint the entire limb with Unna's dressing melted and applied with a brush. Band- age evenly and firmly, first with gauze soaked in hot water, then with dry gauze, and finally with a cotton roller bandage. The dressing should be changed every two, four, or six days, accord- ing to the amount of discharge. Incompatible s. — Tannic acid and formaldehyd. GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 383 CALCII CHLORIDUM, U. S. P., and CALCII LACTAS. (Calcium Chlorid, CaCl 2 , and Calcium Lactate, Ca(C 2 H 4 OH.COO) 2 + 5H 2 0.) Calcium chlorid occurs in white, slightly translucent, hard fragments, very deliquescent, odorless, and of a sharp saline taste. It is soluble in 1.3 parts of water and in 8 parts of alco- hol. Calcium lactate is a white crystalline powder, not readily soluble in water unless freshly prepared. The dose of either salt is from 5-20 gr. (0.3-1.3 gm.) after meals, well diluted. Therapeutics.— The conclusions of Wright, of Netley, England, that calcium salts possess the power of increasing the coagulability of the blood, have led to their extensive use in the treatment of hemophilia, purpura, aortic aneurysjn, and various internal hemorrhages, as well as of a number of con- ditions, such as urticaria, chilblains, and certain persistent headaches, in which blood coagulability is supposed to be defective. Recent observers, however, have failed to confirm Wright's conclusions, and it is very doubtful if calcium can be of benefit in any of the conditions mentioned. Very recently MacCallum and Voegtlin have shown that the intravenous in- jection of a 5 per cent, solution of calcium lactate causes an almost instant arrest of the tetanoid symptoms occurring after parathyroidectomy, and believe that the drug may have some therapeutic importance, not only in postoperative tetany but also in those forms occurring spontaneously. GERMICIDES, ANTISEPTICS, AND DEODORIZERS. Germicides or disinfectants are agents that destroy micro-organisms and their spores. They may act by exerting some specific influence on the micro-organisms, by coagulating their albuminous constituents, or by entering into chemical combination with the microprotein. The chief germicides are : Mercuric chlorid. Phenol (carbolic acid), Cresols, Creosol, Guaiacol, Resorcin, Naphthalen, Betanaphthol, Salicylic acid, Benzoic acid, Aromatic Series. > Benzene derivatives or coal- tar germicides. 384 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. Formaldehyd. Sulphurous acid. Urotropin. Hydrogen dioxid. Silver compounds. Potassium permanganate. Chlorin. Lime. Bromin. The various preparations of quinin also possess a moderate amount of germicidal power ; they are especially destructive to certain protozoa, such as the hematozoa of malaria and the amoebae of dysentery. Heat is the most certain disinfectant. All known pathogenic bacteria and their spores are destroyed by boiling water in from five to ten minutes, and by steam (21 2° F. — ioo°C), at ordinary pressure, within an hour. Steam under pressure is a still more energetic disinfectant. Dry heat, on account of slight penetrating power, is much less effective than moist heat. According to Koch, sporeless bacteria are destroyed in one and one-half hours by hot air at a temperature slightly above 21 2° F. (ioo° C), and spores of bacilli in three hours by hot air at a temperature of 316 F. (140 C). Antiseptics are agents that prevent or hinder the growth of micro-organisms without necessarily destroying them. Whether a substance act as a germicide or as an antiseptic depends largely upon the degree of concentration in which it is employed. By dilution germicides may be reduced to the rank of antiseptics. The following substances may be classed as antiseptics, since in the solutions ordinarily used they ar- rest the development of bacteria, but do not destroy them : Boric acid. Picric acid. Ferrous sulphate. (Eucalyptus. Thyme. Sandalwood. Copaiba. Cubeb. r Methyl-blue. Many anilin derivatives. < Methylene-blue. ( Acetanilid. Iodoform (see p. 319), although it is practically without antiseptic power, nevertheless makes a valuable dressing for in- fected wounds. It probably acts indirectly by absorbing moisture, by liberating iodin, which is antiseptic, and, perhaps, by neutralizing the toxins formed by pyogenic bacteria. DEODORIZERS. 385 Deodorisers are agents that destroy offensive odors. They do not, of necessity, possess either germicidal or antiseptic power. They may act by oxidizing or deoxidizing fetid com- pounds or by abstracting hydrogen from them. The most powerful deodorizers are : Chlorin. Sulphurous acid. Formaldehyd. Potassium permanganate. Lime. Hydrogen dioxid. Charcoal. Pulverized dry earth is a useful deodorant of fecal matter, but it is not to be considered as a disinfectant. General Surgical Antisepsis. — Mercuric chlorid (see p. 327) is the most popular of the germicides for general surgical work. It is energetic, soluble, and cheap. On the other hand, it has three disadvantages : it is very poisonous, it is de- structive to metal instruments, and it is readily converted into an inert compound in the presence of albuminous matters. This last drawback may be offset by adding to its solutions a weak acid (tartaric acid). For the patient's skin and the sur- geon's hands solutions of from 1 : 1000 to 1 : 500 should be employed; for large wounds and cavities, I : 10,000 to I : 5000; and for small wounds, 1 : 2000. On account of its irritant properties it should not be used on serous membranes. Carbolic acid is not nearly so reliable as corrosive sublimate, but it is quite destructive to pus-organisms. It is readily solu- ble, is not affected by albuminous matters, and does not seri- ously injure metal instruments, although it dulls them. On the other hand, it is decidedly toxic, and it has a benumbing effect on the hands of the operator. A solution of 1 : 20 is often employed for cleansing suppurating wounds, sinuses, and abscess cavities. A solution of 1 : 40 is sometimes used as a bath for instruments. Formaldehyd is a very powerful germicide, but it is too irritating to be generally useful in surgical work. One or 2 per cent solutions of formalin (40 per cent, solution of the gas in water), however, are sometimes employed to disinfect wounds and to irrigate sinuses and suppurating cavities. In- struments may be disinfected by immersion in a 2 per cent, solution of formalin, or, better, by subjecting them to the action of the gas in a closed chamber (see p. 403). Disinfection of the Hands. — Furb ringer's method, or some modification of it, is usually followed : after removing all dirt from around and beneath the nails, the forearms, hands, and 25 386 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. nails are thoroughly scrubbed with soap and hot water. The hands are then soaked for at least a minute in alcohol (95 per cent), and before the alcohol has evaporated they are plunged in a hot solution of corrosive sublimate, 1 : 500. Finally, they are rinsed in sterile water and dried. The alcohol removes the soap and grease from the furrows and pores, and favors the penetration of the germicide. Kelly, after scrubbing the hands, dips them in a warm, saturated solution of potassium perman- ganate, then in a warm, saturated solution of oxalic acid, and, finally, in distilled water. Weir's method has been found very satisfactory. It is applied as follows : Scrub the hands and forearms in running hot water, using a brush and green soap ; clean under and around the nails with a bit of soft wood ; place in the palm a tablespoonful of chlorinated lime and an equal quantity of washing soda (not sodium bicarbonate) ; add enough sterile water to make a creamy mass, and rub this cream over the hands and forearms until the harsh soda gran- ules can no longer be felt. This rubbing should occupy about five minutes. Push the paste under and around the nails by means of a piece of sterile orange-wood, and then wash in hot, sterile water. Antisepsis of Mucous Membranes. — The most important bac- terial poisons for use on mucous membranes are mercuric chlorid, silver nitrate, organic silver compounds, boric acid, potassium permanganate, and formalin. G astro-intestinal Antisepsis. — Internally, antiseptics are of service in controlling fermentation and putrefaction in the con- tents of the stomach and bowel. Of course they cannot render the alimentary canal aseptic, nor can they affect bacteria like the typhoid bacillus and the tubercle bacillus, which multiply in the intestinal walls. The chief gastro-intestinal antiseptics are carbolic acid, creosote, guaiacol, naphthalin derivatives, salicylic compounds, sulphites, resorcin, and thymol. Silver nitrate and the mercurial preparations also owe, no doubt, some of their efficacy in affections of the digestive tract to their antiseptic properties. Urinary Antiseptics. — It is quite possible to inhibit the growth of micro-organisms in the urine by administering anti- septic agents by the mouth. Urotropin, salicylic compounds, benzoic acid, and several volatile oils (copaiba, cubeb, sandal- wood) are used for this purpose. Disinfection of Stools and Sputum. — Stools should be thor- oughly mixed with twice their volume of a 1 per cent, chlor- inated lime solution, of a 5 per cent, carbolic acid solution, or of a 2 per cent, formalin solution, allowed to stand for two or three hours, and then buried or discharged into the closet. PHENOL. 387 Infected sputum should be received into cups containing a I per cent, chlorinated lime solution or a 5 per cent, carbolic acid solution ; or the patient may expectorate into moist rags or into impermeable paste-board cups, which should be burnt be- fore the sputum has had time to dry. Disinfection of Rooms and their Contents. — Articles of little value should be burnt. Bedding, clothing, carpets, etc., should be disinfected by steam. Towels, napkins, and sheeting should be soaked in a 5 per cent, carbolic acid solution and then boiled. Woodwork, floors, and plain furniture should be washed with a chlorinated lime solution (1 per cent.) or with a corrosive sublimate solution (1 : 5000). Finally, the room should be fumigated with formaldehyd gas (see p. 4°3) or with sulphur dioxid (see p. 407), preferably with the former. PHENOL, U. S. P. (Phenol ; Carbolic Acid ; C 6 H 5 OH.) Phenol or carbolic acid is obtained from the distillation of coal-tar, and when pure occurs in the form of colorless, needle- shaped crystals of a characteristic odor and of an acrid, burning taste. In the light it acquires a reddish tint, and on exposure to the air it deliquesces. It is soluble in 19.6 parts of water, and freely in alcohol, glycerin, chloroform, ether, and oils. Although it combines with salifiable bases, it is chemically not an acid, but an alcohol of the benzene group. The dose is from \-2 gr. (0.03-0.13 gm.). Preparations. Dose. Phenol Liquefactum, U. S. P. (86.4 per cent. of absolute phenol and 13.6 per cent, of water) \-2. min. (0.03-0. 12 c.c). Unguentum Phenolis, U. S. P. (3 per cent.). Glyceritum Phenolis, U. S. P. (20 per cent.) . 2-10 min. (0.12-0.6 c.c). Physiologic Action. — When applied to the skin, carbolic acid blanches the surface and causes a burning sensation, which is soon followed by numbness. Later the part becomes red and then brown, and the epidermis desquamates. On account of the albuminous coagulum that it forms its caustic action does not extend very deeply into the tissues. Its prolonged application, however, even in dilute solution (5 per cent.), has been followed by gangrene in a number of instances. Absorp- tion readily occurs from cutaneous surfaces, mucous mem- branes, and wounds. 388 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. The heart-beat is first slightly quickened and then slowed, probably as a result of the direct action of the drug on the cardiac muscle. Circulatory System. — In poisoning there is a marked fall in the blood-pressure from depression of the heart and the vasomotor centers. Nervous System. — Toxic doses are quickly followed by stupor and coma, the result of cerebral depression. In man, symptoms referable to the action of the drug on the spinal cord are rarely noted, but in the lower animals tetanic seizures often develop and are followed by paralysis, indicating that the spinal centers are at first excited and then depressed. Locally, the drug acts as an anesthetic by paralyzing the peripheral sensory nerve filaments. Respiratory System. — The respirations are first quickened and then slowed, in consequence, probably, of the primary stimulation and the secondary paralysis of the respiratory cen- ter. In fatal poisoning death usually results from asphyxia. Temperature. — Large doses lower the bodily temperature, probably through a central action, which results in increased heat-dissipation. Elimination. — Carbolic acid is eliminated by all the emunc- tories, but chiefly by the kidneys. In the tissues a part com- bines with sulphuric and glycuronic acids, and is eliminated as the double sulphate and glycuronate of phenol ; a part is oxi- dized into hydroquinon and pyrocatechin, which leave the body also largely as double sulphates and glycuronates. When the amount of phenol ingested has been very large, a part is excreted unchanged. After large doses the urine acquires a smoky or greenish-black color, which is due, prob- ably, to oxidation products of hydroquinon and pyrocatechin. In poisoning ischuria and albuminuria are common symptoms. Action on I/Ower Organisms. — Phenol is fatal to most pathogenic bacteria, but is not very effective against spores. A solution of I : iooo prevents the development of most bacteria ; a solution of I : ioo, under favorable conditions, destroys pyogenic cocci, tubercle bacilli, cholera bacilli, and many other non-spore-forming bacteria. Anthrax bacilli in the spore stage resist the action of a 5 : 100 solution for many days. Alcohol and ether as solvents lessen its germicidal power, and oils practically destroy it. Heat increases its destructive action. Toxicology. — Poisoning may result either from the inges- tion of the drug or from its external application. After the ingestion of a very large dose (1 oz. — 30.0 c.c.) the usual symptoms are unconsciousness, contraction of the pupils, ster- PHENOL. 389 torous breathing, a rapid, feeble pulse, and collapse. If the dose has not been so large, these symptoms may be preceded by those of gastro-enteritis. The characteristic phenomena are the odor on the breath, the white, corrugated patches on the buccal mucous membrane, and the smoky urine. In poisoning from the use of the acid externally the initial symp- toms generally are discoloration of the urine, headache, ver- tigo, pallor, and muscular weakness. Treatment. — Two drugs are of special value when the poison has been taken by the mouth : Alcohol, which neu- tralizes its caustic action, and a soluble sulphate (Epsom salt), which forms with it an innocuous sulphocarbolate. Two or three ounces (60.0-90.0 c.c.) of diluted alcohol should be poured into the stomach through a tube, and then lavage practised with water containing Epsom salt. Demulcents are useful in allaying the irritation. The application of external heat and the subcutaneous administration of diffusible stimu- lants are also indicated. Therapeutics. — As an antiseptic . for general surgical pur- poses carbolic acid no longer holds a prominent place. Solu- tions that are really effective are too irritant and too toxic to be employed. It is rarely used at present even for disinfecting instruments, because it dulls them and at the same time be- numbs the surgeon's fingers. Its prolonged application in the form of a moist dressing, even in weak solution, is dangerous. Harrington has collected 132 cases of gangrene of the fingers or toes from its external application. In most of these cases the strength of solution was less than 5 per cent. A solution of I : 20 is still employed to some extent for cleansing suppurating wounds and abscess cavities. Carbuncles are sometimes aborted by injecting into them in the early stage from 5-10 min. (0.3-0.6 c.c.) of a 10 per cent, solution. Excellent results have been ob- tained in anthrax from the injection of from \-\ dr. (2.0-4.0 gm.) of the pure acid into and around the eschar in the course of a day. Bacelli speaks very favorably of carbolic acid injections in tetanus. He recommends that from -|— § gr. (0.02-0.04 gm.) should be given hypodermically every two or three hours until a daily amount of from 8-15 gr. (0.5-1.0 gm.) has been reached. Pure carbolic acid is sometimes employed to destroy chancroids and venereal warts and to purify sloughing wounds. A 5 per cent, solution may be used for disinfecting soiled clothing and various excretions, like sputum, feces, and vomited matters. In the form of a 2 per cent, spray it may be employed as an inhalation to destroy the fetor of the breath in such affections as bronchiectasis and gangrene of the lung. 390 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. Carbolic is very useful as a local sedative and antipruritic. Carbolized oil, 10 gr. (0.6 gm.) to the ounce (30.0 c.c), although it has no antiseptic power, makes a soothing dressing for super- ficial burns. In the form of a lotion it is the most valuable remedy we possess to allay itching in eczema, urticaria, jaun- dice, and pruritus. It may be employed in the strength of from 2-3 dr. (8.0-12.0 gm.) to the pint (0.5 L.), as in the following formula : R Phenolis, £ij-iij (8.0-12.0 gm.) ; Acidi borici, Ziv (15.0 gm.) ; Alcoholis, f J5J (30.0 c.c.) ; Glycerini, f t ^ss (15.0 c.c.) ; Aquae, q. s. ad Oj (0.5 L.). M. Internally, carbolic acid is used as an antiemetic and as an antiseptic. Doses of from 1-2 min. (0.06-0.12 c.c.) are some- times efficacious in checking vomiting the result of gastric irritability. In the same doses, combined with bismuth, it is of service as an antiseptic in flatulent dyspepsia and in acute diarrhea. Administration. — It may be prescribed in pills, in cap- sules, in powders of bismuth subnitrate, or dissolved in some aromatic water. Incompatibles. — Alkalis, metallic salts, soluble sulphates, collodion. Sodium Sulphocarbolate, or Sodium Phenolsulpho- nate (Sodii Phenolsulphonas, U. S. P.). — This salt occurs in colorless, rhombic crystals, odorless, of a saline taste, and freely soluble in water. The dose is from 5-20 gr. (0.3-1.3 gm.). It is much less poisonous than carbolic acid. It is sometimes of service as an antiseptic in flatulent dyspepsia and in diarrhea. When intended to act in the stomach, it may be prescribed in solution ; when intended to act in the intestine, in keratin-coated pills. £inc Sulphocarbolate, or £inc Phenolsulphonate (Zinci Phenolsulphonas, U. S. P.). — This salt is somewhat more astringent than sodium sulphocarbolate. A solution of 5 gr. (0.3 gm.) to the ounce (30.0 c.c.) is sometimes used as a spray in catarrhal affections of the throat and as an injection in the second stage of gonorrhea. Internally it often acts favorably in diar- rhea. As an intestinal antiseptic the dose is from 2-3 gr. (0.1-0.2 gm.) in keratin-coated pills. Sosoiodol (Sozoiodolic Acid). — This compound is para- phenol-sulphonic acid with 2 atoms of hydrogen displaced by 2 of iodin. Paraphenol-sulphonic acid is prepared by acting on phenol with sulphuric acid in the presence of heat. Sozo- iodol occurs in needle-shaped crystals, soluble in water and in alcohol. It has been used as a substitute for iodoform. Its CRESOLS, CREOSOL, AND GUAIACOL. 39 1 salts — mercury, potassium, sodium, and zinc — have also been employed to some extent as antiseptics. Nosophen (Tetra-iodo-phenol-phthalein). — This compound is prepared by the action of iodin on a solution of phenol- phthalein. It is a pale, yellow, inodorous, and tasteless pow- der. With bases it forms salts, the most important of which is the sodium salt (antinosin). It is recommended as an antisep- tic dusting-powder. Xerofotin (Tribromphenol-bismutJi). — This is a yellowish, odorless, tasteless, and insoluble powder, representing about 50 per cent, of bismuth oxid. It has been used in place of iodo- form as an antiseptic application for infected wounds, burns, etc. CRESOLS, CREOSOL, AND GUAIACOL. Cresols, of which there are three, — metacresol, orthocresol, and paracresol, — are homologues of phenol. They are ob- tained from coal-tar by fractional distillation, and are present in large quantity in crude carbolic acid. They closely resem- ble phenol in their action, and, like the latter, they possess distinct germicidal properties. Their slight solubility in water is an important disadvantage. They are used chiefly for dis- infecting specific excreta. Under the name of cresol the U. S. Pharmacopoeia recognizes a mixture of the three isomeric cresols obtained from coal-tar, and freed from phenol, hydrocarbons, and water. This prepa- ration is a colorless or straw-colored liquid, having a creasote- like odor, and turning yellowish-brown on exposure to light. It is soluble in 60 parts of water, and miscible in all propor- tions with alcohol, ether, benzin, and glycerin. Its germicidal power is nearly three times greater than that of carbolic acid. A 1 per cent, solution may be employed in surgical work for the same purposes as carbolic acid. De Schweinitz recom- mends a 1 : 1000 solution as a solvent for atropin, cocain, and eserin in ophthalmic practice. Such solutions remain free from bacteria and are not irritant to the eye. Liquor Cresolis Compositus, U. S. P. — This is a linseed-oil soap solution of cresol, of 50 per cent, strength. Aqueous mixtures containing from 3 to 5 per cent, of this official solu- tion may be employed with advantage for disinfecting excreta. Mixtures of from 1 to 2 per cent, have been used rather ex- tensively in obstetric practice. Injections containing from 0.5 to I per cent, have been found efficacious in chronic cystitis. Creolin is the trade name of an emulsion of cresols prepared by means of rosin soap. It is a brownish, syrupy liquid, which, diluted with water, forms an opaque mixture. 392 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. Lysol is a cresol preparation made by dissolving in fat, and subsequently saponifying with alcohol that portion of tar-oil which boils between 374 and 392 F. (190 and 200 C). It is a brown, oily liquid, with the odor of creosote. It contains about 50 per cent, of cresols, and mixes with water to form a clear, saponaceous, frothy liquid. It may be used for the same purposes as the compound solution of cresol. While the cresol preparations are comparatively safe, they are not altogether harmless. Poisoning from their absorption has not been very rare. There are at least 20 cases of poison- ing by lysol on record. Creosol and guaiaeol are the chief constituents of creo- sote (see pp. 283 and 286). THYMOL, U. S. P. (Thymic Acid; C 10 H 14 O.) Thymol is a homologue of phenol obtained from the oil of thyme {Thymus vulgaris) and certain other volatile oils. It appears in the form of large, colorless crystals having the odor of thyme and an aromatic pungent taste. It is only sparingly soluble in water, but freely so in alcohol, ether, and oils. The dose is from 1-10 gr. (0.06-0.6 gm.). Preparation. Dose. Liquor Antisepticus, U. S. P. (contains 0.1 per cent, of thymol) . . . \- 2 fi. dr. (2.0-8.0 c.c.). Physiologic Action and Therapeutics. — Thymol re- sembles carbolic acid in its action, although it is decidedly less toxic and less irritant. It has been used as an antiseptic in the dressing of wounds, but its aromatic odor soon becomes dis- agreeable to the patient, and, moreover, is apt to attract flies. A solution of a grain (0.06 gm.) to the ounce of water (30.0 c.c), a little alcohol being used as a solvent, makes a good mouth-wash in the infectious forms of stomatitis and pharyn- gitis. An ointment of thymol, 5-30 gr. (0.3-2.0 gm.) to the ounce (30.0 gm.), has been used with some success by Crocker and others in chronic eczema and psoriasis. The drug makes an excellent lotion in senile pruritus. Internally, thymol is sometimes used as an antiseptic in sub- acute diarrhea. In doses of 30 grains (2.0 gm.) for adults, or 8-15 grains (0.5-1.0 gm.) for children, repeated in two hours, it is the best remedy known for uncinariasis or hook-worm disease. It has also been used to some extent as a vermifuge against the tapeworm and lumbricoid worm. Thymol may be administered in wafers, capsules, or pills. Thymolis Iodidum, U. S. P. — This compound, which is also known as aristol, is chemically dithymol-diodid. It is RESORCINOL. 393 prepared by acting upon thymol in alkaline solution with iodin dissolved in potassium iodid. It is an unstable prepara- tion, containing about 45 per cent, of iodin, and appears as a brownish-red powder, tasteless and almost odorless. It is employed as a substitute for iodoform. Although it has ad- vantages over the latter in being odorless and less toxic, it is generally not so efficacious. RESORCINOL, U. S. P. (Resorcin; Metadioxybenzol ; C 6 H 4 (OH) 2 .) Resorcin is a diatomic phenol, occurring in the form of colorless or faintly reddish prisms or needles having a slightly urinous odor and a sweetish, pungent taste. It is readily solu- ble in water, alcohol, ether, or glycerin. The dose is from 1-5 gr. (0.06-0.3 gm.). Physiologic Action and Therapeutics. — Resorcin acts much like carbolic acid, but it is less poisonous and less irritant. Toxic doses produce vertigo, ringing in the ears, tremors, epi- leptiform convulsions, quickening of the pulse and respiration, unconsciousness, and collapse. The urine becomes of an olive-green color. In health it exerts but little effect on the temperature, but in the febrile state it causes a marked fall, which is accompanied by free perspiration. At the present time resorcin is chiefly employed externally except in certain diseases of the skin. It is a valuable remedy in seborrhea, especially in dandruff, in which disease it may be employed in the form of a 3 to 5 per cent, lotion, as in the fol- lowing formula : R Resorcinolis, ^iss (6.0 gm.) ; Olei ricini, TTlxx-xxx ( 1. 2-2.0 c.c.) ; Spiritus myrciae, q. s. ad f^iv (120.0 c.c). M. A lotion containing from 5 to 20 gr. (0.3-1.3 gm.) to the ounce (30.0 c.c.) is often serviceable in subacute and chronic eczema, especially of the vesicular variety. It is also a useful antipruritic remedy. According to Hartzell, its power to re- lieve itching is increased considerably by the addition of 0.5 per cent, of sodium chlorid to the solution, as in the following formula : R Resorcinolis, gr. xv-xxx (1.0-2.0 gm.); Sodii chloridi, gr. xv (1.0 gm.) ; Glycerini, fzjj (8.0 c.c); Liquoris calcis, q. s. ad f§iv (120.0 c.c). M. Internally, resorcin is occasionally used as an antiseptic in chronic diseases of the stomach and in diarrhea. It should be given in pill or capsule. 394 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. ACIDUM PICRICUM. (Picric Acid; Carbazotic Acid; Trinitrophenol ; C 6 H 2 (N0 2 ) 3 . OH.) Picric acid is the product of the action of nitric acid on phenol-sulphonic acid, which is obtained by dissolving crystal- lized carbolic acid in sulphuric acid. It occurs in yellow, flat crystals, odorless, and of an intensely bitter taste. It is spar- ingly soluble in water, but freely so in alcohol and in ether. Physiologic Action and Therapeutics. — Locally, pic- ric acid in pure form acts as a caustic. Poisonous doses pro- duce vomiting, diarrhea, yellowness of the skin, mucous mem- branes, and urine, convulsions, and collapse. It is a feeble bactericide. Gauze wet with a I per cent, solution of picric acid, cov- ered with cotton, makes an excellent dressing for burns of the first and second degree. For fear of poisoning, how- ever, the drug should not be applied over large or deep burns. A I per cent, lotion has also been found serviceable in acute eczema and in herpes zoster. Occasionally local appli- cations are followed by an erythematous rash. Injections of picric acid, i : 200 to 1 : 100, are recommended by some sur- geons in the treatment of the second stage of gonorrhea. A saturated solution makes a delicate test for albumin in the urine. Internally, ammonium picrate was used for a time as an antimalarial and anthelmintic, but it soon proved unsuitable for either purpose. NAPHTHALENUM, U. S. P. (Napb.tb.alen; Naphthalin; Tar Camphor; C 10 H 8 . ) Naphthalen is a hydrocarbon obtained by distilling coal-tar between i8o°-25o° C. (356°-482° F.). It occurs in white, shining scales, having a strong odor of coal-tar and a burning taste. It is insoluble in water, soluble in 13 parts of alcohol, and in all proportions in ether and chloroform. The dose is from 2-10 gr. (o. 1 3-0.6 gm.). Therapeutics. — Naphthalen was at one time used as an intestinal antiseptic in diarrhea, but it has been almost com- pletely displaced by betanaphthol. BETANAPHTHOL, U. S. P. (Betanapbtol ; C 10 H,OH.) Betanaphthol is a phenol occurring in coal-tar, but usually prepared artificially from naphthalen. It occurs in white, shining scales or as a yellowish-white crystalline powder, having a faint, phenol-like odor and a pungent taste. It is soluble in ACIDUM SALIC YLICUM. 395 about 950 parts of water, and freely soluble in alcohol, ether, and chloroform. The dose is from 2-10 gr. (0.13-0.6 gm.). Physiologic Action and Therapentics.— Betanaphthol resembles carbolic acid in its action, but it is less poisonous. Large doses, however, not infrequently give rise to considerable irritation of the genito-urinary tract. It is eliminated in the urine in combination with glycuronic acid. Locally, in concentrated form, it is irritating to mucous membranes and raw surfaces. Absorption readily follows its local application. Its germicidal power is much greater than that of carbolic acid. Internally, betanaphthol is useful as an antiseptic in chronic diseases of the stomach and in diarrhea. Bouchard and others have recommended it also in typhoid fever ; the course of the disease, however, is not affected in the least by it, although it is sometimes of service in lessening flatulence and diarrhea. In doses of 15 grains (1.0 gm.), repeated in two hours, it has been used successfully in uncinariasis or hook-worm disease. It is best administered in capsules. Externally, it is efficacious as a parasiticide and stimulant application in certain diseases of the skin. In scabies and in ringworm of the scalp or body it may be employed as an oint- ment in the strength of a dram (4.0 gm.) to the ounce (30.0 gm.). Ointments containing from \- 1 dr. (2.0-4.0 gm.) to the ounce (30.0 gm.) have been used also with some benefit in psoriasis, but, as a rule, the drug is less useful in this disease than either chrysarobin or tar. Ben£onapnthol. — This compound is prepared by acting on betanaphthol with benzoyl chlorid. It is said to escape the action of the gastric juice, and to be split up into its compo- nents in the intestine. In doses of from 5-10 gr. (0.3-0.6 gm.) it is a good intestinal antiseptic, having at least one advantage over betanaphthol in being tasteless. Betanaphthol-bismnth {Orphol). — This preparation is a combination of bismuth oxid and betanaphthol. It is a light- brown, insoluble powder, odorless and tasteless. As its de- composition is mainly effected after it leaves the stomach, it is found efficacious in the various forms of intestinal catarrh. The dose is from 10-30 gr. (0.6-2.0 gm.). ACIDUM SALICYLICUM, U. S. P. (Salicylic Acid; HC 7 H 6 3 .) Salicylic acid is an organic acid contained in wintergreen, birch, and various other plants, but chiefly prepared artificially by acting on phenol with caustic soda and carbon dioxid. It occurs in fine white needles or as a crystalline powder, odor- less, and of a sweetish, acrid taste. It is soluble in 308 parts 396 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. of water, 2 parts of alcohol, 2 parts of ether, and 60 parts of glycerin. The dose is from 5-20 gr. (0.3-1.3 gm.). Physiologic Action. — Single, moderate doses of salicylic acid are not followed, as a rule, by any appreciable symptoms. Large doses, or even moderate doses in susceptible subjects, however, give rise to a feeling of fulness in the head and ring- ing in the ears, and, perhaps, to deafness, dimness of vision, flushing of the surface, and perspiration. Toxic doses, in addi- tion to the above symptoms, produce labored breathing, fol- lowed by shallow respiration, subnormal temperature, a slow, feeble pulse, olive-green urine, albuminuria, delirium, ocular palsies, unconsciousness, paralysis of the sphincters, and col- lapse. Death usually results from asphyxia. In some cases the delirium has been associated with delusions and hallucina- tions ; in others, there has been an erythematous, urticarial, or ecchymotic eruption. Circulatory System. — Moderate doses slightly raise the blood-pressure, probably by constricting the deep vessels through a central action. The superficial vessels are dilated. Large doses lower the blood-pressure by depressing the heart and vasomotor center. The administration of salicylic acid results in a moderate leukocytosis. In poisoning, the red cells suffer disintegration. Nervous System. — Salicylic acid has comparatively little influence on the nervous system. The fulness in the head and the disorders of hearing are probably the result of some dis- turbance of the circulation ; the amblyopia has been attributed to the same cause, but there is a suspicion that it is produced by changes in the ganglion-cells of the macula. Respiratory System. — Toxic doses appear first to stimulate and then to paralyze the respiratory center. Alimentary Canal. — Its presence in the alimentary canal, even in small quantities, tends to retard the action of the diges- tive ferments. It is a distinct irritant to the mucous membrane of the stomach, and, in consequence, nausea and vomiting are frequently induced by its administration. It appears to have some power to increase the secretion of bile. Sk- Metabolism. — There is considerable testimony to show that salicylic acid increases the output of urea, uric acid, and the sulphur compounds, but how this is brought about has not been determined. 4. Temperature. — In health salicylic compounds do not exert much influence on the bodily temperature ; in fever, however, they have a marked antipyretic effect, which probably results from dilatation of the cutaneous vessels and an increased loss of heat. 9* ACIDUM SALICYLICUM. 397 Absorption and Elimination. — Salicylic acid enters the blood as an alkaline salicylate. It is eliminated from the body in most of the secretions, but chiefly in the urine, in which it appears for the most part as salicyluric acid, a compound of salicylic acid and glycocoll, although some of the drug is ex- creted unchanged. The greenish discoloration of the urine is said to be due to the formation of indican or of pyrocatechin. Its excretion is attended by some increase in the flow of urine, owing, no doubt, to stimulation of the kidneys. Large doses may excite nephritis. Action on Micro-organisms. — Its germicidal properties are no less pronounced than those of carbolic acid. Therapeutics. — The chief use of salicylic acid and its al- lied compounds is in acute rheumatism, on which disease they exert a specific influence, mitigating the pain, lowering the tem- perature, lessening the liability to cardiac complications, and shortening the duration of the attack. The manner in which these drugs produce their favorable influence is not under- stood, but it is possible that they may act by neutralizing the toxins of the infective agent. From 10 to 15 gr. (0.6-1.0 gm.) of the acid or of one of its salts should be given every two or three hours until tinnitus develops or the articular symptoms are favorably affected, when the interval between the doses may be gradually increased. Salicylic compounds are also J efficacious in certain affections which seem to be in some way related to rheumatism, such as tonsillitis, chorea, lumbago, sciatica, erythema nodosum, and neuritis due to cold. In chronic rheumatism they are of little value, and in rheumatoid arthritis and gout they are useless. In diabetes mellitus, for which they were originally recom- mended by Ebstein, they are frequently of service in lessening the excretion of urine and in relieving pruritus. Salicylic acid is no longer in use as a topical antiseptic, but some of the less soluble combinations of it are employed with advantage in checking fermentation in the intestinal canal. Locally, the acid is an excellent remedy in certain diseases of the skin. The following dusting-powder often affords relief in hyperidrosis : R Acidi salicylici, gr. xxx (2.0 gm.) ; Acidi borici, gj (4.0 gm.); Amyli, gss (15.0 gm.). M. Ointments or pastes containing from 20-40 gr. (1.3-2.6 gm.) to the ounce (30.0 gm.) are of service in many cases of subacute and chronic eczema. Dissolved in collodion, a dram (4.0 gm.) 398 GERMICIDES, ANTSSEPTICS, AND DEODORIZERS. to the ounce (30.0 c.c.), it is employed with success in remov- ing co?') is and warts. Contraindications. — Salicylic compounds must be with- held or used with great care when there is renal irritation or active disease of the middle ear. Administration. — Salicylic acid is more irritating to the stomach than its salts, and for this reason the latter are gener- ally selected for internal use. The acid obtained from oil of wintergreen has no advantage over the cheaper synthetic acid if the latter be of official quality. Salicylic compounds should be given after meals, in some aromatic water, well diluted. When in rheumatism they are not tolerated in any form by the stomach, the acid may be applied directly to the joints, as in the following formula : R Acidi salicylici, giss (6.0 gm.) ; Olei terebinthinae, f gj (4.0 c.c.) ; Adipis lanae hydrosi, ^ss (15.0 gm.) ; Adipis benzoinati, q. s. ad ^ij (60.0 gm.). M. Sig. Spread on muslin and keep in place by means of a flannel bandage. SODII SALICYLAS, U. S. P. (Sodium Salicylate; NaC 7 H 6 3 .) Sodium salicylate is a white amorphous powder, odorless, and of a sweetish, saline taste. It is soluble in 0.8 part of water and in 6 parts of alcohol. The dose is from 5-20 gr. (0.3-1.3 gm.). Therapentics. — It is the most commonly used of all the salts of salicylic acid. Its action is the same as that of the acid, but it has advantages in being more soluble in water and less irritant to the stomach. Like all salicylic compounds, however, it should be given after meals, well diluted. In rheumatism it may be combined advantageously with an alkali, as in the following formula : R Sodii salicylatis, Potassii bicarbonatis, aa ^ss (15.0 gm.) ; Aquse menthae piperitae, q. s. ad f^iv (115.0 ex.). M. Sig. A dessertspoonful in water four times a day. LITHII SALICYLAS, U. S. P. (Lithium Salicylate; LiC,H 5 O s .) Lithium salicylate is a white, deliquescent powder of a sweetish taste. It is freely soluble in water and in alcohol. It is somewhat less irritating to the stomach than sodium salicy- late, for which it may be substituted. The dose is from 5-20 gr. (0.3-1.3 gm.). ACIDUM SALICYLICUM. 399 AMMONII SALICYLAS, U. S. P. (Ammonium Salicylate; NH 4 C 7 H 5 8 .) Ammonium salicylate occurs in clear, colorless prisms, freely- soluble in water. Wood recommends it as being more agree- able to the taste and less depressing and less nauseating than the sodium salt. The dose is from 5-20 gr. (0.3-1.3 gm.). STRONTII SALICYLAS, U. S. P. (Strontium Salicylate ; Sr(C 7 H 6 3 ) 2 .) Strontium salicylate occurs in colorless octahedral crystals, freely soluble in water. It is much less irritating to the stom- ach than the sodium salt. The dose is from 5-20 gr. (0.3-1.3 gm.). METHYLIS SALICYLAS, U. S. P. (Methyl Salicylate; Artificial Oil of Wintergreen ; CH 3 C 7 H 6 3 .) Methyl salicylate is prepared synthetically by distilling methyl alcohol with salicylic and sulphuric acids. It is a colorless or slightly yellowish oily liquid, having the charac- teristic odor and taste of wintergreen. It appears to be almost identical in its properties and actions with the natural oil of wintergreen (Oleum Gaultherice, U. S. P.) and the oil of sweet birch {Oleum Betulce, U. S. P.), which are composed almost en- tirely of pure methyl salicylate. The dose of either the artificial product or of the natural oils is from 5-20 min. (0.3-1.2 c.c). Therapeutics. — These preparations may be used internally in rheumatism interchangeably with salicylic acid and the min- eral salicylates. They are more likely, however, to disturb digestion than either ammonium or strontium salicylate, and, moreover, their strong flavor often turns the patients against them. Externally, they serve an excellent purpose as local applications to the affected joints. For internal use they may be given on sugar, in capsules, or in an emulsion. As a local remedy methyl salicylate is as efficient as oil of wintergreen, and very much cheaper. Mesotan. — This is the trade name of the methyl oxymethyl of salicylic acid. It is a yellow liquid, miscible with oils and other organ solvents. Diluted with from 20 to 30 per cent, of some bland oil, it has been recommended as a local remedy in rheumatic affections. Though more irritating, it does not appear to be any more effective than methyl salicylate or oil of gaultheria. Moreover, it is costly. BISMUTHI SUBSALICYLAS, U. S. P. (Bismuth Subsalicylate; Bi(C 7 H 5 3 ) 3 Bi 2 s .) Bismuth subsalicylate is a white, odorless, tasteless, and in- 400 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. soluble powder, containing about 62 per cent, of bismuth tri- oxid. It is used almost entirely as an intestinal antiseptic and astringent in diarrhea. The dose is from 5-20 gr. (0.3-1.3 gm.). PHENYLIS SALICYLAS, U. S. P. (Phenyl Salicylate ; Salol ; C 6 H 6 C T H 6 3 .) Salol is a white crystalline powder, of a faintly aromatic odor, and almost tasteless. It is nearly insoluble in water, but soluble in 5 parts of alcohol, 0.3 part of ether, and readily in oils. The dose is from 5-20 gr. (0.3-1.3 gm.). Physiologic Action and Therapeutics.— Salol resists to a great extent the action of the gastric juice, but is slowly broken up by the alkaline fluids of the intestine into salicylic acid (60 parts) and carbolic acid (40 parts). After very large doses poisoning results from carbolic rather than from salicylic acid. Like other salicylic compounds, it is useful in the various manifestations of rheumatism, but in the more severe forms of the disease its action is less prompt and powerful than that of sodium or ammonium salicylate. As its dissociation does not occur until it has escaped from the stomach, it may be em- ployed advantageously as an antiseptic in all forms of intestinal catarrh associated with abnormal fermentation. In cystitis and urethritis it is often combined with such drugs as oil of sandal- wood and balsam of copaiba for the purpose of sterilizing the urine. It should always be used with considerable caution when there is evidence of active nephritis. It may be prescribed in powders, capsules, pills, or in an emulsion. Tablets and hard pills may fail of solution and escape in the feces. Aspirin or Acetylsalicylic Acid. — This compound dif- fers from salol in possessing an acetyl instead of a phenol radical. It is a white crystalline powder having an acidulous taste, soluble in 100 parts of water and in 5 parts of alcohol. It passes unchanged through the stomach, but undergoes dis- sociation in the alkaline fluids of the duodenum, liberating salicylic acid. It acts like the latter, but being split up slowly it is less irritant and less prone to cause unpleasant side effects ; at the same time its action is less prompt and less powerful than that of the free acid. It is incompatible with alkalies and their carbonates and bicarbonates. It cakes with antipyrin. Heat and moisture also decompose it. The dose is from 5-1$ gr. (0.3-1.0 gm.) in capsules, cachets, or powders. ACIDUM BENZOICUM. 401 Salophen {Acetyl-paramido-phenyl Salicylate). — This is a compound ether of salicylic acid, occurring in tasteless and in- odorous white scales, insoluble in water, but soluble in alcohol and ether. It contains about 50 per cent, of salicylic acid. It was introduced as a substitute for salol, on account of the ill effects thought to result from the liberation of phenol from the latter. It is decomposed in the intestine into salicylic acid and the comparatively innocuous acetyl-paramido-phenyl. It is much less active in rheumatism than sodium salicylate, but being tasteless and unirritating to the stomach, it is a valuable remedy in the milder manifestations of the disease. The dose of salophen is from 5-30 gr. (0.3-2.0 gm.). Betol differs from salol in containing a naphtyl instead of a phenyl group. It is decomposed in the intestine into beta- naphthol and salicylic acid. It is used in the same doses and for the same purposes as salol. SALICINUM, U. S. P. (Salicin; C 13 H 18 O r ) Salicin is a glucoside obtained from several species of willow (salix) and poplar (poptdus). It occurs in white, silky needles, odorless, and of a very bitter taste. It is soluble in 21 parts of water and in 71 of alcohol. The dose is from 10-40 gr. (0.6-2.6 gm.). Salicin was the first of the salicylic preparations to be used in rheumatism, Maclagen, of Dundee, having prescribed it in 1874, a year before the introduction of salicylic acid by Buss, of Basle. It is partially converted in the body into salicylic acid, and rapidly appears in the urine partly as salicin and partly as saligenin, salicyluric acid, and salicylic acid. It is well borne by the stomach, but it is far less active and reliable than salicylic acid or the salicylates. ACIDUM BENZOICUM, U. S. P. (Benzoic Acid; HC 7 H 5 2 .) Benzoic acid (see p. 277) is an organic acid contained largely in benzoin, balsam of Peru, and balsam of tolu. It is obtained from benzoin, from the urine of herbivorous animals, and arti- ficially from toluene, a coal-tar derivative. It occurs in white or slightly yellow scales or needles, of an aromatic odor and taste. It is sparingly soluble in water, but freely so in alcohol, ether, and chloroform. The dose is from 5-20 gr. (0.3—1.3 gm.). Therapeutics. — The germicidal power of benzoic acid is about equal to that of salicylic acid. Internally, it is very use- 26 402 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. ful as a urinary antiseptic in cystitis with ammoniacal urine. The acid itself and its salts have also been employed to some extent as intestinal antiseptics in catarrhal enteritis. Senator and others have recommended the benzoates in rheumatism, but they have been found much less efficacious than the salicy- lates. Externally, in the form of balsam of Peru (see p. 279), ben- zoic acid is much used as a parasiticide in scabies. FORMALDEHYDUM. (Formaldehyd ; Formic aldehyd ; Oxymethylene ; CH 2 0.) Formaldehyd is a colorless gas obtained by oxidizing methyl alcohol (wood-alcohol). A 37 per cent, aqueous solu- tion of the gas is official as Liquor Formaldehydi. The latter is a clear, colorless, neutral liquid, of a very pungent odor and a caustic taste. Other preparations of the same nature are variously known as formalin, formal, methylaldehyd, etc. In solution the gas readily polymerizes, forming paraformaldehyd or paraform (trioxymethylene, (CH 2 O s )), a white crystalline powder, which yields formaldehyd on heating. Physiologic Action and Therapeutics. — Formaldehyd is an intensely irritating gas, causing, when inhaled, severe con- gestion and even inflammation of the mucous membrane of the entire respiratory tract. On cutaneous surfaces concentrated solutions or even dilute solutions if the contact be prolonged, not infrequently excite an erythematous or eczematous erup- tion. Concentrated solutions coagulate albuminous matters, but weak solutions do not. To higher animals it is compara- tively harmless, but prolonged inhalation may cause fatal pneumonitis. In a case cited by Zorn, an ounce (30.0 c.c.) of formalin produced the following symptoms : burning in the throat and stomach, nausea, vomiting, diarrhea, a weak, feeble pulse, dyspnea, cyanosis, vertigo, and anuria lasting for several hours. The urine passed later contained albumin and casts. Large doses, as in Kliiber's case, may cause also stupor and coma. The antidote for formaldehyd poisoning is ammonia in the form of the water or spirit, which combines with formal- dehyd to form the harmless hexamethylenamin (urotropin). The fate of formaldehyd in the body is not definitely known, but a portion at least appears to be eliminated in the urine unchanged. Germicidal Power. — The germicidal power of formaldehyd is little, if at all, inferior to that of mercuric chlorid. A I per cent, solution of the official preparation kills pure cultures of FORMALDEHYD. 403 pathogenic bacteria in an hour, and, according to Harrington, bacteria of the highest resistance, when freely exposed to an atmosphere produced by vaporizing 1 10 c.c. of liquor formal- dehydi in each 1000 cubic feet, are killed within two and a half hours. Though very diffusible, formaldehyd has little penetrating power ; it cannot be considered, therefore, except under the most favorable conditions, more than a surface dis- infectant. As it unites readily with hydrogen sulphid, mer- captan, ammonia, and fetid ammonia bases to form inodorous compounds, it is a powerful deodorizer. As a surface disinfectant for rooms it has decided advantages in being comparatively harmless to the higher forms of animal life, and in having no injurious effects on delicate fabrics or metals. On account of its weak penetrating power, however, it is not a suitable disinfectant for upholstered furniture, carpets, bedding, books, etc. As the aqueous solution when vaporized from an open vessel loses most of its germicidal power through the polymerization of the formaldehyd into paraform, some special device has been found necessary for securing an ade- quate supply of the gas. Lamps devised for generating for- maldehyd directly from methyl alcohol were first employed, but they did not prove reliable. A sufficient quantity of gas may be obtained by vaporizing paraform tablets in a suitable lamp, or by subjecting a fine stream of the aqueous solution by means of a special contrivance to a high degree of heat. If the paraform lamp be used, it must be placed inside the room to be disinfected; but if the second form of apparatus be employed, it may be placed outside, the gas being conducted mto the room by means of a tube passed through the keyhole. At least 60 paraform tablets or a quart (1.0 L.) of the official solution should be vaporized for every 1000 cubic feet of room to be disinfected. Another simple but very reliable method is to add formalin to powdered potassium permanganate. The mixture should be made in a galvanized iron pail that has been slightly heated beforehand, and 20 ounces (570.0 c.c.) of for- malin and 8 J ounces (245.0 c.c.) of the permaganate should be used for every 1000 cubic feet of room space requiring disin- fection. To secure the best results with any of these methods the room should be sealed as hermetically as possible before the operation, and should be kept closed after it for at least ten hours. Subsequently ammonia water may be evaporated in the room to destroy the formaldehyd. An excellent method of sterilizing small i?istruments without dulling or tarnishing them is to expose them for ten minutes 404 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. in an air-tight tin box to the vapor evolved from a 5 gr. (0.3 gm.) paraform tablet. A 5 per cent, solution of the official preparation (1 : 20 parts of water) in excess is a reliable disinfectant for stools and sputa. The irritant properties of formaldehyd detract from its use- fulness in general surgical work, but a I or 2 per cent, solution of liquor formaldehydi may be employed to cleanse wounds and to irrigate sinuses and suppurating cavities. A solution of the same strength containing glycerin makes a useful wash for the nose and throat in infectious diseases. Solutions of from I : 1000 to 1 : 500 have been found serviceable in chronic otor- rhea. A solution of 1 : 2000 has been used successfully as a collyrium, especially in ulcerative keratitis. A lotion contain- ing from 2 to 4 per cent, of liquor formaldehydi is sometimes very efficacious in bromidrosis and hyperidrosis. There is considerable evidence to show that formaldehyd added to milk as a preservative lessens its nutritive value and interferes with digestion ; it is but fair to state, however, that Tunnicliffe and Rosenheim conclude from a recent study of the subject that in the proportion ordinarily used the drug has no appreciable influence on perfectly healthy children. Incompatibles. — Ammonia, alkalis, gelatin, tannin, and mineral salts. Glutol. — This is a combination of formaldehyd and gelatin, appearing as a gray, odorless, and tasteless powder. It has been well spoken of as a substitute for iodoform in the treat- ment of infected wounds and ulcers. Tannoform (see p. 357) is a combination of formaldehyd and tannic acid. It is chiefly useful as a dusting-powder in hyperidrosis. HEXAMETHYLENAMINA, U. S. P. (Hexamethylenamin ; Urotropin; (CH 2 ) 6 N 4 .) Hexamethylenamin, or urotropin, is the product of the action of formaldehyd on ammonia. It occurs in colorless rhombic crystals, odorless, and of a sweetish taste. It is soluble in 1.3 parts of water, less soluble in alcohol, and insoluble in ether. It is readily decomposed by acids and by heat. The dose is from 3-10 gr. (0.2-0.6 gm.), dissolved in water, thrice daily between meals. Physiologic Action and Therapeutics. — When taken internally in moderate doses, urotropin produces no special symptoms, but is rapidly absorbed and rapidly eliminated, partly unchanged and partly as formaldehyd. The bulk of it HEXAME THYLENAMINA. 40 5 escapes in the urine, but, according to Crowe, after large doses enough appears in the bile and cerebrospinal fluid to exercise a decided bactericidal action. Urine passed shortly after the administration of urotropin remains sterile for a long period, even when exposed to the air. It does not materially increase the quantity of urine nor affect the elimination of solids, but it has more power than any other internal remedy of ridding that secretion of bacteria. Large doses, especially if long con- tinued, sometimes cause frequent micturition, burning in the bladder, and even hematuria ; but these symptoms speedily disappear upon the withdrawal of the drug. As a urinary anti- septic urotropin is most efficacious in typhoid cystitis, in chronic cystitis accompanying prostatic enlargement ox urethral stricture \ and in simple bacteriuria. Its power to arrest ammoniacal de- composition of the urine is sometimes truly remarkable. To secure a lasting effect, however, it should be given for a con- siderable period after the urine has become apparently sterile. If the urine be alkaline when secreted by the kidneys, formaldehyd may not be liberated; in such cases urotropin, to be effectual, should be preceded by a course of benzoic acid. When bacteria, instead of being free in the urine, are chiefly in the tissues of the bladder, as they are in tuberculous and gonorrheal cystitis, urotropin is of little value. As the urine of typhoid patients frequently contains typhoid bacilli long after the establishment of convalescence, and as this secretion is frequently the means, no doubt, of spreading the infection, Horton-Smith, Richardson, Gwyn, and others have advocated as a routine prophylactic measure the ad- ministration of urotropin during the last weeks of the disease. Keyes, Otis, and others have found the drug of value as a prophylactic remedy in preventing infection when administered for several days before and several days after operations on the genito-uri7iary tract. It is important, however, that it should not be used too freely, since when eliminated in large quantities it tends to retard healing. Crowe believes that urotropin maybe of great value both in preventing and in combating i?ifection of the gall-bladder and of the cerebrospinal meninges. 406 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. CHLORUM. (Chlorin; CI.) Chlorin is a heavy, yellowish-green gas, of a suffocating odor and a caustic taste. It may be prepared by heating to- gether sodium chlorid, sulphuric acid, and manganese dioxid or by acting upon chlorinated lime with an acid. Preparation. Dose. Liquor Chlori Compositus, U. S. P. (contains at least 0.4 per cent, of the gas with some oxides of chlorin and potassium chlorid) . . 1-2 fl. dr. (4.0-8.0 c.c). Physiologic Action and Therapeutics. — In concen- trated form chlorin acts as a powerful irritant, even upon cuta- neous surfaces. When inhaled it excites pain in the chest, cough, dyspnea, spasm of the vocal cords, and, ultimately, mucopurulent or fibrinous bronchitis with inflammation and edema of the lungs. Owing to its affinity for hydrogen and its power to separate nascent oxygen from water, it is an ener- getic germicide, especially in the presence of moisture. For the same reasons it is also an active deodorizer. As a gaseous disinfectant for rooms, however, it has serious disadvantages in being exceedingly irritant and poisonous, in being destructive to wall-paper and other colored fabrics, and in being so heavy that it diffuses with difficulty. The com- pound solution of chlorin (chlorin water) is a very unstable preparation ; for disinfecting excreta it is, therefore, less reli- able than chlorinated lime. Largely diluted, it has been used to some extent as a wash for fetid sores and as a spray for the nose and throat in infectious diseases. Internally, it has been recommended as an intestinal antiseptic in typhoid fever, but it is of very doubtful utility. CALX CHLORINATA, U. S. P. (Chlorinated Lime.) Chlorinated lime is a preparation containing not less than 30 per cent, of available chlorin, and is obtained by acting on slaked lime with chlorin gas. It consists chiefly of the hypo- chlorite and the chlorid of calcium, and appears as a grayish- white powder, having a strong odor of chlorin and a disagree- able saline taste. It is partially soluble in water and in alcohol. Action and Uses. — A solution of 0.5-1 per cent, of freshly prepared chlorinated lime kills most bacteria within ten min- utes. A 0.5 per cent, solution makes a reliable disinfectant ACIDUM SULPHUROSUM. 407 wash for bare walls and woodwork. A solution of the same strength is also useful for disinfecting white clothes. A 1 per cent, solution may be employed to sterilize feces and sputa. Wquor Sodae Chlorinatse, U. S. P. (Solution of Chlo- rinated Soda, or Labarraque's Solution). — This is a solution of several chlorin compounds of sodium containing at least 2.4 per cent, of available chlorin. It is used for the same pur- poses as chlorinated lime. ACIDUM SULPHUROSUM, U. S. P. (Sulphurous Acid; H 2 S0 3 .) Sulphurous acid gas, or sulphur dioxid (S0 2 ), when required in large amounts, is usually obtained by burning sulphur. In the official preparation, however, which is a 6 per cent, aque- ous solution of sulphur dioxid, the gas is obtained by reducing sulphuric acid with charcoal. Physiologic Action and Therapeutics. — Sulphur di- oxid is an intensely irritating, suffocating gas, quite capable, if inhaled in sufficient quantity, of destroying life. It has con- siderable germicidal power, especially in the presence of mois- ture, and before the introduction of formaldehyd it was the most popular gaseous disinfectant for rooms, hospital wards, and ships. Formaldehyd, however, being much more reliable and being without injurious effects on colored fabrics, has largely displaced it. To be at all effective, at least 4 pounds of sulphur should be burned for every 1000 cubic feet of air- space in the apartment. The sulphur, in the form of small fragments, should be put in a pan, and the latter should be placed inside of a tub partly filled with water. Before being ignited the fragments should be well saturated with alcohol. To secure the required amount of moisture steam may be gen- erated at the same time or the walls and contents of the room may be previously sprayed with water. Key-holes and other openings should be carefully sealed, and the gas should be allowed to act for from ten to twelve hours. A more convenient method of sulphurous acid disinfection, but one not always available, is to use the gas that has been liquefied under pressure and has been stored in metal cylinders. Official sulphurous acid, though somewhat irritant, is a reliable parasiticide in ringworm of the body. It may be applied in full strength or diluted. As light and air gradually con- vert sulphurous into sulphuric acid, only fresh preparations should be employed. 408 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. AQUA HYDROGENII DIOXIDI, U. S. P. (Solution of Hydrogen Dioxid; Solution of Hydrogen Peroxid.) Hydrogen dioxid (H 2 2 ) is a very unstable compound, pre- pared by the action of mineral acids or barium dioxid. It is employed in medicine only in the form of aqueous solutions. The official solution, when freshly prepared, contains about 3 per cent, by weight, of the pure dioxid, an amount correspond- ing to about 10 volumes of available oxygen. This solution is a colorless liquid, odorless, of a slightly acidulous taste, and producing a foam in the mouth. It contains a small amount of free acid as a preservative. Sunlight, protracted agitation, heat, and many metallic substances serve to decompose it into oxygen and water. Physiologic Action and Therapeutics. — The therapeu- tic value of hydrogen dioxid depends upon the readiness with which it parts with oxygen when it is brought in contact with the tissues and fluids of the body. When it is applied to a suppurating wound, effervescence follows from the liberation of oxygen, the pus is discharged, and the surface is left per- fectly clean and protected by a delicate coagulum. When taken internally it causes no special symptoms, its decomposi- tion into oxygen and water being speedily effected in the stomach. According to Egbert, it has no inhibitive influence on the unorganized ferments, such as ptyalin and pepsin. When injected intravenously or subcutaneously, however, it may kill suddenly by forming gaseous emboli in the blood. The same accident has also resulted from its introduction into one of the large serous sacs. Owing to its oxidizing power also it is an active germicide and deodorizer. A 20 per cent, solution of the official preparation quickly destroys pyogenic cocci and other non-spore-bearing bacteria. As an antiseptic for general surgical purposes its drawbacks are its proneness to deteriorate and the short duration of its action ; its advan- tages are its freedom from odor and from irritant and toxic properties. Its chief use is in the preliminary treatment of septic wounds, abscess cavities, and fistulous tracts ; its efficacy in these cases being due in part to its antiseptic action and in part to its mechanical action in expelling pus, blood-clots, and detritus. It is generally applied diluted with from 1 to 3 parts of water. It should not be injected into deep abscesses, unless there is a free exit for the gas and pus, as otherwise serious harm may result from the increased tension within the cavity ; neither should it be introduced, under any circumstances, into a large serous sac, like the pleura or peritoneum. POTASSII PERMANGANAS. 409 A 25-50 per cent, solution of the official preparation makes an excellent wash or spray for the nose and throat in diph- theria. If an atomizer be used, the tube and nozzle should be of hard rubber or of glass, as contact with metal favors the decomposition of the dioxid. A solution of the same strength is also serviceable in mercurial stomatitis, in noma, and in fol- licular tonsillitis. Harris has found copious rectal injections of a dilute solution (1 '.4 or 8) of some benefit in amebic dysen- tery. The bleaching properties of hydrogen dioxid render it use- ful, according to Bulkley, in hiding superflous black hair upon the face of women. Its physical action also makes it useful in removing the particles of carbon in gunpowder burns. With the hope that it might impart some of its oxygen to the blood it has been recommended internally in a number of diseases, but in none has it gained any reputation. POTASSII PERMANGANAS, U. S. P. (Potassium Permanganate; KMn0 4 .) Potassium permanganate occurs in the form of slender, dark- purple prisms, odorless, and of a sweetish, astringent taste. It is soluble in 15 parts of water, and is decomposed by alcohol. The dose is from 1-3 gr. (0.06-0.2 gm.) in pill form, after meals. Physiologic Action and Therapeutics. — In concen- trated solution potassium permanganate acts as an irritant or mild caustic. By the mouth, if the dose be sufficiently large, it produces the symptoms of a corrosive poison. In the pres- ence of organic matter it quickly yields its oxygen ; hence it is a prompt germicide and deodorant. Unfortunately, its use- fulness is considerably restricted by the facility with which it is rendered inert by deoxidation. Solutions of potassium per- manganate, however, make valuable deodorizing and detergent washes in many diseases attended with offensive discharges ; thus, solutions of from 1-3 gr. (0.06-0.2 gm.) to the ounce (30.0 c.c.) may be used with advantage in gangrenous stomatitis, cancer of the tongue, ozena, cancer of the uterus, foul idcers, and bromidrosis. A warm saturated solution makes a good disin- fectant for the hands, provided it be followed by a saturated solution of oxalic acid to reinforce the permanganate and to remove the stain. A solution of from 1 : 6000 gradually in- creased to 1 : 1000, used by irrigation or by injection, is quite efficacious in gonorrhea. Internally, potassium permanganate is used as an emmena- gogue (see p. 248) and as an antidote to morphin poisoning (see P.95). 41 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. Incompatibles. — Potassium permanganate has an exceed- ingly wide range of incompatibilities. With oxidizable sub- stances, especially organic ones, like alcohol and glycerin, it is explosive. CALX, U. S. P. (Lime; Quicklime; Burned Lime; CaO.) Lime is obtained by burning the purest natural varieties of calcium carbonate. It occurs in hard, white lumps, odorless, and of a sharp, caustic taste. It is soluble in 760 parts of water and is insoluble in alcohol. In the presence of water it evolves heat, and is gradually converted into calcium hydrate or slaked lime. Mixed with 3 or 4 parts of water, it forms a magma which is known as milk of lime. Preparations. Dose. Liquor Calcis, U. S. P \-2 fl. oz. (15.0-60.0 ex.). Syrupus Calcis, U. S. P. (lime, 6.5 parts ; sugar, 35; water, to make loo parts) . . £-1 fl. dr. (2.0-4.0 c.c.). Linimentum Calcis, U. S. P. (Carron oil : equal parts of lime water and linseed oil) . Potassa cum Cake (Vienna paste; 50 per cent, of each). Physiologic Action and Therapeutics. — Locally, lime is a quickly acting but superficial escharotic. It is never em- ployed by itself as a caustic, but in the form of potassa cum cake it is occasionally used to destroy small epitheliomata. When thoroughly mixed with putrefying matter quicklime favors disintegration, dispels offensive odors, and acts directly to a limited extent as a disinfectant. Freshly prepared milk of lime is sometimes employed to disinfect fecal discharges. Cal- cium hydrate, in the form of lime-water (see p. 172) and the syrup of lime, is used as an antacid and a mild astringent. SODII THIOSULPHAS, U. S. P. (Sodium Thiosulphate ; Sodium Hyposulphite; NajS 2 3 .5H 2 0.) Sodium thiosulphate, or sodium hyposulphite, occurs in white, transparent prisms, odorless, and of a cooling, somewhat bitter taste. It is freely soluble in water. The dose is from 5-20 gr. (0.3-1.3 gm.). m Therapeutics. — It is an excellent unirritating parasiticide in ringworm — tinea circinata and tinea sycosis — and in tinea versi- color. It may be applied either as a lotion or as an ointment in the strength of a dram (4.0 gm.) to the ounce (30.0 c.c. or gm.). It is also very effective in ivy -poisoning, in which it may be prescribed as follows : A CID UM B ORICUM. 4 1 1 R Sodii thiosulphatis, ^j (30.0 gm.) ; Glycerini, fjjss (15.0 c.c. ) ; Aquae, q. s. ad fjfviij (240.0 c.c). M. Sig. Keep constantly applied. A solution of 30 gr. (2.0 gm.) to the ounce (30.0 c.c.) makes a useful mouth-wash in thrush. Internally, it has been found of service as an antiseptic in gastrectasis, when sarcinae and yeast are present in large quantities in the stomach-contents. Sodii Sttlphis, U. S. P. (Sodium Sulphite ; Na 2 S0 3 . 7H 2 0) and Sodii Bisulphis, U. S. P. (Sodium Bisulphite ; NaHSO s ). — These are salts sometimes employed as substitutes for sodium hyposulphite. ACIDUM BORICUM, U. S. P. (Boric Acid; Boracic Acid; H 3 BO s .) Boric acid occurs in colorless, transparent, pearly scales or crystals, odorless, and of a bitterish taste. It is soluble in 18 parts of water, 15.3 of alcohol, and 4.6 of glycerin. The dose is from 5-20 gr. (0.3-1.3 gm.). Preparations. Liquor Antisepticus, U. S. P. (contains 2 per cent, of boric acid, 0.1 per cent, of benzoic acid, 0.1 per cent, of thymol, 25 per cent, of alcohol, and minute quantities of eucalyptol, oil of peppermint, oil of gaultheria, and oil of thyme). Glyceritum Boroglycerini, U. S. P. (contains 31 per cent, of boric acid in glycerin). Unguentum Acidi Borici, U. S. P. (10 per cent.). Physiologic Action. — In single moderate doses boric acid produces no appreciable symptoms. It is rapidly absorbed and rapidly eliminated, the bulk of it escaping in the urine within twenty-four hours after its administration. In very large doses it acts as an irritant poison. Its continued use in doses of a dram (4.0 gm.) a day not infrequently leads to a train of symp- toms to which the term borism has been applied. The most important features of this condition are digestive disturbances, marked dryness of the skin and mucous membranes, a ten- dency to alopecia, erythematous or eczematous eruptions, areas of local edema, albuminuria, and cachexia. The same phe- nomena have also been observed after repeated external appli- cations and rectal injections of boric acid. Although Annett found that kittens could not live longer than four weeks if fed upon milk containing small quantities of boric acid, it is the opinion of most experimenters (Rideal and Foulerton, Chitten- 412 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. den and Gies, Tunnicliffe and Rosenheim, Vaughan and Veen- boer) that the" drug when used as a food preservative does not, at least in adults, unfavorably affect nutrition. According to Sternberg, boric acid has pronounced antiseptic properties, but is inefficient as a germicide. Therapeutics. — As an unirritating, antiseptic wash, a solu- tion of boric acid (10 gr. : I fl. oz. — 0.6 gm. : 30.0 c.c.) has a wide range of usefulness in inflammatory diseases of the nose and throat. A solution of from 5-15 gr. (0.3-1.0 gm.) to the ounce (30.0 c.c.) may be employed with advantage as an eye- wash in simple conjunctivitis and during operations on the eye. Insufflations of boric acid are very valuable in chronic otorrhea ; in acute inflammation of the middle ear, however, especially when the discharge is profuse and contains much mucus, the drug may prove dangerous by clogging the outflow. Daily injections into the bladder of a warm solution (5 : 10 gr. to 1 fl. oz. — 0.3—0.6 gm. to 30.0 c.c.) are often useful in cystitis. Lotions, ointments, and dusting-powders containing boric acid are extensively used in many acute inflammatory skin diseases, such as erythema intertrigo, eczema, superficial burns, and mili- aria. In pruritus a lotion of boric and carbolic acids frequently affords relief. R Phenolis, ITLxx (1.2 c.c); Acidi borici, gr. xl (2.6 gm.) ; Glycerini, f ^iss (6.0 c.c.) ; Aquae, q. s. ad f^iv (120.0 c.c). M. Dusting-powders containing boric acid are sometimes of service in bromidrosis : R Acidi borici, ^iss (6.0 gm.) ; Acidi salicylici, gr. xx (1.3 gm.) ; Pulv. amyli, 3iv (16.0 gm.). M. Internally, boric acid is of some value in cystitis with alka- line uri?ie, but, as a rule, it is less efficacious than urotropin or benzoic acid. Incompatibles. — Carbonates and bicarbonates. Sodii Boras, TJ. S. P. (Sodium Borate ; Borax ; Na 2 B 4 7 . ioH 2 0). — This salt occurs in colorless, transparent prisms or as a white powder, inodorous, and of a sweetish, alkaline taste. It is soluble in 20.4 parts of water and in 1 part of gly- cerin, and is insoluble in alcohol. The dose is from 5-20 gr. (0.3-1.3 gm.). Its action is very similar to that of boric acid, for which it is often substituted. Internally, it has been used with some success in epilepsy, but it is much less useful than GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 413 the bromids, and, moreover, in the large doses required it is often productive of grave constitutional symptoms. It is in- compatible with acids, metallic salts, and alkaloids. Glycerin slowly converts it into boric acid. CARBO. (Carbon.) Carbon is official in the following forms : Animal charcoal {Car bo Animalis, U. S. P.), purified animal charcoal {Carbo Animalis Purificatus, U. S. P.), and charcoal {Carbo Ligni, U. S. P.). Animal charcoal, or bone-black, is prepared by burning bones in closed iron cylinders. It is composed of carbon and calcium carbonate and phosphate. Purified animal charcoal is bone-black from which the earthy salts have been removed by hydrochloric acid. Wood char- coal is prepared from soft wood and is finely powdered. The dose is from \-2 dr. (2.0-4.0 gm.). Charcoal has the property of absorbing many times its own volume of gases or vapors. Owing to the oxygen condensed within its pores it has considerable oxidizing power, which may be utilized to destroy offensive gases, like hydrogen sulphid, and to hasten the decomposition of organic matter. Thorough wetting destroys its activity. As it is not absorbed when taken internally, it exerts no specific action on the body. Charcoal is employed chiefly as an absorbent and a deodor- ant. In the form of a poultice it was at one time a favorite application tor foul ulcers, but it has been largely displaced by more cleanly dressings. While it is a satisfactory agent for deodorizing fecal discharges, it has less disintegrating action than dry earth. Internally, it is sometimes useful as an absorbent in flatulent dyspepsia. In may be given as a powder or in lozenges. Animal charcoal is not used for medicinal purposes, but it is largely employed by chemists for removing coloring-matter from alkaloids. It was formerly regarded as an excellent fil- tering medium for drinking-water, but it has been shown to be unsafe for this purpose, since by adding phosphates and nitrates to the water it actually favors the development of bacteria. OTHER GERMICIDES, ANTISEPTICS, AND DEODORIZERS. Silver Compounds (see pp. 369-374). — The salts of silver are powerful germicides. Many of the organic salts are not 4 14 ANTIMALARIALS. so irritant as the nitrate, and, moreover, are not affected by albuminous matters or chlorids. They are used especially on mucous membranes. Bromin (see p. 454). — This substance is an energetic dis- infectant, but it is rarely used on account of its destructive and intensely irritant properties. A weak solution (1 1400), how- ever, is occasionally employed as a deodorizer for cisterns, trenches, slaughter-houses, etc. Ferrous Sulphate (see p. 294). — This salt is a very feeble disinfectant. It is sometimes used as a deodorizer for middens, cesspools, etc. Volatile Oils. — Many of the volatile oils, while they are not actively germicidal, have considerable power as antisep- tics. The oils of sandalwood, copaiba, and cubeb (see pp. 230-232) are largely used as genito-urinary antiseptics. Methyl-blue (Pyoktanin). — This substance, like many of the anilin dyes, has some power as an antiseptic, but very little as a germicide. A solution of I : 1 000 has been used with some success in ophthalmic surgery. Methylene-blue (see p. 420). — This compound, in doses of from 1-3 gr. (0.06-0.2 gm.), has been used as a urinary anti- septic in gonorrhea. It is also of value as an antimalarial, though it is decidedly inferior to quinin. Acetanilid (see p. 347). — This compound has been used to some extent as a substitute for iodoform in the treatment of burns and ulcers. ANTIMALARIALS. Antimalarials are drugs that exert a curative influence in malaria by acting destructively upon the specific parasites pres- ent in the blood. The alkaloids of cinchona, especially quinin, are by far the most important members of this class. Methylene- blue and Warburg's tincture, while they have some virtue, do not approach quinin in efficacy. Arsenic, though useful in correcting the anemia caused by the parasites, does not appear to have any special action. Many other drugs have been rec- ommended as antimalarials, but they have not been found trustworthy. CINCHONA. 415 CINCHONA, U. S. P. (Peruvian Bark.) Cinchona is the bark of Cinchona Calisaya and other species oi^ cinchona, tall evergreen trees indigenous in South America, and at present largely cultivated in India, Java, and Jamaica. Its activities depend upon a number of alkaloids, the most important of which are quinin, quinidin, cinchonin, and cinchonidin. To be up to the official standard the bark should contain at least 5 per cent, of total anhydrous cinchona alkaloids and not less than 4 per cent, of anhydrous ether — soluble alkaloids (quinin, quinidin, and cinchonidin). In addition to its alkaloids, cinchona contains quinic acid, quinovic acid, and quinotannic acid. Preparations. Dose. Fluidextractum Cinchonas, U. S. P. . . . £-1 fl. dr. (2.0-4.0 c.c). Tmctura Cinchonas, U. S. P 1-2 fl. dr. (4.0-8.0 c.c). Tinctura Cinchonas Compositae, U. S. P. (Huxham's Tincture: red cinchona, 10; bitter orange-peel, 8 ; serpentaria, 2 ; gly- cerin, 7.5 ; water, 7.5 ; alcohol, to make 100) 1-4 fl. dr. (4.0-15.0 c.c). The following alkaloids and their salts are also employed medicinally : Quinina, U. S. P ] Quininae Sulphas, U. S. P Quinina? Bisulphas, U. S. P Quininae Hydrochloridum, U. S. P. . Quininae Hydrobromidum, U. S. P. . Quininae Salicylas, U. S. P Quininae Tannas Quininae Valeras Quininae Dihydrochloridum 1-30 gr. (0.06-2.0 gm.). Quininae Dihydrochloridum Carbamidata (qui- nin and urea hydrochlorid) I-20 gr. (0.06-2.0 gm.). Oleatum Quininae, U. S. P. (25 per cent.). Cinchoninae Sulphas, U. S. P "I .«,«,„./««£«« \ Cinchonidinae Sulphas, U.S.P } 1-30 gr. (0.06-2.0 gm.). Cinchonidinae Salicylas i-io gr. (0.06-0.6 gm.). Euquinin (an ethyl-carbonic ester of quinin) 5-60 gr. (0.3-4.0 gm.). Quinin also enters into iron and quinin citrate, bitter wine of iron, syrup of the phosphates of iron, quinin, and strych- nin, compound syrup of hypophosphites, glycerite of the phos- phates of iron, quinin, and strychnin, elixir of iron, quinin and strychnin phosphates, and Warburg's tincture. Quinin is the most important alkaloid of cinchona, and represents very largely its active properties. r 1-3° g r - (0.06-2.0 gm.). 10 gr. (0.06-0.6 gm.). 4 1 6 ANTIMALARIALS. QUININA, U. S. P. (Quinin.) Quinin occurs in the form of a white, flaky, amorphous or crystalline powder, odorless, and of an intensely bitter taste. It is almost insoluble in water, but is readily soluble in acidu- lated water, alcohol, and ether. Physiologic Action. — In large doses (20.0 gr. — 1.3 gm.) quinin causes a feeling of fulness in the head, ringing in the ears, deafness, headache, and sometimes dimness of vision. The term cinchonism is applied to this group of symptoms. Toxic doses may cause in addition circulatory weakness, dysp- nea, delirium, stupor, convulsions, and coma. Although alarming symptoms have been produced by over- doses of quinin, it is very doubtful whether in a human being death has ever resulted directly from the use of the drug. Circulatory System. — Small doses do not materially affect the circulation, but very large doses decrease the force and frequency of the pulse by directly depressing the heart or its contained ganglia. Nervous System. — Toxic doses congest the brain, and prob- ably first stimulate and then depress the cerebral and spinal centers. The tinnitus aurium and deafness occurring in cin- chonism are doubtless the result of an intense congestion of the middle ear and labyrinth. In rare instances, apparently owing to chronic inflammation of the auditory passages or to hemorrhage into the labyrinth, the deafness has been permanent. Recent studies tend to show that quinin amblyopia results di- rectly from the toxic effects of the drug on the ganglion-cells of the retina, and not, as was formerly supposed, from con- striction of the retinal arteries and secondary changes in the optic nerves. Permanent blindness from quinin is exceedingly rare. Respiratory System. — Respiration is not affected by quinin except in poisoning, and then it may be slow and labored from depression of the center in the medulla. Alimentary Canal. — In small doses it whets the appetite and stimulates gastric peristalsis. Large doses have an irritant effect and sometimes excite nausea and vomiting. Uterus. — Quinin will sometimes intensify labor-pains when they are inefficient owing to weakness or fatigue. The con- tractions induced by it are less prolonged than those following the use of ergot, and are probably caused by the direct action of the drug on the uterine muscle. It does not seem capable of originating labor-pains and acting as an abortifacient. CINCHONA. 417 Blood. — As Binz originally noted, quinin, when added to freshly drawn blood, arrests the ameboid movement of the white cells. Moreover, when applied in very dilute solution to the exposed mesentery of a frog, it suspends, almost immedi- ately, the migration of the leukocytes. These effects are ascribed to the toxic action that the drug exercises on all forms of undifferentiated protoplasm. Drawn blood, when mixed with quinin, loses in oxidizing power, as shown by its failure to strike a blue color with guaiac in the presence of turpentine and to decolorize indigo by transforming it into isatin. Metabolism. — Under the influence of quinin there is a con- siderable falling off in the nitrogenous excretion, and as this continues for some time after the withdrawal of the drug, it would seem to be due to a retardative effect upon metabolism. Temperature. — In health the bodily temperature is not ap- preciably influenced by quinin ; in febrile states, however, large doses exert a pronounced antipyretic effect, which is thought to be due to an inhibition of metabolism, in consequence of which heat-production is diminished. Absorption and Elimination. — Quinin is absorbed chiefly from the stomach, and is eliminated for the most part by the kidneys. Under favorable conditions it enters the blood very quickly, and traces of it may be found in the urine within twenty minutes after its ingestion. Its elimination, however, does not keep pace with its absorption, and after large doses, several days may elapse before all of it has left the body. It is excreted very largely unchanged, but a small part appears to be converted in the tissues into dihydroxyl-quinin. Action on Lower Organisms. — Quinin is not an active ger- micide, although it is very destructive to certain protozoa, like the ameba and the hematozoon of malaria. It is, however, an energetic antiseptic, and, in the proportion even of 1 : 800, it inhibits the growth of bacteria in fluids con- taining considerable organic matter. Untoward Effects. — Idiosyncrasies to quinin are not in- frequently encountered. In some individuals a dose of from 2-3 gr. (0.1-0.2 gm.) will cause intense cinchonism. Impair- ment of vision is fortunately rare, and has generally been pro- duced by very large doses. Quinin rashes are not uncommon ; of 60 cases analyzed by Morrow, 38 were erythematous, 12 urticarial, 5 purpuric, and 2 vesicular and bullous. Irritability of the bladder and urethra is occasionally noted. Therapeutics. — Owing to its destructive action on the parasites of malaria, quinin is to be regarded as a specific in this 27 4 1 8 ANTIMALARIALS. disease. The quartan and tertian hematozoa readily succumb to it, but the estivo-autumnal hematozoa are more resistant, especially when in the crescentic or ovoid form. In ordinary intermittent fever doses of from 15-30 gr. (1.0-2.0 gm.) a day will generally arrest the paroxysms within three or four days. The drug is most effective when its administration is so timed that the maximum amount shall be in the blood during the paroxysm — that is, while sporulation is in progress. Thus, the daily dose may be divided into smaller doses of 5 gr. (0.3 gm.) each, the first being given about eight hours and the last not less than three hours before the expected chill. When, however, the patient is not seen until within a short time of the expected paroxysm, a single large dose should be given at once. The remedy should be continued in full doses until the paroxysms fail to appear, and then gradually withdrawn over a period of several weeks. The administration of a laxative dose of calomel as a preliminary measure increases the efficacy of the quinin, probably by facilitating its absorption. During convalescence arsenic may be advantageously associated with the quinin. In estivo-autumnal fever large doses — 30-40 gr. (2.0-2.6 gm.) a day — are usually required. In pernicious malarial fever the patient should be cinchonized as quickly as possible by inject- ing at once into the tissues of the thigh or buttock about 30 gr. (2.0 gm.) of a soluble salt of quinin like the dihydro- chlorid. Whether the administration of quinin is at times responsible for the occurrence of hemoglobinuria in malarial subjects, as was first suggested by Veretas in 1858, is still a mooted ques- tion. Even if the affirmative be true, there does not seem to be any good reason for withholding the drug in cases of hemoglobinuria when malarial parasites can be detected in the blood. Bastianelli has summed up the matter in the fol- lowing rules: If hemoglobinuria occurs during the par- oxysms and parasites are found, use quinin ; if parasites are not found, do not use quinin ; if quinin has been used before the hemoglobinuria begins and there are no parasites, discon- tinue the quinin. Quinin is not only a curative remedy in malaria, but also a valuable prophylactic agent. Daily doses of from 4-8 gr. (0.26-0.5 gm.) will generally prevent the incidence of the dis- ease in persons living in malarial regions. The drug does not afford immunity from the disease, but prevents the develop- ment of the parasites. CINCHONA. 419 Quinin, in doses of from 1-3 gr. (0.06-0.2 gm.), has long been used as a general tonic in states of lowered vitality follow- ing acute disease or brought on by overwork. In such cases it may be combined conveniently with iron and strychnin. Small doses are thought to be of some value also in acute in- fections, like septicemia, diphtheria, and influenza. It is possi- ble that the drug owes its efficacy in these diseases, at least in part, to its retarding influence on the tissue changes. Warm rectal injections of the alkaloid (1 : 5000 to 1 : 2000) have been found of service in amebic dysentery. In whooping-cough moderately large doses are sometimes useful in lessening the severity and frequency of the paroxysms, but it is not known how the drug acts. Quinin has been recommended in neu- ralgia and in headache, when the attacks are more or less periodic, but unless these affections can be traced to a malarial origin, the drug is not likely to do good. The use of quinin as an antipyretic (see p. 352) is almost obsolete. In doses of from 20-30 gr. (1.3-2.0 gm.) it un- doubtedly has a pronounced effect upon high temperature, especially if it be given a few hours before a natural remission is expected to occur ; but when drugs must be used at all as antipyretics, the preference should generally be given to the coal-tar derivatives, on account of the promptness and certainty of their action and their comparative freedom from disagreeable by-effects. Quinin (10-15 gr. — 0.6-1.0 gm.) is sometimes of value as an ecbolic (see p. 256) in the first stage of labor when the pains are infrequent and inefficient, owing to simple uterine inertia. Contraindications. — The chief contraindications are men- ingitis and acute middle-ear disease. It should be administered cautiously when acute inflammation of the genito-urinary tract exists. There is some evidence to show that the drug some- times acts unfavorably in epileptics in increasing the number of seizures. Of course, quinin should be withheld from pa- tients in whom, owing to idiosyncrasy, it has previously caused grave symptoms. Administration. — Under ordinary circumstances quinin should be given by the mouth. It may be prescribed in cap- sules, cachets, freshly made pills, or in solution. The last method of prescribing it, however, is objectionable on account of its intensely bitter taste. Old pills skould be avoided, since they are liable to escape from the stomach before the alkaloid has been liberated and absorbed. The sulphate, though it is most commonly selected, is not so eligible as the more soluble 420 ANTIMALARIALS. dihydrochlorid (4 parts of water), bisulphate (8.5 parts of water), and hydrochlorid (18 parts of water). If the sulphate be used, it should be rendered soluble by associating with it a few drops of one of the mineral acids. To children the drug may be given suspended in syrup of yerba santa, syrup of chocolate, or elixir of licorice. The tan- nate, while it has less than half of the alkaloidal strength of the sulphate, is only slightly bitter, and may, therefore, be given to children in the form of chocolates. Euquinin is a tasteless and insoluble preparation, somewhat more active than the tannate. Quinin is absorbed very imperfectly from the bowel, but for young children it may be prescribed in the form of supposi- tories, each containing 2 or 3 gr. (0.13-0.2 gm.) of a soluble salt like the dihydrochlorid. For hypodermic use only the most soluble salts should be used, such as the dihydrochlorid, carbamidated dihydro- chlorid, or bisulphate. If the bisulphate be chosen, the solu- tion should be slightly acidulated with tartaric acid to prevent the precipitation of the salt by the alkaline juices of the tissues. The injections should be intramuscular rather than subcutane- ous, and should be given with the most thorough antiseptic precautions. Bacelli has reported excellent results in pernicious malarial fever from the employment of intravenous injections of quinin. He recommends the following solution : Be Quininse hydrochloride gr. xv (1.0 gm.); Sodii chloridi, gr. xij (0.8 gm.) ; Aquae destillatae, f giiss (9.2 c.c). M. Sig. Boil and filter; inject while still warm. Of the fluid preparations of cinchona, the compound tinc- ture is the most effective. It is rarely used, however, except as a restorative. Incompatibles. — Alkalis, tannic acid, iodids, and spirit of nitrous ether. Cinchonin and Cinchonidin. — The action of these alka- loids is very similar to that of quinin, but it is much less powerful. METHYLTHIONINiE HYDROCHLORIDUM, U. S. P. (Methylthionin Hydrochlorid; Tetramethylthionin Hydrochlorid; Methylene- blue; CHjgNaSCl.) Methylene-blue is a complex anilin derivative, occurring in dark -blue crystals or as a bronze-like powder, slightly soluble METHYLTHIONIN^l HYDROCHLORIDUM. 42 1 in water and in alcohol. The dose is from 1-4 gr. (0.065- 0.26 gm.). Its action has not been carefully studied. When taken by the mouth or injected subcutaneously, it enters the blood and soon reappears in the secretions, especially in the urine, to which it imparts an intensely blue or greenish-blue color. Large doses irritate the stomach and also excite fre- quent and painful micturition. Achard and Castaigne, having found that in cases of renal disease the elimination of methyl- ene-blue when injected intramuscularly is retarded as com- pared with the elimination in a normal subject, suggested that the degree of permeability of the kidneys might be determined by using as a criterion the time intervening between the injec- tion of the drug and its reappearance in the urine. Subse- quent studies, however, showed that this method, while of some value in determining the presence of interstitial nephritis, could not be depended upon in cases of parenchymatous nephritis. The fact that methylene-blue is one of the best stains for the hematozoa of malaria suggested its use as a remedy in this disease. While it undoubtedly has some virtue, its effi- cacy is distinctly inferior to that of quinin. It may be used with advantage, however, when, owing to an idiosyncrasy, quinin cannot be taken. Berthier has found it useful in dysen- tery ; he recommends warm injections containing from ij— 3 gr. (0.1-0.2 gm.) to a pint or quart (0.5-1.0 L.). Flint found it of service in cases of filariasis, but in a case studied by Henry it was without effect. The drug appears to be of some value as an antiseptic in inflammatory diseases of the genito- urinary tract, especially in gonorrhea. The strong affinity shown by Ehrlich to exist between the axis-cylinders of nerves and methylene-blue prompted the use of the drug as an analgesic and a sedative. It has been em- ployed as an analgesic by Lemoine, Klemperer, and others with asserted good results in neuralgia, sciatica, and migraine, and as a sedative by Bodoni and others in various forms of insanity characterized by excitement. Methylene-blue may be administered by the mouth or sub- cutaneously. The former is the better method, as the injections are quite painful. It should be prescribed in pills or capsules, combined with half its weight of powdered nutmeg, the latter serving to prevent gastric disturbances and irritation of the bladder. If it be given hypodermically, the solution should first be sterilized by boiling, otherwise abscess is liable to occur. Patients should always be warned of the discoloration of the urine caused by the drug. 422 ANTHELMINTICS. WARBURG'S TINCTURE. (Antiperiodic Tincture.) Warburg's tincture was for a time a proprietary preparation, but in 1875 the originator himself made known its composi- tion. As a number of the ingredients recommended by War- burg are no longer obtainable, the remedy is at the present day prepared after a somewhat simpler formula than the origi- nal one. Each fluidounce (30.0 c.c.) contains : Quinin, 10 gr. (0.65 gm.) ; rhubarb and angelica seed, of each, 3-I- gr. (0.2 gm.) ; elecampane, saffron, fennel, and extract of aloes, of each, l i S T - ( 0 Salolis, gss (2.0 gm.) ; Bismuthi subnitratis, ^iij (12.0 gm.). M. Fiant chartulae No. xv. Sig. — One powder every three or four hours. R Argenti nitratis, gr. iij (0.2 gm.); Pulveris opii, gr. vj (0.4 gm.). M. Fiant pilulse xii. Sig. — One pill every three or four hours. 512 APPLIED THERAPEUTICS. In very obstinate cases copper sulphate with opium in pill proves efficacious. Constipation. — Constipation lasting but two or three days requires no special treatment. Sometimes meat broths or strained oatmeal gruel given alternately with the milk will exert a nvld laxative effect. When more than a modification of the diet is necessary, an enema of soapy water or glycerin should be tried before resorting to remedies by the mouth. In obstinate cases small doses of calomel, of Epsom salt, or of castor oil may be given at short intervals until the desired effect is obtained. Tympanites. — Troublesome tympanites is often entirely overcome by substituting albumin and water for milk. In other cases it may be relieved by the external application of turpentine stupes and by the internal administration of some antiseptic remedy, such as turpentine, beta-naphthol, beta-naphthol bis- muth, creosote, or salol. Enemas of turpentine or of asa- fcetida are also efficacious. In certain persistent cases, appar- ently paretic in nature, the author has successfully employed eserin salicylate in doses of ■£$—■£$ gr. (p.ooi-O.0016 gm.) two or three times daily, as recommended by von Noorden. Fin- ally, when the tympanites is extreme and other measures have failed to afford relief, a soft rectal tube may be introduced as far as possible into the colon. Persistent Vomiting. — When the stomach is excessively irritable, it is better to withhold milk for a time and to give in its stead albumin and water in small quantities at frequent intervals. Occasionally it may be necessary to withhold all food by the mouth for twenty-four hours and to support the patient by rectal alimentation. The best gastric sedative in such cases is bismuth subnitrate in powder, with cerium oxalate or cocain hydrochlorid, or in water with dilute hydrocyanic acid. A mustard-plaster to the epigastrium is often efficacious. Hemorrhage from the Bowels. — The patient must be kept at absolute rest. Cold bathing must be suspended. If the hemorrhage is severe, the bowel-movements should be received in a folded towel instead of in a bed-pan. An ice-bag may be applied with advantage to the right iliac region, and ice may be given by the mouth. It is advisable slightly to elevate the foot of the bed. For ten or twelve hours the ali- ment should be reduced to the smallest possible amount. The best drug is opium ; it controls peristalsis and allays excite- ment. Oil of turpentine, in doses of from 10-20 min. (0.6-1.2 c.c.) ACUTE INFECTIOUS DISEASES. 513 every two hours, is also efficacious. Some writers speak favor- ably of oil of erigeron. Preparations of ergot are of no value. In cases of recurrent hemorrhage gelatin (see p. 381), subcu- taneously or by the bowel, should be tried. Rectal injections both of iced water and of very hot water (no° F. — 43. 5 C.) have been recommended. If collapse is threatened, diffusible stimulants, like ether and alcohol, should be given freely. The acute anemia following copious bleeding is best treated by subcutaneous or intravenous injections of warm saline solu- tions (see p. 496). Headache. — In most cases absolute rest, quiet, and cold applications to the -head suffice. If the pain is severe, it may be necessary to give sodium or potassium bromid (10-15 gr. — 0.65-1.0 gm.) or small doses (5 gr. — 0.3 gm.) of phenacetin. Insomnia. — Opium is generally the best hypnotic. In some cases, however, sodium bromid or chloralamid acts better. Chloral is also very efficacious, but it should not be used when the heart is weak. Delirium is best managed by hydrotherapy. Low, mut- tering delirium usually calls for stimulants. An ice-cap is useful. Camphor or musk may be tried ; the former is best given hypodermically, the latter by the bowel. In active or violent delirium no drug is so generally useful as morphin. In some cases hyoscin ( 1 | - 1 ^ gr. — 0.00043-0.00064 gm.) acts well. Hypostatic Congestion of the I,ungs. — Frequent change of position and the timely use of cardiac stimulants will frequently prevent serious pulmonary congestion. When severe enough to embarrass the respiration and circulation, dry cups or stupes should be applied to the chest, and strych- nin or ammonium carbonate given internally. In grave cases oxygen inhalations afford relief, but their effects are usually temporary. Perforation. — Recovery from peritonitis is so exceedingly rare under medicinal treatment that operative interference is called for in all cases which are not obviously moribund. The operation should be done at the earliest possible moment. Mauger reports 25 recoveries in 107 cases, and Harte and Ashhurst 362 cases with 94 recoveries. From these statistics operation appears to save life in from 20 to 25 per cent, of the cases. Bed-sores. — This complication can usually be prevented by absolute cleanliness, frequent change of position, the appli- 33 514 APPLIED THERAPEUTICS. cation of whisky or whisky and alum to parts most sub- jected to pressure, and the timely use of a water-bed or of air-cushions. Slight abrasions may be painted with flexible collodion or dusted with a powder of bismuth subnitrate and iodoform or of boric acid and starch. When there is great difficulty in keeping the parts dry, zinc ointment may be freely applied. Ulcers should be washed with weak antiseptic lotions, dusted with some antiseptic powder like iodoform or iodol, and then protected by a large piece of soap-plaster. An ointment of balsam of Peru (i : 30) is sometimes very efficacious. TYPHUS FEVER. As typhus fever is a contagious disease, the patient must be isolated and every precaution must be taken to prevent the dissemination of the morbific agent, whatever it may be. Those who have had experience in typhus epidemics assert that free ventilation is often in itself sufficient to arrest the transmission of the disease. There is no specific treatment. The diet should be nutritious and easily assimilable. As in other continued fevers, liquids are better borne than solids, although special precautions are not so imperatively demanded as they are in typhoid fever. The pyrexia, nervous phenomena, heart-failure, and pulmonary congestion will require the same treatment as in typhoid fever. RELAPSING FEVER. As in all contagious diseases, isolation, free ventilation, and disinfection of excreta and clothing are important safeguards against the spread of the virus. The treatment is purely symptomatic. Absolute rest, good nursing, and proper diet will do much to avert complications. The chief indications are to control the fever, to quiet the stomach, to relieve the intense pains in the head, back, and limbs, and to support the heart. On account of the short duration of the febrile paroxysms the fever itself is not so important a factor as it is in many other acute infections. Ordinarily, the application of ice to the head, with frequent cold sponging of the body, will suffice. Cold baths are not well borne on account of the severe mus- cular pains. Hyperpyrexia must be controlled by the cold pack and the administration of phenacetin or antipyrin or of large doses of quinin. Vomiting is sometimes exceedingly difficult to control. Cracked ice, carbonated water, dilute hydrocyanic acid (1-2 min. — 0.06-0.1 ex.), cocain hydrochlorate (J gr. — 0.016 gm.), ACUTE INFECTIOUS DISEASES. 5 15 or wine of ipecac (i min. — 0.06 c.c.) should be tried. A mus- tard-plaster to the epigastrium is sometimes efficacious. For the relief of the pains, restlessness, and insomnia no drug is so useful as morphin. A quarter of a grain (0.016 gm.) may be given hypodermically two or three times a day. Hot- water bags may also be ordered for the backache, and rube- facient liniments for the muscular pains. Stimulants are not generally required, but when there is any tendency to heart- failure they should be administered freely. CEREBROSPINAL FEVER. Cerebrospinal fever being communicable, the same precau- tions should be observed as in the case of other serious con- tagious diseases. The sick-room should be quiet, darkened, and well ventilated. The diet should be liquid and support- ing. Milk and animal broths may be given freely at fre- quent intervals. In some cases, in order to secure the inges- tion of enough nourishment, it may be necessary to resort to nutrient enemata or forced feeding by means of a stomach- tube. Cardiac failure must be combated by stimulants, of which the best are whisky and brandy. The number of patients treated with the antiserum prepared by Flexner (see p. 434) is still too small to justify a positive opinion concerning its exact value and limitations ; neverthe- less, the reports to date are sufficiently favorable to warrant a thorough trial of the remedy in all cases, even of suspected meningococcic meningitis. Morphin hypodermically is the best drug for the relief of headache, pain, and restlessness. Chloral, bromids, and phenacetin in safe doses are rarely effective. Cold applied to the head affords some relief. Warm baths (105 °-i io° F.) twice a day for ten minutes are often very efficacious. When there are evidences of excessive intraventricular pres- sure (intense headache, retraction of the head, convulsions, and stupor), the withdrawal of from 30 to 40 c.c. of fluid from the spinal canal sometimes has a happy effect. After the subsidence of the acute symptoms the absorption of the exudation may be attempted by the administration of potassium iodid. When symptoms indicating pressure on the brain or spinal cord persist, repeated blisters or light applica- tions of thermocautery are sometimes useful. Tonics — iron, strychnin, cod-liver oil — are generally indicated during con- valescence. Local palsies will require massage and electricity. 5 l6 APPLIED THERAPEUTICS. Even after convalescence has been well established all mental and physical excitement should be avoided for a considerable period. MALARIAL FEVER. It has been definitely established that the hemocytozoan discovered by Laveran in 1880 is the sole cause of malarial fever, and that the mosquito plays an important role in trans- mitting the infection. Prophylactic measures include the ex- termination of mosquitos, the prevention of infection of mos- quitos, and the prevention of infection by mosquitos (Manson). The most useful methods of suppressing mosquitos are the efficient drainage of pools and swamps and the cultivation of damp soils. Covering the surface of the water with petroleum will also free pools from larvas for from two to four weeks. To prevent the infection of mosquitos, malarial patients should be carefully screened. The chief means of preventing infection by mosquitos are avoidance of sleeping in the open air, and of exposure to the evening and early morning air, adequate protection from the insects, and the use of quinin in daily doses of from 2-5 gr. (0.13-0.3 gm.). Quinin is the only reliable remedy for malarial fever. Methylene-blue and Warburg's tincture possess some value, but, being distinctly less efficacious than quinin, they should be employed only when the latter is not well borne. Arsenic is useful in correcting the anemia caused by malarial fever, but it probably has no parasiticidal influence. The methods of administering quinin and other antimalarial remedies has already been considered (see p. 414). Symptomatic Treatment. — During the cold stage of the par- oxysms the patient should be well covered with warm blankets and given hot drinks. Opium in the form of paregoric is sometimes useful in mitigating discomfort. It may be com- bined with a few minims of aromatic spirits of ammonia, chloroform, or Hoffmann's anodyne. Generally, alcoholic stimulants are better avoided, since they tend to increase the severity of the reaction. In the algid type of pernicious malarial fever, however, it may be necessary to give alcohol freely, with digitalis and strychnin, to tide the patient over the paroxysm. In the hot stage much relief is afforded by fre- quently sponging the body with cool water, giving cold drinks, and administering, if the symptoms are very severe, a small dose of phenacetin. When the bowels are constipated and the tongue is thickly coated, laxative doses of calomel or of blue-mass may be given with advantage. Vomiting and purging are occasional symp- toms ; they are best controlled by an opiate. ACUTE INFECTIOUS DISEASES. $iy In the graver congestive type, with coma and high fever, cold bathing and rectal injections of cool water are indicated. For the anemia following malarial infection arsenic and iron should be given (see p. 311). Malarial cachexia requires tonic and hygienic treatment. Arsenic, iron, and cod-liver oil are especially valuable. As in other manifestations of malaria, quinin is indicated so long as the blood shows parasites. According to Wood, it is much better to produce distinct cinchonism at intervals than to give the drug continuously in moderate doses. When there is constipation, mild bitter laxatives are beneficial. Change of locality is sometimes necessary to effect a cure. For the en- larged spleen, ergot has been warmly advocated, but it is of doubtful utility. INFLUENZA* Although we possess no certain safeguards against the spread of influenza, yet an effort should always be made to protect healthy members of the household, especially the young, old, and delicate, from infection. To this end the patient should be isolated, and the secretion from the catar- rhal surfaces should be thoroughly disinfected. No specific has yet been discovered for the disease. Hy- gienic measures are of the first importance ; these include im- mediate and absolute rest in bed, a carefully selected diet, pure air without draft, and attentive nursing. Complications and relapses can generally be traced to a neglect of these rules. In mild cases little in the way of special treatment is re- quired. A hot foot-bath, some mild refrigerant, such as spirit of nitrous ether or solution of ammonium acetate, and at night a dose of Dover's powder (5-10 gr. — 0.3-0.6 gm.), will usually suffice. If there be constipation, a few minute doses of calomel may be given with advantage; active purgation, however, should always be avoided. In the more severe cases quinin, if well borne, may be given in small doses (2-5 gr. — 0.13-0.3 gm. — thrice daily) throughout the attack. Rheumatoid pains are controlled to some extent by combinations of phenacetin with salicylates or benzoates. Only small doses, however, are admissible, and these should be carefully watched. The following is often useful : R Acetphenetidini, Salophen, Sodii benzoatis, aa £j (4.0 gm.). M. Fiant chartulae No. xii. Sig. — One every four hours. 5 l8 APPLIED THERAPEUTICS. When the suffering is intense, there need be no hesitation in administering morphin hypodermically. Violent headache is treated best by small doses of phenacetin and the applica- tion of an ice-cap to the head. Sulphonal and chloralamid are, perhaps, the most satisfactory drugs for combating trouble- some insomnia. When the stomach is persistently irritable, the diet should be restricted to liquids, and all drugs, except those of a soothing character, withheld. Antiemetics, like bismuth subnitrate, hydrocyanic acid, cerium oxalate, and cocain, are indicated. A sinapism to the epigastrium may also be recommended. In many cases of influenza cardiac weakness is a prominent feature. It demands the free use of alcoholic stimulants and of strychnin. The latter is especially well borne, and may be given, if necessary, in doses of ^o~ 2V °f a S r - (0.002-0.003 gm.) every three or four hours. If more stimulation is required, aromatic spirits of ammonia and digitalis or strophanthus may also be given. As the course of the disease is comparatively short, the fever, even when high, will rarely call for special medica- tion. Antipyretic drugs in large doses are always inad- missible. Delirium is another symptom that may usually be ignored. In the respiratory type expectorants are usually needed. When the cough is hard and dry, combinations of ipecac and potassium citrate, like the following, will be found useful : R Potassii citratis, £ij (8.0 gm.) ; Syrupi ipecacuanhse, Tincturae opii camphoratae, aa fjij (8.0 c.c.) ; Succi limonis, Glycerini, aa fjss (15.0 c.c); Aquae, q. s. ad fijjiij (90.0 c.c). M. Sig. — A dessertspoonful every two or three hours. When expectoration is established, expectorants like ammo- nium chlorid, squills, and terpin hydrate may be substituted for ipecac and potassium citrate. Stupes or sinapisms to the chest are also useful in relieving cough. When pneumonia is threatened, dry cupping is often efficacious. The convalescence should be most carefully watched, and strict injunctions given as to diet, rest, and the avoidance of exposure. Tonics are usually indicated and may be continued for several weeks. Change of air will materially help to restore strength and to overcome the peculiar mental depression. ACUTE INFECTIOUS DISEASES. 519 CROUPOUS PNEUMONIA. Prophylaxis against croupous pneumonia consists largely in the avoidance of influences which tend to lower the resistance of the tissues. Undue exposure to cold and the excessive use of alcohol are important predisposing factors. Persons who have had one attack of pneumonia should be particularly at- tentive to their personal hygiene. The sick-room should be well ventilated, but free from drafts. Indeed, the open-air treatment, as applied to tubercu- losis, cannot be too strongly recommended. Fresh, pure air may be secured by screening off the bed and a portion of the room next to a window. This method of treatment may be adopted without regard to seasons or atmospheric conditions. The patient's sputum and all articles liable to be soiled with the sputum should be disinfected. The diet should be fluid or semifluid. Milk, junket, wine- whey, broths, eggs, and gruel are suitable forms of nourish- ment. Cool water should be given freely. Specific Treatment. — Croupous pneumonia cannot be aborted. Many methods of specific treatment have been recommended, but none has proved satisfactory. From the time of Laennec down to about the middle of the last cen- tury venesection was thought to be imperative. To-day, it is rarely practised except to meet certain indications. In robust subjects, at the very onset, when the invasion is violent and attended with high fever, a bounding pulse, marked dyspnea, and severe pleuritic pain, the abstraction of from 10-20 oz. (300.O-600.0 c.c.) of blood may afford great relief. Later in the course of the disease, if cyanosis and orthopnea develop in consequence of overdistention of the right ventricle, venesection may also prove useful. Tartar emetic, which at one time was thought to possess the power of aborting croupous pneumonia, has been entirely abandoned. The same fate has almost overtaken veratrum viride, although some clinicians still recommend it as a sub- stitute for venesection. The treatment of pneumonia by large doses of digitalis, — 1-2 oz. (30.0-60.0 c.c.) of the tincture daily, — originally pro- posed by Petresco of Bucharest, has never had many advo- cates in this country. In 1894 Petresco reported 1192 cases treated by this method, with a mortality of 2.66 per cent. But the author himself states that the treatment is not applicable to very grave cases, and that his observations were made in a military hospital on young and robust men. Petresco's fig- 520 APPLIED THERAPEUTICS. ures lose much of their significance when we compare them with the death-rate in the German army, which, according to Osier, was only 3.6 per cent, in 40,000 cases of pneumonia among healthy picked men. Aufrecht ardently advocates the hypodermic administration of quinin, — 8 gr. (0.5 gm.) once or twice a day, — not as an antipyretic, but as a specific, remedy. The mortality under this treatment in a series of 261 patients treated in the Altstadt Hospital at Magdeburg was 8.8 per cent., but we learn from Strusberg that in the medical clinic at Bonn during the same period the mortality under symptomatic treatment was only 7.97 per cent. Carbonate of creosote (2-3 fl. dr. — 8.0-1 1. o c.c. daily) has recently been highly extolled as a specific by Van Zandt, Weber, and others. In the author's experience this drug has not hastened the crisis nor exerted any appreciable influence on the general toxemia. Of all the special remedies recommended for pneumonia, antipneumococcic serum was the most promising. Perhaps sufficient time has not yet elapsed to warrant a final opinion upon its efficacy, but certainly those who have given it a fair trial will admit that it has fallen considerably below their ex- pectations and has yielded results in no way comparable to those obtained in diphtheria from the use of antitoxin. In a fair test made by J. C. Wilson in the German Hospital, Phila- delphia, the mortality under serum treatment in one series of 18 cases was 22.2 per cent., and in another series of 18 cases, 35.3 per cent. Although we have yet no specific treatment, much may be done in the way of symptomatic treatment to avert a fatal issue." The indications, however, are extremely variable and must be carefully considered in each case. Routine treatment is to be rigidly avoided. In a large number of cases no drugs are needed. The symptoms that most often demand special attention are the pain, cardiac weakness, cough, fever, dyspnea, insomnia, and delirium. Pain. — Morphin hypodermically is the best drug for sub- duing pleuritic pain. It also serves to overcome the restless- ness and anxiety which often mark the onset of the disease, and which, if allowed to continue, tend to augment the ex- haustion. Hot or cold applications to the chest are also use- ful. When the suffering is very severe, a few wet or dry cups to the affected side, followed by poultices, will be found effica- cious. ACUTE INFECTIOUS DISEASES. 52 1 Cardiac Weakness. — Alcohol is the best stimulant. When the pulse becomes compressible and dicrotic, and the diastolic sound at the pulmonary area loses its force, it should be given freely. Often 3 or 4 ounces (90.0-1 18.0 c.c.) of good whisky in the twenty-four hours will suffice, but in some instances two or three times this amount may be given with advantage. The patients who need it most are the old, the debilitated, and the alcoholic. Digitalis is undoubtedly useful in some cases, but its action is uncertain and often disappointing. In the author's experience it has been almost invariably badly borne when administered for the irregular flagging pulse of the period im- mediately following the crisis. Its frequent failure at other times maybe explained by the fact that the cardiac insufficiency in the majority of cases is not dependent on simple dilatation or relaxation of the ventricles, but on degenerative changes in the myocardium, or perhaps, in some instances, on disturbances of the motor ganglia of the heart, brought about by the infection. Mechanical distention of the right ventricle undoubtedly does occur in some cases. It may be recognized by the enlarge- ment of the area of cardiac dulness, by the marked cyanosis, the orthopnea, and the small pulse. In this condition digitalis, by driving the blood with great force against an impassable barrier, is likely to do harm ; it is better to relieve the strain on the right ventricle by judicious venesection. As a circulatory stimulant, strychnin generally proves much more efficacious than digitalis. It should be given in ascend- ing doses of from q - ^ of a gr. (0.001-0.0043 gm.), careful watch being kept for the appearance of untoward symptoms. In order that there may be immediate absorption, large doses should always be given hypodermically. Caffein is a useful adjuvant to stiychnin, but it should not be used when there is cerebral excitement or insomnia. Wood speaks well of cocain — E~i S r - (0.01-0.03 gm.) — alternately with strychnin, one or the other being given in grave cases every two hours. In threatening collapse the author has found no stimulant so generally serviceable as camphor. It is especially useful in tiding the patient over the profound depression that often accompanies or follows the crisis. It is available also when pulmonary edema arises as a complication, and in this con- dition it may be advantageously combined with atropin. To secure the best results, camphor should be given hypoder- mically, dissolved in ether or sterile olive oil, in doses of from 1-2 gr. (0.06-0.13 gm.) every two or three hours. Subcutaneous injections of normal salt solution have also been useful in overcoming adynamia. 522 APPLIED THERAPEUTICS. Cough. — For the hard, dry cough, especially of the first stage, no remedy is so useful as opium in the form of Dover's powder. Expectorants are rarely needed. The inflammatory exudation in the air-vesicles is removed almost entirely by absorption, and to attempt its expulsion by means of a drug is useless. When, however, there is a good deal of bronchial catarrh, with much viscid sputum, ammonium carbonate may be given to facilitate expectoration, but it should be withdrawn immediately if it causes any disturbance of digestion. Fever. — The fact that in a very large proportion of the gravest cases the temperature is not high indicates that the chief factor in bringing about the exhaustion is not the fever itself, but the toxemia. This being the case, and as the febrile period is generally of a comparatively short duration, anti- pyretic measures may be restricted in the majority of cases to frequent cold sponging and the application of an ice-bag or an ice-poultice to the affected side. Persistent high temperature is best controlled by cool baths (8o° F. — 27.5°C). Experience is strongly against the syste- matic employment of antipyretic drugs, like phenacetin and antipyrin. Dyspnea. — Cardiac stimulants, since they favorably in- fluence the pulmonary circulation, are also of service in re- lieving dyspnea. Naturally, the circulatory stimulants that are also respiratory stimulants, like strychnin, caffein, and cocain, are the most useful. Oxygen makes the breathing easier, lessens cyanosis, and conduces to sleep, and to this extent aids in conserving energy. Insomnia and Delirium. — When insomnia and delirium are sufficiently severe to demand the use of drugs, morphin will generally be found the most efficacious. Of course, it should not be used when there is extreme dyspnea or when there are evidences of pulmonary edema. When the circula- tory depression is not marked, chloral may be used. In other cases, chloralamid or sulphonal may be tried. Delayed resolution is a troublesome complication. For- tunately, it is of rare occurrence. It sometimes yields to repeated blistering and the free use of tonics. Riess has recommended injections of pilocarpin, and Dieulafoy, Forbier, and Lepine the production of aseptic abscesses by means of turpentine injections. Edsall and Pemberton have recently reported three cases in which rapid improvement occurred under the use of ;r-rays. ACUTE INFECTIOUS DISEASES. $2$ DIPHTHERIA, Diphtheria being a highly contagious disease, the utmost care should be taken to prevent the spread of the specific virus. General prophylactic measures include the isolation of the sick, absolute cleanliness in the sick-room, and the thorough disin- fection of all articles of clothing and fomites that may have become contaminated with the secretions from the infected area. As diphtheria bacilli often remain in the throat for weeks or even months after the disappearance of the false membrane, isolation should be urged until the bacilli can no longer be detected in the throat by bacteriologic examination. Physicians and nurses, in applying local remedies, must be exceedingly careful lest they become infected directly by shreds of false membrane expelled by the patient in coughing. Finally, exposed persons, especially children, should receive an immunizing dose of diphtheria antitoxin (see p. 431). The sick-room should be well ventilated, and the tempera- ture maintained at about Jo° F. (21 C). It is desirable to have the atmosphere moist, and this may be accomplished by generating steam in an ordinary kettle or in a steam atomizer, or by slaking large quantities of quicklime in the room. Young children, especially when laryngeal symptoms are present, are best treated in a steam-moistened tent. Absolute rest must be enforced. The diet should be of the most nutritious and easily digested character. Milk, junket, ice-cream, eggs, and unseasoned broths may be allowed. After tracheotomy it may be necessary, in order to introduce sufficient nourishment, to feed through a soft-rubber nasal tube. Cool water should be given freely. The medicinal treatment of diphtheria is both local and constitutional. I/OCal Treatment. — Local treatment is of great importance, but often difficult to carry out. When the applications cause violent struggling and exhaust the child, it may be better to desist. Applications should be made with utmost gentleness, should be unirritating, and should be frequently repeated. Remedies may be applied by means of absorbent cotton on a swab, or by sprays, injections, or irrigations. In pharyngeal diphtheria the first method is usually the best, while in nasal diphtheria the employment of a syringe or irrigator is prefer- able. The nozzle of the instrument should be blunt and cov- ered with soft rubber, and the nurse should be instructed to introduce it gently and in a horizontal direction. In both nasal and pharyngeal diphtheria, when the child cannot be raised, the fluid may be poured into the nose from a spoon, minim- dropper, or, better, from a nasal cup (Jacobi). Sprays are not 524 APPLIED THERAPEUTICS. very efficacious. In laryngeal diphtheria local treatment is rarely feasible, except by means of medicated vapors. Many local remedies have been recommended ; the following are, perhaps, the most generally useful : Solution of hydrogen dioxid (1:2 of lime-water), Loffler's solution (see p. 293), or corrosive sublimate (1 : 5000 to 1 : 1000). All applications to the nasal mucous membrane should be warm. False mem- brane should never be torn off, but when it is very loose, it may be carefully dislodged and removed. Emetics are some- times useful in expelling false membrane from the larynx, but when there are marked symptoms of obstructive dyspnea, the operation of intubation or tracheotomy should not be deferred. Externally, hot or cold applications, whichever may be more grateful to the patient, are useful in relieving pain and soreness in the throat. When there is marked swelling of the cervical glands, an ointment of mercury and belladonna is sometimes of service. Constitutional Treatment. — Statistical reports from all parts of the world prove conclusively that the remedy of greatest value in the treatment of diphtheria is the blood- serum of animals rendered artificially immune against the dis- ease (see article on Diphtheria Antitoxin, p. 431). Apart from antitoxin, the most important remedies are those which tend to maintain the bodily strength. Alcoholic stimulants are usually indicated, especially in the late stage of the disease. In septic cases alcohol is particularly well borne, a child of three years often being able to take several ounces of whisky a day with advantage. Next to alcohol, strychnin is the best stimulant. In profound adynamia, digitalis, caffein, camphor, and musk are also useful. Two drugs which are believed to be of special value, but which have lost some of their reputation since the introduc- tion of antitoxin, are the tincture of the chlorid of iron and mercury. From 3-5 min. (0.2-0.3 c.c.)of the tincture of ferric chlorid may be given in glycerin or water every two or three hours to a child of four years. It should, however, be sus- pended on the first appearance of digestive disturbance. Children with diphtheria are usually very tolerant of mercury, and as much as -fa of a grain (0.0016 gm.) of corrosive sub- limate may be given every three hours to a child of three or four years. Potassium chlorate is another popular remedy. Its action, however, is a purely local one. On account of its irritant effects on the kidneys it should never be used internally. Convalescence must be managed with special care, on account ACUTE INFECTIOUS DISEASES. $2$ of the tendency to cardiac weakness. Anemia, a common sequel, ■will require good hygienic surroundings, plenty of nourishing food, and iron. Diphtheric paralysis usually yields to strych- nin and other tonics, combined with the use of massage and electricity. SCARLET FEVER. To prevent the spread of the disease, the patient should be rigidly isolated. The sick-room should be large and airy, and, if possible, it should be at the top of the house. All unneces- sary furniture should be removed from the room, and no one should be allowed to enter it except the physician and nurse. The nurse should wear a loose wrapper and cap, to be left inside the room when she is obliged to leave it. All articles that have been in contact with the patient should be thoroughly disinfected before they are permitted to be taken from the room. Finally, to prevent the dissemination of the scales, some bland ointment (cold cream, olive oil, cocoa-butter) should be applied to the patient's body at least once a day until desquamation is complete. During the period of active desquamation the inunctions should be preceded by warm alkaline baths. The treatment of scarlet fever is purely symptomatic. The patient should be kept in bed until the end of desquamation. The diet should consist of milk, junket, koumiss, ice-cream, fruit-juices, and gruels. So as not unnecessarily to tax the kidneys, animal broths and meat should be withheld, if pos- sible, until convalescence is well established. Water should be given freely to relieve thirst and to keep the secretions active. In many cases no special medication is required beyond the use of a mild refrigerant mixture, such as the following : R Spiritus aetheris nitrosi, fzvj (22.5 c.c.) ; Liquor ammonii acetatis, q. s. ad fgiij (90.0 c.c). M. Sig. — Dessertspoonful with water every three hours for a child of five years. Vomiting. — When vomiting is severe, it may be necessary to withhold food for several hours and to administer an anti- emetic, such as ice, carbonated water, bismuth subnitrate with hydrocyanic acid, or cocain ( 2 1 o ~ i 1 q S r - — O.003-0.006 gm.). In very obstinate vomiting opium suppositories or chloral enemata should be tried. Fever. — Tepid sponging is very grateful throughout the febrile period. Fever above 103 F. (39.5 ° C.) should be com- bated with cold packs or gradually cooled baths (8o° F. — 526 APPLIED THERAPEUTICS. 26. 5 C), and by cold applications to the head. Phenacetin, antipyrin, and other antipyretic drugs should not be used except as a last resort, and then only in small doses. Cardiac Weakness. — If the heart shows signs of failing, alcoholic stimulants will be demanded. Many practitioners believe that the tincture of ferric chlorid (1 drop a dose for each year of the child's age) exerts a favorite influence upon the general toxemia. Threatened collapse will require the use of such remedies as strychnin, digitalis, camphor, ammonia, and musk. Nervous Symptoms. — Restlessness, jactitation, head- ache, and insomnia will generally yield to small doses of a bromid and to the application of cold to the head. When these symptoms are severe, however, no remedy is so useful as chloral. It may be given in doses of from 3-5 grains (0.2-0.3 gm.) every three or four hours. Nervous symptoms the result of high fever will, of course, require vigorous anti- pyretic treatment. Throat Symptoms. — Cleansing of the nose and throat with mild antiseptic sprays or washes will do much to prevent the development of septic adenitis and middle-ear disease. Weak DobelPs solution or solution of hydrogen dioxid (1:3) may be used for this purpose. When tonsillitis is severe, the following application will be found useful : R Potassii chloratis, gr. xx (1.3 gm.) ; Tincturse ferri chloridi, Glycerini, aa f^ss (15.0 c.c.) ; Aquae, q. s. ad fljij (60.0 c.c). M. Sig. — Apply to the tonsils several times a day with a cotton swab. Pain and swelling in the neck are best relieved by ice poul- tices ; in some cases, however, hot compresses are more grate- ful. When suppuration occurs, the abscess should be freely opened and dressed antiseptically. In acute Otitis media nothing affords so much relief as gently syringing the auditory canal with hot water. The application of a leech behind the ear is also useful. When the tympanic membrane bulges, indicating the presence of pent-up pus, the latter should be evacuated by puncture. Nephritis. — A milk diet, tepid bathing during the febrile period, and the avoidance of exposure for several weeks after the subsidence of the fever are important prophylactic meas- ures against nephritis. Should this complication develop, however, dry cupping over the loins, followed by warm fomen- tations, will often prove of value. Aperients, especially salines, ACUTE INFECTIOUS DISEASES. $2? are indicated. Warm baths, hot packs, vapor baths, or pilo- carpi ( jV ' r o S r - — 0.004-0.006 gm.) should be used to pro- mote diaphoresis. When the urine is scanty, unirritating diu- retics, like potassium acetate or bitartrate and digitalis, are of service. MEASLES AND RUBELLA. The prophylactic measures described in connection with scarlatina are applicable in measles and rubella. Measles is a self-limited disease and cannot be aborted. The temperature of the sick-room should be maintained at about 68° F. (20 C). The patient should be kept in bed until all traces of the rash ha\e disappeared, and confined to his room for a week or ten days longer. On account of the photophobia the room should be moderately darkened, and the bed so arranged that the face will be directed away from the light. When the cough is troublesome, the atmosphere should be kept moist. Milk, junket, fruit-juices, broths, eggs, and gruels are suita- ble forms of nourishment. Water should be proffered at fre- quent intervals. Stimulants are rarely required except in malignant cases. Daily inunctions of the body with cold cream or olive oil will serve to allay burning and itching of the skin. Spraying the nose and throat at frequent intervals with warm Dobell's solution will aid in preventing buccal and aural complications. When conjunctivitis is marked, the eyes should be protected with dark glasses and frequently cleansed with a solution of boric acid (15 gr. to the oz. — 1.0 gm. to 30.0 c.c). Hot baths and hot drinks are indicated when the rash is delayed. Fever, unless persistently high, may be left alone. When antipyretic measures are required, tepid sponging or immer- sion for a few minutes in water gradually cooled from 95 ° F. (35 C.) to 8o° F. (26.5 C.) will be found the most satisfactory. Antipyretic drugs should be used only as a last resort. The medicinal treatment of measles is usually very simple. Constipation should be relieved by small doses of calomel or by glycerin suppositories. Severe vomiting may require cracked ice, lime-water, bismuth subnitrate, cocain, or suppositories of opium. Diarrhea will generally yield to a few doses of bismuth subnitrate and opium. Troublesome headache and insomnia are best treated by bromids or small doses of chloral. Cough very frequently requires attention. The application of sinapisms to the chest, the inhalation of steam, and the 528 APPLIED THERAPEUTICS. administration of sedative expectorants with opium are meas- ures calculated to afford relief. The following mixture will be found useful : R Potassii citratis, gij (8.0 gm.) ; Vini ipecacuanhas, fgij (8.0 c.c.) ; Tincturae opii camphoratse, fgiij (11.0 c.c); Syrupi tolutani, fifj (30.0 c.c.) ; Aquae cinnamomi, q. s. ad fgiij (90.0 c.c). M. Sig. — A teaspoonful every three or four hours. A mixture of ammonium chlorid and syrup of squill will be efficacious when the cough loosens. The treatment of rubella does not differ materially from that of measles. SMALLPOX. The preventive measures against smallpox include the com- plete isolation of the patient (preferably in a special hospital), the thorough disinfection of all objects that have been in con- tact with him, and, above all, the vaccination of all who have been or who are likely to be exposed to the contagion. Vaccination. — Vaccination does not afford complete and permanent immunity against smallpox, but in the vast majority of cases it renders the person insusceptible to the disease for a number of years. In Prussia the death-rate from smallpox per 100,000 of population prior to the enforcement of general vaccination (1846-74) was 24.4, while after the enforcement of general vaccination (1874-86) it was only 1.5 (Abbott). In the hospitals of London, from 1876-79, there were admitted 11,412 smallpox patients who had been vaccinated in infancy, but not a single case was known to have occurred in a person who had been successfully revaccinated (Welch). Vaccination should be performed at the third month (earlier if smallpox be epidemic), again at puberty, and subsequently whenever smallpox is prevalent. Only bovine lymph should be used, and preference should be given to that which has been glycerinated and preserved in hermetically sealed glass tubes. The part selected should be thoroughly cleansed, first with soap and water, then with alcohol, and finally with pure water. Many methods of performing the operation are recom- mended. The simplest is to make, with a sterile lancet or special scarificator, a number of cross scratches, only deep enough to allow of a little oozing of pinkish serum. The with- drawal of blood is to be carefully avoided, as it tends to wash away the vaccine material. The virus is now applied and well rubbed into the exposed lymphatic spaces by additional scan- ACUTE INFECTIOUS DISEASES. $ 2 9 fication. A shield may be worn for a few hours, until the wound has become perfectly dry ; after that it should be dis- carded, since it serves, especially if tight-fitting, to intensify the inflammatory reaction. For a vaccination to be considered successful the vaccine lesion should pass through a papular, vesicular, and pustular stage, and leave behind a permanent cicatrix. A typical vesicle resembles " a section of a pearl on a rose leaf" (Jenner). A good scar is pale, sharply defined, and pitted. General Management. — There is no specific for small- pox. Absolute rest in bed, light bed-clothing, a well-ventilated room of a temperature of 65 F. (18.5 C), an easily assim- ilable but sustaining diet, and the free use of cool drinks are requisites of treatment. The severe lumbar pains will require opium and the application of hot-water or hot-bran bags. Fever above 103 F. (40 C.) is best combated by hydrotherapy — cold sponging, cold packs, or cold baths. Antipyretic drugs should be used with great caution. Gastric irritability may be controlled by dilute hydrocyanic acid (2 min. — 0.1 c.c), subnitrate of bismuth (10 gr. — 0.6 gm.), or cocain (-|- gr. — 0.008 gm.). Diarrhea should be remedied by the use of bismuth and morphin powders (see p. 375). When nervous symptoms — jactitation, delirium, and insomnia — are not relieved by hydrotherapy, opium with bromids or chloral with bromids should be tried. Alcoholic stimulants are frequently demanded, especially in confluent cases. Quinin is also useful in the adynamia of sepsis. An attempt should be made to keep the nasopharynx clean by means of antiseptic sprays or douches. For this purpose . Dobell's solution or solution of hydrogen dioxid (1:4) will be found useful. The eyes should also be kept clean by fre- quent applications of a warm boric-acid solution (15 gr. to the ounce — 1.0 gm. to 30.0 c.c). The Eruption. — Cool antiseptic washes, such as carbolic, I : 200, or corrosive sublimate, 1 : 5000-1 : 10,000, are, per- haps, the most useful applications that can be made to the skin. Compresses wet with these solutions may be kept constantly on the face and hands to exclude the light, which, there is some reason to believe, acts unfavorably on the pocks. Many remedies have been recommended to prevent pitting, but it is doubtful whether any are really efficacious. An old plan was to open the vesicles and touch their base with a stick of silver nitrate. Dujardin-Beaumetz recommended an ointment of sodium salicylate (4 parts) and cold cream (100 parts). Hebra speaks favorably of continuous warm baths. Finsen, Feilberg, 34 530 APPLIED THERAPEUTICS. and others recommend the exclusion of the chemical rays of light from the sick-room, red light only being admitted ; but this plan of treatment does not appear to be particularly bene- ficial, and has the drawback of putting a check on the supply of fresh air. In the stage of desiccation, warm baths followed by inunc- tions with cold cream or olive oil are useful in allaying itching and in hastening the removal of the crusts. YELLOW FEVER. In the absence of any specific remedy, the treatment of yellow fever must be mainly expectant. Absolute rest and quiet, a sick-room well ventilated but free from drafts, and careful nursing are essential. The patient should be isolated, and protected by nets and wire screens from mosquitoes. Only the blandest articles of food should be allowed, and these should be given in small quantities. Peptonized milk, milk with lime-water, junket, koumiss, milk-punch, barley-water, toast- water, and iced champagne are available. Carbonated waters, like Vichy and Apollinaris, are grateful and useful. Sternberg, Touatre, and many other clinicians of wide experience in the treatment of the disease advocate the withholding of all food during the first two or three days. If the patient be seen in the first twenty-four hours of his illness, a hot mustard foot-bath may be given with advantage. If there be a tendency toward constipation, a few small doses of calomel may be administered and followed by a Seidlitz powder, or a purgative enema may be used. It is very questionable whether any drug has the power of modifying the course of the disease as a whole, although Stern- berg is firmly convinced of the efficacy of the following com- bination : R Sodii bicarbonaiis, £iv (15.0 gm.) ; Hydrargyri chloridi corrosivi, gr. ss (0.03 gm.); Aquae destillatae, Oj (475.0 c.c). M. Sig. — In severe cases, two teaspoonfuls every hour, day and night ; in mild cases, every hour by day and every two hours by night ; administer ice-cold. Obstinate vomiting should be combated by the applica- tion of an ice-bag or a sinapism to the epigastrium and by the administration of sedatives, like cracked ice, lime-water, hydro- cyanic acid, or cocain. In severe cases it is best to let the stomach have complete rest and to give morphin hypodermi- cally or by the bowel. ACUTE INFECTIOUS DISEASES. 53 I Systematic cold sponging keeps down the temperature, lessens nervous excitability, and favors diuresis. High temperature should be controlled by the cold bath. Suppression of urine will call for dry cupping over the loins, alkaline diuretics, hot-air or hot-water baths, and, perhaps, rectal or subcutaneous injections of warm saline solutions (see pp. 488-498). If there are signs of heart-failure, alcoholic stimulants should be given freely : iced champagne and iced brandy with soda water are the remedies most favored. Threatened collapse will require subcutaneous injections of strychnin, ether, or cam- phor, hot baths, and enemata of black coffee or brandy. Remedies have little, if any, control over black vomit. Guiteras recommends tincture of ferric chlorid, and Carroll, oil of turpentine. CHOLERA. Hygienic measures are of the utmost importance in prevent- ing the spread of cholera. Personal prophylactic measures against the disease include removal from the infected districts ; restriction of the diet to bland, easily digested food; thor- ough sterilization of drinking-water and milk ; the protection of all food from contamination by flies and other insects ; the avoidance of overwork, exposure to wet and cold, and undue excitement ; and the prompt treatment of any gastro- intestinal disturbance that may arise. Certain acids, especially sulphuric acid, have long been advocated as preventives of cholera. Finally, vaccination with attenuated cholera cultures, as practised by Haffkine in India, has given encouraging results. Precautionary measures pertaining to the sick comprise iso- lation, absolute cleanliness, and the thorough disinfection of excreta, soiled clothing, etc. The medicinal treatment of cholera resolves itself into that of the prodromal stage, that of the algid stage, and that of the reaction stage. Prodromal Stage. — From the first appearance of diarrhea the patient should go to bed and remain there. Food should usually be withheld. If there be a history of indigestible food having been taken, a laxative dose of calomel or of castor-oil should be given ; otherwise, aperients should be avoided. Hot stupes maybe applied to the abdomen. If there be much colic, morphin may be given hypodermically. In the last European epidemic (1892) many good observers reported adversely upon the use of opium by the mouth. For the diarrhea, bismuth subnitrate is perhaps the best astringent. 532 APPLIED THERAPEUTICS. Algid Stage. — Intravenous injections of warm saline solu- tions (see p. 496 s ) undoubtedly afford the best means of com- bating the anhydremia and of restoring the failing circula- tion. Rectal injections of hot tannic solutions (2 per cent), as strongly recommended by Cantani, may also be used. The body-temperature should be maintained by hot applications or hot baths. Diffusible stimulants, like ether and camphor, may be given hypodermically. To allay thirst, ice, ice-water, or iced Seltzer water may be given at frequent intervals. The painful cramps are best treated by warm applications, hot baths, gentle friction with anodyne liniments, and, above all, by intermittent chloroform inhala- tions. In suppression of urine the most promising measures are dry cupping over the loins, and rectal and intravenous in- jections of saline solutions. Reaction Stage. — In this stage liquid foods in small quantities are permissible. Milk with lime-water, whey, thin gruels, albumin-water, and light broths are the most appro- priate. The return to ordinary food should be effected most gradually. Water should be given freely, since it tends to restore vascular fulness and favors diuresis. Any tendency to recurrent diarrhea should be met by the administration of bis- muth subnitrate with an intestinal antiseptic or of silver and opium pills. Bitter tonics are often of service during con- valescence. Change of air is a valuable aid to the restoration of health. WHOOPING-COUGH. The , chief elements in the prophylaxis of whooping-cough are isolation of the patient and the thorough disinfection of all articles that have been used by him. Quarantine should last until the cough ceases, which will seldom be before the end of six or eight weeks from the onset of the disease. As there is no specific, treatment must be directed to reliev- ing the catarrh, allaying the irritability of the respiratory mucous membrane, and warding off complications. Fresh air, sunlight, protection from changes of weather, and a light but nutritious diet are essential. In some cases it may be desirable to keep the patient in his room, or even in bed, for the first few days, but ordinarily, if the weather be good, he need not be confined indoors. In advanced cases sea air often acts most favorably. In some instances, when the vomiting is very per- sistent, it may be desirable to withhold food by the mouth for a short period and to substitute nutritive enemata. Expectorants are rarely of service except in the first stage, ACUTE INFECTIOUS DISEASES. 533 when the cough lacks the distinctive whoop and is hard and dry. At this period a mixture of potassium citrate, ipecac, and paregoric (see p. 528) may be useful in rendering the ex- pectoration less viscid. Special Remedies. — Of the numerous special remedies advocated, the chief are belladonna, quinin, bromids, antipyrin, bromoform, and alum. No one drug is of service in every case, and after failing with one, another should be tried. Bella- donna has a long-established reputation ; to be effective, it must be given in ascending doses until a constitutional impression is perceptible (see p. 80). Quinin, first recommended by Letzer- ich, is undoubtedly of value in many cases ; it must be given, however, in large doses, — 10-12 gr. (0.65-0.8 gm.) a day for a child of three or four years, — and these may disturb digestion. The bromids, especially of sodium and strontium, are often of service in lessening the frequency and severity of the parox- ysms. They may often be advantageously combined with belladonna. Antipyrin has been advocated since 1886, and is, on the whole, perhaps, the most reliable remedy. The dose should be gradually increased until a child one year old receives from j— 1 gr. (0.03-0.06 gm.) every two hours. It is particu- larly efficacious in combination with a bromid, as in the fol- lowing formula : R Sodii bromidi, gr. 1 (3.2 gm.) ; Antipyrinse, gr. xv (1.0 gm.) ; Glycerini, fjjss (15.0 c.c.) ; Aquae menthae piperitae, q. s. ad f^iij (90.0 c.c). M. Sig. — A teaspoonful every two hours for a child one year old. Bromoform, introduced by Stepp in 1887, has been warmly recommended by Fischer, Burton-Fanning, and others. The initial dose for a child under two years of age should not exceed 1 min. (0.06 c.c.) four times a day (see p. 117). Alum is a very old remedy ; in small doses — 1 gr. (0.06 gm.) every two hours for a child of one year — it is occasionally useful when there is copious secretion. Chloral (3 gr. — 0.2 gm. — for a child of two years) or Dover's powder (1 gr. — 0.06 gm.) may be given in severe cases at bed- time to secure sleep. The inhalation of chloroform or of amyl nitrite may be necessary when the paroxysms are so violent as to threaten hemorrhage or convulsions. For the prevention of excessive vomiting, Kilmer highly recommends the application of an abdominal belt made of linen, with a strip of elastic webbing two inches wide, inserted on each side. The belt extends from the axillae to the pubes and laces in the back. 534 APPLIED THERAPEUTICS. I/OCal Treatment. — Mild but persistent counterirritation over the chest is sometimes useful, particularly when the catar- rhal element is prominent. Medicated steam inhalations with eucalyptol, benzoin, creasote, or terebene are also very bene- ficial when there is excessive bronchitis or a pneumonic com- plication. Good effects have been claimed for oxygen and ozone inhalations. Antiseptic and sedative sprays, when feasi- ble, sometimes afford much relief; the best are the solution of hydrogen dioxid (i part to 6 parts of water), menthol (5-10 per cent, in liquid paraffin), resorcin (1 per cent, aqueous solu- tion). Insufflations of drugs in the form of a fine powder — quinin, bode acid, tannin, benzoin, etc. — have been warmly advocated by many, but they are of doubtful benefit. Convalescence. — During convalescence it is necessary to exercise considerable care, on account of the great danger of catarrhal pneumonia. Tonics, especially quinin, iron, and cod- liver oil, are very useful. When there is persistent enlarge- ment of the bronchial glands, iodid of iron internally, with inunctions of europhen (5 per cent), will be found efficacious. Change of air is always beneficial. ERYSIPELAS. As in other contagious diseases, isolation and disinfection are the most important prophylactic measures. Especially necessary is it to guard parturient and surgical patients from the contagion. Internal Treatment. — A supporting liquid diet should be given. Alcoholic stimulants are sometimes required in con- siderable quantities. High fever is best controlled by cold sponging or the cold pack. Restlessness, delirium, and insom- nia will call for applications of ice to the head, and perhaps the administration of morphin, chloral, or bromids. Of the numerous special remedies recommended for erysip- elas, the one which has enjoyed the most favor is the tincture of ferric chlorid (20-30 min. — 1.2-2.0 c.c. — every three hours), first suggested by Bell in 185 1. While apparently of some service, this drug is not a specific, and should be withdrawn if it disturbs digestion. The therapeutic status of antistrepto- coccus serum has not yet been definitely determined, although it has been frequently administered in severe cases with alleged good results. I/OCal Treatment. — Among the numerous local applica- tions recommended for erysipelas may be mentioned mixtures of zinc oxid, boric acid, and starch on cotton-wool ; lotions of ACUTE INFECTIOUS DISEASES. 535 lead- water and laudanum, of carbolic acid (1 : 40), of corrosive sublimate (1 : 5000), of picric acid (1 : 100), and of magnesium sulphate (saturated aqueous solution on a mask of from 1 5 to 20 thicknesses of gauze) ; and ointments of ichthyol (30 per cent.) and of soluble silver (15 per cent). In the author's hand, ichthyol (see p. 335) and soluble silver (see p. 374) have proved the most satisfactory local remedies. Eschars made with the stick of silver nitrate or strong car- bolic acid beyond the infected area are occasionally successful in arresting the spread of the disease. The cellular infiltration caused by these irritants probably serves to check the migra- tion of the cocci. The injection of antiseptics, such as car- bolic acid and corrosive sublimate, around the diseased area is of very doubtful utility. Local abscesses should be incised and treated antiseptically. Extension to the nose and throat will call for antiseptic sprays or washes. Should the larynx become involved, the constant sucking of ice may serve to control the swelling ; whenever, however, dyspnea becomes urgent, scarification of the larynx or tracheotomy will be demanded. TETANUS. The most important safeguard against the occurrence of tetanus is the thorough cleansing and disinfection of all wounds. As tetanus antitoxin is practically harmless and has been shown to possess considerable immunizing power, it is advisable to employ it as a prophylactic remedy in all suspicious wounds, especially those which have become contaminated with garden earth, street dirt, or stable refuse. When tetanus has actually developed, the indications for treatment are to prevent the further production of toxin at the seat of injury ; to neutralize the toxin that has already been absorbed and is exerting a baneful influence on the nervous system ; to subdue the convulsions ; and to maintain nutrition until the disease shall have run its course. The first indication is to be met by promptly enlarging the wound, freeing it from all foreign matter, and treating it with some active antiseptic. The most hopeful means of meeting the second indication is by administering tetanus antitoxin (see p. 432). Of 290 cases of tetanus treated by the subcutaneous injection of serum, death occurred in 117 (Moschowitz). 1 While an analysis of the statistics does not justify the conclusion that antitoxin is very potent in acute cases, it does suggest that the l Medical News, October 13, 1900. 536 APPLIED THERAPEUTICS. remedy is of distinct value in subacute and chronic tetanus. As no ill effects result from the administration of the serum, and as its use does not interfere in any way with other methods of treatment, we believe that it should be used in large doses in every case, and as soon as possible after the onset of the symptoms. When the symptoms are grave it would seem to be advisable to inject the serum directly into the brain or into the subarachnoid space of the spinal cord. Forty-eight cases treated by cerebral injections presented a little over 50 per cent, of recoveries. All these cases, however, were of the severest type (Moschowitz). According to von Leyden, of II severe cases treated by subarachnoid injections, recovery occurred in the last 5. Bacelli has reported excellent results (1 death in 40 cases) in the treatment of tetanus from the subcutaneous administra- tion of carbolic acid in large doses (see p. 389), but other observers outside of Italy have not been able to repeat his success. It is not improbable that tetanus runs a milder course in Italy (PfeifTer). As the central nervous system seems to possess some antitoxic power, the injection of brain-substance subcutaneously has been recommended. The drugs most effective in subduing convulsions are the bromids and chloral. These should be given in large doses. Morphinand eserin are useful adjuvants. Subarachnoid injec- tions of magnesium sulphate (see p. 217) have yielded satis- factory results in a few cases. Inhalations of chloroform or of amyl nitrite sometimes afford temporary relief. Of course, the patient should be kept absolutely quiet and protected from cold and from even the slightest external irritation. The maintenance of nutrition by the administration of nutri- ment in liberal quantities is of the utmost importance. In severe cases, milk, raw eggs, and animal broths are suitable forms of nourishment. Alcohol is often necessary, sometimes in large quantities. When swallowing is impossible, feeding must be carried out by means of a tube passed through the nostril. RHEUMATIC FEVER, General Management. — Absolute rest in a comfortable bed is essential, and, with the view of preventing permanent injury to the heart, this should be maintained for at least ten days or two weeks after the temperature has become normal and all the arthritic symptoms have subsided. To guard against chilling of the body, the patient should wear a loose ACUTE INFECTIOUS DISEASES. 537 flannel night-dress and lie between blankets. The room should be well ventilated, but free from draft. Milk and cereals are the most suitable articles of diet. Junket, koumiss, ice-cream, milk-toast, boiled rice, and gruels may be given. During the febrile period animal food is best avoided. During convales- cence, however, fish, oysters, eggs, and broths are admissible. The free use of water and of lemonade should be encouraged. Alcohol, unless the heart is seriously involved, is not often required. Internal Treatment. — Salicylic compounds have consid- erable power in mitigating pain, shortening the duration of the attack, and of lessening the liability to cardiac complications. The more typical the case, the more decided are the good effects of these drugs. From 10 to 15 gr. (0.65-1.0 gm.) of ammonium or sodium salicylate should be given every two or three hours, until a decided impression is made upon the dis- ease or the phenomena of salicylism are produced, when the interval between the doses should be lengthened to four or six hours. It is advisable to continue the drug for several days after the subsidence of the symptoms. When the ammonium or sodium salt is not well borne, strontium salicylate (see p. 399) or aspirin may be substituted. Alkalis are also remedies of value ; they may be combined with the salicylates or they may be given alone. About 20 gr. (1.3 gm.) of potassium citrate or acetate should be given every two or three hours until the urine becomes decidedly alkaline ; then every four or six hours, the influence of the remedy being maintained for at least a week after all symptoms have disappeared. Opium, in the form of Dover's powder or of morphin hypo- dermically, is sometimes of great value in allaying pain, sub- duing restlessness, and procuring sleep. Antipyrin or phe- nacetin, in moderate doses, is also a useful adjuvant to salicy- lates or alkalis when the pain is severe. When adynamia is marked, quinin (5 gr. — 0.3 gm. — thrice daily), as recommended by Garrod, Duckworth, and DaCosta, is frequently beneficial. Anemic patients are usually benefited by iron. A useful com- bination is the ferrosalicylate mixture recommended by S. S. Cohen : R Sodii salicylates, ^iij (12.0 gm.) ; Glycerini, fgvj (22.5 c.c.) ; Mucilaginis acacise, f^iij (12.0 c.c); Olei gaultheriae, Tltxij (0.8 c.c); Liquoris ammonii citratis (B. P.), f^iss (45.0 c.c) ; Solve et adde guttatim, Tincturae ferri chloridi, fjiij (12.0 c.c). M. Sig. — One to two teaspoonfuls in water every three hours. 538 APPLIED THERAPEUTICS. In some cases, when the usual remedies prove unsatisfactory, syrup of iodid of iron, in large doses (1-3 fl. dr. — 4.0-1 1.0 c.c. — daily), as recommended by J. C. Wilson, is quite effectual. Hyperpyrexia is best controlled by the cold bath (see p. 493). The treatment of endocarditis and of pericarditis will be treated in another part of this volume. The importance of prolonged rest in cases in which the heart becomes affected cannot be overestimated. During convalescence, tonics, like iron, quinin, and arsenic, and a liberal diet are necessary. I/Ocal Treatment. — In mild cases the application of cot- ton-wool to the affected joints will suffice. When the pain is severe, hot alkaline lotions sometimes afford relief; but, as a rule, compresses soaked in methyl salicylate and covered with oiled paper are much more effective. Ointments containing salicylic acid (see p. 398) are also useful. In some cases small blisters applied about the inflamed joints are of great utility. According to Osier, however, they are not nearly so beneficial as light applications of the thermocautery. No matter what local remedy is selected, it is very impor- tant that the affected joints should be kept at complete rest. This may be accomplished by means of padded splints and a roller bandage or, often better, by the use of starch bandages or plaster casts. Lingering swelling will often yield to an ointment of mer- cury and belladonna, with firm strapping of the articulation. Blisters are also useful. When the effusion is very great and persistent, it may be necessary to aspirate the joint. For the stiffness of the joints induced by rheumatism, mas- sage, warm baths, and inunctions with an ointment of iodin will be found useful. The hot-air treatment (see p. 485) also does good in some cases. MUMPS. In the majority of cases but little treatment is required. The patient should be confined to a warm room and preferably to bed. Isolation should last about three weeks from the onset of the disease. As deglutition is painful, the nourishment must be fluid. A mild aperient may be administered at the outset. If febrile symptoms are marked, refrigerants, like aconite, spirit of nitrous ether, and solution of ammonium acetate will be found useful (for formula, see p. 63). Pain in the throat is best relieved by sucking ice. I/Ocal Treatment. — In mild cases, covering the gland with cotton batting will be all that is necessary. When there CONSTITUTIONAL DISEASES. 539 is decided pain, hot fomentations proove soothing. Emollient applications with laudanum (1 fl. dr. to 1 oz. — 4.0 c.c. to 30.0 gm.) are frequently recommended. An ointment of guaiacol (5 per cent.) has recently been warmly advocated. Orchitis will require rest, suspension of the affected gland, and the application of lead-water and laudanum or, better still, of an ointment of guaiacol (10 per cent). After the tender- ness has subsided, an ointment of mercury and belladonna will be found useful in reducing the swelling. CONSTITUTIONAL DISEASES. DIABETES MELLITUS. The treatment of diabetes mellitus is dietetic, hygienic, and medicinal. Dietetic Treatment. — The general rule is to eliminate from the dietary, at least for a time, all starchy and saccharin foods. Some relaxation of this rigid rule, however, is often desirable and even necessary. Each case must be carefully studied from the standpoint of the urine, the body-weight, and the general health. In mild types of the disease, after the glycosuria has once been controlled by strict dietetic regimen, it is generally possible to add a certain amount of carbohydrate matter without causing the reappearance of sugar in the urine. The exact amount and character of the carbohydrates that can be tolerated should be determined in each instance by frequent quantitative estimations of the sugar excreted. Again, in severe cases it is frequently necessary, in spite of some increase of glycosuria, to permit greater latitude in diet, in order to sustain the patient's strength. " There can be no doubt that a diabetic patient whose strength is well maintained is better off than one whose urine contains only 1 per cent, of sugar, but yet is daily growing weaker " (Striimpell). The strict diet precludes the use of the following articles : bread, cakes, and pastry made of wheat, rye, rice, or corn, sago, barley, tapioca, beets, carrots, turnips, parsnips, peas, sweet fruits, chestnuts, chocolate, syrup, preserves, sweet wines, malt liquors, cordials, and all preparations containing cane-sugar or glucose. Potatoes are generally classed among the forbidden articles, but Mosse and Saundby have shown that they are not only permissible in many cases, but even useful. Mosse advances two hypotheses to explain the beneficial action of potatoes ; the first is that they yield a sugar more easily warehoused 540 APPLIED THERAPEUTICS. than that from bread ; and second, that they introduce a sub- stance (potash) into the organism which favors glycolysis. The following articles may be allowed : Animal Food. — Meats of various kinds (except liver), game, light broths and soups, fish, and eggs. Fats, when well digested, are beneficial and may be taken freely. Vegetables. — Spinach, cabbage, Brussels sprouts, cauliflower, celery, lettuce, water-cress, string-beans, young onions, toma- toes, mushrooms, asparagus tips, cucumbers, and dandelion. Bread. — In very many cases a small amount (2 or 3 ounces a day) of bran bread or whole-wheat bread may be permitted. Gluten bread is also used, but most so-called gluten flours contain a large percentage of starch. Many substitutes have been recommended for wheat bread, but even the best of these are rather unpalatable and heavy. The best known are bread or biscuit made of pure bran (Prout), of almond meal (Pavy), of inulin (Kulz), of Soya bean (Dujardin-Beaumetz), and of aleuronat, a glutinous flour obtained as a by-product in the manufacture of starch (Ebstein, von Noorden). Beverages. — Buttermilk, skimmed milk, carbonated waters, mineral waters (Vichy, Carlsbad, Vals, and Saratoga), tea and coffee without sugar, and alcoholic beverages containing little or no sugar (claret, Rhine wines, dry Moselle, Bordeaux, dry sherry, well diluted brandy or whisky). No restriction should be placed on the amount of water desired. Relishes. — Caviare, olives, pickles, and cheese. Fruits and Nuts. — Grape-fruit, lemons, sour cherries, cran- berries, red currants, and nuts (except chestnuts) are allowable in small quantities. Sweetening Agents. — Certain forms of sugar appear to be assimilable. Thus milk, although it contains a considerable quantity of lactose, is usually well borne. Levulose (see p. 473), also in moderate amounts, seems to be harmless. The chief substitutes for sugar are saccharin and glycerin. Hygienic Treatment. — Fresh air and systematic exercise are of great value. The patient must be warned, however, against overexertion. Moderation must be observed in all things. Flannel should be worn next to the skin, and all undue exposure avoided. Massage has been strongly recom- mended. Hydrotherapy, as first suggested by Bouchardat, is decidedly efficacious. If the patient is vigorous, Turkish baths may prove useful. Diabetics who still possess a fair measure of health frequently derive much benefit from a visit to certain mineral springs, such as Neuenahr, Homburg, Carlsbad, and Vichy. Obese, gouty subjects often do remarkably well at Carlsbad. CONSTITUTIONAL DISEASES. 54 1 Medicinal Treatment. — The medicinal treatment of dia- betes is purely empiric. The drugs which have been shown to be of most value are opium, bromids, salicylic compounds, antipyrin, alkalis, and arsenic. Opium is generally the most reliable drug, especially in the severe nervous cases. It relieves thirst, promotes sleep, allays restlessness, and diminishes the excretion of urine and sugar. Patients can often take with advantage from 5-8 gr. (0.3-0.5 gm.) a day. Upon the disappearance of the symptoms it should be gradually withdrawn. Saline aperients may be associated with it, when necessary, to prevent constipation. Codein is sometimes preferable to opium. Doses of \ gr. (0.03 gm.), thrice daily, may be gradually increased until the glycosuria disappears or ceases to be affected. Bromids, either alone or as adjuvants to opium, are very useful in subduing nervous symptoms. Salicylic compounds rank next in efficacy to opium. While they yield the best results in gouty cases, their good effects are by no means lim- ited to that class. From 40-80 gr. (2.5-5.0 gm.) of strontium or ammonium salicylate may be given in the twenty-four hours. This treatment should be discontinued upon the slightest evi- dence of intolerance. Some cases do remarkably well upon antipyrin in doses of from 10-15 gr. (0.6-1.0 gm.) thrice daily. It may often be combined advantageously with an alkaline carbonate, salicylate, or bromid. Alkaline carbonates and alkaline mineral waters have long enjoyed a reputation as remedies in diabetes. While they do not appear to have a decided influence on the glycosuria, they often relieve dyspeptic symptoms and constipation and tend to avert coma. Arsenic, especially in the form of the so-called bromid of arsenic or Clemens' solution (see p. 312), occasionally succeeds when other remedies fail. Cod-liver oil, strychnin, iron, and alcohol are useful at times in meeting special indications. Among other remedies which have been recommended, but which are of somewhat doubtful utility, may be mentioned: Jambul (Banatvala), uranium nitrate (West), glycolytic ferment from the pancreas (Lepine), ergot (Dougall), and calcium car- bonate and phosphate (Grube). Special Symptoms. — Constipation \s best treated by saline cathartics or the alkaline mineral waters. Remedies which lessen the polyuria also serve to quench the thirst. Acidulous drinks are sometimes of service. Pruritus of the genitals should be treated by frequent spong- 54 2 APPLIED THERAPEUTICS. ing, especially after micturition, with a saturated solution of boric acid. Lotions containing carbolic acid, resorcin (see p. 393), or sodium hyposulphite may also be tried. Diabetic Coma. — When coma is threatened, prophylactic treatment consists in substituting milk with some carbohy- drate for the strict proteid dietary, in the administration of sodium bicarbonate, — an ounce (31.0 gm.) or more a day, — in keeping the bowels freely opened with saline aperients, and in sustaining the circulation with strychnin and whisky. In the presence of actual coma treatment is usually unavailing. The most useful measure is the intravenous injection of a 2 to 3 per cent, solution of sodium bicarbonate to the extent of 1 or 2 pints (0.5-1.0). To insure rapid action of the bowels, a brisk cathartic (croton oil) should be given. Hypodermic injections of ether and strychnin are useful. The inhalation of oxygen has been highly recommended. DIABETES INSIPIDUS. The hygienic treatment suggested for diabetes mellitus is applicable in diabetes insipidus. The patient should have a nutritious but digestible diet. No benefit is derived from re- stricting the quantity of water desired. Acidulated drinks, like lemonade, aid in assuaging thirst. Many remedies have been recommended; those possessing the most extended reputation are opium (4-8 gr. — 0.25-0.5 gm. a day), valerian (|— 1 fl. oz. — 15.0-30.0 c.c. of ammoniated tincture daily), ergot (•|— I dr. — 2.0-4.O gm. of the extract or of ergotin daily), anti- pyrin (10 gr. — 0.6 gm. three or four times a day), bella- donna (5 min. — 0.3 c.c. of the tincture three times a day, the dose being gradually increased), and gallic acid (1 dr. — 4.0 gm. a day). Galvanism — one pole applied to the neck and the other to the loins — has also been recommended. Tonics — cod-liver oil, iron, and strychnin — are sometimes required. In syphilitic cases good results may be anticipated from a thorough trial of mercury and potassium iodid. The dryness of the skin may be relieved by warm baths, followed by inunctions with olive oil (Saundby). GOUT. Chronic Gout. — No absolute rule can be laid down regard- ing the diet. The special features in each case should receive careful study. Some patients do well upon a non-proteid diet, others do not. Simplicity and moderation are of the utmost importance. Generally speaking, a diet composed for the CONSTITUTIONAL DISEASES. 543 most part of milk, farinaceous foods, succulent vegetables, eggs, nsh, and lean meats is most suitable. The foods most likely to disagree are veal, liver, sweetbreads, hashes, croquettes, concentrated soups, vegetables rich in nucleins, — peas and beans, — pastry, sweets, coffee, malt liquors, and heavy wines. Some patients are exceedingly intolerant of acid fruit. Milk taken as a beverage at meals is objectionable. Alcoholic stimulants, as a rule, should be avoided; occasionally, how- ever, a small quantity of well-diluted whisky at meals aids digestion and is well borne. Water-drinking between meals should be encouraged. The quantity as well as the character of the food must be regulated. No more should be eaten than is absolutely neces- sary to satisfy hunger. The patient should be warmly clothed and should avoid as far as possible exposure to sudden atmos- pheric changes. Systematic exercise in the open air is ex- tremely beneficial. Well-nourished patients should be urged to take walking trips, to play golf or tennis, or to try horse- back riding. When active exercise is not feasible, massage may be strongly recommended. All overwork of mind should be forbidden. Hydrotherapy — tepid sponge-baths and douches — is useful. Heavy robust patients often derive much benefit from the Turkish bath. Visits to certain mineral springs — Bedford, Saratoga, Har- rowgate, Carlsbad, Contrexeville, Aix-les-Bains — are some- times of the greatest value. The good effects of the spa treat- ment are only in part due to the waters drunk : change of scene, fresh air, strict diet, and freedom from business and household cares are important factors. Residence during the winter months in a dry, warm, inland climate is desirable. Remedies calculated to improve digestion are frequently indicated. In some cases a combination of an alkali with a bitter (see p. 175) before meals is of much service. Daily action of the bowels should be secured. The occasional use of calomel or blue-mass at night, with a saline in the morning, is often of value. Among the special remedies advocated for gout may be mentioned alkalis and alkaline mineral waters, colchicum, guaiac, arsenic, and iodids. Of these, the alkalis, especially the vegetable salts of potas- sium, are the most useful (see pp. 226, 231, 243). Colchicum is most effective in the acute paroxysms, although small doses with alkalis may be of benefit in the interval. Guaiac (see p. 338) probably ranks next in efficacy to the alkalis. The prolonged use of arsenic in small doses has seemed to us to be of some value. Iodids are sometimes of service in relieving 544 APPLIED THERAPEUTICS. the concomitants and sequels of gout, — arthritis, bronchitis, arteriosclerosis, — but have little, if any, effect upon the disease itself. Salicylates relieve pain, but are distinctly inferior to colchicum. Such remedies as piperazin, lycetol, and quinic acid (see p. 244) are of doubtful utility. Chronic affections of the joints are best treated by gentle massage, friction, and warm sulphur baths. Acute Gout. — The most efficient remedy is colchicum; from 5-10 min. (0.3-0.6 gm.) of the wine may be given well diluted three or four times a day. It should be stopped as soon as relief is obtained. Alkalis are useful adjuvants (for formula, see p. 338). Water-drinking should be encouraged. At the outset a brisk mercurial purgative, followed by a saline, is usually advisable. Excruciating pain will demand the use of morphin. Phenacetin is sometimes effective. The diet should be light and non-stimulating. The affected part should be elevated and wrapped in cotton- wool or covered with cloths soaked in lead-water and laudanum. CHRONIC RHEUMATISM. Strict attention should be paid to hygiene. The patient should be warmly clothed, wool or silk being next to the skin, and great care should be taken to guard against wet and sud- den changes of temperature. The food should be nourishing, but digestible. Fatty foods, when well borne, are of much value. Hot sulphur and hot saline baths are often very use- ful. Massage and Swedish movements are excellent adjuvants to hydrotherapy. Vigorous patients may be benefited by Turkish baths. Residence in a dry, warm, equable climate — Southern California, Arizona, Riviera, Egypt — especially dur- ing the changeable seasons, is always desirable. Tonics and certain alteratives, such as cod-liver oil, iron, and arsenic, are the most generally useful internal remedies. Iodides are sometimes of service, but on the whole they are inferior to arsenic. Salicylates are efficacious in relieving acute ex- acerbations, but they have no permanent effect. Colchicum is useless. Guaiac, sulphur, cimicifuga, ichthyol, and many other drugs have been recommended. I/OCal Treatment. — Massage, if employed systematically, often accomplishes much good. Superheated air-baths are occasionally useful. Electricity is of little value. Rubefacient liniments have a palliative influence in mild cases. An oint- ment of mercury, belladonna, and ichthyol, well rubbed into CONSTITUTIONAL DISEASES. 545 the affected part, is sometimes very efficacious. When the pain is severe and persistent, blisters ©r light applications of the actual cautery prove effective. MUSCULAR RHEUMATISM, In mild cases it will suffice to put the affected muscles at rest. In pleurodynia this is accomplished best by strapping the affected side as in fracture of the ribs, and in lumbago by applying a large piece of adhesive plaster from the floating ribs to the iliac crests. In more severe cases it will be necessary to apply rubefacient liniments, sinapisms, or, better still, hot fomentations, and to administer a salicylate, combined, per- haps, with a coal-tar analgesic : R Salophen, gij (8.0 gm.) ; Acetphenetidini, ^j (4.0 gm.). M. Fiant chartulse No. xii. Sig. — One every three hours. A rubefacient ointment like the following is often efficacious : R Methylis salicylatis, gss (2.0 c.c.) ; Guaiacolis, TTLxx (1.3 c.c.) ; Mentholis, gr. xx (1.3 gm.); Adipis, 5ij (8.0 gm.); Cerati, 5iiss (10.0 gm.). M. Sig. — Rub in a small quantity over seat of pain twice daily. A blister is occasionally required. When the pain is intense, hypodermic injections of morphin (J gr. — 0.016 gm.) with atro- pin (y^-Q- gr.— 0.0005 g m w ^ afford great relief. In lumbago, acupuncture (see p. 438) sometimes yields excellent results. Hot packs and baths are often efficacious, but great care must be exercised to guard against exposure after their use. Per- sistent myalgia is often very favorably affected by massage and applications of the faradic current. In chronic cases, potas- sium iodid and guaiac should be tried. Gelsemium in large doses (Brunton) and ammonium chlorid (Anstie, Ringer, Roberts, DaCosta) have also been recommended. RHEUMATOID ARTHRITIS. The most that can be expected from treatment is ameliora- tion of the symptoms, and, perhaps, some retardation of the progress of the disease. The hygienic treatment is as for 35 546 APPLIED THERAPEUTICS. chronic rheumatism (see p. 544). An important indication is to maintain nutrition. Tonics are frequently necessary. Cod- liver oil in such doses as the stomach will tolerate is often very beneficial. The most satisfactory special agents are arsenic and the iodids, particularly the former. Garrod has repeatedly seen good effects follow the prolonged use of the syrup of ferrous iodid. Luff, in a large experience with the disease, has found guaiacol carbonate, 5 gr. (0.3 gm.), gradually increased to 15 gr. (1.0 gm.), thrice daily, an excellent adjuvant to the iodids. The remedies relied upon in gout are useless in rheumatoid arthritis. Salicylates are sometimes of service in acute exacerbations. Change of scene and climate, especially in the early period of the disease, frequently exerts a favorable influence. Visits to hot mineral springs (Hot Springs of Vir- ginia or Arkansas, Bath, Baden-Baden) are recommended. lyOcal Treatment. — Massage is of the greatest value in preserving the mobility of the joints and in maintaining the nutrition of the muscles. Acute exacerbations should be treated by rest and the application of cold compresses. Rubefacient liniments, inunctions with mild iodin or mercurial ointments, and small blisters are sometimes of benefit. The Bier method of producing hyperemia has been highly recommended. Elec- tricity and superheated air occasionally afford much relief; x- rays have yielded good results in a few instances. RHACHITIS. The treatment of rhachitis is mainly dietetic and hygienic. If the mother is deemed unfit for nursing, the child must be brought up by a wet-nurse or by hand. In most cases the latter method must be chosen. Generally speaking, the best substitute for natural food is diluted fresh cows' milk to which have been added cream and milk-sugar. The degree of dilution and the percentage of cream and sugar to be added will vary with the age of the infant and its power of assimilation. Lime- water and barley-water are the best diluents. Milk that has been partially predigested is in many cases an excellent food. Older children require undiluted milk, cream, beef-juice, veal- broth, eggs, scraped beef, pounded mutton, and fruit-juices. Starchy foods should be avoided. Very often it is necessary to correct digestive distuibaix^e^ oerore ordering a liberal diet. Fresh air, day and night, is essential. The child should be carefully protected, however, from the vicissitudes of the leather, and should be warmly clad in flannel. Sea-air is often very beneficial. Daily bathing, with friction and gentle massage, is to be recommended. DISEASES OF THE BLOOD AND DUCTLESS GLANDS. $47 Dyspepsia, diarrhea, and constipation should receive appro- priate treatment. When well borne cod-liver oil is the best rem- edy. The dose should be increased gradually from a few minims to a teaspoonful, three or four times a day. When cod-liver oil cannot be taken by the mouth, it may be given by inunction (see p. 305). Phosphorus, which has been strongly recom- mended by Kassowitz and Jacobi, is of doubtful value (see p. 300). The lactophosphate and hypophosphite of calcium are frequently combined with cod-liver oil for their tonic effect. Stoeltzner has obtained good results from the use of supra- renal extract, and Mendel, from the use of thymus extract. When there is anemia, an unirritating preparation of iron should be given. For the excessive sweating, atropin, in doses of -g-J-g- of a grain (0.0008 gm.) two or three times a day, has been recommended (Holt). DISEASES OF THE BLOOD AND DUCTLESS GLANDS, CHLOROSIS. Fresh air, sunlight, open-air exercise, and nourishing food are valuable aids in treatment. Change of climate or a sea- voyage is often beneficial. Very severe cases sometimes re- quire complete rest in bed and massage. If there be a good reaction, warm baths, followed by short cold douches, are effi- cacious. Iron is almost a specific. It is most frequently pre- scribed in the form of Blaud's pills (see p. 292), of which the dose is three pills, gradually increased to nine a day. In some cases other preparations of iron, such as iron and ammonium citrate, ammonioferric tartrate, albuminate, and pyrophosphate, are better borne. Laxatives, preferably mild salines, rank next in importance to iron, Arsenic is distinctly less valuable than iron. Bitters, such as nux vomica, gentian, and calumba, are often useful adjuvants, especially when there is anorexia with tardy digestion. Superacidity of the gastric juice is best treated by alkalis. PERNICIOUS ANEMIA. While the outlook in pernicious anemia is exceedingly grave, marked improvement and even apparent recovery are not im- possible. Fresh air, rest, and a diet as liberal as the digestive power of the patient will permit, are requisite. Rest in bed, warm salt baths, and massage are valuable adjuvants to inter- nal treatment. The teeth should receive careful attention. If there be gingivitis or pyorrhoea alveolaris, antiseptic mouth- washes should be used at frequent intervals. 548 APPLIED THERAPEUTICS. Arsenic is the most valuable drug. It may be given in the form of Fowler's solution, the dose being gradually increased from 2 or 3 min. (0.1-0.2 c.c.) to 15 or 20 min. (1. 0-1.2 c.c.) three times a day. Iron is rarely of service, but may be tried when arsenic fails. Bone-marrow is sometimes efficacious. Dock has often used mercuric chlorid with benefit, not only in syphilitic cases, but also in others. Inhalations of oxygen have been recommended (Shattuck). Appropriate anthelmintic remedies should be given, of course, in the cases in which in- testinal parasites (Bothriocephalus latus, ankylostoma) are present. Digestive disturbances are often benefited by the administration of diluted hydrochloric acid and a bitter. LEUKEMIA, PSEUDOLEUKEMIA, AND SPLENIC ANEMIA. An effort should be made to maintain the general nutrition by regulating the diet and attending to hygienic measures. Rest is often advisable. Among drugs, arsenic appears to be of some service. Iron, quinin, and cod-liver oil occasionally are beneficial. Inhalations of oxygen may be tried. In pseudo- leukemia Gowers and Broadbent have found phosphorus of benefit. In leukemia, repeated applications of the Rontgen rays are sometimes followed by marked improvement, and even a symptomatic cure. A relapse, however, is to be ex- pected. According to Stengel and Pancoast, the best results are achieved when the rays are applied to the bones, various portions of the body being treated in succession, and the spleen not exposed until it is reduced considerably in size and the patient's general condition is much improved, and even then only w r ith caution. In neither leukemia nor pseudoleukemia is operative treatment of avail. In splenic anemia, however, removal of the spleen is a justifiable procedure. Of 32 cases of splenic anemia treated by splenectomy, in 23 recovery fol- lowed (Armstrong). SCURVY. The prime requisites in the treatment of scurvy are suitable nourishment and proper hygiene. Complete rest is generally advisable. The diet should include plenty of fresh vegetables, — potatoes, lettuce, cabbage, and onions, — with 3 or 4 ounces (90-120 c.c.) of lemon-juice daily. When the digestion is feeble and the gums are tender, it may be necessary to 'restrict the diet to such foods as beef-juice, animal broths, milk, raw e gg s > an d orange- or lemon-juice. Tonics, like iron, quinin, and strychnin, are often of service. In some cases alcoholic stimulants are required. The mouth should be cleansed at DISEASES OF THE BLOOD AND DLCTLESS GLANDS. 549 frequent intervals with some antiseptic wash, such as D obeli's solution, and the spongy gums should be painted two or three times a day with a solution of silver nitrate, 20 grains (1.3 gm.) to the ounce (30.0 ex.). Infantile scurvy usually responds very promptly to correc- tion of the diet. The foods most worthy of confidence are fresh cows' milk, beef-juice, and orange-juice. PURPURA HAEMORRHAGICA. In many cases a favorable termination follows in the course of one or two weeks without special medication, while in others the disease progresses toward a fatal issue in spite of the most careful treatment. Hemostatics, both internal and external (see p. 377), are the remedies indicated. Great efficacy has been claimed especially for oil of turpentine, gelatin, and calcium chlorid. Heart-failure should be treated by cardiac stimulants, and restlessness and insomnia by opium in small doses. Secondary anemia will require iron and arsenic. HEMOPHILIA. The treatment of hemophilia is largely protective and pallia- tive. All operations liable to cause hemorrhage should be avoided. Bleeding will call for rest, the application of cold compresses and of styptics, and the administration of internal hemostatics (see p. 377). The drugs most worthy of confi- dence are, perhaps, gelatin and calcium chlorid. Weil, Labbe, and others have found fresh blood-serum markedly efficacious. It may be given in doses of 20 to 30 c.c. subcutaneously. The effect of the serum is at its height in twenty-four hours and lasts several weeks. The serum should not be over two weeks old ; human, horse, or rabbit serum may be used. In default of other varieties, fresh antidiphtheria serum may be employed. Combemale and Gaudier and Delace have used thyroid extract with asserted good results. Inhalations of oxygen have been strongly recommended. Wright advises inhalations of carbon dioxid when there is epistaxis. The resulting anemia is bene- fited by iron and arsenic. ADDISON'S DISEASE. As the primary lesion in Addison's disease is not amenable to therapeutic measures, little can be done beyond maintaining the patient's strength and relieving symptoms. Nutritious but readily digestible food, the avoidance of mental and phys- ical excitement, and good hygienic surroundings are important 550 APPLIED THERAPEUTICS. factors in the treatment. When there is marked asthenia, absolute rest should be enjoined. Very marked improvement in the symptoms sometimes follows the administration of suprarenal extract (see p. 68). Tonics, like iron, arsenic, and strychnin, are of service. Irritability of the stomach will call for such sedatives as bismuth subnitrate, hydrocyanic acid, and cerium oxalate, and diarrhea for mild astringents and anti- septics. MYXEDEMA. As patients with myxedema are extremely susceptible to low temperatures, they should be warmly clad and protected from exposure to cold. Residence during the winter in a warm, sunny climate is desirable. Warm baths are often beneficial. Modern treatment consists in the administration of some prep- aration of thyroid gland (see p. 343). By continuing this rem- edy throughout life it is possible in many cases to hold the symptoms in complete abeyance. EXOPHTHALMIC GOITER. The general nutrition should be improved by rest, a gener- ous, readily digestible diet, healthy hygienic surroundings, and hydrotherapy. Residence in a warm seaside locality often promotes comfort and aids recovery. In severe cases absolute rest in bed is an essential point in the treatment. Applications of cold to the precordia, by means of Leiter's tubes or ice- bags, lessen the palpitation. Medicinal treatment is very uncertain. A drug that has been efficacious in one case may in another prove useless or harmful. Belladonna, recommended by Gowers, is undoubt- edly of value in many cases. It should be given in ascending doses until some dryness of the throat is produced. When the circulation is feeble, digitalis may be found of service ; on the other hand, when the heart is strong, better results may be obtained with aconite or veratrum viride. When anemia exists, iron is useful. Bromids are sometimes of service in controlling nervous symptoms. Starr has observed marked improvement from the use of sodium glycerophosphate in doses of 20 grains (1.3 gm.) three or four times a day, as originally recommended by Trachewsky. Mikulicz, Owen, Mackenzie, and others have found thymus extract (see p. 344) of some value. Musser has found small doses of opium suc- cessful in some cases. Among other remedies which have been recommended, but which are of more doubtful value, may be mentioned ergot, iodids, quinin hydrobromid, and DISEASES OF THE DIGESTIVE TRACT 55 1 bromid of gold. The consensus of opinion is decidedly ad- verse to the use of thyroid extract. Specific antithyroid therapy has given encouraging results in a fairly large number of cases. The preparations chiefly used have been Moebius' serum (serum from thyroidectomized animals), thyroidectin (dried blood of thyroidectomized animals), rodagen (dried milk of thyroidectomized goats), and Beebe's and Rogers' serum (serum from horses inoculated with nu- cleoproteids and thyroglobulin from pathologic and normal thyroids). All these preparations are expensive. Of 86 pa- tients receiving specific treatment, except that of Beebe and Rogers, 80 were benefited and 6 were not (Bulkeley). Beebe and Rogers report 90 cases in which their serum was used, with the following results : 23 patients were cured, 52 im- proved, 1 1 not benefited, and 4 died. Galvanism (see p. 483) sometimes proves more effective in controlling the symptoms than any other remedy. Recently some very favorable results have been reported from the use of ^■-rays. Finally, after other measures have been given a thorough trial, operative interference should be considered. Accord- ing to Rehn, in 177 partial excisions of the gland 57.6 per cent, of the patients were cured, 26.5 improved, 2.3 per cent, unimproved, and there were 13.6 per cent, of deaths. In 32 resections of the sympathetic 31.1 per cent, were cured, 50 per cent, were improved, 12.5 per cent, were unimproved, and death occurred in 9.5 per cent. After ligation of the thyroid arteries in 14 cases 24 per cent were cured, 50 per cent, im- proved, and the remainder died. Of 59 cases operated on by Kocher, 45 were cured, 8 were decidedly improved, 2 were slightly improved, and 4 died from tetany as a result of the operation. Halstead has operated on 90 patients with 2 deaths and Mayo on 176 patients with 8 deaths. DISEASES OF THE DIGESTIVE TRACT. STOMATITIS. The source of the local irritation should be sought for and removed. Errors of hygiene should be corrected. The diet and the state of the alimentary tract should receive careful attention. The mucous membrane of the mouth should be washed at frequent intervals with cool antiseptic solutions. In mild catarrhal stomatitis a solution of boric acid, 5-10 gr. (0.3- 0.6 gm.) to the ounce (30.0 c.c), will suffice. In obstinate cases the mouth, after being carefully cleansed, may be lightly painted 552 APPLIED THERAPEUTICS. with a solution of silver nitrate, 4 gr. (0.26 gm.) to the ounce (30.0 c.c). Ulcers may be touched with solid silver nitrate or copper sulphate. In aphthous stomatitis a mild mercurial aperient is often of service. In addition to the frequent use of antiseptic washes (boric acid, potassium permanganate), the occasional applica- tion of silver nitrate — 10 gr. (0.6 gm.) to the ounce (30.0 c.c.) — is desirable. In thrush the mouth should be cleansed at frequent inter- vals, especially after every feeding, with one of the following solutions: sodium hyposulphite, 20 gr. (1.3 gm.) to the ounce (30.0 c.c); boric acid, 15 gr. (0.9 gm.) to the ounce (30.0 c.c); or potassium permanganate, 1 gr. (0.065 gm.) to the ounce (30.0 c.c). In ulcerative stomatitis potassium chlorate is almost a spe- cific It should be used both locally and internally (see p. 231). The ulcers may be painted with a solution of silver nitrate, 10 gr. (0.6 gm.) to the ounce (30.0 c.c). Tonics, like quinin and iron, are called for in some instances. Gangrenous stomatitis demands energetic treatment. The sloughing surface and the tissue immediately surrounding it should be promptly destroyed under anesthesia with the actual cautery or strong nitric acid. After the operation the mouth should be cleansed at frequent intervals with a solution of hydrogen dioxid (1:3) or of potassium permanganate (1 per cent). Concentrated nutritious food, stimulants, and tonics are urgently indicated. The treatment of mercurial stomatitis has already been con- sidered (see p. 323). ACUTE PHARYNGITIS, In mild cases a gargle of potassium chlorate (see p. 368) will suffice. In severe cases the application to the throat of cloths wrung out of cold water proves grateful. The sucking of pieces of ice affords much relief. Gargles or sprays of the distillate of hamamelis (50 per cent.) are useful. A spray of menthol, 2 gr. (0.13 gm.) to the ounce (30.0 c.c.) of liquid petrolatum, is also efficacious. Lozenges containing cocain will often relieve pain and allay the tickling sensation in the throat. The following formula, recommended by Bosworth, answers the purpose admirably : R Cocainse hydrochloride gr. v (0.3 gm.); Extracti kramerise, gr. ij (0.13 gm.) ; Sodii bicarbonatis, gr. xv (1.0 gm.); Extracti glycyrrhizae, ^iiss (10.0 gm.). M. Fiant trochisci No. xxx. DISEASES OF THE DIGESTIVE TRACT. 553 Internally, a mild aperient may be given at the outset. Sodium benzoate has a beneficial effect. From 5-10 gr. (0.3- 0.6 gm.) may be given every three hours. Belladonna with aconite is also recommended. The rheumatic form usually yields promptly to a mild salicylic preparation, like salophen. CHRONIC PHARYNGITIS. The removal of the cause is of prime importance. All sources of local irritation, such as misuse and overuse of the voice, mouth-breathing, excessive smoking, and intemperance in eating and drinking must be avoided. Patients should be instructed to expel sounds by the aid of the diaphragm and abdominal muscles instead of the muscles of the throat. Nasal obstructions and adenoid growths must be removed. The habit of hawking and scraping to clear the throat should be rigidly interdicted. Digestive disturbances should receive careful attention. Tonics, like iron, strychnin, and cod-liver oil, are sometimes required. I/OCal Treatment. — The nasopharynx should be kept clean by frequent spraying with an antiseptic alkaline liquid, like Dobell's solution (see p. 172), Astringent applications are often of service ; one of the following may be employed : Zinc sulphate, 5 gr. (0.3 gm.) to the ounce (30.0 c.c.) ; tannin, 1 dram (4.0 gm.) to the ounce (30.0 c.c.) of glycerin ; silver nitrate, 10-20 gr. (0.6-1.3 S m -) to tne ounce (30.0 c.c). In the follicular variety it is advisable to destroy the enlarged follicles by means of the galvanocautery, after which the astringent applications may be made. ACUTE TONSILLITIS. The patient should be confined to a warm room, and, if there be much fever, to bed. A mild aperient is indicated at the outset. The diet should be light but sustaining. The suck- ing of ice affords relief. The most reliable internal remedies are the salicylic compounds and sodium benzoate. They should be given in full doses at frequent intervals. Guaiac is also recommended. A dram (4.0 c.c.) of the ammoniated tincture of guaiac may be given in milk every three hours. Febrile symptoms, if pronounced, may be controlled by small doses of phenacetin or by a combination of aconite and spirit of nitrous ether (see p. 63). The pain may be so intense as to require the use of opium. I/OCal Treatment. — Externally, cold applications aid in bringing about resolution ; if, however, suppuration be inevi- 554 APPLIED THERAPEUTICS. table, warm applications should be employed to hasten the process. Antiseptic sprays, like Dobell's solution (see p. 172) or a solution of hydrogen dioxid ( 1 14), are of benefit. Direct applications to the surface of the glands of the tincture of ferric chlorid — 1 dram (4.0 c.c.) to the ounce (30.0 c.c.) of glycerin or of a saturated ethereal solution of iodoform — are often useful. The treatment of follicular tonsillitis by the thorough application of very finely powdered aspirin, after the glands have been mopped with a warm solution of sodium bicarbonate, as recommended by Kieffer and Fetterolf, gives excellent results. Applications of dry sodium bicarbonate have also been highly recommended. Pus should be evacuated as soon as its presence can be detected. In the majority of cases it is best to make the in- cision not in the tonsil itself, but in the soft palate, a little above and to the outer side of the gland. ACUTE CATARRHAL GASTRITIS. Absolute rest is essential. If the stomach has not been completely emptied, an emetic, such as warm water or ipecac, should be employed. Locally, a mustard plaster or a turpen- tine stupe will aid in relieving distress. As a rule, no food should be given by the mouth until the stomach becomes retentive. Ice, however, may be allowed to quench the thirst. In delicate subjects nutrient enemata will be required. If there be constipation, a mercurial laxative may be given with advantage. Such a combination as the following usually acts favorably : R Hydrargyri chloridi mitis, gr. j (0.065 g 1 * 1 -) > Bismuthi subnitratis, gr. xx (1.3 gm.). M. Fiant chartulae No. vj. Sig. — One on the tongue every hour, to be followed by a Seidlitz powder, if necessary. Pain, nausea, restlessness, and insomnia are best relieved by opium suppositories or hypodermic injections of morphin. Sedatives by the mouth are also useful; thus, bismuth subni- trate may be given alone or combined with hydrocyanic acid (see p. 161), with creosote (\ min. — 0.03 c.c), or with cocain (l gr. — 0.0 1 gm.). The following combination of ipecac and nux vomica is often serviceable : 5c Tincturse nucis vomicae, Vini ipecacuanhae, aa fgij (8.0 c.c). M. Sig. — Two drops every hour. DISEASES OF THE DIGESTIVE TRACT. 555 After the lapse of twenty-four or thirty-six hours it is gen- erally possible to give bland nourishment by the mouth. Barley-water, champagne with soda-water, milk and lime- water, peptonized milk, and light broths may be given in small quantities at frequent intervals. The return to solid food should always be carried out very gradually. INDIGESTION. The first thing to be done in the treatment of all cases of indigestion is to find its cause, and to remove this, if possible. In many cases indigestion is merely a symptom of some con- stitutional disturbance, such as anemia, tuberculosis, Bright's disease, or diabetes, or is the result of passive hyperemia of the stomach induced by chronic cardiac, hepatic, or pulmonary disease. It is obvious that in such cases treatment must be directed very largely to the underlying condition. In the primary form of gastric indigestion the methods of eating and the character of the food are the factors of greatest importance. Regularity in the time of meals, slowness in eating, and thor- ough mastication of food must be insisted upon. The patient should be cautioned against overeating and the taking of large quantities of liquid, especially of iced water, during meals. Overindulgence in alcohol, tobacco, coffee, and tea should be forbidden. The resumption of mental or physical work imme- diately after meals should also be avoided. Dietetic Treatment. — It is impossible to lay down any absolute rules in the matter of diet. The conditions present in each case must receive careful study, and considerable allowance must be made for individual peculiarities. Generally speaking, such articles as fried meats, salted meats, pork, veal, hashes, croquettes, coarse vegetables and fruits, fried or boiled sweet and white potatoes, fresh bread, pastry, puddings, nuts, and malt liquors must be interdicted. In many cases of atonic dyspepsia (sub acidity), nervous dyspepsia, and mild gastric catarrh an ordinary mixed diet of readily digestible food is admissible. It may usually include boiled, baked, or grilled beef and mutton, chicken, sweetbread, boiled fish, oysters, soft-boiled or poached eggs, stale bread, toast, pulled bread, fresh butter, baked potato, young string-beans, small peas, spinach, hearts of celery, thoroughly cooked cereals (rice, wheat, oatmeal), baked apples, calves'-foot jelly, and junket. Tea, coffee, and cocoa may or may not be permissible. Indigestion associated with hyperacidity will require a bland, unirritating diet, composed largely of albuminous foods. A 556 APPLIED THERAPEUTICS. moderate quantity of water or weak tea at meals is desirable. Condiments, spices, acids, oils, and alcoholic beverages are strongly contraindicated. When the expulsive power of the stomach is weak and there is a tendency to retention, the food should be nutritious and concentrated. Foods that are bulky and are liable to ferment should be avoided. Much fluid is undesirable. An exclusive milk diet sometimes acts exceedingly well in nervous dyspepsia and indigestion attended by hyperacidity. It is contraindicated when there is marked hypo-acidity, motor insufficiency, retention, or intestinal fermentation. Most cases do best without alcohol, but when there is pro- nounced subacidity or motor insufficiency, a small amount of diluted whisky, brandy, or sherry with meals may prove bene- ficial. Alcohol in any form is contraindicated when there is excessive secretion of acid or when there is hyperesthesia of the gastric mucosa. Generally, it is best to prescribe a definite bill-of-fare and to modify this from time to time as occasion demands. In de- termining the suitability of a given diet we must be guided chiefly by the patient's sensations and the state of his general nutrition. As a rule, no more than three meals a day should be allowed. When there is a tendency to retention, however, it may be advisable to give the food in smaller quantities and at more frequent intervals. On the other hand, in some cases of gastric catarrh with slow digestion it may be advantageous to limit the number of meals to two a day. Hygienic Treatment. — In a large number of cases sys- tematic exercise in the open air accomplishes much good. Anemic and neurasthenic patients, however, may require the " rest-cure." Hydrotherapy is often very serviceable. Mas- sage is also useful, especially when there is myasthenia. Change of scene, a sunny climate, good hours, and freedom from business worry and household cares often prove more beneficial than any other measure employed. Medicinal Treatment. — In cases of atonic dyspepsia and of mild gastric catarrh with subacidity the administration of a bitter — calumba, gentian, nux vomica, cinchona — some time before meals often proves efficacious. In many cases the bitter may be combined advantageously with an alkali (see p. 175). Diluted hydrochloric acid, with or without pepsin, may also be of benefit when there is subacidity. It should be given after meals. When the stomach is unnaturally sensitive or when there is supersecretion, silver nitrate will be found a valuable remedy. DISEASES OF THE DIGESTIVE TRACT. $$? It may be given in pill form, with extract of hyoscyamus or of belladonna, half an hour before meals, or when this method of administration is not satisfactory, by means of the intragas- tric douche (see p. 372). Bismuth subnitrate in large doses before meals is also of service in such cases. In nervous dyspepsia short courses of strontium bromid are sometimes efficacious. When anemia is marked, an unirri- tating preparation of iron may be given with advantage. Systematic lavage (see p. 500) is of great value in certain cases, but it has been much abused. Its chief indications are retention of food with ferme?itation y excessive secretion of mucus, and excessive secretion of acid. When lavage cannot be tol- erated, the stomach may be cleansed by a glass of hot alkaline water slowly sipped a half-hour or more before breakfast. Motor insufficiency is often benefited by strychnin. Intragas- tric faradism and the intragastric spray (Einhorn) may also be recommended in cases of pronounced stagnation. Symptomatic Treatment. — Deficient Secretion. — When the digestive power is impaired owing to a deficiency of secre- tion, diluted hydrochloric acid with pepsin (seep. 182), taken shortly after meals, may be found useful. In many cases, however, better results are obtained from the administration of pancreatin with sodium bicarbonate. Hyperchlorhydria. — Severe pain occurring at the height of digestion and caused by hyperacidity is best treated by the administration of an alkali (sodium bicarbonate or magnesia) in large doses. Heartburn and pyrosis are also relieved by alkalis. Flatulence and fermentation are sometimes controlled by such antiseptic drugs as creosote, bismuth subsalicylate, bis- muth betanaphthol, and thymol. The following combination is often of value : R Creosoti, foss (2.0 c.c. ) ; Bismuthi betanaphthoiis, gr. c (6. 5 gm.) ; Strychninse sulphatis, gr. ss (0.03 gra.) ; Oleoresinge zingiberis, TT^v (0.3 c.c). M. Pone in capsulas No. xx. Sig. — One after meals. Vomiting usually yields to rest and proper diet. If trouble- some, sedatives like bismuth subnitrate, hydrocyanic acid, and silver nitrate may be employed. Constipation. — As far as possible constipation should be overcome by regulation of the diet, systematic exercise, and abdominal massage. Strong purgatives should be avoided. 558 APPLIED THERAPEUTICS. A glass of water in the morning upon rising or in the evening before retiring often suffices in mild cases. If necessary, a small quantity of sodium phosphate or of the following arti- ficial Carlsbad salt may be added : R Sodii sulphatis, £x (40.0 gm. ) ; Sodii bicarbonatis, giv (16.0 gm.) ; Sodii chloridi, 2^ij (8.0 gm.). M. Sig. — A teaspoonful in a glass of water an hour before breakfast. One of the natural sulphated waters may often be used with advantage, especially when there is a tendency to excessive secretion of acid. Suppositories containing glycerin and ene- mata of warm water are harmless and generally effective. In some cases mild vegetable laxatives, like cascara sagrada and rhubarb, are required. The occasional use of calomel in small, frequently repeated doses sometimes serves a good purpose. GASTRALGIA. The hygienic and dietetic treatment described under Indi- gestion is applicable to gastralgia. Especially important is it to forbid the excessive use of tobacco, tea, coffee, and alcohol. When the attacks show a tendency to occur midway between meals, the administration of 3 or 4 ounces (90.0-120.0 c.c.) of milk with lime-water, two or three hours after meals, is often of service. Treatment of the Attack. — Stupes or hot compresses should be applied over the epigastrium. Internally, such remedies as chloroform (5-10 min. — 0.3-0.6 c.c), Hoffmann's anodyne (20-30 min. — 1.2-2.0 c.c), diluted hydrocyanic acid (2-3 min. — 0.1-0.2 ex.), and antipyrin frequently afford relief. The following combination will be found of value in many cases : R Acidi hydrocyanici diluti, TTlxxxv (2.0 c.c.); Antipy rinse, ^ij (8.0 gm.) ; Tincturse opii camphoratae, f %] (30.0 c.c.) ; Aquse chloroformi, q. s. ad f ^iij (90.0 c.c). M. Sig. — A dessertspoonful in hot water. If the pain be very severe, it will be necessary to resort to the hypodermic injection of morphin and atropin. Treatment. — The two most useful remedies are silver nitrate and arsenic. The former should always be selected when there is hyperesthesia of the mucous membrane or hyperchlorhydria. It may be combined with belladonna, as in the following formula : DISEASES OF THE DIGESTIVE TRACT. 559 R Argenti nitratis, gr. v (0.3 gm.) ; Extracti belladonna, gr. iv (0.26 gm.) ; Mannae, q. s. Fiant pilulse No. xx. Sig. — One pill half an hour before meals. The best preparation of arsenic is Fowler's solution, which should be given after meals in increasing doses. Galvanism is sometimes of service ; the anode may be placed over the epigastrium, and the cathode over the dorsal spine. Very severe cases may demand a complete change of scene and air or a modified " rest-cure." Gastralgia depending upon anemia, locomotor ataxia, or malaria is to be treated, of course, on special principles. GASTRIC ULCER, Rest and appropriate diet are the most important factors in the treatment of gastric ulcer. The rest should be kept up for from six to twelve weeks, and for the first two or three weeks of this period the patient should be confined to bed. If hem- orrhage has recently occurred or if vomiting be urgent, it is advisable to withhold all food from the stomach for a few days and to nourish the patient by means of nutritive enemata. The following enema of Boas is usually well borne : & Milk, 250 grams ; Yolk of two eggs, Salt, 2 grams ; Claret, 15.0 cubic centimeters; • Baked flour, 15 grams. Use 1 to 3 in twenty-four hours. The following preparation suggested by Ewald is also use- ful : A tablespoonful of baked flour (dextrinized) is boiled with one-half of a glass of a 15 per cent, solution of glucose, and a wineglassful of claret is added. Two or three eggs, which have been beaten up with a tablespoonful of water and a pinch of salt, are stirred into the mixture after it has cooled suffi- ciently to prevent the coagulation of the albumin. The entire quantity should not measure more than \ pint (0.25 L.). After the pain and vomiting have sensibly abated, feeding by the mouth should be resumed. The diet should consist of milk, buttermilk, beef-juice, animal broths, egg-white, and thin pap. As soon as the gastric symptoms have completely dis- appeared, which will rarely be before the lapse of three or four weeks, the patient may be allowed such articles as soft-boiled eggs, scraped beef, boiled sweetbreads, the tender part of oysters, white meat of chicken, well-made gruel, and custard pudding. 560 APPLIED THERAPEUTICS. Medicinal Treatment. — The most useful drugs are alka- lis, silver nitrate, and bismuth subnitrate. The alkalis are useful in overcoming the superacidity of the gastric juice. Sodium bicarbonate is one of the best ; it may be combined with magnesia or chalk, according as there is constipation or diarrhea. Artificial Carlsbad salt (see p. 558) is an excellent alkaline laxative ; of this a teaspoonful or more may be taken in half a pint of hot water before breakfast. Silver nitrate and bismuth subnitrate undoubtedly possess some value, although they probably exert no specific influence on the ulcer itself. The two drugs may be given alternately, each for a period of a week or ten days (see pages 372 and 375). Vomiting usually yields to complete rest, rectal feeding, and the administration of silver or bismuth. In some cases it may be necessary to use in addition a local sedative, like hydro- cyanic acid (see p. 160) or cocain. Morphin administered hypodermically is often very efficacious. Violent pain will also demand morphin, although the danger of inducing a habit must always be borne in mind. Exter- nally, stupes or sinapisms are sometimes useful. In the treatment of hematemesis absolute rest is essential. No food of any kind should be given by the mouth. An ice- bag should be applied over the stomach and morphin should be given hypodermically. The application of firm bandages to the four extremities may act favorably. Ergot and local astringents like tannic acid, iron sulphate, and lead acetate are of very doubtful utility. Ewald and Minkowski have recom- mended rinsing the stomach with ice-water as a last resort. Collapse following hemorrhage will call for diffusible stimu- lants, the external application of heat, and subcutaneous and rectal injections of warm saline solutions. Operative interference is rarely warranted unless the hemor- rhage be repeated. Surgical Treatment. — In all cases of perforation an opera- tion should be done at the earliest possible moment. The mortality in 123 cases operated on for perforation since 1896 was 47.15 per cent. (Bidwell). In a series of 18 cases operated on within twelve hours after perforation, and reported since 1896, the mortality was only 16.66 per cent. (Keen). When life is threatened by repeated hemorrhage, operation, in the interval between attacks (gastro-enterostomy or pyloroplasty) offers the best method of relief. Again, an operation (gastro- enterostomy, pyloroplasty, or partial gastrectomy) should be considered if the disease does not yield to medical treatment and the life of the patient is endangered by malnutrition. DISEASES OF THE DIGESTIVE TRACT. 56 1 GASTRIC CANCER. Medicinal Treatment. — The medicinal treatment of gas- tric cancer is purely palliative. The chief indications are to maintain nutrition and to relieve distressing symptoms. In the early stages of the disease, when the pylorus is still free, a mixed diet of readily digested food is often well borne. Later, when there is retention, food should be selected which leaves but little residue in the stomach. Eggs, finely divided tender meats, sweet-bread, soft part of oysters, clear soups, calf's-foot jelly, and thin gruels are admissible. A small quantity of light wine with meals is sometimes very beneficial. Milk is often badly borne. If the stomach is unretentive re- course should be had to rectal feeding. Bitters — nux vomica, calumba, gentian — may often be em- ployed with advantage. Condurango (see p. 177) is an excel- lent stomachic, wholly lacking, however, in the specific prop- erties with which it was at one time credited. In many cases, but by no means invariably, hydrochloric acid is a useful adjuvant to the bitters. Lavage affords the very best means of relieving the distress- ing symptoms resulting from retention. Vomiting that is not dependent upon retention may be treated with such remedies as carbonated water, hydrocyanic acid, bismuth subnitrate, creasote, cerium oxalate, and chloroform. In obstinate cases rectal feeding may be required for a time. Acid eructations and flatulency are sometimes relieved by antacids and anti- septics, but in the majority of cases lavage is much more effective. The pain, if severe, will require codein or morphin. Milder attacks may be relieved by lavage, the administration of ant- acids or of sedatives, like carbolic acid, hydrocyanic acid, or chloroform, and by the external application of hot compresses or stupes. Constipation may be treated by simple enemata, glycerin suppositories, or by mild vegetable laxatives. Surgical Treatment. — Statistics of the surgical treatment of gastric cancer do not present a very favorable showing, although the mortality of the operative procedures is diminish- ing year by year. There are but two operations to be con- sidered — partial gastrectomy and gastro-enterostomy. The former is curative in its aim, the latter purely palliative. In 291 cases of resection of the pylorus or of a portion of the stomach recorded between 1890 and 1898, the mortality, 36 562 APPLIED THERAPEUTICS. according to Guinard, was about 35 per cent. Earlier inter- vention and improvement in technic has gradually lessened the mortality, and at present it is probably not more than 25 per cent. Unfortunately, very few patients have remained free from recurrence longer than three years after the operation. Wolfer cites 3 patients who lived over four years, 4 over five years, I over six years, and 2 over eight years. Gastro-enterostomy is preferable to gastrectomy in cases with extensive adhesions or marked glandular involvement. Moynihan has reported 35 cases with 5 deaths, and Robson 34 cases with 3 deaths. When performed successfully, this opera- tion affords great relief and may prolong life several months, and, occasionally, even a year or two. DILATATION OF THE STOMACH. The treatment of dilatation of the stomach is medical and surgical. Medical treatment is frequently curative when there is no actual stenosis of the pylorus. The diet is of the first importance. Foods should be selected which are nutritious, which are not bulky, and which do not readily ferment. Ten- der meats, eggs, light cereals, fresh butter, cream, and toasted bread may usually be allowed. Milk is often badly borne, and in many cases liquids of all kinds must be somewhat re- stricted, but it is rarely necessary to resort to the dry diet of Schroth and other writers. In severe cases predigested meat preparations are often of service. P. Cohnheim has found olive oil useful when spasm of the pylorus is a factor. In the majority of cases it is best to limit the meals to three or four a day; occasionally, however, it will be found neces- sary to give the food in small quantities at frequent intervals. The time required for the stomach to empty itself should be ascertained in each case, and should be the guide in determin- ing the number of meals a day. To prevent retention, to control fermentation, and to cleanse the stomach no measure is so valuable as lavage (see p. 500). In the cases due to atony, massage, exercise in the open air, and hydrotherapy are valuable aids. A carefully adjusted abdominal bandage nearly always affords comfort and gives mechanical support to the stomach. Faradization of the stomach is useful in promoting muscular contraction. DISEASES OF THE DIGESTIVE TRACT 563 Few drugs are of value. Nux vomica may often be given with advantage. When there is hypo-acidity, diluted hydro- chloric acid is indicated. Such remedies as creosote and the salicylic compounds are sometimes of benefit in checking fer- mentation, but the relief they afford is not to be compared to that obtained through systematic lavage. Constipation should be treated, as a rule, by simple enemata or by glycerin sup- positories. Surgical Treatment. — In the large majority of cases of non-obstructive dilatation medical treatment suffices. Occa- sionally, however, surgical intervention is demanded on account of persistent suffering and progressive emaciation. The oper- ation indicated in these cases is gastroplication. In 15 cases collected by Keen (1898) all the patients recovered but one. In cases of pyloric obstruction of a benign character an operation is indicated when it is impossible to maintain nutri- tion by proper medical treatment. As Loreta's digital divul- sion of the pylorus has been largely abandoned, owing to its high mortality (31.1 per cent), there may be said to be but two operations available — pyloroplasty and gastro-enterostomy. The mortality in 14 cases of pyloroplasty reported by Carle was 7 per cent, while Morison has reported 1 1 cases, and Mayo 8 cases without a death. When performed by a surgeon hav- ing exceptional skill, gastro-enterostomy, in benign affections, yields a mortality of less than 8 per cent. The question of operative intervention in malignant stricture of the pylorus has already been considered (see p. 560). CHRONIC CONSTIPATION. In many cases chronic constipation can be successfully treated by attention to hygienic measures and by careful regu- lation of the diet without resorting to drugs. Not infrequently the normal activity of the bowels may be restored by repeated daily attempts at defecation at some special hour. Systematic exercise and cold bathing are of the greatest benefit. Abdom- inal massage, especially digital kneading in the direction of the colon, is often quite effectual. In persons with relaxed abdom- inal walls the wearing of a snugly-fitting binder will be found of service. Food should be selected which leaves considerable undi- 564 APPLIED THERAPEUTICS. gested residue. Green vegetables, oatmeal, corn-meal, whole- wheat bread, and cooked fruits are available. Oils may often be given with advantage. Water-drinking should be encour- aged. In mild cases a glass of cold water taken in the morn- ing shortly after rising may suffice. When hygienic treatment proves insufficient, drugs will be required. Any underlying condition of which the constipation may be but a symptom should receive careful attention. Gen- eral tonics, like iron and strychnin, are often indicated. Min- eral waters, like Friedrichshall, Hunyadi Janos, or the milder Saratoga or Bedford waters, are very useful, but possess no special advantages over the saline laxatives (sodium phosphate, or Rochelle salt), when the latter are taken in small amounts well diluted. Enemata of soapy water or of glycerin, or suppositories of gluten, soap, or glycerin, often prove highly satisfactory. Vegetable cathartics are usually necessary in obstinate cases. The mild ones should always be tried first, and even with these considerable care should be exercised lest the patient comes to rely upon drugs to the exclusion of the hygienic and dietetic measures already indicated. Of the mild laxatives, cascara sagrada is one of the best ; from 10 to 30 min. (0.6-2.0 c.c.) of the fluid extract, or a corresponding dose of an agreeable elixir, may be administered at bedtime and re- peated, if necessary, in the morning. In some cases a combi- nation of several laxatives acts better than any one singly. The drugs to be preferred for conjoint use are rhubarb, aloes, podophyllin, and euonymin. As adjuvants, nux vomica or physostigma may be added to overcome atony of the bowel, and belladonna or hyoscyamus to prevent griping. The most suitable combination must be determined in each case by ex- perience. A pill, like one of the following, will generally be found efficacious : R Resinae podophylli, gr. iv (0.26 gm.); Aloes purificatae, gr. xx-xl (1.3-2.6 gm. Extracti nucis vomicae, Extracti belladonnae, da gr. iv (0.26 gm.). M. Fiant pilulae No. xx. Sig. — One pill at bedtime. R Pulveris rhei, Extracti rhamni purshianae, ad gr. xxiv (1.5 gm.) ; Extracti euonymi, gr. xij (0.8 gm.) ; Extracti physostigmatis, Extracti belladonnse, da gr. iv (0.26 gm.). M, Fiant pilulae No. xxiv. Sig. — One pill at bedtime. DISEASES OF THE DIGESTIVE TRACT. 565 R Aloini, gr. iv (0.26 gm.) ; Pulveris rhei, gr. xxxvj (2.3 gm.); Pulveris ipecacuanhae, gr. vj (0.4 gm.) ; Resinae podophylli, gr. iij (0.2 gm.) ; Extract! hyoscyami, gr. xij (0.8 gm.). M. Fiant pilulae No. xxiv. Sig. — One pill at bedtime. ACUTE DIARRHEA. Acute Diarrhea in Adults. — Rest in bed and the substi- tution of bland nourishment for the ordinary diet are all that is required in many cases. Boiled milk, milk and arrow-root, and mutton, veal, or chicken broth are suitable foods. If the patient is seen at the outset and there is reason to believe that irritant material is still present in the bowel, it is advisable to administer an unirritating purgative, such as castor oil, Epsom salts, or fractional doses of calomel. Occasionally a second dose of the purgative may be given with benefit. Externally, stupes or sinapisms are frequently efficacious. If there be much pain, opium should be administered. Dover's powder and paregoric are deservedly popular prepara- tions. If the diarrhea continue, mild astringents, like bismuth subnitrate and chalk, are indicated. They may be combined advantageously with an antiseptic, as in the following formulae : R Bismuth i subnitratis, £iij (12.0 gm.) ; Bismuthi subsalicylatis, gj (4.0 gm.). M. Fiant chartulse No. xij. Sig. — One powder every two or three hours. R Salolis, ^ss(2.ogm.); Bismuthi subnitratis, Cretae praeparatss, aa ^ij (8.0 gm.) ; Pulveris acacias, q. s. Aquae cinnamomi, q. s. ad fgiij (90.0 c.c). M. Sig. — A dessertspoonful every two or three hours. When opium is indicated, it is better to prescribe the drug separately, so that it may be discontinued more readily when no longer required. Preparations containing tannic acid are rarely needed, but when the discharges are very profuse and watery, small doses of tannalbin or of tannigen (see p. 356) may prove serviceable. Cases in which gastric indigestion is an important factor are often benefited by pancreatin in con- junction with bismuth subnitrate and an alkali. If the diar- rhea shows a tendency to become chronic, mineral astringents, like silver nitrate and lead acetate, with opium, in pill form, will be found effective. When there is reason to believe that the colon is especially 566 APPLIED THERAPEUTICS. involved, local treatment is of the utmost value. Copious in- jections of warm water both cleanse the bowel and exert a soothing effect upon the irritated mucous membrane. Small enemata (1-2 oz. — 30.0-60.0 c.c.) of starch-water with lauda- num (5-10 min. — 0.3-0.6 c.c.) are very useful. In subacute colitis enemata containing silver nitrate (see p. 372) often prove efficacious. Treatment of Acute Diarrhea in Infants. — Preventive treatment is of the utmost importance. Improper food and faulty methods of feeding are the two prime factors in causing the disease. Fresh cows' milk containing a minimum number of bacteria to the cubic centimeter should form the basis of all food that is intended to replace healthy breast-milk. In sum- mer the milk should be received from the dairyman twice in the day, if possible, and should be placed immediately in a good refrigerator and kept there until such times as it is wanted. In very warm weather it may be necessary to resort to sterili- zation or pasteurization as a further means of preservation, but it must be remembered that neither of these processes can re- move from the milk any pre-existing impurities. The strength and quantity of the food and the number of meals per day must be carefully adapted to the infant's age and its digestive powers. As an additional precaution in extremely hot weather it may be advisable to dilute the milk a little more than usual in order to lessen the percentage of fats and proteids. Next to purity and freshness of the milk, it is important to insist upon absolute cleanliness of all the feeding apparatus. The nursing bottle and rubber nipple should be thoroughly washed after each meal. The child should have a daily morn- ing bath, and on very warm days it is advisable to give one or two tepid sponge baths (90 F. — 32 ° C.) in addition to the ordinary bath. In summer, if the weather be good, the child should pass most of the time in the open air, protected, of course, from the winds and the direct rays of the sun. The first indication in the treatment of the disease is to with- draw the milk at once, and to withhold it for several days or until the stools become quite natural. Indeed, in many cases it is well to suspend all nourishment for the first twenty-four hours, allowing nothing by the mouth but barley-water or plain boiled water. Subsequently, albumin-water, fresh beef- juice, veal broth, or a liquid peptone preparation may be given in lieu of milk. Milk feeding should always be resumed very gradually. Absolute rest in the recumbent position is essen- tial. Removal to the seashore or mountains is often of the greatest benefit. DISEASES OE THE DIGESTIVE TRACT. 567 After the withdrawal of the milk, the next most important step in the treatment is the administration of a purgative like castor oil or calomel. Of these, calomel should be given the preference when the stomach is irritable. In many cases free purgation alone suffices to cleanse the bowel, but when the stools are offensive or there is marked toxemia enteroclysis should also be practised once or twice a day, according to the severity of the attack. In cholera infantum intestinal irrigation may be employed to meet several indications : to lower tem- perature, to combat collapse, to relieve the anhydremia, and to stimulate renal secretion (see p. 498). In choleraic forms of the disease lavage and hypodermoclysis are also of great value. In most cases of acute diarrhea it is necessary to follow the purge with a sedative astringent, like bismuth subnitrate or chalk. From 5-10 gr. (0.3-0.6 gm.) of one of these drugs may be given every two or three hours. Intestinal antiseptics (salol, bismuth salicylate, betanaphtol bismuth) are useful adju- vants. Some such combination as the following may be ordered with advantage : R Bismuthi subnitratis, ^ij-iv (8.0-16.0 gm.) ; Salolis, gr. xxiv (1.5 gm.) ; Misturse cretae, ffiij (90.0 c.c). M. Sig. — A teaspoonful every two hours. A more active astringent, like tannalbin or tannigen, may be given in addition to the bismuth subnitrate or chalk when the discharges are exceedingly profuse and watery. In ileocolitis intestinal irrigation may be followed by injections of I or 2 ounces (30.O-60.O c.c.) of a solution of silver nitrate (|- gr. to the ounce — 0.03 gm-30.0 c.c), of from \ to 1 ounce (15.0-30.0 c.c.) of a mixture of bismuth subnitrate (1 dram to the ounce — 4.0 gm-30.0 c.c), or of from 3 to 4 ounces (90.0-120.0 c.c.) of a solution of tannin (1 per cent.). If the injection containing silver nitrate excite pain, the bowel should be flushed with salt solution. Opium is often of the utmost value, but extreme caution must be exercised in its use. On the whole, it has undoubtedly caused more harm than good. In many cases there is abso- lutely no indication for it. It is called for when the diarrhea continues in spite of the thorough unloading of the bowel and the administration of mild astringents. One of the best prepa- rations is paregoric ; of this, from 3 to 5 minims (0.2-0.3 c.c) may be given every two, three, or four hours according to cir- cumstances. Opium should not be added to mixtures, but should be prescribed by itself. When the stomach is unreten- 568 APPLIED THERAPEUTICS. tive, laudanum in doses of from I to 2 minims (0.06-0.1 c.c.) may be added to starch-water (J- ounce — 15.0 c.c.) and admin- istered by the rectum. In cholera infantum small doses of morphin (yfg- gr. — 0.0006 gm.) with atropin (-g-^- gr. — 0.00008 gm.) may be given hypodermically. Stimulants are often required. Whisky and brandy are perhaps the best. From 10 to 20 minims (0.6-1.2 c.c.) of one or the other may be given in cold water every two, three, or four hours. When the stomach is unretentive, it will be neces- sary to administer stimulants hypodermically. Hypodermo- clysis also affords a valuable means of preventing exhaustion. In threatened collapse hot packs or hot baths may prove bene- ficial. Fever, according to its intensity, should be controlled by cold sponging, cold packs, or cool baths (85°~75° F. — 29.5 - 24 C). Intestinal irrigation with cool water may also be used for its antipyretic effect. CHRONIC DIARRHEA. The first thing to do is to ascertain the cause and to remove this, if possible. The diet, clothing, habits, occupation, and mode of living of the patient should receive the most careful attention. No definite rules can be laid down in reference to the diet. Many patients do well upon an exclusive milk diet. Scraped beef, raw or underdone, is often well borne. In some cases it is an advantage to have the food peptonized. When the disease is not very severe and is confined for the most part to the colon, a selected mixed diet may be allowed. In such cases pulled bread or toast, tender beef or mutton, oysters, raw or boiled eggs, boiled rice, arrow-root, and plain cus- tard are available. Foods that are bulky and leave much resi- due are always inadmissible. Protection of the body against chilling is of vital importance. Woolens should be worn next to the skin. A snugly fitting abdominal bandage may be worn as an additional safeguard. Rest in bed is sometimes essential. The obstinate diarrhea occasionally encountered in hysterical women is often benefited by a modified rest cure. When the general nutrition is not too much impaired, a change of air and scene may prove very effectual. The medicinal treatment of chronic diarrhea is very un- satisfactory. Mineral astringents, especially bismuth subni- trate (30-40 gr. — 2.0-2.5 g m J> silver nitrate (J-J gr. — 0.016- 0.03 gm.), copper sulphate (J-i gr. — 0.016-0.06 gm.), and lead DISEASES OF THE DIGESTIVE TRACT. 569 acetate (1-3 gr. — 0.06-0.2 gm.), enjoy the most repute. These drugs should always be given a thorough trial, as even under the most favorable conditions improvement is slow in appear- ing. Intestinal antiseptics — salol, thymol, bismuth subsalic- ylate, creasote, betanaphthol-bismuth, and benzonaphthol — are useful adjuvants to astringents, especially when there is con- siderable intestinal fermentation. Opium in small amounts is often required, particularly in acute exacerbations. Wood has found the following tar-water mixture a most effective remedy in many cases : R Picis liquidae, f^iij (90.0 c.c.) ; Triturentur cum liquore calcis, Oviij (4.0 L. ), ad saturationem, et percolentur per prunum vir- ginianam, ^viij (250.0 gm.). M. Sig. — A wineglassful one to two hours after meals. In the diarrhea of hysterical women strontium bromid is sometimes of value. Arsenic (see p. 310) has been highly recommended in that form of diarrhea characterized by an uncontrollable desire to evacuate the bowel immediately after taking food. In malarial cases a cure is generally rapidly effected with quinin. When there is decided anemia, tincture of ferric chlorid will be found serviceable. In many cases it is a good plan to resort to intestinal irrigation from time to time or to administer a purgative (castor oil, Epsom salts, or calomel) occasionally to remove from the bowel scybalous masses or viscid mucus. When the disease is situated chiefly in the colon, local treat- ment is of the greatest service. Starch-water and laudanum enemata are sometimes useful. Generally, however, astringent injections are more successful. Irrigation of the bowel, two or three times a week, with a solution of silver nitrate (see p. 372) is especially to be recommended. DYSENTERY. Rest in bed is imperative, even in chronic cases. In acute dysentery the diet should be liquid or semiliquid. Milk with lime-water, whey, milk-toast, animal broths, and egg-white may be given. Predigested foods are often very useful. In the chronic form of the disease it may be necessary to give a some- what more liberal diet in order to maintain nutrition. Soft- boiled eggs, pulled bread, boiled rice, oysters, and tender meats (chicken, mutton, and beef) may be allowed. The intestinal discharges should be disinfected immediately as in the case of typhoid fever. 5/0 APPLIED THERAPEUTICS. An unirritating purgative (castor oil, Epsom salts, or calo- mel) is nearly always indicated at the onset. After the bowel has been thoroughly emptied, opium may be given to check peristalsis and to relieve the tormina and tenesmus. It is best given hypodermically in the form of morphin or by the bowel in the form of starch-water and laudanum injections or opium suppositories (J-i gr. — 0.03-0.06 gm.). Hot fomentations, tur- pentine stupes, or sinapisms to the abdomen also afford relief. Persistent tenesmus may sometimes be controlled by iodoform suppositories (2-5 gr. — 0.13-0.3 gm.). Wood speaks favorably of ice suppositories, inserted for a length of time, one after another. Some benefit may be derived from the administration of bis- muth subnitrate (20-30 gr. — 1. 3-2.0 gm.j by the mouth, com- bined with an antiseptic like salol or betanaphthol-bismuth. Sulphur is another remedy well worthy of trial in obstinate cases. Ten grains (0.65 gm.) should be given three or four times a day, combined with a small quantity of opium. In many cases the adynamia is so pronounced that stimulants must be used freely. In cases in which the typhoid state is well developed oil of turpentine, 5-10 minims 10.3-0.6 c.c.) in emulsion, often acts favorably. After the most acute symptoms have subsided intestinal irri- gation may be employed with the greatest benefit. The patient's hips should be elevated and the fluid should be introduced very gently and slowly by means of a fountain syringe. When the rectum is very irritable, it is advisable to inject a small quantity of cocain solution (4 per cent.) before introducing the irrigator. In acute dysentery normal salt solution at a tempera- ture of ioo°-i03° F. (38°-39.5° C.) may be employed for the irrigation. Weak solutions of boric acid (J dram to 1 quart — 2.0 gm.-i.o L.) and of potassium permanganate (2—5 grains to 1 quart — o. 1 3-0.3 gm. to 1.0 L.) have also been recom- mended. Hare has used zinc sulphocarbolate (40 grains to I quart — 2.6 gm. to 1.0 L.) with very satisfactory results. In amebic dysentery warm injections of quinin (from 1 : 5000 to I : 1000) have been found very efficacious. In chronic dysen- tery weak solutions of silver nitrate (10-30 grains to 1 pint — 0.6-2.0 gm. to 0.5 L.) are generally the most useful (see p. 37 2 )- Three special methods of treatment merit consideration : that by ipecac, that by salines, and that by antibacterial serum. Many practitioners who have had much experience in the treatment of dysentery in India have borne testimony to the value of ipecac. At the onset it is customary to give a large DISEASES OF THE DIGESTIVE TRACT. 57 1 dose (30 gr. — 2.0 gm.), and this usually induces vomiting. After vomiting has occurred the drug is administered in smaller doses (2-5 gr. — 0.13-0.3 gm.) at intervals of two hours. To insure the retention of the latter doses opium is generally given a short time in advance of the ipecac. A successful result is indicated by the appearance, usually within twelve hours, of a copious black stool. In the sporadic dysentery of temperate zones this treatment has not proved very satisfactory. Magnesium sulphate is another remedy which has been brought prominently forward within the last few years, espe- cially in India and other tropical countries. In 1900, Buchanan reported a series of 453 cases of dysentery treated by this drug in which there were but 5 deaths. A purgative dose is first administered, and after the bowel has been thoroughly emptied, smaller doses (1 dr. — 4.0 gm.) are given three or four times a day, preferably in combination with aromatic sulphuric acid, as in the following formula : R Magnesii sulphatis, ^iss (45.0 gm.) ; Acidi sulphurici aromatici, fgij (8.0 c.c); Aquae cinnamomi, q. s. ad f^vj (180.0 c.c). M. Sig. — Tablespoonful three or four times a day. The treatment should be continued for several days after the stools have ceased to be dysenteric. Unlike the ipecac treat- ment, this plan not infrequently gives good results in the acute dysentery met with in temperate regions. The discovery that one form of acute dysentery is caused by a special organism, the bacillus of Shiga, is sufficient ground for hope that a curative serum will be forthcoming. Indeed, Shiga claims to have reduced the mortality in a recent epi- demic in Japan from 37 to 8 per cent, by means of an antibac- terial serum. APPENDICITIS. There is a considerable diversity of opinion among physi- cians and surgeons as to the best method of treating appendi- citis. Some advise surgical intervention in all cases as soon as the diagnosis is made ; others, among whom are the greater number of representative surgeons, advocate a policy of intel- ligent discrimination and selection. The author is of the opinion that operation should be urged — (1) At once in all cases in which the onset is very severe, the symptoms indicating special severity being marked right-sided tenderness and rigidity, distention, and vomiting, with or with- out fever ; (2) in cases of moderate severity which manifest no 572 APPLIED THERAPEUTICS. improvement after the lapse of forty-eight hours ; and (3) in cases in which the symptoms, after decided improvement, re- turn. On the contrary, operation is rarely required, at least during the attack — (1) In cases of a mild type, in which the pain is unaccompanied by rigidity, distention, nausea, or vom- iting ; and (2) in cases of moderate severity in which improve- ment is noticeable within forty-eight hours. Operation during the quiescent stage, when the element of danger is almost en- tirely removed, is to be recommended — (1) When an acute attack has been followed by persistent tumefaction and tenderness, intestinal disturbances, or impairment of the general health ; (2) when there have already been two attacks, even of moderate severity ; and (3) when mild attacks occur with such frequency as to induce disability. Medical Treatment. — The medical treatment of appendi- citis is Very simple. The patient should be kept in bed at absolute rest. The diet should be restricted to small quantities of bland liquids — milk, albumin-water, and broths. Purga- tives, as a rule, should be avoided, although there is usually no objection to administering a mild saline aperient at the onset of the attack. Constipation is best relieved by enemata of warm water. Locally, cold or heat may be applied, according to the sensations of the patient. Applications should not be used which affect the integrity of the skin, as they render sur- gical intervention more difficult should it subsequently be re- quired. If the pain be very severe, morphin may be adminis- tered hypodermically ; only the minimum amount necessary to afford a measure of relief is to be used, however, as by ob- scuring the symptoms the drug prevents an accurate study of the progress of the case. CATARRHAL HEPATITIS. Diet is of the first importance. Fatty, starchy, and saccha- rine foods should be avoided. Milk, buttermilk, broths, egg- albumen, lean meats, oysters, toast, pulled bread, and well- cooked cereals — wheat, rice, and oat-meal — are admissible. Water-drinking is distinctly beneficial. Alkaline mineral waters, like Vals, Vichy, and Hathorn, are frequently of service. If constipation resists the action of these waters, daily evacua- tions should be secured by means of sodium phosphate, Carls- bad salts, Rochelle salts, or a sulphated water, like Hunyadi Janos or Friedrichshall. Bismuth subnitrate and silver nitrate are often of value in relieving the primary gastroduodenal catarrh. Ammonium chlorid (10 gr. — 0.65 gm. — thrice daily, after meals) is also use- DISEASES OF THE DIGESTIVE TRACT. S73 ful. In obstinate cases, nitrohydrochloric acid, as originally recommended by Scott, may prove beneficial. Daily irrigation of the colon with from i to 2 quarts (1.0-2.0 L.) of cold water, as advocated by Krull, is sometimes followed by improvement Intestinal fermentation and flatulence may yield to inspissated ox-gall or to an antiseptic like salol, bismuth salicylate, or betanaphthol-bismuth. Itching should be treated with tepid alkaline baths and lotions of carbolic acid, boric acid, or diluted hydrocyanic acid. Internally bromids, in full doses, may be tried when the pruritus is severe. CHOLELITHIASIS. Medical Treatment.— Gall-stones in the gall-bladder or in the biliary passages cannot be dissolved. Turpentine and ether (Durande's mixture), chloroform, sodium succinate, sodium choleate, sodium oleate, and a host of other drugs have been recommended with a view to their solvent effects, but they have been found wholly ineffectual. Attempts to accom- plish the extrusion of calculi by means of drugs have proved equally futile. Probably not more than 5 per cent, of those who have gall-stones suffer any inconvenience from their pres- ence (Kehr). When symptoms occur, they result, in the large majority of cases, from a coincident cholecystitis. As the latter is the chief factor in exciting the violent expulsive efforts which force the stones from the gall-bladder into the ducts, it is mainly responsible for the recurrent attacks of colic. As we have no solvents for gall-stones and no remedies capable of effecting their expulsion, our efforts must be directed to keep- ing the stones quiescent, and this can be accomplished only by allaying catarrhal inflammation of the gall-bladder and by guarding against its recurrence. Diet and hygiene are of the utmost importance. The food should be plain and readily digestible. Saccharine matters, fat meats, and highly seasoned dishes are undesirable. With the view of promoting a more continuous flow of bile it is often advantageous, when the gastric digestion is well maintained, to give the food in small quantities at comparatively short inter- vals. A light meal at bedtime has been especially recommended by Kehr. Frequent feeding may prove very harmful, how- ever, when there is slow digestion with atony of the stomach. Water-drinking between meals should be encouraged. Regular exercise in the open air, provided the symptoms are latent, is extremely beneficial. Constriction of the upper part of the abdomen by corsets or other articles of dress is to be rigidly avoided. The practice of manipulating the gall-bladder 574 APPLIED THERAPEUTICS. for the purpose of expelling calculi, which has been advocated by some, cannot be too strongly condemned. Freedom from worry and mental effort, probably by con- ducing to good digestion, often exerts a marked salutary effect. Digestive disturbances should receive appropriate treatment. Among drugs, alkalis and alkaline mineral waters are undoubt- edly efficacious. Sodium bicarbonate or sodium phosphate may be taken well diluted in the morning an hour before break- fast and also between meals. If there be decided constipation, a small quantity of Rochelle salt or sodium sulphate may be added to each potation. The natural mineral waters, notably those of Carlsbad and Vichy, have acquired a high reputation. When there is a tendency to so-called bilious attacks, an oc- casional course of calomel in fractional doses will be found of benefit. In similar cases irrigation of the bowel, once or twice a week, with from I to 2 quarts (1.0-2.0 L.) of cool water is also very useful. Finally, when there are no evidences of active inflammation in the gall-bladder and the patient's circumstances will permit, we may recommend a course of treatment at Carlsbad, Vichy, or Contrexeville, with some degree of confidence. An extended visit to one of these resorts is often followed by considerable improvement, and in rare cases by permanent relief. The benefit from a stay at one of these spas probably depends more upon change of air and scene, genial surroundings, regular hours, and freedom from worry than upon the waters them- selves. Hepatic Colic. — When the pain is violent it will be necessary to give morphin and atropin hypodermically at short intervals. As the opium habit is readily formed in these cases, it need scarcely be added that great caution should be exercised in the use of the drug. Agonizing pain often yields very promptly to a few whiffs of chloroform. In the mild but rather persistent attacks a few doses of antipyrin in hot water may suffice. The external application of heat is very useful. Hot poultices or fomentations may be applied to the region of the liver, or, when circumstances permit, the patient may be kept in a hot bath. Exceptionally, an ice-bag affords more relief than any of the hot applications. When vomiting is urgent, carbonated water, cracked ice, or small quantities of champagne may be given. In threatened collapse diffusible stimulants are needed. Acute Obstruction of the Common Duct. — The measures best suited for promoting the advance of the stone into the bowel are rest, regulation of diet, the free use of alkaline mineral waters, the occasional exhibition of saline laxatives, and the DISEASES OF THE DIGESTIVE TRACT 575 application of heat to the hypochondriac region. Olive oil (see p. 465) has been recommended as a special remedy, but it is of doubtful efficacy. As the sequelae of impaction of the common duct are so numerous and so grave, surgical aid should be invoked if the obstruction is not removed under medical treatment within a period of two or three weeks. Surgical Treatment. — Surgical intervention is called for — (1) When, despite medical treatment, attacks of colic occur so frequently and are of such severity as to cause disability or make the addiction to morphin a likelihood ; (2) in persistent obstruction of the common duct ; (3) in hydrops of the gall- bladder due to impaction or stricture of the cystic duct ; and (4) in suppurative inflammation of the gall-bladder or gall- ducts. In the hands of experienced operators the mortality of cholecystotomy in uncomplicated cases is very low, certainly not more than I or 2 per cent. The mortality of choledochot - omyis higher, although in Kehr'slast 137 cases it was only 6.5 per cent, and in a continuous series of 80 operations performed by Mayo Robson, it was less than 4 per cent. After operation medical treatment should be continued on the lines already laid down for the management of cholelithi- asis that is more or less latent, with the view of preventing the further formation of stones. CIRRHOSIS OF THE LIVER. As cirrhosis of the liver is almost invariably associated with congestion of the stomach and gastric catarrh, these conditions are the first to demand attention. A diet of bland, readily digestible food is indicated. Alcohol should be forbidden. Tea, coffee, fatty matters, and highly spiced or seasoned dishes are inadmissible. Milk, eggs, oysters, sweetbread, tender meats, and well-cooked cereals may usually be allowed. In advanced cases an exclusive milk diet is advisable. As in simple gastric catarrh, such drugs as silver nitrate and bismuth subnitrate are sometimes of service. Lavage of the stomach should not be practised for fear of wounding the varicose veins at the lower end of the esophagus. Measures which promote the action of the skin and kidneys should not be neglected. Portal congestion is best relieved by saline aperients and the occasional use of a mild mercurial. Mineral waters, such as those of Vichy, Carlsbad, Saratoga, Hunyadi Janos, and Fried- richshall, taken hot an hour before meals, often have an excel- lent effect. 576 APPLIED THERAPEUTICS. Potassium iodid has been largely employed with the hope that it might favor the absorption of the overgrown connective tissue. While it is apparently useless in the absence of syph- ilis, in syphilitic cases it may prove very beneficial. Ascites. — Effusion that is only moderate in amount can sometimes be removed by the administration of cathartics and diuretics. A concentrated solution of Epsom salts (-§— I oz. — 15.0-30.0 gm.), taken in the morning before breakfast, is usually the most efficient purgative. Occasionally it may be desirable to substitute compound jalap powder or elaterium. The diuretics of approved value are potassium acetate or bitartrate, digitalis, and squills. The combination of blue-mass, digitalis, and squills, known as Niemeyer's pill (see p. 52), has a well- deserved reputation. Murchison and Fagge advocated resin of copaiba (15 gr. — 1.0 gm., daily), but it often disturbs the stomach. The use of drugs should not be persisted in ; if the ascites does not diminish in the course of a few days, it is far better to resort to paracentesis. The operation is readily per- formed, and if done under antiseptic precautions, is attended with but very slight risk. It not only affords speedy relief, but, by removing the pressure from the abdominal veins, it also assists the action of diuretics. Occasionally, after one or two tappings, the fluid does not return for a long period — per- haps several months or even years ; generally, however, the abdomen quickly refills, so that frequent repetition of the opera- tion becomes necessary. The operation of paracentesis abdominis is performed as fol- lows : The bladder having been emptied, the patient is placed in a semirecumbent position, and a spot in the median line midway between the umbilicus and the symphysis pubis is anesthetized by means of a block of ice sprinkled with salt. A stout trocar is now introduced with a quick thrust into the abdominal cavity, a rubber tube is attached to the cannula for the purpose of conveying the fluid into a pail placed below the patient's bed, and the trocar is then withdrawn. While the fluid is escaping a many-tailed bandage is adjusted to the abdomen and gradually tightened. The application of such a binder should never be omitted. It gives support to the relaxed abdominal walls, and tends to prevent syncope and hematemesis. When the fluid ceases to flow, the cannula is removed, and the opening sealed with an antiseptic pad and a few strips of adhesive plaster. Surgical Treatment. — Talma's operation (suture of the omentum to the margin of an abdominal incision, and irritation of the peritoneal surface of the liver and spleen), or one of its DISEASES OF THE RESPIRATORY SYSTEM. 577 modifications, has proved of some benefit in a limited number of cases of liver cirrhosis with ascites. The object of the operation is to establish a compensatory circulation by making accidental adhesions and thus increasing the anastomoses between the vessels of the portal system and those of the systemic circulation. In 227 cases collected by Sinclair White (November, 1906) death from the operation occurred in 33 per cent, failure in 15 per cent, improvement in 13 per cent., and symptomatic cure in 37.3 per cent. The duration of the cure at the date of publication was between one and two years in 7 cases, between two and three years in 17 cases, and over three years in 5 cases. The operation is contraindicated when cardiac or renal disease coexists. DISEASES OF THE RESPIRATORY SYSTEM. ACUTE RHINITIS. In mild attacks little treatment is required. If the constitu- tional symptoms be severe, it is advisable for the patient to remain in his room, or even in his bed. When the patient is seen at the outset and is willing to remain indoors for twenty- four hours, a hot foot-bath, with a full dose of Dover's pow- der, followed in the morning by a Seidlitz powder or another saline aperient, often gives excellent results. When the patient is fully able to go about, the following capsules will usually afford considerable relief: Be Pulveris camphorae, gr. yj (0.4 gm,) ; Extracti belladonna, Codeinae sulphatis, aa gr. iss (0.1 gm.); Cinchoninae sulphatis, gr. xij (0.8 gm.). M. Pone in capsulas No. xij. Sig. — One every two or three hours. I/OCal treatment is very useful. In the early stage, when there is marked swelling of the mucous membrane, the appli- cation of cocain (2-4 per cent, solution) is sometimes exceed- ingly efficacious. If, however, no lasting effect is secured after three or four trials, its use should be discontinued. Warm Dobell's solution (see p. 172) or warm distilled extract of witch-hazel (diluted with 1 part of water), used as a spray at intervals, and followed in a few minutes by an oily application like the following, generally renders satisfactory service : R Mentbolis, gr. iij (0.2 gm.) ; Olei pini pumilionis, tit v (0.3 c.c.) ; Petrolati liquidi, q. s. ad f^j (30.0 c.c). M. 37 578 APPLIED THERAPEUTICS. Among numerous vapor-inhalations recommended for their soothing effect the following are worthy of mention : Com- pound tincture of benzoin, I dram (4.0 c.c), and hot water, I pint (0.56 L.); chloroform, 1 dram (4.0 c.cj, and hot water, 1 pint (0.5 L.); iodin, 1 or 2 grains (0.06-0.13 gm.), and ether, 1 ounce (30.0 c.c.) ; camphor, 1 dram (4.0 gm.), and hot water, 4 ounces (120.0 c.c). CHRONIC RHINITIS. The treatment of chronic rhinitis is both general and local. It is highly important to ascertain the existence of any consti- tutional vice and to remove this if possible. Attention to hygienic conditions is most essential. Fresh air, out-door exercise, and frequent bathing, followed by friction of the skin, are to be insisted upon. Tonics, especially strychnin and cod- liver oil, are aften required. When the disease is not far advanced, much can be accom- plished by keeping the nasal passages thoroughly clean. For this purpose detergent alkaline fluids may be applied by means of a coarse spray or the nasal douche-cup. A large number of combinations have been suggested, of which Dobell's solu- tion (see p. 172) and the following are good examples : R Sodii bicarbonatis, Sodii boratis, aa gr. xxx (2.0 gm.) ; Sodii chloridi, gr. iij (0.2 gm.) ; Thymolis, Mentholis, aa gr. ss (0.03 gm.); Olei gaultheriae, TTLij (0.12 c.c); Glycerini, f ^ij (8.0 c.c.) ; Alcoholis, f^ss (2.0 c.c.) ; Aquae, q. s. ad f § viij (240.0 c.c). M. In the early stage, when the redundant tissue is not very dense, local remedies of an astringent or alterative character are often very efficacious. The following applications are in common use : A mixture of iodin and glycerin containing 6 grains (0.4 gm.) of iodin, 12 grains (0.8 gm.) of potassium iodid, and 1 ounce (30.0 c.c.) each of glycerin and water; aqueous solution of ichthyol (20-40 per cent.) ; solution of zinc sulphocarbolate (2-5 per cent.); solution of resorcin (10 per cent); and solution of silver nitrate (1-2 per cent). When the hypertrophic process has progressed so far that these simple measures prove ineffective, a more energetic treat- ment is demanded. The obstruction must be removed by means of caustics (chromic acid, trichloracetic acid, and acetic acid), the galvanocautery, or the snare, the proper use of which usually requires the services of a skilled specialist. DISEASES OF THE RESPIRATORY SYSTEM. 579 Atrophic Rhinitis (Osena). — Improvement in the gen- eral health by the aid of fresh air, good food, and of such remedies as cod-liver oil, iron, arsenic, and strychnin is often requisite. If any syphilitic taint is suspected, potassium iodid and mercury should have a fair trial. Subcutaneous injections of antidiphtheritic serum have been used in a number of in- stances with alleged good results, this treatment having been tried in consequence of the assertion made by Belfanti and Delia Vedova, and confirmed by other observers, that a bacillus identical with the bacillus of diphtheria is the cause of ozena. The first requisite of local treatment is thorough cleanliness of the nasal passages, and to secure this the patient should be directed to spray the nose two or three times a day with Dobell's solution or some other mild detergent fluid. When the crusts are difficult to remove, they may be softened by pledgets of cotton soaked in a solution of hydrogen dioxid. After the nares have been cleansed, an oily solution like the following may be used to moisten and protect the parts : R Mentholis, gr. xx (1.3 gm.) ; Thymolis, gr. vj (0.4 gm.) ; Eucalyptolis, TT[xx (1.2 c.c.) ; Petrolati liquidi, fgvj (180.0 c.c.). M. Among the many local remedies which have been employed for their stimulant effects ichthyol is perhaps the best (see p. 335). When there is much secretion, insufflations of zinc stearate (75 per cent, with boric acid), as recommended by C. C. Rice, are sometimes useful. Interstitial electrolysis has been used by some observers with considerable success. The modus operandi of this method of treatment is as follows : The nasal fossae having been cleansed and anesthesia having been produced by means of a 10 per cent, solution of cocain, a copper needle attached to the positive pole is introduced beneath the mucous membrane of the middle turbinated body, and a platinum needle attached to the negative pole is introduced into the lower part of the septum or into the outer wall of the inferior meatus of the same nos- tril. The intensity of the current employed has varied from 6 to 1 5 milliamperes, and the duration of the sittings from ten to fifteen minutes. For destroying the offensive odor a large number of drugs have been suggested, of which the following may be mentioned : Citric acid (see p. 469), formalin (1 : 1000 to 1 : 500), Labar- raque's solution (1 : 30), potassium permanganate (2 grains to the ounce — 0.13 gm-30.0 c.c), and creolin (1 : 100). 580 APPLIED THERAPEUTICS. ACUTE LARYNGITIS. In severe cases the patient should be confined to bed, and the temperature of the room kept uniformly at 70°-72° F. (2i°-22° C). The air should be rendered moist by means of steam. A hot foot-bath at the onset is often beneficial. The use of the voice should be avoided as much as possible. The external application to the throat of cold compresses or of an ice-bag is of service. In grave forms of the disease it may be advisable to apply a few leeches to the upper part of the sternum. Warm inhalations afford considerable relief. A dram (4.0 c.c.) of compound tincture of benzoin, half a dram (2.0 c.c.) of oil of turpentine, or half a dram (2.0 c.c.) of oil of cubebs may be added to a pint (0.5 L.) of boiling water and the fumes in- haled. For want of a special apparatus for the administration of these inhalations steam may be collected and conducted by means of an ordinary tin funnel which has been inverted over a bowl containing the medicated hot water. In vaporizing oily substances it is advisable to mix them first with magne- sium carbonate in order to aid their suspension in the water. In the early stage direct local applications are rarely re- quired ; later in the disease, however, the application of astrin- gents by means of the atomizer often proves useful. Alum, 5-10 gr. (0.3-0.6 gm.) to the ounce (30.0 c.c); silver nitrate (1-2 per cent, solution) and zinc sulphate, 2-3 gr. (0.13-0.2 gm.) to the ounce (30.0 c.c), often give satisfactory results when used in this manner. Internal medication may do much good. At the onset of the disease it is usually advisable to administer a saline purge. If the cough be troublesome, a sedative, like Dover's powder, codein, or heroin, may be given in conjunction with a mild expectorant, such as ipecac, potassium citrate, or ammonium chlorid. In acute edematous laryngitis, when the swelling does not yield promptly to local bloodletting, the external application of ice, astringent sprays, scarification of the mucous mem- brane, and active catharsis, tracheotomy should be performed without delay. Spasmodic Croup. — The indications are to arrest the paroxysms and to prevent their recurrence. When the par- oxysms are severe, the child may be placed in a warm bath (100 F. — 38 C.) for ten or fifteen minutes, or an emetic (ipecac or alum) may be given instead. Occasionally the dyspnea is so intense as to demand the inhalation of a few drops of chloro- DISEASES OF THE RESPIRATORY SYSTEM. 58 1 form or amyl nitrite. Mild attacks usually yield to the appli- cation, over the larynx, of a sponge wrung out of hot water. The remedial measures which have been advocated for simple laryngitis are also of service in preventing attacks of pseudo-croup. Such a combination as the following will generally be found useful: ]£ Tincturae aconiti, Tt\, v j (0.4 c.c.) ; Vini ipecacuanhae, f 3J (4.0 c.c.) ; Potassii bromidi, gss (2.0 gm.) ; Potassii citratis, 3J (4.0 gm.) ; Syrupi tolutani, f 3J (30.0 c.c.) ; Aquae, q. s. ad f^ij (60.0 c.c). M. Sig. — A teaspoonful every two or three hours for a child of eighteen months. CHRONIC LARYNGITIS. It is highly important to determine in each case the under- lying cause of the local irritation, and to remove this if possi- ble. Injurious habits, such as the excessive use of tobacco or alcohol, must be corrected. The diet, exercise, bathing, and clothing must be carefully regulated. While it is essential that the body should be warmly clad, the practice of wearing thick scarfs about the neck as a means of protection from cold should be condemned. Daily sponging the neck and chest with cool water is a far better way of guarding against recur- rent attacks of inflammation. In some cases a change of occupation is imperative. Rest of the voice is always indi- cated. Not infrequently improper or excessive use of the voice is the main etiologic factor, and when this is the case permanent relief can be secured only by the correction of the error. As in a large group of cases a morbid process in the nasopharyngeal passages is the sole cause of the laryngeal irritation, it follows that the removal of this primary disease must often be the fundamental principle in the treatment. Any constitutional disease, such as rheumatism or gout, or any derangement of the digestion or circulation that may be pres- ent should receive careful attention. Change of scene and climate is often of the greatest benefit, a warm, dry climate being especially favorable to the condition. In many cases of chronic laryngitis tonics, like iron, strych- nin, and cod-liver oil, are efficacious. Even when there is no evidence of syphilis, potassium iodid in small doses is sometimes useful, especially when there is a great lack of secretion with a tendency to the formation of crusts. Expectorants have little, if any, effect upon the chronic process, but often prove serviceable in acute exacerbations. 582 APPLIED THERAPEUTICS. Local treatment is of prime importance. Remedies are best applied by means of sprays or a camel's-hair brush or cotton swab. Lozenges are also of benefit in certain condi- tions. Vapor inhalations and insufflations of dry powders are not so satisfactory. Thorough cleanliness, not only of the larynx itself, but also of the nose and pharynx, is always requisite. This is best secured by spraying the parts at fre- quent intervals with a mild alkaline solution. If there be deficient secretion, one of the following solutions may be em- ployed as a spray after the mucous membrane has been cleansed : Sodium chlorid, 5 gr. (0.3 gm.) to the ounce (30.0 c.c.) ; potassium chlorate, 5 gr. (0.3 gm.) to the ounce (30.0 c.c.) ; ammonium chlorid, 5 gr. (0.3 gm.) to the ounce (30.0 c.c.) ; or potassium iodid, 5 gr. (0.3 gm.) to the ounce (30.0 c.c). Lozenges containing 1 or 2 gr. (0.6-0.13 gm.) of ammonium chlorid may also afford relief, especially if the pharynx be much affected. When there is excessive secre- tion, astringent sprays are indicated, and one of the following may be selected : Alum, 3-5 gr. (0.2-0.3 g m -) to tne ounce (30.0 c.c); zinc acetate, 3-5 gr. (0.2-0.3 gm.) to the ounce (30.0 c.c); zinc sulphocarbolate, 2-3 gr. (0.13-0.2 gm.) to the ounce (30.0 c.c) ; or lead acetate, 1-3 gr. (0.06-0.2 gm.) to the ounce (30.0 c.c). When more active astringents are re- quired, they should be applied directly to the larynx by means of a cotton swab or camel's-hair brush. Thus, benefit may be derived from a solution of tannin, 10 gr. (0.6 gm.) to the ounce (30.0 c.c.) of glycerin, or from a solution of silver nitrate, 5-10 gr. (0.3-0.6 gm.) to the ounce (30.0 c.c.) of water. Actual abrasions may be touched with a strong solu- tion of silver nitrate, 40-60 gr. (2.6—4.0 gm.) to the ounce (30.0 c.c). When there is scab-formation, a 20 per cent, solu- tion of ichthyol often proves useful. Large varicose vessels should be cauterized (chromic acid) under cocain anesthesia. Tuberculous laryngitis. — Hygienic, climatic, dietetic, and general medicinal treatment should be that of pulmonary tuberculosis (see p. 592). In the early stage medicated in- halations and sprays are of benefit. Such remedies as crea- sote, terebene, compound tincture of benzoin, and eucalyptol may be used in a respirator or inhaled from the surface of boiling water. As a rule, sprays are more satisfactory. After the mucous membrane has been thoroughly cleansed with an alkaline detergent spray, one of the following sprays may be used: Corrosive sublimate (1 : 5000 to 1 14000), resorcin (1-2 per cent.), formalin (1 : 1000), or menthol (1-2 per cent). In tuberculous ulceration the treatment may be radical or DISEASES OF THE RESPIRATORY SYSTEM. 583 palliative. Unfortunately, the latter is the only form of treat- ment that is applicable in the large majority of cases. When, however, the disease in the lung is not far advanced and the ulceration in the larynx is circumscribed and readily accessi- ble, the thorough removal of the diseased tissue may be attempted. The most approved method of radical treatment consists in the rubbing-in of lactic acid after the ulcer has been thoroughly cureted. If the ulcer be quite superficial, the curetment may be omitted. The parts must be carefully anesthetized with cocain (20 per cent, solution), and the acid applied in the proportion of 30, 50, or 75 per cent, solution, or even stronger, according to the effects. Ichthyol (undiluted) and guaiacol (undiluted) have been used in some cases instead of lactic acid. When the ulceration is more diffuse and is associated with considerable infiltration, better results may be obtained from one of the following applications : Carbolic acid, J— I dram (2.0-4.0 c.c.) to the ounce (30.0 c.c.) of glycerin ; tannin, 1 dram (4.0 gm.) to the ounce (30.0 c.c.) of glycerin ; formalin (1-10 per cent, in glycerin); or chromic acid (2-3 per cent.). In the advanced stages of the disease only sedative applica- tions to relieve pain and dysphagia are justifiable. Among the agents most generally useful as insufflations may be men- tioned orthoform, iodoform, cocain, and morphin. Semon recommends iodoform (1 gr. — 0.06 gm.), boric acid (1 gr. — 0.06 gm.), and morphin sulphate (^ gr. — 0.0 1 gm.). Fasano speaks highly of the following combination : Thiocol, 1 ; co- cain, 2 ; boric acid, 10. A 5-10 per cent, solution of menthol in liquid petrolatum used as a spray often affords much relief. Intratracheal injections have also been recommended. Vacher has had excellent results from injections of 30 minims (2.0 c.c.) of the following : Guaiacol, 5 parts ; eucalyptol, 2 parts ; men- thol, 1 part ; and saturated solution of iodoform in ether, 100 parts. When dysphagia is very severe, it may be well to apply cocain to the larynx before eating, using a 2-4 per cent, solution as a spray or a 5-10 per cent, solution as a direct application. When deglutition is extremely painful, Wolfen- den suggests that the patient take liquid food while lying prone, the head hanging over the edge of a couch, and the nourishment being sucked through rubber tubing from a bowl on the floor. Syphilitic I^aryngitis. — Constitutional treatment with iodids and mercurials is of the first importance. Local clean- liness should be secured by thorough spraying with some alkaline antiseptic solution. Ulcers may be touched with 584 APPLIED THERAPEUTICS. silver nitrate (melted on a silver probe), acid nitrate of mer- cury (1 to 5 parts of water), or chromic acid (1 to 8 parts of water). Insufflations of iodoform are also useful. Cicatricial stenosis may call for gradual dilatation or even tracheotomy. ACUTE BRONCHITIS. If the patient be weak or old, he should be confined to his room or even to bed; the atmosphere of the room should be kept warm and moist. If the patient be seen at the outset, it is useful to promote free diaphoresis, and this may be accom- plished by means of a hot foot-bath, with hot drinks and a full dose of Dover's powder. Warm inhalations, such as have been suggested in acute laryngitis (see p. 580), are also of service. Counterirritation to the chest in the form of sina- pisms or stupes is very beneficial. When there is much dyspnea, as there frequently is when acute bronchitis compli- cates emphysema, the application of dry cups, or even of a few wet cups, to the chest often has a marked salutary effect. The food should be simple and readily digestible, and the bowels should be kept regularly open by the aid of mild aperients. Distressing dry cough is usually best controlled by one of the opium derivatives — codein or heroin- — and fever by aconite with spirit of nitrous ether or by small doses of phenacetin. When for any reason opium is objectionable, hyoscyamus, spirit of chloroform, sodium bromid, or diluted hydrocyanic acid may be used instead. When the cough remains persist- ently dry sedative expectorants may be given to favor secre- tion. For this purpose potassium citrate, ipecac, apomorphin, and antimony are extensively employed. The combination of potassium citrate and ipecac given on page 271 is especially useful in this stage of the disease. In young, robust persons antimony is decidedly efficacious, and may be prescribed according to the formula suggested on page 272. When the bronchial secretion becomes more abundant, stim- ulant expectorants are indicated. Ammonium chlorid is one of the most reliable members of this class ; it may be pre- scribed in some simple vehicle, like brown mixture, or with squill, as in the formula given on page 276. Expectorants of an oily nature, such as terebene, oil of eucalyptus, oil of santal, and oil of copaiba are also very efficacious, but more liable than the ammonium salt to derange digestion. Such a combination as the following is often very serviceable when the catarrh tends to become subacute : DISEASES OF THE RESPIRATORY SYSTEM. 585 Be Terebeni, Olei eucalypti, aa f £ss (2.0 c.c.) ; Strychninae sulphatis, gr. £ (0.02 gm.) ; Codeinae sulphatis, gr. ii-iij (0.13-0.2 gm). M. Pone in capsulas No. xij. Sig. — One every four hours. When the expectoration is purulent and heavy, a creasote derivative, like guaiacol carbonate, may be used with great advantage (for formula, see p. 287). In the aged and infirm alcoholic stimulants are often re- quired to combat general adynamia. Strychnin is a most valuable adjunct to the expectorants when there are indica- tions that the heart is becoming strained by the violent parox- ysms of cough. Should there be evidence of pronounced cardiac failure, it will be necessary to employ digitalis. Such tonics as cod-liver oil, iodid of iron, quinin, and arsenic are often useful during convalescence from severe and pro- longed attacks. Much benefit will also be obtained from suitable change of climate. CHRONIC BRONCHITIS. To meet with any measure of success, treatment must be directed largely toward the prevention of recurrent attacks, and the removal, if possible, of the underlying cause. Indiscrimi- nate routine treatment is to be rigidly avoided. Change of climate, especially in winter, is most beneficial, and should be urged if the circumstances of the patient will permit. When there is much bronchial secretion, a dry, warm climate, such as that of New Mexico or Southern California, in this country, and that of Egypt or the Riviera abroad, is generally to be recommended, whereas if there be little expectoration, a moist warm climate, such as that of Florida, the West Indies, Ma- deira, Pau, or Algiers, is preferable. When patients are unable to avail themselves of the benefits to be derived from a suitable climate, they should remain indoors as much as possible in bad weather, and take every precaution against exposure. Flannel should at all times be worn next to the skin, the feet should be kept perfectly dry, and the night-air should be avoided, The diet should be simple but nutritious. In many cases alcohol in some form acts beneficially. Underlying chronic diseases should always receive appropri- ate treatment. When cardiac insufficiency is present, digitalis, strychnin, or caffein may be required. When there is anemia with general malnutrition, such remedies as iron, arsenic, cod- liver oil, and hypophosphites may be given with advantage. When gout is a factor, benefit may be expected from the ad- 586 APPLIED THERAPEUTICS. ministration of potassium iodid and alkalis. When renal inadequacy is coexistent, the diet must be very carefully supervised, and such measures adopted as will promote the functional activity of the various emunctories. The direct remedies most generally useful are the expector- ants of a terebinthinate or balsamic character, such as tere- bene, oil of eucalyptus, myrtol, oil of santal, oil of copaiba, and oil of cubeb. Tar is another remedy of value. It may be used in substance made into pills, or in the form of tar- water or the wine of tar. When the sputum is heavy and purulent, no drug acts so well as creasote or the carbonate of guaiacol. Potassium iodid is of service in some cases, but it is difficult to state definitely the exact conditions under which it is likely to prove beneficial. It may be tried tenta- tively when the expectoration is very scanty and viscid, or when there is evidence of a gouty diathesis. In acute ex- acerbations recourse must be had to such expectorants as potassium citrate, ipecac, antimony, apomorphin, and ammo- nium chlorid. When the cough is much in excess of what is required to expel the exudation, mild anodynes, like codein or heroin, may be used from time to time to keep it in subjection. Alkalis (sodium bicarbonate, aromatic spirit of ammonia), with or without a few minims of the spirit of chloroform, taken in hot water before rising, will often lessen morning cough and facili- tate expectoration. Dry cough may be largely the result of habit, and if this be the case much can be accomplished by discipline. The following formulae will serve to illustrate the manner in which the various remedies may be combined : R Terebeni, Olei eucalypti, Olei santali, aa fgi-fgiss (4.0-6.0 c.c); Codeinae, gr. iij-vj (0.2-0.4 gm.). Misce et pone in capsulas No. xxiv. Sig. — One after each meal and at bedtime. R Terpini hydratis, gj (4.0 gm.) ; Guaiacolis carbonatis, ^ij (8.0 gr.); Strychninae sulphatis, gr. ss (0.03 gm. ) ; Codeinae, gr. iij (0.2 gm.). Misce et pone in capsulas No. xxiv. Sig. — One or two capsules three or four times a day. R Apomorphinae hydrochloridi, gr. ss (0.03 gm.); Syrupi pruni Virginianae, f^ij (60.0 c.c.) ; Syrupi picis liquidae, f^iv (120.0 c.c). M. Sig. — A tablespoonful thrice daily. (Murrell.) DISEASES OF THE RESPIRATORY SYSTEM. 587 Inhalations are sometimes efficacious, especially when the disease appears to be situated chiefly in the trachea and larger bronchi. The volatile agent may be used in a special steam nebulizer, or preferably, if the patient must be about, in an oro-nasal respirator. The most suitable drugs for inhalation are terebene, eucalyptol, oil of Scotch fir, creasote, carbolic acid, iodin, compound tincture of benzoin, and spirit of chloro- form. A number of these remedies may often be combined with advantage, as in the following formula : R Chloroformi, fjss-fjj (2.0-4.0 c.c.) ; Creosoti, Terebeni, Olei pini sylvestris, aa fgiss (6.0 c.c.) ; Alcoholis, q. s. ad fgj (30.0 c.c). Sig. — From 5 to 20 drops to be used in the inhaler several times a day. Intratracheal injections have given good results in certain in- stances. From 1-3 fl. dr. (4.0-1 1.0 c.c.) of a 1 per cent, solu- tion of creasote or guaiacol, or of a 2 per cent, solution of menthol in olive oil may be injected between the vocal cords into the trachea once a day, a syringe with a long curved cannula being used for the purpose. The fluid should be in- jected in three or four separate portions, while the patient takes a slow, full inspiration. Inhalation of compressed air by means of Waldenburg's apparatus, the pneumatic cabinet, or a pneumatic chamber like that in use at Brompton Hospital, affords considerable relief in some cases. According to Oertel, the good effects of the com- pressed air are to be attributed to the increased pressure within the bronchi, causing a diminution of the hyperemia, and, con- sequently, less exudation of serum into the bronchial walls and less pressure on the lymphatic system. Counterirritation, preferably with iodin or small blisters, is often of great service in lessening the severity of acute exacer- bations. ASTHMA, The cause must be sought for in every case, and removed if possible. When the source of the reflex irritation is in the nasal passages, local treatment may be followed by marked improvement, or even cure. In a certain number of cases the source of the primary irritation is in the stomach, consequently digestive disturbances should always receive careful attention. Chronic bronchitis, emphysema, and dilatation of the heart are frequent concomitants of asthma and call for special treatment. 588 APPLIED THERAPEUTICS. A general toxemia, such as occurs in gout, may be responsible for the attacks, and if this be the case appropriate measures must be employed to remove or control it. Unfortunately, in the majority of cases the chief etiologic factor appears to be a peculiar hyperesthesia of the bronchial mucosa, a morbid con- dition which at present we have no very potent means of com- bating. Although we are unable fully to meet the causal indication in many instances, nevertheless much can often be done by well-directed hygienic measures and empiric medication to lessen the frequency and severity of the paroxysms. The diet should consist of plain, readily digestible food. A light even- ing meal is advisable, especially when the paroxysms tend to occur at night. Vicissitudes of temperature must be care- fully guarded against and flannel always worn next to the skin. Much benefit is often derived from systematic exercise in the open air and from hydrotherapy, judiciously employed. In delicate, poorly nourished subjects the administration of iron, cod-liver oil, hypophosphites, and other tonics does much good. A change of climate, even though slight, generally proves of decided service, but the choice of locality must be determined very largely by the personal experience of the patient. Many sufferers do better in the smoky atmosphere of cities than in the country. Asthmatics with moist bronchial catarrh usually do well in a dry, warm climate, while those with dry catarrh generally derive more benefit from an atmos- phere that is somewhat humid (see p. 585). Elevated regions are mostly unsuitable for old persons with emphysema, but in young adults they may prove very advantageous. The inha- lation of compressed air has been highly recommended by Ber- tin, Sandahl, Theodore Williams, and others. If employed, it is best carried out by means of the pneumatic cabinet or the " air-bath." The inhalation of oxygen has also been advocated. Among special remedies potassium iodid holds the first place. While it often fails entirely, it undoubtedly possesses more power in averting attacks than any other drug. To be effective, it must be given in doses of from 5-20 gr. (0.3-1.3 gm.) three times a day for long periods. Sodium or strontium iodid is sometimes better borne by the stomach than the potas- sium salt. Tincture of belladonna, in doses of 3-5 min. (0.2-O.3 c.c), thrice daily, is a valuable adjunct to the iodid. Arsenic has long been esteemed as a potent remedy, and may be tried when iodids prove of no avail. Grindelia robusta (see p. 283) is sometimes useful when there is much bronchial catarrh. Strychnin is of service in cases associated with em- DISEASES OF THE RESPIRATORY SYSTEM. 589 physema. Occasionally the prolonged administration of bro- mids, by allaying the nervous erethism, seems to increase the interval between the attacks. Nitroglycerin has also been highly extolled by some writers, but its action is uncertain and equivocal. VonNoorden has recently recommended the use of atropin, giving first a daily dose of y^- gr. (0.0005 g m -) an< ^ cautiously increasing this until ^ gr. (0.004 g m -) * s given daily, and then gradually diminishing the dose. He repeats such a course of treatment every few months, using less of the drug each period. The Attack. — The most suitable remedy for a particular case can only be determined by trial. A drug or a combination of drugs that succeeds admirably in one case may fail utterly in another. As a rule, drugs which are taken by inhalation give the most speedy relief. Some patients derive great benefit from the fumes of ignited stramonium or belladonna leaves or paper which has been impregnated with potassium nitrate. These agents may be burnt in the patient's room or smoked in a pipe or in the form of cigarets. Occasionally tobacco proves very efficacious. Marked alleviation of the paroxysms is often obtained from the inhalation of amyl nitrite (5-6 min. — 0.3- 0.4 c.c.) or ethyl iodid (10-20 min. — 0.6-1.2 c.c). In some cases the paroxysms yield readily to a few whiffs of chloro- form, though generally the effects of the drug are only tempo- rary. When there is decided turgescence of the nasal mucosa, such as occurs in the asthma of autumnal catarrh, the topical use of adrenalin solution (1 : 5000), applied on a pledget of cotton or as a spray, will be found very effective. If such measures fail to afford relief, internal remedies must be used. In some cases strong hot coffee acts most happily ; in others more benefit is derived from hot whisky and water. Among the numerous special remedies which have been advocated the following appear to be the most reliable : opium, belladonna, bromids, chloral, paraldehyd, Hoffmann's anodyne, lobelia, and que- bracho. Few attacks will resist the action of morphin hypodermically with atropin, but the greatest caution must be exercised in order that the patient may not become addicted to the drug. Heroin hydrochlorid hypodermically in doses of from -^ t° -fa gr. (0.005-0.006 gm.) may often be substituted for morphin with great advantage. When the attacks are associated with bronchial catarrh a combination like the one suggested on page 283, or the following, will be found of value : 590 APPLIED THERAPEUTICS. R Tincturse belladonna, fgj (4.0 c.c.) ; Tincturae lobeliae, fgiij (ii.oc.c); Fluidextracti aspidospermatis, f^ss (i5.0c.cl; Spiritus setheris compositi, f^v (18.5 c.c.) ; Strontii bromidi, 3'ijss (10.0 gm.); Elixiris aromatici, q. s. ad f^iv (120.0 c.c). M. Sig. — A dessertspoonful in water every two or three hours. Among other measures that have been found useful in alle- viating asthmatic attacks may be mentioned the application of sinapisms to the chest, the inhalation of compressed air, and the inhalation of oxygen. EMPHYSEMA. The treatment of emphysema is chiefly that of the accom- panying disease. The various means suggested for the cure or relief of chronic bronchitis (see p. 585) may often be used here with great advantage. When asthma is the primary disease, treatment calculated to lessen the frequency and severity of the paroxysms should be instituted (see p. 587). When fully established, emphysema is incurable, although it is susceptible to alleviation. Violent exercises and over- exertion of all kinds must be proscribed. A diet that is light but sustaining is indicated. All foods likely to induce flatu- lence should be avoided. Much benefit is often derived from a change of climate, the choice of locality, however, depending somewhat upon the character of the complicating bronchitis (see p. 585). As a rule, high elevations are to be avoided. The inhalation of compressed air by means of the pneumatic cabinet or the " air-bath " is usually followed by a marked im- provement in the symptoms. The inspiration of compressed air with expiration into rarefied air has been especially advo- cated. Striimpell speaks favorably of rhythmic compression of the lower portion of the thorax during expiration, as recom- mended by Gerhardt This should be done systematically by another person two or three times a day during fifty or sixty respirations. General tonics, like iron and cod-liver oil, are required in some cases to improve the general health. Strychnin, being both a respiratory and a cardiac stimulant as well as a general tonic, is particularly useful. Digitalis will be found a service- able remedy when signs of cardiac insufficiency appear. Am- monium carbonate, in conjunction with strychnin and digitalis, usually has an excellent effect upon acute exacerbations of the bronchial catarrh. At such time sinapisms applied to the chest may also afford considerable relief. When sleep is disturbed DISEASES OF THE RESPIRATORY SYSTEM. 59 1 by troublesome cough and oppressive dyspnea no drug is so generally useful as heroin. When the breathing is very diffi- cult, the face suffused and livid, and the pulmonary circulation much impeded, recourse should be had to bloodletting, either local or general, according to the urgency of the symptoms. CATARRHAL PNEUMONIA. Hygienic treatment is of the utmost importance. The atmosphere of the sick-room should be kept at an even temperature of 6S°-yo° F. (20°-2i° C), and should be rendered moist with steam. The diet should be liquid and nutritious. Milk, light broths, gruels, egg-white, and junket are suitable forms of nourishment. Alcoholic stimulants are often required. When the circulatory depression is pronounced, whisky or brandy may be given in doses of from 10 to 30 min. (0.6-2.0 c.c.) in milk to a child of two years every two or three hours. At the outset it is often advantageous to administer a mild purgative, preferably calomel or castor oil. In the absence of any special indication for local treatment it will only be neces- sary to provide ample protection for the chest. This may be done satisfactorily by means of the jacket of cotton-wool. When there is harsh, dry cough, mild rubefaction produced by the application of the tincture of iodin of suitable strength generally affords some relief. In adults sinapisms or stupes may be used instead of the iodik. Fever is best controlled by outward applications. Com- presses wrung out of cold water may be wrapped around the chest and changed for fresh ones at intervals of from twenty to thirty minutes. This treatment not only serves to lower tem- perature, but it also affects very favorably the pulse and respira- tion, and conduces to sleep. When the fever is high recourse should be had to cold packs or cold baths (85°-8o° F. — 29.5 °- 26.5 ° C). Expectorants are almost invariably required. In the early stage, when the cough is harassing and the sputum viscid, potassium citrate is very serviceable. It may often be com- bined advantageously with spirit of nitrous ether and solution of ammonium acetate, as in the following formula : R Potassii citratis, ^iss (6.0 gm.) ; Spiritus aetheris nitrosi, f^vj (22.5 c.c.) ; Liquoris ammonii acetatis, f^j (30.0 c.c); Syrupi tolutani, Aquse, aa q. s. ad f^iv (120.0 c.c). M. Sig. — Dessertspoonful every three hours for a child of three yeare. 592 APPLIED THERAPEUTICS. Later, the ammonium salts, especially the carbonate, are more efficacious. From I to 2 gr. (0.06-0.13 gm.) of the latter may be given every three or four hours to a child of two years. Ammonium iodid is also useful in facilitating expectoration, and may be employed as an adjuvant, as in the following formula : R Ammonii carbonatis, gr. xlviij (3.1 gm.); Ammonii iodidi, gr. xxiv (1.5 gm.) ; Syrupi tolutani, Syrupi acaciae, aa q. s. ad f^iij (90.0 c.c). M. Sig. — Teaspoonful every two or three hours for a child of three years. In adults the author has found creasote carbonate to be a reliable expectorant. When the bronchial secretion is very abundant belladonna is a valuable remedy. To a child of two years a min. (0.06 c.c.) of the tincture may be given every hour or two until the desired effect is produced. When the child is unable to expel the accumulated mucus and the breath- ing becomes much oppressed, an emetic (ipecac, alum, or zinc sulphate) will generally prove of great service. Inhalations of oxygen sometimes lessen cyanosis and make the breathing easier. Strychnin is also of benefit at this time in combating respiratory failure. When these measures fail to afford relief alternate douches of hot and cold water should always be tried, since by provoking violent respiratory efforts they may serve to dislodge the retained secretion and to bring about a thor- ough inflation of the lungs. If the symptoms of cardiac failure are especially pronounced, digitalis must be given in addition to alcohol and strychnin. Extreme restlessness and insomnia will sometimes require the use of the bromids or some other mild sedative. Except at the onset, when their administration may be neces- sary to relieve pleuritic pain and to control harassing cough, opiates should not be used. PULMONARY TUBERCULOSIS. Prophylaxis. — Efforts intended to prevent the extension of tuberculosis should be made in two directions, that of checking the dissemination of the bacillus, and that of ren- dering the tissues of the individual less susceptible to infec- tion. The Bacillus. — As the sputum of consumptive patients is the chief source of the bacillus, the disposition of this secre- tion becomes of the utmost importance. Such patients should be impressed with the danger, both to themselves and others, DISEASES OF THE RESPIRATORY SYSTEM. 593 of indiscriminate spitting, and should be taught never to ex- pectorate except in a proper receptacle. To be suitable, the spittoon should be provided with a closely fitting cover, and should be of such construction that it can be readily cleansed and disinfected. It should contain at all times some disin- fectant fluid, such as a 5 per cent, solution of carbolic acid, and should be thoroughly scalded with boiling water at least twice a day. A very good cuspidor, and one that can be burned when filled, is made of impervious cardboard. Feeble bed-ridden patients should expectorate in moist rags or paper napkins, which should be burned before they have become dry. It need scarcely be said that the sputum should never be swallowed. Consumptive patients should always sleep alone. Their rooms should be freely accessible to the sunlight, well venti- lated, and kept scrupulously clean. Stuffed furniture, carpets, and woolen hangings are undesirable. All articles used by the patient and liable to be contaminated with sputum should be disinfected by means of scalding water. Rooms which have been vacated by consumptives should not be occupied again until they have been thoroughly disin- fected (see p. 387). Phthisical patients should refrain from kissing and other modes of salutation necessitating very intimate association. Tuberculous mothers should not suckle their children. The marriage of consumptives should be discouraged. Through the enactment and rigid enforcement of special laws much can be done by the State to limit the dissemination of tuberculosis. Laws should be enacted providing for the systematic inspection by skilled veterinarians of all dairies and slaughter-houses with the view of declaring unmarket- able the milk and meat of tuberculous animals. Compulsory registration of phthisical patients, although it entails great hardships on individuals and their families, is desirable. Flick is probably right in recommending that consumptives in the infectious stage of the disease should be retired from occupations in which they can infect others. Spitting upon sidewalks and the floors of public buildings and conveyances should be made a penal offence. Finally, the State should provide special hospitals for the indigent suffering from tuberculosis. The Individual. — Persons with a marked predisposition to tuberculosis, whether hereditary or acquired, can do much to increase their power of resistance by strict attention to hygiene. Fresh air and sunlight, a healthy residence, an 38 594 APPLIED THERAPEUTICS. outdoor occupation, the wearing of warm clothes, with flan- nel next to the skin, a diet of wholesome and nutritious food, temperate living, systematic exercise, and daily cold sponging, followed by friction of the skin, are the factors to be relied upon in attempting to overcome individual susceptibility. Persons recovering from catarrhal pneumonia, pleurisy, measles, whooping-cough, influenza, and other diseases which predispose to tuberculosis should be treated with the utmost care. As enlarged tonsils, adenoid growths, and other ob- structions in the upper air-passages, by interfering with free respiration, increase the risk of infection, they should be re- moved. Finally, all local foci of tuberculosis, such as frequently appear in the cervical lymph-glands, joints, and bones, should receive immediate attention. Sanatorium Treatment.— The value of pure air in the treatment of pulmonary tuberculosis is universally admitted. By adding to pure air an abundance of nourishment in a readily digestible form, rest alternated with graduated exer- cise, and constant medical supervision we supply our phthis- ical patient with the best means which medical science has at present to offer of securing restoration to health, or, if this be impossible, of obtaining alleviation of his symptoms. Indeed, if these measures are beyond the reach of the invalid all others are likely to prove unavailing. Nowhere are all the means just enumerated so available as in a well-managed modern sanatorium. Such an institution may be located in almost any climate, even within a few miles of a large city, the only requisites being moderate elevation, well-drained soil, abun- dant sunshine, and protection from cold winds. Open Air. — In summer not less than nine or ten hours, and in winter not less than six or seven hours, are spent in the open air. In Falkenstein the patients remain out of doors in their chairs from seven to ten hours a day all the year round, in spite of fog, rain, wind, or snow, and even with the ther- mometer at 12° C. below zero, and often no sunshine (Knopf). Of course, they are sheltered from the wind and rain, and are well covered with blankets or fur robes. The bed-room windows are kept open both winter and summer. As a rule, patients soon accustom themselves to live in a low tem- perature without discomfort. Nourishment. — When there is no gastric derangement the patient is given an ordinary diet of wholesome food, and en- couraged to eat as heartily as his digestive capacity will per- mit. Milk, eggs, beef, mutton, lamb, fish, fowl, fresh vege- DISEASES OF THE RESPIRATORY SYSTEM. 595 tables, cereals, and fruits are considered suitable forms of nourishment. As a rule, the meals are given more frequently than in health. Thus, before rising the patient takes hot milk, cocoa, or gruel; at breakfast — beef-steak, chops, eggs, or fish, bread and butter, and coffee or milk ; at the mid-day dinner — soups, fish, meat, vegetables, salad, fruit, and wine; at 4 o'clock — milk with bread and butter, milk with raw egg, or bouillon with toast; at supper — cold meat, bread and butter, cocoa, fresh or preserved fruit ; at bed-time — a glass of hot milk or an egg-nog. In some cases the anorexia is so pronounced that it be- comes necessary to resort to forced feeding, but generally the patient can be persuaded to eat, especially if the food be presented to him in an appetizing form. Under the influence of fresh air the appetite often returns with remarkable rapidity. Rest and Exercise. — When the disease is active the patient is kept at absolute rest. For most of the day he lies on a bamboo couch or a reclining chair in the open air, warmth being maintained by abundant covering and, if necessary, by a hot stone placed at the feet. In the incipient stage and in quiescent tuberculosis moderate exercise is generally recom- mended, every precaution being taken, however, to guard against fatigue. Medical Supervision. — This is an important item of the sana- torium treatment. Everything that the patient does is re- viewed by the attending physician, and the treatment is re- duced to an organized system. " Success depends upon the ability of the doctor to discriminate and to shape his treatment according to the physical and mental wants of each individual case ; the patient must not be made to feel that he is merely an inmate of an institution the regime and regulations of which he has rigidly to observe, but rather, that he is a well-liked guest, who, while conforming to certain rules of the house for the benefit of his health, is at liberty otherwise to enjoy life in his own fashion " (Muthu). The results obtained under the sanatorium treatment fully justify its employment; it undoubtedly gives the patient in the early stage of the disease the best chance of complete recovery. The shortest period of treatment which will benefit a patient is rarely less than three months, and to secure a lasting improvement he should remain at least six months. Climatic Treatment. — Since the open-air treatment has been shown to be about equally successful in nearly all coun- tries, the selection of a special locality has become a matter of secondary importance. Still, there are some patients, with 596 APPLIED THERAPEUTICS. ample means at their disposal, to whom a protracted stay in a sanatorium would become exceedingly irksome and dis- tasteful. To such patients prolonged residence in a favorable climate offers the greatest hope of cure. The requisites of a suitable climate are purity of atmosphere, equability of tem- perature, and abundance of sunshine. The age of the patient, the extent and type of the disease, and the condition of the other organs must be carefully considered in deciding the question of altitude, of temperature, and of humidity. Other matters which should not be overlooked in choosing a locality are wholesome food in abundance and well-prepared, good accommodations, and available medical advice. Young subjects with considerable constitutional vigor, who have but a small area of lung involved, generally do well in high altitudes, such as are found in Colorado, Wyoming, and Montana, and in Switzerland (Davos and St. Moritz). The presence of cardiac disease, albuminuria, or emphysema is to be regarded as a contraindication to high elevations. The moderate elevation of the Adirondack Mountains and of the mountains of North Carolina is well adapted to many patients who have but a limited area of pneumonic consolida- tion, and who cannot afford to remain away from home longer than a few months. Phthisical patients who have much tendency to bronchial catarrh, and who manifest great constitutional irritability, gen- erally do better in warm climates with little elevation, such as Southern California, Southern Arizona, and Florida in this country, and the Riviera and Egypt abroad. In some cases an extended sea-voyage is very useful. Ac- cording to Douglas Powell, it is most suitable to patients in the early stages, who have been previously healthy, who have overworked nervous systems, and in whom the disease is more or less quiescent. Patients in the advanced stages of the disease should not be sent far from home. Treatment at Home. — The large majority of patients are unable to avail themselves of the advantages afforded by a stay in a sanatorium or by residence in a salubrious climate. These may be consoled by the fact that not a few cases of phthisis do well at home when the conditions are not too unfavorable. Treatment at home should be made to imitate as closely as circumstances will permit that which is followed in the sanatorium. An earnest attempt should be made to secure the freest possible supply of air and of sunlight. The airiest and sunniest room in the house should be selected for DISEASES OE THE RESPIRATORY SYSTEM. S97 the patient. So long as he has fever absolute rest should be insisted upon. During the day, if the weather be clement, he should rest in a reclining chair in the open air for from six to ten hours, according to the season, and at night sleep with the windows open. There is no danger, even in the presence of fever and sweating, in breathing cold air, providing the body itself is kept warm. As much nourishing food should be supplied as the digestive capacity of the patient will allow. Artificial Aerotherapeutics. — Inhalations of rarefied air by means of the pneumatic cabinet have been found very beneficial by Piatt, Quimby, Knopf, and others. A reduction of the atmospheric pressure about half a pound to the square inch is sufficient. According to Knopf, the seances should be given at first every day, and their duration should be grad- ually increased from two minutes to six or eight minutes. C. Theodore Williams, who has had a large experience in the treatment of phthisis by means of compressed air, con- cludes that beyond lessening slightly the cough and expec- toration, the baths are of no benefit. On the contrary, in several of the cases hemoptysis came on either in the bath or shortly after the treatment. Medicinal Treatment. — The chief indications in the me- dicinal treatment of tuberculosis are to increase the resisting power of the tissue, to reduce the local irritation, and to relieve the distressing symptoms. It is the opinion of most clinicians of large experience that tuberculin (see p. 435) is of definite but limited value. Its administration, however, de- mands extreme care, as in unsuitable cases or in too large doses it is capable of doing irreparable harm. Patients who have little or no fever and whose general nutrition is fairly good are the ones most likely to be benefited by it. On the other hand, it should be avoided when there is rapid emacia- tion, high fever, a persistently frequent pulse, or active nephritis. Recent hemoptysis is also to be regarded as a contraindication. The dosage may be regulated either by following the opsonic- index curve or by closely observing the clinical manifestations. At no time should the quantity injected be enough to cause an immediate subjective or objective reaction. In the last fifty years no remedy has been so universally esteemed in the treatment of phthisis as cod-liver oil. When well tolerated and digested it is undoubtedly of service in im- proving the general nutrition. It is to be regarded, however, as a food rather than as a medicine. If it occasion nausea, impair the appetite, or derange the digestion in any way, it should be withdrawn. The best methods of administering cod-liver oil have been considered on p. 304. 598 APPLIED THERAPEUTICS. Olive oil, cream, and butter may be used as substitutes for cod-liver oil when the latter is not well borne. Arsenic is another remedy which has many warm advocates. To be effective it must be given in small doses for several months. Jacobi speaks highly of arsenic in conjunction with digitalis in tuberculosis of childhood. Alcohol is useful in some cases, but not in all. Each case must be carefully considered by itself. The danger of induc- ing the alcoholic habit must also be borne in mind. Malt liquors and wines are usually the best preparations when digestion is good, but when the digestive power is feeble whisky or brandy, well diluted, is preferable. Alcohol is best given with the food. Various drugs which have tonic properties and tend to improve the general nutrition are of service in phthisis. Of these the most valuable are the hypophosphites y strychnin, and other vegetable bitters. Preparations of iodin seem to be useful, especially in the early stages of the disease. A good method of administering iodin without deranging digestion is that of Flick, which is to rub into the chest twice daily an ointment (10 per cent.) of europhen, a compound containing a large percentage of loosely combined iodin. Creosote (see p. 284). — While the view is no longer ten- able that creosote exerts a specific influence on the tubercle bacilli, the testimony of numerous observers is convincing that the drug is of value in allaying cough and in lessening expectoration. It is especially useful when the sputum is very abundant and purulent. Creosote carbonate and guaiacol carbonate (see p. 286) do not have the disagreeable odor and taste of creosote itself, and appear to be equally efficacious. Counter irritation. — This is a method of treatment less fre- quently employed than its merits justify. Counterirritation by iodin or, better, by small " flying " blisters, has seemed to the author to be of the greatest use, especially in chronic pul- monary tuberculosis. Treatment of Special Symptoms. — Digestive Disturb- ances. — In a large number of phthisical cases the first indica- tion is to correct disordered digestion. No medicines likely to irritate the stomach should be ordered. Only the most bland and readily digestible forms of nourishment should be allowed. The time of eating, as well as the character of the food, should be carefully revised. No special rules can be laid down for treatment. The various measures and drugs which are serviceable in the ordinary forms of indigestion DISEASES OF THE RESPIRATORY SYSTEM. 599 (see p. 555) are applicable here. The most potential measures are fresh air and rest. Acute indigestion brought on by over- eating is often promptly relieved by a mercurial purge fol- lowed by a saline. When anorexia and slow digestion are the chief features, an alkali with a vegetable bitter before meals (see p. 175) may have a very happy effect. Vomiting that is dependent upon extreme irritability of the stomach is often relieved by such sedatives as bismuth sub- nitrate and hydrocyanic acid (see p. 160), taken before meals. Emesis excited by cough sometimes subsides when the patient is kept in bed and put on a liquid diet. Chloroform-water taken a few minutes after the meals is useful. Counterirrita- tion over the diseased area in the lung is very often successful. Vomiting occurring shortly after a meal and preceded with a sense of suffocation, with or without coughing, is best con- trolled by the administration of from 5-10 minims (0.3-0.6 c.c.) of liquor potassae (Habershon). Vomiting caused by ulceration of the epiglottis or larynx will call for local anes- thetics — cocain, iodoform, orthoform, and morphin. Cough. — In many cases of phthisis cough is indispensable, and is best treated by promoting expectoration. For this purpose creasote, guaiacol carbonate, terebene, oil of euca- lyptus, myrtol, and santal oil are reliable remedies. They may often be combined advantageously with strychnin. Ex- pectorants in the form of syrups should be avoided. Morning paroxysms of cough are often made more easy by the admin- istration of a glass of hot water before rising, to which aro- matic spirits of ammonia has been added. Intratracheal injec- tions (see p. 587) are also useful in modifying bronchial secre- tion and promoting expectoration. Hard, dry cough calls for special treatment. When such cough results from habit, as is sometimes the case, it can be suppressed by discipline. Absolute rest is a valuable aid. Inhalations of creasote, chloroform, and volatile oils (see p. 587) are often very effective. Inhalations of formalin have been highly recommended by Murrell, Muthu, Huggard, and others. The strength of the solution should at first not exceed 2 or 3 per cent, of ordinary formalin in alcohol. From 5-10 minims (0.3-0.6 c.c.) of this solution should be used from time to time in an inhaler placed over the mouth only, the entire time of the inhalation being from three to six hours daily. The strength of the solution may be gradually in- creased to 6 per cent., or even to 10 per cent. When the cough is very irritable chloroform may be added to the inhalation. In many cases of chronic phthisis no measure proves so 600 APPLIED THERAPEUTICS. successful in relieving cough as blistering. Periodic fits of cough at night call for warm, demulcent, nourishing liquids, such as milk or beef-tea, with a little brandy, if there be much exhaustion (J. Mitchell Bruce). When the cough is very violent and occasions exhaustion it may be necessaiy to resort to internal sedatives. Of these, those least objectionable are codein, heroin, and spirit of chloro- form. The combination mentioned on p. 161 or one like the following will be found useful : R Codeinae sulphatis, gr. vi-viij (0.4-0.5 gm.) ; Spiritus chloroformi, fcj (4.0 c.c.) ; Glycerini, f|j (30.0 c.c.) ; Succi limonis, f5ss (15.0 c.c.) ; Aquas, q. s. ad fjiij (90.0 c.c). — M. Sig. — A teaspoonful as occasion demands. Hemoptysis. — Absolute rest is essential. An ice-bag may be placed over the suspected seat of the hemorrhage, but it should be removed at once if it aggravate the coughing. Bits of cracked ice may be given to the patient to suck. There is no more useful internal remedy than morphin, which serves to allay excitement and to check cough. It should be given hypodermically in full doses. The application of firm liga- tures to the limbs, in order to lessen the volume of blood re- turning to the lungs, may prove efficacious. When the hemorrhage is protracted a saline purge is some- times useful. It probably acts by lowering the blood-press- ure. The nitrites may prove beneficial in some cases. Among other remedies which seem to be of service may be mentioned oil of erigeron, fluidextract of hamamelis, and gelatin. Ergot cannot be recommended (see p. 378). Inhalations of vaporized solutions of astringent drugs, like alum and ferric sulphate, are useless. The assurance that pulmonary hemorrhage in phthisis is not necessarily a dangerous symptom or even a drawback to recovery has a most salutary effect on the patient. The pros- tration appearing after a first attack of hemoptysis is often, as Flint observed, a moral effect rather than the exhaustion caused by the loss of blood. Night-sweats. — Sponging the body before bedtime with vinegar and water, alcohol and water, or formalin and alcohol often checks excessive sweating. Dusting the surface with a powder of tannoform (1 part) and zinc oxid (3 parts) is also effective. A glass of cold milk with brandy just before retir- ing sometimes affords relief. The most reliable internal reme- dies are atropin, picrotoxin, agaracin, sulphuric acid, and cam- phoric acid (see p. 263). DISEASES OF THE RESPIRATORY SYS TEA! 6oi Pyrexia. — In many cases the pyrexia yields to absolute rest in bed or in a reclining chair, combined with life in the open air. Cold sponging is to be recommended when the tempera- ture is high. In obstinate cases the administration of 2 or 3 grains (0.13-0.2 gm.) of phenacetin about two hours before the temperature is expected to rise may be tried. The high irreg- ular fever resulting from secondary infection by pyogenic cocci is sometimes favorably influenced by creasote or one of its derivatives. Pleurisy. — Mild attacks of pleuritic pain generally yield to sinapisms or the application of iodin. Strapping the affected side also affords relief. Severe pains should be treated by the application of a blister and the subcutaneous adminis- tration of morphin. The treatment of tuberculous pleurisy with effusion is much the same as that of primary pleurisy with effusion. Thoracentesis, however, is inadvisable when the effusion is only moderate and the patient is very feeble. Diarrhea. — Diarrhea the result of indigestion usually yields promptly to restriction of the diet, rest, and the admin- istration of a mild mercurial or saline aperient. When intestinal tuberculosis is present diarrhea becomes a most troublesome complication. Large doses of bismuth sub- nitrate, combined with opium in some form, may afford temporary relief. Combinations of tannigen or of tannalbin with intestinal antiseptics like betanaphtol-bismuth, salol, or thymol, sometimes prove useful. Pills of lead acetate and opium or of copper sulphate and opium occasionally succeed. PLEURISY. The first indications in the treatment of acute pleurisy are to relieve the pain and to check the progress of the inflamma- tion. For the first, the application of a blister or of wet or dry cups, together with the hypodermic injection of morphin, will be found effective. Strapping the affected side from mid- spine to mid-sternum with broad strips of adhesive plaster, as originally suggested by Frederick T. Roberts, is also very useful. Cold applications are not often tolerated. Unfortunately, we have no very potent means of checking the inflammatory process in the pleura. The patient should be kept in bed and restricted to a liquid diet. A mercurial or saline aperient may be prescribed at the onset. Acute sthenic cases, accompanied by decided fever, are often favor- ably influenced by the administration of salicylates, a method of treatment which has been warmly advocated by Aufrecht, Fiedler, Dock, and others. From 1-1^ drams (4.0-6.0 gm.) 602 APPLIED THERAPEUTICS. of sodium or ammonium salicylate should be given in the twenty-four hours, the dose being gradually reduced as the good effects become manifest. In asthenic, protracted cases of pleurisy the salicylates are of no avail. After the acute symptoms have subsided the indications are to accomplish the removal of the fluid, to maintain nutri- tion, and to secure complete expansion of the lung. Removal of Serous Effusion. — Counterirritation by means of iodin or flying blisters appears to be useful in promoting absorption. In vigorous subjects the administration of saline purgatives according to the method suggested by Matthew Hay is sometimes followed by improvement. The object of this treatment is to deplete the blood of its serum, and thereby favor the abstraction of fluid from the lymph- spaces. The quantity of fluid consumed by the patient is restricted to a minimum, and every morning or every other morning from J—i oz. (15.O-30.0 gm.) of magnesium sulphate is given in con- centrated solution an hour before breakfast. This produces copious watery discharges. Diuretics (digitalis, caffein, potassium acetate) are sometimes of service, but their action is much less certain than that of the purgatives. Potassium iodid has also been extensively employed as an absorbent, but is of doubtful efficacy. Dia- phoretics (hot-air baths, pilocarpin) cannot be recommended. While the effusion eventually disappears in a large propor- tion of cases under medicinal treatment alone, much saving of time is often effected by an early resort to paracentesis. In the author's opinion this operation should not be delayed ordinarily longer than ten days or two weeks when the effu- sion is considerable and shows no signs of receding. The presence of fever is not a contraindication ; indeed, the tem- perature often falls upon the removal of the fluid. Irrespective of the period of the disease paracentesis is demanded: (1) When there is sufficient fluid to excite severe dyspnea, cyanosis, persistent cough, or failing pulse ; (2) When the fluid reaches the level of the second rib, and there is marked dislocation of the neighboring organs. The sus- pected presence of pus is always to be regarded as sufficient ground for operative interference. Paracentesis. — The patient should be brought to the edge of the bed, placed in a semirecumbent position with the thorax inclined slightly toward the healthy side, and supported by an assistant. The most favorable site of the puncture is usu- ally the sixth or seventh intercostal space between the mid- axillary line and the angle of the scapula. The operation should DISEASES OF THE RESPIRATORY SYSTEM. 603 be done under strict antiseptic precautions. The needle should be inserted with a quick thrust along the upper mar- gin of the rib, the depth of the puncture being gauged by the forefinger. Local anesthesia is not necessary, but if desired it may be secured by means of a spray of ethyl chlorid or the application of a block of ice which has been dipped in salt. Having introduced the canula, the operator should satisfy himself that it is freely movable, should hold it in position throughout the operation, and as the evacuation proceeds should slowly raise the exposed end so as to keep the inner opening below the level of the fluid in the pleural sac. The aspiration should be effected slowly, and at intervals it should be stopped by compressing the conducting tube. Too rapid evacuation may excite engorgement of the lung and edema. The amount of fluid which should be removed depends somewhat upon the size of the effusion and the ease with which it can be evacuated. Even with large effusions it is rarely necessary to withdraw more than a quart (1.0 L.). The removal of small quantities is in many cases followed by the rapid absorption of the remainder. Under no circum- stances should extreme efforts be made to obtain the largest possible amount of fluid. The operation should be termi- nated at once if incessant cough, severe pain, dyspnea, palpi- tation, tendency to syncope, or other untoward symptoms appear. When the requisite amount of fluid has been evacuated, the needle should be withdrawn quickly from the chest, and the puncture closed with adhesive plaster. If the exudate reaccumulate, aspiration maybe repeated after the lapse of a week or ten days. Free incision of the thoracic wall with thorough drainage has given excellent results in cases in which the fluid has reaccumulated after repeated tappings. Occasionally attempts at aspiration are unsuccessful. The cause of failure may be plugging of the canula, great thicken- ing of the pleura, or encapsulation of the effusion. Under these circumstances it may be necessary to make repeated trials before a flow can be established. The aspiration of pleural exudates is rarely attended by accidents of any kind. Sudden death, the result of cerebral anemia, has been reported. Such an accident is not likely to occur if the evacuation be effected slowly and arrested immediately on the first appearance of any untoward symptom. Another grave and even fatal complica- tion of thoracocentesis, but also extremely rare, is a peculiar form of pulmonary edema, which is manifested by cough, in- 604 APPLIED THERAPEUTICS. tense dyspnea, and profuse albuminous expectoration. Accord- ing to Riesman, who has collected 32 cases from the literature, the principal cause of this condition seems to be either too rapid or too great a withdrawal of fluid. To Maintain Nutrition and Secure Complete Expansion of the Lung. — Apart from the restriction of liquids the diet during the stage of resorption should be abundant and nutritious. Tonics like iron, cod-liver oil, and arsenic are very useful. After the exudate has entirely disappeared the patient should be urged to take such exercises as will bring into play the muscles of respiration. Open-air living and change of climate are also to be recommended, especially when there is a decided phthisical tendency. Empyema. — The treatment of empyema is surgical. The indications are to evacuate the pus and to secure thorough drainage. Simple puncture cannot be recommended, although in children repeated tappings sometimes result in cure. In the large majority of cases treatment by free incision and the in- troduction of a large-sized drainage-tube proves successful. Irrigation of the pleural sac should not be practised unless the exudate is putrid. Excision of one or more ribs (Estlander's operation) or ex- cision of the ribs and intercostal tissues (Schede's operation) may be necessary when the empyema is of long standing or occurs in elderly persons with rigid thoracic walls. Fowler recommends, in chronic empyema, decortication of the lung in preference to either Estlander's or Schede's operation, claiming that it combines the advantages of restoration of the function of the lung, so far as this is possible, with closure of the em- pyemic cavity. DISEASES OF THE CIRCULATORY SYSTEM, PERICARDITIS. One of the chief indications in the treatment of acute peri- carditis is to allay the excited action of the heart. Absolute rest of body and mind is imperative. During the first week, at least, milk is the most suitable diet. Among local applications none is so generally useful in subduing palpitation as the ice- bag. Local blood-letting is of great service when the disease occurs in a fairly robust subject and is attended with much pain. Blistering also serves to allay pain, but it does not seem to exert any influence on the progress of the disease. Internally, mor- phin is often required to control restlessness and to relieve pain. DISEASES OF THE CIRCULATORY SYSTEM. 605 Drugs which stimulate the cardiac inhibitory mechanism are of doubtful utility, although digitalis may be given when accele- ration of the pulse is accompanied by decided lowering of the arterial tension. If heart failure occur such stimulants as alco- hol, strychnin, caffein, and camphor must be employed. Pericardial Bffiision.— When the exudate is serofibrin- ous, is moderate in amount, and causes no marked subjective symptoms, an expectant plan of treatment may be pursued with the assurance that resolution will follow in due time. When, however, the effusion is extensive and causes some embar- rassment of the heart's action, efforts should be made which will tend to hasten absorption. Of the value of vesicants in this stage there can be no reasonable doubt. If the patient's strength will permit, saline purges may be administered in the manner suggested by Matthew Hay (see p. 602). Diuretics, such as digitalis and caffein, may be tried. Potassium iodid is recommended, but it is of doubtful efficacy. Diaphoretics, particularly pilocarpin, should not be used. In cases in which the symptoms become urgent, or in which absorption does not occur after a thorough trial of the remedies just mentioned, operative interference becomes necessaiy. In the case of serofibrinous effusions, aspiration is the operation of choice, although it yields far less favorable results than it does in pleurisy. The most suitable site for paracentesis is ordinarily in the left fifth intercostal space, about an inch or an inch and a half from the edge of the sternum. According to Osier, in large effusions the pericardium can also be readily reached without danger by thrusting the needle upward and backward close to the costal margin in the left costoxiphoid angle. In a number of instances, owing to an error in diag- nosis, the needle has pierced the right ventricle. Fortunately, this accident has rarely produced serious consequences, although Broadbent recalls two cases in which it resulted fatally through hemorrhage. In pericarditis with purulent effusion the indications are to incise the sac and to afford the freest possible outlet for the pus. Three methods of approaching the pericardium have been practised : By incision through an intercostal space, by trephining the sternum, and by epigastric incision. C. B. Porter excises the cartilage of the fifth rib, ligates the internal mammary vessels, and, after introducing a needle to corroborate the diagnosis, opens the pericardium obliquely downward and outward close to the border of the sternum. He then stitches the edges of the pericardium to the skin, irrigates, and intro- duces two rubber drainage-tubes. The advantages claimed for 606 APPLIED THERAPEUTICS. this operation are that it avoids opening the pleura and secures permanent free drainage. The mortality of incision for pyopericardium in 47 cases was about 60 per cent. ACUTE ENDOCARDITIS. The treatment of acute endocarditis is mainly that of the causal condition. Too much emphasis cannot be given to the need of frequent examination of the patient's heart during the course of all acute infections, in particular of acute articular rheumatism, even of the mildest type (see page 536). The special indication is to secure complete resolution of the in- flammatory process or, if this be impossible, to favor the estab- lishment of the highest attainable degree of compensation. Prolonged ajid complete rest is the most important factor of the treatment. The patient should be confined to bed not only during the attack, but for several weeks after it has subsided, in order to allow sufficient time for the damage to be repaired or for compensatory hypertrophy to be thoroughly established. In the period of convalescence extraordinary efforts are often required to prevent those indiscretions which are so liable to cause a fresh invasion of the valves or to strain the already overburdened heart. Mental and emotional excitement must also be avoided as much as possible, since they both tend to in- crease the force and frequency of the pulse. The diet should be liquid and unstimulating. For a week or two milk is the most appropriate food ; later milk-toast, eggs, thin gruels, light broths, and steamed rice are admissible. Externally, an ice-bag is often useful in allaying excitement of the heart. Internally, at the outset and from time to time throughout the illness, mild mercurial or saline aperients may be used for their depurative effect. Digitalis may be of service when the pulse is weak and irregular, but in the large majority of cases this remedy is not indicated. Heart-failure is to be combated by such stimulants as alcohol, ammonia, strych- nin, and caffein. Morphin is sometimes required to re- lieve severe pain, allay nervous perturbation, and to promote sleep. To these measures is to be added, of course, the treat- ment appropriate to the disease upon which the endocarditis has supervened. Treatment by continuous vesication and the prolonged ad- ministration of potassium iodid has seemed to most practitioners of large experience to be of doubtful utility, although it has been ardently advocated by Pepper in this country, Andre DISEASES OF THE CIRCULATORY SYSTEM. 6oj Petit in France, Rosenstein in Germany, and Walsh and Caton in England. Caton, 1 especially, has presented some very strong evidence in favor of these measures as auxiliaries to prolonged rest in bed. He reports that of 39 cases of acute endocarditis treated by this method, 29 left the hospital with normal heart-sounds and 10 with a bruit, and that of 13 treated expectantly 12 left the hospital with a bruit. Many of the cases were kept under observation subsequently for a long period, and every care was taken to make the observations accurate. CHRONIC ENDOCARDITIS, Period of Compensation. — Treatment during this stage must be chiefly hygienic. No specific medication should be advised unless there be a definite indication for its employ- ment. Our aim should be to maintain the heart-muscle in the highest possible state of efficiency by carefully regulating the habits of life, preventing excessive cardiac strains, and protect- ing the patient against intercurrent diseases likely to induce a fresh attack of endocarditis or to weaken the myocardium. In many cases it is well to inform the patient of his valvular de- fect, without unnecessarily alarming him, in order to secure his thorough cooperation. Violent exertion, mental fatigue, intense emotional excite- ment, intemperance in eating and drinking, and venereal ex- cesses are to be rigidly avoided. As a protection against rheumatism and bronchitis the patient should habitually wear flannel next to the skin, and should avoid unnecessary exposure to cold and wet. In the absence of any digestive disturbances, a varied diet of plain wholesome food is suitable. The meals should be taken at regular intervals, and followed by a rest of from twenty to thirty minutes. In elderly persons and those inclined to obesity a spare diet is generally advisable. Tea, coffee, alcohol, and tobacco should be used very moderately, if at all. The bowels should be made to move daily, a mild aperi- ent being given if necessary, and the skin should be kept active by frequent tepid baths. Exercise judiciously employed is often of the greatest bene- fit in prolonging the period of compensation. It is very im- portant, however, that the muscular efforts should be carefully graduated and adapted to the working capacity of the heart. The character and duration of the exercises must be deter- mined experimentally in each individual case, the subjective 1 Liverpool Med.-Chirurg. Jour. y July, 1895. 608 APPLIED THERAPEUTICS. symptoms of the patient being taken as a guide. All physical effort should stop short of producing palpitation, pronounced dyspnea, or fatigue. In persons who have just recovered from acute endocarditis the exercise should be confined to massage and passive movements, as originally practised in Sweden by ling. In cases in which compensation has been completely established, but is maintained with some difficulty, exercises consisting of movements made against slight resistance, as car- ried out by Schott, of Nauheim, may be recommended (see p. 488). Vigorous patients may derive some benefit from the method of treatment urged by Oertel, which consists in grad- uated climbing exercises taken in the open air at a moderate elevation. It is not often necessary to recommend a change of occupa- tion unless the patient be engaged in a pursuit requiring a great expenditure of energy. Children with chronic valvular disease in whom compensation has been perfectly established need not be debarred from outdoor games which involve only moderate exertion. Thus, baseball, cricket, golf, and lawn ten- nis are usually permissible. On the other hand, amusements which require sudden or prolonged effort, such as racing, swimming, football, and wrestling, had better be avoided. General tonics, like iron, arsenic, and cod-liver oil, may be used with advantage when there is distinct anemia or impaired nutrition. Period of Broken Compensation. — The most important element in the treatment of this stage of chronic valvular dis- ease is absolute rest. Under the influence of this alone it fre- quently happens that the urinary secretion increases, the venous engorgement and edema subside, and compensation is grad- ually restored. While the recumbent posture is generally preferable, it is sometimes advisable to consult the inclinations of the patient and to allow him to sit up in an arm-chair, prop- ped up by pillows and carefully protected from the cold. When the digestive functions are well maintained a carefully selected mixed diet may be allowed. Eggs, oysters, sweet- bread, scraped beef, lean lamb or mutton chops, white meat of chicken, boiled fish, baked potato, steamed rice, well-made gruels, toast, junket, wine jelly, and plain custard are suitable forms of nourishment. Coffee and tea should be used very sparingly, if at all. Alcohol in the form of brandy or whisky is often of great value. Full evening meals should be avoided, the chief meal being taken in the middle of the day. When there is much flatulence benefit will be derived from a consid- erable limitation of the carbohydrates. When the cavities of DISEASES OF THE CIRCULATORY SYSTEM. 609 the heart are overfilled and there is decided edema, it is often very advantageous to reduce the ingestion of liquids to a min- imum, although in this as in other matters pertaining to the diet we should be guided largely by observation. In severe cases it is often a good plan to restrict the diet, at least for a time, to milk, giving from 3-4 ounces (90.0-120.O c.c.) every two hours. Should these measures prove inadequate to restore the equi- librium of the circulation, recourse must be had to special cardiac stimulants. The best and most reliable of these is digitalis. The chief indications for using this drug are fre- quency, weakness, and irregularity of the pulse, edema of the limbs, and deficient urination. When these symptoms are present digitalis may be employed whatever the nature or seat of the lesion. From 10-20 minims (0.6-1.2 c.c.) of a good tincture may be given two or three times a day (see p. 50). The first evidences of its beneficial effects are an increase in the secretion of urine and an improvement in the rhythm and tone of the pulse. Failure to secure immediate results should not cause disappointment, as decided benefit may not be observed until thirty-six or forty-eight hours after the institution of treatment. Digitalis is of most service in mitral regurgitation. In mitral stenosis its action is less certain, but nevertheless /it may be prescribed with considerable confidence when there is failure of the right ventricle with dropsy and ischuria. In disease of the aortic area it must be used with some circum- spection. When the chief symptoms are slight dyspnea, pre- cordial distress, vertigo, and tendency to syncope, it generally fails or acts unfavorably, but when venous congestion, cyanosis, and edema appear as the result of back pressure in the heart and lungs, it frequently does good. In many cases certain adjuvants must be employed before digitalis can be made effec- tive. When the right side of the heart is embarrassed and the tissues are engorged, purgatives are essential. Without their aid digitalis may afford little or no relief. Mercurial aperients are specially serviceable in lowering the venous tension. An appropriate dose of calomel or blue mass may be given in the evening, and followed in the morning by a saline. Subsequently, in some cases it is advantageous to combine the mercury with the digitalis, as in the well-known Niemeyer's pill (see p. 52). When the right ventricle is greatly overdistended and cyanosis is marked, venesection to the extent of a pint (0.5 L.) or more often affords prompt relief. Indeed, in this condition digitalis usually proves wholly unavailing when used before the veins have been thus depleted. 39 6lO APPLIED THERAPEUTICS. Strychnin is one of the most valuable accessories to digitalis we possess. It is particularly useful in temporary breakdowns of compensation in which there are pulmonary complications. When the myocardium is much involved it may often be given for many months or even years with benefit. Caffein is another remedy that may in many cases be combined advan- tageously with digitalis. It is especially serviceable when dropsy is a prominent symptom. Its chief drawback is its tendency to induce restlessness and insomnia. Excellent re- sults are frequently obtained by giving nitroglycerin or one of the other nitrites in conjunction with digitalis when there is high arterial tension or considerable precordial pain. In myo- cardial degeneration it serves a useful purpose as corrigent of digitalis in counteracting the constricting effect of the latter on the blood-vessels. In cardiorenal disease with persistent or paroxysmal dyspnea it is also useful. Iron and arsenic are valuable adjuncts to digitalis when there is anemia. The latter especially has been highly extolled by Balfour, Bramwell, and others in cases of aortic regurgitation and of fatty or fibroid heart with anginoid symptoms. As a circulatory stimulant strophanthus is distinctly less reliable than digitalis, although it is somewhat more prompt in its action than the latter. It may be used in the cases in which digitalis is not well borne by the stomach or fails to give the desired result. It is also very valuable as an alternate when the administration of digitalis must be interrupted. Convallaria and adonidin may be mentioned as drugs which occasionally succeed after digitalis and strophanthus have failed. Treatment of Special Symptoms.— Dropsy. — In many cases absolute rest in bed, restriction of liquid ingesta, and the administration of digitalis suffice to restore compensation and, consequently, to remove the dropsy. Gentle massage of the affected parts by promoting the lymphatic and venous return is often beneficial. The application of smooth firm bandages to the swollen limbs sometimes affords much relief. Purgatives are very valuable, although some caution must be exercised in their employment lest they prove exhausting to the patient Salines in concentrated solution, compound jalap powder (30- 40 gr. — 2.0-2.6 gm.), and elaterin (^ gr.— -0.003 gm.) should be tried in the order named. Diuretics are also useful. Digi- talis, on account of its favorable influence on the circulation, is generally the most suitable. The best adjuvants are caffein, the vegetable salts of potassium, theobromin, theocin, and squill. The following mixture of potassium acetate and the infusion of digitalis often acts happily : DISEASES OF THE CIRCULATORY SYSTEM. 6l I R Potassii acetatis, ^ij (8.0 gm.) ; Infusi digitalis, f^iij (90.0 ex.). — M. Sig. — A tablespoonful three or four times a day. Another time-honored remedy is the pill containing 1 gr. (0.065 gm.) each of blue mass, digitalis, and squill, which may- be given every three or four hours until diuresis, free purga- tion, or both, are obtained. It is generally inadvisable to em- ploy diaphoretics like hot-air or vapor baths and pilocarpin, since they may induce profound exhaustion. When all other measures have failed recourse may be had to paracentesis of the internal cavities and to scarification of the most swollen and most dependent parts. The insertion of fine silver canulae with thin rubber tubes attached (Southey's tubes) often serves to drain off large amounts of fluid. Not infrequently curved incisions behind the ankles prove less annoying to the patient than either scarification or the insertion of tubes. Strict antiseptic precautions must always be taken in carrying out any of these operative measures, otherwise septic inflammation is very liable to ensue. Dyspnea. — Chief reliance must be placed upon those meas- ures which have already been recommended as useful in restoring the balance of the circulation. Free wet cupping or venesection is of the greatest service in relieving dyspnea the result of pulmonary engorgement. Counterirritation by means of sinapisms is much less efficacious. Oxygen inhalations are sometimes useful. Aspiration will be required in cases of hydrothorax. The nitrites are very valuable in paroxysmal dyspnea or cardiac asthma, especially when high arterial ten- sion coexists. Dyspnea excited by flatulent distention of the stomach is usually promptly relieved by carminatives — spirit of chloroform, Hoffmann's anodyne, or spirit of mint. In many cases no remedy is so reliable as morphin. In the later stages of heart-disease it is indispensable. It should be given hypodermically in doses of from \- \ gr. (0.008 gm.-o.oi gm.) combined with atropin (-5-^ gr. — 0.0003 gm.). Morphin should not be used, however, when there is edema of the lungs. Palpitation. — Cold to the precordia is a valuable sedative. When there is marked hypertrophy of the heart with a bound- ing pulse aconite (1-3 min. — 0.06-0.25 ex., every three hours) will be found of service. Palpitation of purely nervous origin is often benefited by the administration of bromids. When flatulence is an exciting factor carminatives usually afford relief. When the attacks are obstinate and interfere with sleep mor- phin is to be recommended. 6l2 APPLIED THERAPEUTICS. Pain. — Temporary precordial oppression is often relieved by warm or cold applications and the administration of Hoff- mann's anodyne or brandy with aromatic spirits of ammonia. Severe continuous pain may yield to leeching or blistering. In paroxysmal pain of an anginoid character, nitroglycerin will generally be found a speedy remedy. In the anginoid pains, which frequently occur in aortic disease, potassium iodid, 10 gr. (0.65 gm.), thrice daily, is also of service. In some cases morphin is the only remedy that will afford com- plete relief. Cough and Hemoptysis. — These symptoms rarely call for special treatment. Cough occurring after failure of compen- sation is referable to pulmonary congestion and bronchial catarrh, and can be controlled successfully only by remedies employed directly against the cardiac failure. Hemoptysis is not often excessive and is generally salutary. When it is attended with dyspnea and precordial distress it calls for vene- section or leeching and aperients. Vomiting. — Vomiting may be due to faulty diet or to digi- talis or other medicines. In many cases, however, it is of serious import, being the result of stasis in the vessels of the stomach. In severe cases it is advisable to rest the stomach. No food should be given by the mouth except a little iced champagne with Apollinaris, brandy with soda-water, or milk with lime-water, whey, or liquid peptonoids. Calomel in frac- tional doses is useful in depleting the engorged portal system. Anti-emetics (see p. 168) are seldom efficacious. Sinapisms over the epigastric region sometimes afford relief. Cardiac stimulation is best maintained by administering digitalin and strychnin hypodermically. Insomnia. — In mild cases Hoffmann's anodyne (f3ss-f3j — 2.0-4.0 c.c.) or a mixture of aromatic spirits of ammonia with whisky may suffice. Bromids are sometimes serviceable. Of the more active soporifics, veronal, chloralamid, and trional are worthy of confidence. Bramwell has found paraldehyd very useful in cases in which there is associated bronchitis. Chloral should usually be avoided on account of the depression it causes. On the whole, no somnifacient is so generally effi- cacious as morphin, especially when sleeplessness is attended with pain, precordial anxiety, and restlessness. One-sixth of a grain (0.0 1 gm.) with y^ gr. (0.0004 gm.) of atropin, hypo- dermically, is often sufficient. Sudden heart-failure must be met by the administration of diffusible stimulants, such as ammonia, alcohol, and ether. The application of heat to the precordia is also useful. DISEASES OF THE CIRCULATORY SYSTEM. 613 CHRONIC MYOCARDIAL DISEASE. Attention to the minutiae of life is of the utmost importance. No one " rule of thumb " can be laid down for every patient. Each individual must be carefully studied as regards the state of the arteries, the character of the pulse, the digestive powers, the existence or absence of any constitutional vice, and the actual condition of the heart, so far as this can be ascertained. Exercise and diet are the points to which attention should first be directed. It is not always necessary that the patient should give up his occupation, but it is imperative that the sum of his exertions should be carefully adapted to the strength of his heart. It must be borne in mind that the fret and worry incident to many pursuits may exert as baneful an effect upon the circulation as undue physical effort. In some cases when the pathologic changes are not far advanced, and particularly if they consist in fatty overgrowth rather than degeneration of the muscular fiber, graduated exercises coupled with warm saline baths, as in the well-known Nauheim treatment (see p. 488), have a very salutary influence. When, however, palpita- tion, irregularity, pain, or pronounced dyspnea follow exertion, absolute rest is essential. In such cases massage is very use- ful, since it gives the patient the advantages of exercise without throwing any strain upon his heart. As with exercise so with diet, no hard and fast rules can be laid down. The diet must be carefully adapted to the digestive powers and to the needs of the system. Rich foods, bulky foods, and foods which induce flatulence should be withheld. Eating between meals should be prohibited. The question of the quantity of food is also a matter of great importance. Degenerative changes in the heart usually occur at a period of life when the amount of food can often be considerably re- stricted without impairing the general nutrition. Chambers, Balfour, and others have dwelt upon the advisability of restrict- ing the amount of liquids taken with meals in the case of fail- ure of the myocardium. By this means the tension in the venous system may be lowered and the arterial resistance reduced. If thirst be complained of it is better for the patient to sip a moderate amount of hot water between meals than drink copiously during meals. Some judgment, however, must be exercised in the matter of drink, as the amount of liquid required to secure a free evacuation of waste products from the system must vary in different cases. Tea and coffee should be used very sparingly, if at all. Alcohol also is better dispensed with. Smoking should be 614 APPLIED THERAPEUTICS. forbidden. Excesses of all kinds must be rigidly avoided. Constipation must be relieved. When it does not yield to judicious exercise and the regulation of diet, an aloetic aper- ient (see p. 565) should be given at night or a mild saline in the morning. This may be supplemented from time to time by a pill of blue mass. In many cases no single remedy affords such prompt relief from the general distress as a mer- curial laxative. If there be a gouty diathesis it should be met by appropriate treatment, and if syphilis be a factor antiluetic remedies should be employed. As to special treatment, strychnin appears to be the most generally useful drug. In doses of from ^ to^- gr. (0.001- 0.002 gm.), two or three times a day, it rarely fails to be of some benefit. When there is anemia iron is a useful adjuvant. Arsenic in small doses, over long periods, is often of the greatest service. Balfour considers that " arsenic is indispen- sable in all forms of weak heart accompanied by pain." He recommends it in combination with iron and strychnin, twice a day, after food. Nitrites usually prove very beneficial in cases in which high arterial tension, anginoid pains, or cardiac asthma are prominent symptoms. Huchard and others have spoken in the highest terms of the prolonged use of the iodids, especially when angina pectoris is a feature of the cardiac failure. They are most effective, as Osier has stated, in robust middle-aged men in whom the angina is the sole symptom. They are contraindicated when the myocardial disease is associated with advanced arterial degeneration and chronic nephritis. Digitalis is of service in some cases. The less advanced the degeneration the more likely is it to be useful. Large doses are generally badly borne, but persistently employed in doses of 2 or 3 minims (0.1-0.2 c.c.) of the tincture, twice a day, it often exerts a most favorable tonic effect. Even with these small doses of digitalis it may be necessary to guard against the constricting influence of the drug on the arterioles by com- bining with it a vasodilator, such as nitroglycerin, erythrol tetranitrate, or sodium nitrite. Not infrequently tincture of strophanthus, in doses of 3 or 4 minims (0.2-0.25 c.c), twice daily, proves more efficacious than digitalis. When neither digitalis nor strophanthus is well received, cafTein, convallaria, or adonidin may be tried. For the treatment of the more serious symptoms of cardiac failure the reader is referred to the article on Chronic Endo- carditis (see p. 607). DISEASES OF THE CIRCULATORY SYSTEM. 615 ANGINA PECTORIS. The general treatment of true angina pectoris is for the most part that of myocardial degeneration. The patient should lead a quiet, easy life, should avoid, as far as possible, all mental and physical excitement, and should abstain, as a rule, from tobacco and alcohol. Small meals of readily digested food are to be recommended. The evening meal especially should be light. Muscular exertion or mental excitement after meals is particu- larly injurious. The bowels should be kept regularly open, mild aperients being used for the purpose if necessary. Un- less the heart is very weak and sensitive gentle exercise in the fresh air is to be recommended. Cold, however, is to be avoided. After a very severe attack it is generally necessary to enjoin absolute rest in bed for several days. Any constitu- tional disease that may be present, such as gout or syphilis, must receive appropriate treatment. In the anemic and debil- itated, tonics, especially iron and strychnin, are very useful. The most valuable special remedies in the order of their effi- cacy are the nitrites, the iodids (see p. 614), and arsenic. The Attack. — When the attacks are brought on by indi- gestion they can frequently be staved off by the timely use of a brisk mercurial or saline purge. Marked flatulency should be met by the prompt administration of a stimulant carmina- tive like spirit of mint, Hoffmann's anodyne, or spirit of cam- phor. For the instant relief of the pain no drug is so useful as amyl nitrite. In the majority of cases a mere whiff of this speedily arrests the paroxysm. The patient should carry the remedy on his person in a small vial or, better, in the form of glass pearls containing from 3-5 min. (0.2-0.3 c.c), which can be broken in a handkerchief and inhaled as soon as he perceives the pain. When the attacks are severe and pro- longed, morphin (J-J gr. — 0.016-0.032 gm.) should be given hypodermically. In some cases, as Yeo has pointed out, there is a remarkable tolerance of this drug. Atropin is a valuable adjunct to morphin. When amyl nitrite and morphin fail, recourse should be had to chloroform inhalations (see p. 127). The application of a mustard plaster to the precordial region is often useful. In those cases in which the attacks occur in very rapid succession flying blisters or light touches of the actual cautery sometimes bring relief. The cardiac depression following grave seizures should be combated by such drugs as strychnin, ammonia, ether, and camphor. 6l6 APPLIED THERAPEUTICS. DISEASES OF THE KIDNEYS. ACUTE NEPHRITIS. Absolute rest in bed for a period varying from four to six weeks is imperative.* Even after the patient feels perfectly well he should not be permitted to leave his bed until the urine has been absolutely free from albumin for at least a week. The patient should be well covered, woolen being worn next to the skin, and great care should be taken to guard against draughts. The best diet for acute Bright's disease is milk. While it is desirable to add to the milk one-fourth or one-third part of lime-water, barley-water, carbonated water or Vichy, it is not advisable for the patient to drink excessive quantities of water. Beef-tea and broths should be interdicted. When the kidneys begin to secrete more actively, thin gruels, rice, and milk-toast may be given. During convalescence, bread and butter, baked potatoes, green vegetables, and fruits are permissible. The return to nitrogenous food should be most gradual, the effect on the urine of each addition to the diet being carefully watched. In the absence of any direct remedies the indications are to divert the blood from the inflamed kidneys, to lessen their work as much as possible by increasing the action of the bowels and skin, and to meet the symptoms as they arise. At the onset, if there be pain or suppression of urine, dry cupping, or, in severe cases, wet cupping, over the region of the kidneys is of value. Following the cupping warm poul- tices may be applied to the loins with advantage. Cantharides, turpentine, or similar drugs are not to be used. The bowels should be kept freely opened by means of daily purges, the best in this condition being salines in concentrated solution and compound jalap powder. For children magnesia will be found sufficient. Very vigorous purgation is not called for unless there be dropsy or uremia. Free sweating is very useful in promoting elimination by the skin. It may be effected by means of hot-water baths, hot packs, vapor baths, or hot-air baths (see p. 494). In chil- dren hot baths and hot packs are eminently satisfactory, espe- cially if spirit of nitrous ether or solution of ammonium acetate be administered at the same time. If the baths afford but little relief their action may be supplemented by the hypoder- mic administration of pilocarpin in doses of from ^ 6 - ■ ^ gr. (0.004-0.0065 gm.). DISEASES OF THE KIDNEYS. 617 There is much difference of opinion as to the use of diuret- ics. Some observers believe that all diuretics are irritating to the kidneys and therefore should be withheld at least during the stage of engorgement. Most authorities admit, however, that mild alkaline diuretics, like the vegetable salts of potas- sium, often serve a useful purpose in removing from the urinif- erous tubules proliferated epithelium, albuminous plugs, and effete matter. From 20-30 gr. (1.3-2.0 gm.) of the citrate or acetate of potassium may be given three or four times a day, well diluted. Later in the disease, when the pulse tension falls, experience has proved that digitalis is often of great value. From 2-4 fl. dr. (8.0-15.0 c.c.) of the infusion should be given every three or four hours. It may be combined advantageously with an alkaline diuretic as in the following formula : R Potassii acetatis, ^ij (8.0 gm.); Infusi digitalis, fjjiij (90.0 c.c). M. Sig. — A tablespoonful, well diluted, every four hours. Symptomatic Treatment. — The symptoms of acute nephritis which may demand special attention are excessive dropsy, uremia, nausea and vomiting, and anemia. Excessive Dropsy. — When the dropsy is extreme and does not yield to the purgative, diaphoretic, and diuretic remedies which have already been indicated, recourse must be had to puncture of the swollen parts, to free incision on the inner or outer side of each ankle, or to the insertion beneath the skin of South ey's tubes (see p. 611). Large accumulations in the serous sacs should be removed by paracentesis. Uremia. — This complication calls for very prompt and ener- getic treatment. The chief indication is to favor the elimina- tion of effete matter through the only available emunctories — the bowels and the skin. Two drops (0.065 c.c.) of croton oil, diluted with olive oil or glycerin, or \ gr. (0.0 1 gm.) of elate- rium should be given at once. Sweating should be promoted by hot-air or vapor baths and the hypodermic administration of pilocarpin (-j— J- gr. — 0.015-0.02 gm.). If coma or convul- sions appear, and the patient is not too feeble, venesection may be practised, the removal of from 15 to 20 ounces (450.0- 600.0 c.c.) of blood sometimes exerting a very happy effect. In children a few ounces of blood may be abstracted from the loins by means of wet cups. Hypodermoclysis is another potent remedy (see p. 496). It may be resorted to whether blood-letting is deemed necessary or not, although it is more 6l8 APPLIED THERAPEUTICS. efficacious when practised after blood has been withdrawn. Enteroclysis (see p. 498) is also useful, though less effective than the subcutaneous injection of salt solution. Convulsions may be controlled by chloroform inhalation or the administration of chloral. If the patient be unable to swallow, from 20-30 gr. (1.3-2.0 gm.) of chloral may be injected into the rectum. If these measures fail, morphin may be used cautiously (see p. 97). Nausea and Vomiting. — When these symptoms persist food should be withheld. Pieces of ice may be given to suck. A mixture containing bismuth subnitrate and diluted hydrocyanic acid (see p. 161) often affords relief. Carbolic acid, wine of ipecac, or tincture of nux vomica, in one-drop doses, may be tried. Anemia. — After the acute symptoms have subsided iron may be employed to combat the anemia. For adults Basham's mixture is a suitable preparation. Of this from 2-4 fl. dr. (8.0-15.0 c.c.) may be given thrice daily. For children the following mixture will be found more agreeable : R Tincturae ferri chloridi; Acidi phosphorici diluti, da fgiss (6.0 c.c.) ; Glycerini, fzvj (22.5 c.c.); Syrupi acidi citrici, q. s. ad f^iij (90.0 c.c). M. Sig. — Teaspoonful in water three times a day. Convalescence. — It is advisable to keep the patient under observation for many weeks after all symptoms of the disease have disappeared. He should be warmly clad and carefully guarded from exposure to wet and cold. While the diet should be liberal it should be such as will not overtax the kidneys. Overexertion must be rigidly avoided. The skin and bowels should be kept active, the former by frequent tepid baths and the latter by saline aperients if necessary. A change of air to a warm, equable climate will be found to be very beneficial. CHRONIC NEPHRITIS. The indications for treatment in chronic nephritis are to lessen the work of the kidneys by reducing the production of nitrogenous waste and increasing the activity of the other excretory organs, to maintain the general nutrition, and to meet the symptoms as they arise. The patient must be guarded against vicissitudes of weather by wearing flannel next to the skin in all seasons, both night and day. If he can afford it he should be urged to spend the winter months in a warm, equable climate. DISEASES OE THE KIDNEYS. 619 In the absence of any obtrusive symptoms, moderate exer- cise short of fatigue should be encouraged, but all violent exertion should be prohibited. Mental strain and worry are also injurious, and should be avoided as far as possible. When the symptoms are well developed rest becomes an important factor in the treatment, and much time should be passed in bed. The use of tobacco and alcohol should be discontinued. Warm baths with friction are necessary to promote free action of the skin, but great care must be exercised after their use to avoid chilling. In the early stages of chronic interstitial neph- ritis an occasional Turkish bath is often very advantageous. The hot-air bath, vapor bath, or hot pack may be used at home once or twice a week, or oftener if there is much edema, or if uremia threaten. Cold bathing should be interdicted. The bowels should be kept active by an occasional saline aperient. A great deal depends upon diet. No hard-and-fast rules, how- ever, can be laid down, each case being a study in itself. When the symptoms are quiescent, a simple nourishing diet compris- ing a moderate quantity only of nitrogenous matter, may be allowed, its effect on the urine being carefully watched. Green vegetables, potatoes, farinaceous food, and ripe fruits usually agree best, but a certain amount of animal food in the form of eggs, oysters, fish, and mutton, or other tender meats, is often well borne. Indeed, considerable caution must be exercised lest in our zeal to relieve the kidneys we reduce the strength of the patient by adhering too strictly to a non-nitrogenous diet. The common dogma that red meats are more harmful than white meats in chronic Bright's disease receives no support from the observations of von Noorden, Offer and Rosenquist, or KaufT- mann and Mohr, who conclude that the various forms of meats are suitable in such cases purely in proportion to their digesti- bility. Water-drinking between meals is generally beneficial, and a mild alkaline mineral water, such as Vichy or Vals, may be taken to the extent of a pint (0.5 L.) or more a day. In many cases of chronic parenchymatous nephritis, especially when there is decided edema or a tendency to uremia, an absolute milk diet is most suitable. The patient should take at stated intervals such quantities of milk as will aggregate in the twenty-four hours from 2-4 quarts (2.0-4.0 L.). The milk should not be skimmed, but diluted with carbonated water or an alkaline mineral water. In chronic interstitial nephritis an absolute milk diet is not always successful. Indeed, as von Noorden has pointed out, much good sometimes results from restricting in this form of nephritis the fluids to between 40 and 50 ounces (1200.0- 620 APPLIED THERAPEUTICS. 1 500.0 c.c), especially when there is dilatation of the heart and a tendency to cardiac asthma. Medicinal Treatment. — We possess no remedies that are directly curative. In the interstitial form potassium iodid (1-5 gr. — 0.06-0.3 gm.) or bichlorid of mercury ( 6 V ~~ A g r - — 0.001-0.0016 gm.), two or three times a day, occasionally seems to have a beneficial effect, but in the large majority of cases these remedies are of no avail. Mild hematinics, like Basham's mixture, are often useful, especially in chronic paren- chymatous nephritis, but only small doses should be used. The indiscriminate use of iron in chronic interstitial nephritis, as Tyson has shown, is often productive of harm. It is indi- cated only when there is evident anemia. Strychnin and the simple bitters are valuable adjuvants to iron in many cases. Late in the disease, when the urine becomes scanty and dropsy appears, hydragogue diuretics are called for, although they often prove disappointing. Those most likely to succeed are digitalis, the vegetable salts of potassium, carTein, and theo- bromin. Operative Treatment. — Edebohls claims that chronic Bright's disease in its early stages is curable or susceptible to amelioration by renal decapsulation. The good results of the operation are attributed to the development of numerous blood-vessels, particularly arteries, in the firm adhesions be- tween the kidneys and the surrounding tissues, the blood stream passing from the latter to the kidneys. This, it is thought, leads to gradual absorption of the intertubular inflam- matory products, thus freeing the tubules and glomeruli from compression, and permitting the re-establishment of a normal circulation, with regenerative production of new epithelium capable of carrying on the secretory function. Edebohl's operation has not been employed extensively enough as yet to warrant positive conclusions as to its therapeutic value. That it has resulted in marked improvement in some cases must be admitted ; that actual cure has ever been effected by it, how- ever, is extremely doubtful. Treatment of Special Symptoms. — For the anemia the most effectual measures have already been enumerated (see p. 618). Dropsy. — Hydragogue cathartics and hot-air baths are chiefly to be relied upon for abstracting the water from the body. Among the former, Epsom salt, compound jalap powder, and elaterium are the most serviceable. Injections of pilocarpin may also prove useful, but they should be withheld when the DISEASES OF THE KIDNEYS. 621 heart is weak or when there is any tendency to pulmonary edema. Diuretics are sometimes efficacious. The best are digitalis, the vegetable salts of potassium (bitartrate or acetate), caffein, theocin, and theobromin. The dechloridation treatment of Widal and Javal is at times very successful and is well worth trying. It consists in giving food with a minimum amount of salt. When dropsy is extreme and does not yield to the usual remedies, operative measures may be required (see p. 617). High Blood-pressure. — A certain increase in the arterial tension is necessary. It compensates for the renal inadequacy. When, however, the tension in the vessels becomes excessive and gives rise to headache, vertigo, palpitation, and dyspnea, it should be reduced by saline laxatives, warm baths, and the administration of nitroglycerin (yj-g- gr. — 0.00065 gm. — three times a day, increased if necessary until the desired effect is accomplished). Heart-failure with low arterial tension will require the use of such stimulants as digitalis, strychnin, caffein, and alcohol. Asthma should be treated as a manifestation of uremia. Nitrite of amyl, nitroglycerin, or ethyl nitrite affords some re- lief. When there is pulmonary congestion or edema, dry or wet cupping is often useful. Insomnia may be caused by the retention in the blood of excrementitious matter, or may be due to high arterial tension. In the first case a milk diet and the administration of elimi- nants are called for ; in the second, vasodilators (nitroglycerin or erythrol tetranitrate) will be helpful. When the insomnia is sufficiently severe to demand the use of hypnotics, bromids, veronal, chloral, paraldelyd, and trional may be tried in the order named. Opium should be avoided. Headache is best treated by cold to the head, and the ad- ministration of saline purges and caffein (2-3 gr. — 0.13-O.2 gm.) or nitroglycerin (1-2 min. — 0.06-0.12 ex.). Vomiting. — When vomiting is persistent it is best to with- hold food entirely for a time, allowing carbonated water or cracked ice only by the mouth. Sinapisms over the epigas- trium sometimes afford relief. Such gastric sedatives as diluted hydrocyanic acid, bismuth subnitrate, cocain, and oxalate of cerium are worthy of trial. Diarrhea should not be checked too quickly. When treat- ment is desirable mild astringents and intestinal antiseptics may be given. Opium should be used with extreme caution, if at all, not only in this but in all other complications of chronic nephritis in which sedatives are indicated. 622 APPLIED THERAPEUTICS. NEPHROLITHIASIS. Medical treatment should be given a thorough trial in all cases of suspected renal calculus. It is doubtful whether stones once formed in the pelvis of the kidney can ever be dissolved, especially if they have already attained a consider- able size, but much can be accomplished by internal remedies in preventing the formation of fresh deposits and in mechan- ically washing down into the bladder small concretions. As uric-acid calculi are by far the commonest, efforts should be directed toward lessening the formation of uric acid and preventing its precipitation in the urinary passages. The patient should use only those articles of food which experience has shown to be most easily digested. The foods most likely to disagree are concentrated soups, hashes, croquettes, pastry, sweets, acid fruits, malt liquors, heavy wines, and all articles rich in nucleins, like the internal organs and young germi- nating plants. The quantity as well as the character of the food must be regulated. No more should be eaten than is absolutely necessary to maintain normal nutrition. Too long an interval should not be allowed to elapse be- tween meals. Gentle exercise in the open air and hydrotherapy are to be recommended since they favorably affect the underlying diath- esis. Much benefit accrues from abundant water-drinking between meals. This not only favors the expulsion of small concre- tions from the kidney, but by diluting the urine it also tends to prevent the precipitation of uric acid. Alkaline mineral waters, like Carlsbad, Vichy, Vals, and Buffalo and London- derry lithia waters have been extensively employed, but they are no more efficacious than plain water which has been ren- dered alkaline by the addition of potassium citrate, J— I dr. (2.0-4.0 gm.) to the quart (1.0L), or of potassium bicarbonate, 40 grains (2.5 gm.), and lithium citrate, 20 grains (1.3 gm.), to the quart. About a quart of such water should be consumed, as a rule, in the twenty-four hours. In mild cases a single copious draught at bedtime may suffice to prevent recurrence of colicky pains. Some care is necessary not to allow the urine to become too alkaline, since this may lead to a deposi- tion of phosphates about the uric-acid stone. Among special remedies brought forward as solvents of uric acid (see p. 243) may be mentioned piperazin, lycetol, lysidin, piperidin tartrate, and urosin. While some authors claim to have seen beneficial effects follow the use of these drugs, the DISEASES OF THE KIDNEYS. 623 majority of unprejudiced observers are sceptical as to their merits. Recently Croftan has recommended calcium carbonate (15-20 gr. — 1. 0-1.3 g m - — thrice daily), which was first advo- cated by Von Noorden. The theory is that calcium, owing to its great affinity for phosphoric acid, unites with this acid in the blood to form calcium phosphate, which is subsequently eliminated in great part through the bowel, thus ridding the urine of mono-sodium phosphate, a precipitant of uric acid, while leaving in the urine di-sodium phosphate, an active sol- vent of uric acid. Phosphatic Calculi. — Since phosphatic calculi can be depos- ited only from alkaline urine the indication is to render the urine acid, a task often difficult of accomplishment. Instead of a vegetable diet, one composed largely of readily digestible proteids should be ordered. Among special remedies recom- mended for the purpose of acidifying the urine may be men- tioned benzoic and boric acids. From 5-15 gr. (0.3-1.0 gm.) of either of these drugs may be given in capsule, three to four times a day. Unfortunately, the continued use of these acids is prone to cause indigestion, an effect which detracts mate- rially from their value. As in the case of uric-acid concre- tions, the copious ingestion of plain or distilled water is to be encouraged in order to prevent concentration of the urine. Oxalate-of-lime Calculi. — As there is reason to believe that oxalates are formed under conditions very similar to those which give rise to an excess of uric acid, what has been said concerning the treatment of the uric-acid diathesis applies equally to that of the oxalate of lime. Renal Colic. — The indications are to relieve the pain and to relax the spasm. This is best accomplished by hypodermic injections of morphin and atropin, coupled with hot baths or local applications — hot poultices or fomentations. If the pain is extreme it may be desirable to administer chloroform. Simple diluents should be given freely. In mild attacks full doses of phenacetin or antipyrin, with an abundant supply of hot drinks, may suffice. Surgical Treatment. — In a certain number of cases sur- gical intervention affords the only hope of permanent relief. Operation is urgently demanded when the attacks of renal colic occur with such frequency as to prove disabling, when there are evidences of severe pyelitis, and when there is reason to believe that the calculus is impacted in the ureter. Unless there be pyonephrosis, nephrolithotomy is the operation to be 624 APPLIED THERAPEUTICS. recommended, as it is attended with much less risk than that of nephrotomy or nephrectomy. The mortality in 82 cases of nephrolithotomy for non-suppurative nephrolithiasis was 2.4 per cent. (Newman and Legue). The average mortality in suppurative cases is not less than 15 per cent. The low mor- tality of early operation contrasted with the high mortality of late operation, when the kidney structure has been seriously damaged, is a strong argument for early interference. DISEASES OF THE NERVOUS SYSTEM, ACUTE CEREBRAL LEPTOMENINGITIS. The treatment should be conducted on the same lines as that of cerebrospinal fever (see p. 515). When middle-ear disease is the exciting factor, and the symptoms can be defi- nitely localized, operation may be justifiable. Several writers have recently spoken favorably of frequently repeated warm baths, as originally recommended by Aufrecht in 1894, com- bined with lumbar puncture (see p. 507). CEREBRAL HEMORRHAGE. Prophylaxis. — Patients predisposed to apoplexy should lead a quiet life, one as free as possible from mental and phys- ical excitement. The food should be nutritious and easily digestible. Moderation in eating and regularity of meals are matters of prime importance. Alcohol should be interdicted. The bowels should be made to act daily, a mild aperient being given if necessary. The Attack. — If the patient be seen early, he should be placed in a reclining position with the head and shoulders well elevated. Bowles advocates turning the patient over on the paralyzed side to lessen the stertor. An ice-bag should be applied to the head, and warm bottles to the feet. The bowels should be promptly emptied by an enema, and later by a drastic cathartic, preferably croton oil, one or two drops of which, mixed with a little sweet oil, may be placed upon the tongue. In sthenic cases, when the face is congested and the pulse is slow and full, venesection to the amount of \~\ pint (250.0- 500.0 c.c.) is indicated. The abstraction of blood cannot undo damage that is already done, but by lessening the supply of blood to the brain it may serve to arrest bleeding that is still in progress or to prevent an early recurrence. If venesection does not seem justifiable, lowering of the arterial pressure may be effected by the administration of aconite or veratrum viride. DISEASES OF THE NERVOUS SYSTEM. 625 When the heart's action is feeble and the face is blanched, stimulants like alcohol, ether, and camphor may be given very cautiously, although it is unlikely that they will be of much avail. When the respiration fails before the circulation, artificial respiration may be practised with advantage. In a case cited by H. C. Wood, in which final recovery was complete, it was necessary for nearly two days for an attendant to hold forward the jaw and tongue by raising the ramus of the jaw upward and forward, in order to prevent mechanical asphyxia. Thorough cleanliness, bathing with alcohol, frequent change of position, and the avoidance of roughnesses in the bed are necessary in order to prevent the development of bed-sores. Since blisters are produced more readily than in health, special care should be taken in using hot applications of any kind. Retention of urine is apt to occur, and if it does the patient must be catheterized. After the Seizure. — Absolute rest in bed must be main- tained. Even in the mildest cases the patient should not be allowed to leave his bed for two or three weeks, and during this time the diet should be light and unstimulating. The ice- cap should still be kept upon the head. Aconite in small doses with sweet spirits of nitre is often useful in subduing the fever of reaction and in decreasing arterial tension. For rest- lessness and wakefulness, small doses of a bromid or of chlo- ral may be given. Potassium iodid is often prescribed with the hope that it may aid in absorbing the clot, but it is of doubtful utility, and moreover, it is very prone to disturb the digestion. After the acute symptoms have entirely disappeared, which will rarely be earlier than ten days or two weeks after the attack, massage should be systematically practised. It often contributes much to the restoration of power, or when this is impossible, to the prevention of contractures. After the lapse of three or four weeks, triweekly applications of the faradic current may be of service (see p. 481). Strychnin is often given at this time, but it probably exerts no other influence than that of a general tonic. In some cases warm saline baths (90°-95° F. — 32°-35° C), combined with passive movements, prove useful adjuvants. LOCOMOTOR ATAXIA. Rest is an important factor in the treatment. The sense of fatigue being impaired in this disease, patients are very prone to overtax their strength. Erb advises that the patient should live as if he were an old man, quietly, regularly, and with no excitements. In many cases it is well to begin treatment with 40 626 APPLIED THERAPEUTICS. absolute rest in bed for several weeks. Mental fatigue should also be avoided. Sexual excesses are exceedingly injurious. The diet should be nutritious and easily digestible. Alcohol and tobacco should be used sparingly, if at all. Patients suffering from locomotor ataxia should wear flannel next to the skin, and should avoid exposure to wet and cold, as well as sudden alterations of temperature. When practi- cable a change to a warm, equable climate during the winter months may be recommended with advantage. Massage affords a valuable means of securing the benefits of exercise without the expenditure of energy. Systematic re-education of co-ordinating movements, as originally recommended by Frenkel, has been found a most effective remedy for the ataxia (see p. 486). Even in advanced cases, in which there is marked disturbance of sensation, this method of treatment is not without benefit, and the improve- ment may last for years if the disease is stationary or only slowly progressive. The treatment by suspension, introduced by Motschukowski, and that by nerve-stretching, proposed by Langenbuch, have become obsolete. Tepid baths of 8o°-85° F. (26.^-2^° C.) are sometimes of distinct service. On the other hand, hot baths, vapor baths, and cold baths are usually harmful, and often provoke lanci- nating pains. Various natural springs enjoy a special reputa- tion, the most popular being the Hot Springs of Arkansas, those of Virginia, and those of Los Vegas, New Mexico, in this country, and the thermal baths at Rehme, Nauheim, and Aix- la-Chapelle in Europe. Patients in whom the disease is far advanced should, of course, be spared the cost and discomforts attendant upon a long journey. According to Frenkel, treat- ment by baths should be forbidden while the exercise treatment is being used. While electricity is undoubtedly of service in relieving certain sensory disorders of ataxia, there is no ground for believing that it can affect in the slightest degree the mor- bid process in the spinal cord. Mercury and iodids should be given a thorough trial in all cases in which syphilis is suspected. It must be admitted, however, that antisyphilitic treatment rarely accomplishes any good unless the infection by syphilis has been quite recent. Most of the cases of tabes that have recovered under mercury have been examples of peripheral neuritis. Among numerous special remedies which have been in vogue at various times, but which are of very doubtful utility, may be mentioned silver nitrate, ergot, calabar bean, strychnin, bella- donna, phosphorus, chlorid of gold, arsenic, corrosive subli- mate, and spermin. DISEASES OF THE NERVOUS SYSTEM. 627 Treatment of Special Symptoms. — When the pains are severe the most potent remedial measure is absolute rest in bed. Light touches of the actual cautery or sinapisms over the root of the nerve supplying the affected part often afford re- lief. Deep massage is sometimes of service. Mitchell has found the alternate application of ice and hot water useful. Flannel bandages applied firmly from the toes up to the middle third of the thigh sometimes do much good. A snugly fitting abdominal binder may also be used to lessen girdle pain. Electricity in the form of the faradic brush, static spark, or stabile galvanic anode, is worthy of a trial. The most generally useful anodynes are phenacetin, anti- pyrin, and acetanilid. Cannabis indica occasionally succeeds. According to Osier, the prolonged use of nitroglycerin, given in increasing doses until the physiologic effect is produced, is of great service in allaying pains and diminishing the frequency of crises in all cases of tabes in which there is increased arte- rial tension. In many cases recourse must be had to morphin, but its use should be deferred as long as possible. Gastric Crisis may require the withholding of food by the mouth for a time, the patient being sustained by nutritive enemata. Lavage is often beneficial. The application of sina- pisms over the epigastrium may do good. Morphin hypoder- mically may be necessary. Laryngeal crisis may be relieved by local applications of cocain, inhalations of chloroform or amyl nitrite, or the admin- istration of anodynes. Numbness and paresthesia often yield for a time to local applications of faradism given with the wire brush. Vesical and rectal tenesmus may be relieved by suppositories of opium with belladonna, or applications of cocain. Mitchell has found faradism of great service (see p. 482). Obstinate priapism is best treated by tepid hip-baths or gen- eral baths and the administration of anaphrodisiacs — bromids, monobromated camphor, or hyoscin. Sexual intercourse should be avoided. Vesical weakness should receive the most careful attention. The bladder must be thoroughly emptied, if need be by cathe- terization. On the first appearance of cystitis the bladder should be thoroughly washed out with weak antiseptic solu- tions. MYELITIS. Acute Myelitis. — No time should be lost in placing the patient at absolute rest. In severe cases a water-bed should be employed. Such antiphlogistic measures as cupping, blis- 628 APPLIED THERAPEUTICS. tering, and cauterizing are of doubtful utility. Cold, however, in the form of Chapman's ice-bags, may be applied to the spine. Daily warm baths (90 F. — 3 2.2 ° C.) lasting from ten to fifteen minutes are useful. Drugs are of little value. Ergot is often used for the purpose of constricting the spinal vessels and thus limiting the local congestion. Every precaution must be taken against the development of bed-sores. Frequent change of the patient's position, absolute cleanliness of the parts subjected to pressure, and bathing with alcohol and water will do much toward obviating this com- plication. If bed-sores are already formed they should be treated thoroughly according to surgical principles. Retention of urine must be met by systematic catheterization under the most strict antiseptic precautions. When there is constant incontinence a carefully adjusted urinal should be employed. Any tendency to cystitis will call for daily irrigation of the bladder with a solution of boric acid or other mild antiseptic solution. If recovery with partial paralysis result, massage and electricity may aid in bringing back some of the lost power. Chronic Myelitis. — Hygienic measures are far more im- portant than drugs. Prolonged rest is desirable. Residence in a warm, equable climate is often serviceable. Daily warm baths are grateful. Counterirritation in the form of light touches of the actual cautery is useful in relieving pain, but it does not seem to exert any direct influence on the progress of the disease. When there is reason to suspect the existence of syphilis, mercury and iodids should be given a thorough trial. Tonics*are often indicated. Massage, passive movements, and electricity are useful in maintaining the nutrition of the affected muscles. Early measures should be taken to prevent the formation of bed-sores and the development of cystitis. POLIOMYELITIS. Acute Poliomyelitis. — In the acute stage absolute rest in bed is requisite. Not the slightest benefit accrues from the application of wet cups or leeches to the spine, or from any other form of counterirritation. Mild mercurial laxatives and febrifuge medicines may be used with some advantage. Ergot is often prescribed for the purpose of diminishing congestion of the ventral horns, but it is of very doubtful utility. The affected limbs should be thoroughly wrapped in cotton-wool to maintain warmth and circulation. After the acute symptoms have subsided, which will prob- ably be at the end of two or three weeks, an effort should be made to promote the restoration of the paralyzed muscles. DISEASES OF THE NERVOUS SYSTEM. 629 General hygienic measures must not be neglected. Nutritious food and fresh air are valuable aids. Little is to be expected from internal medication. Tonics like iron and cod-liver oil are sometimes of service. Strychnin seems to do some good. Massage in the form of effleurage and kneading is the most useful measure. It should be practised for ten or fifteen minutes daily for several months, or even for a year. Local bathing with shampooing may also be employed with benefit. Electricity, while less efficacious than massage, is worthy of a thorough trial. As faradism generally fails to elicit any re- sponse, recourse must be had to an interrupted galvanic cur- rent. One pole (cathode) may be placed over an indifferent point, such as the spine, while the other (anode) is slowly stroked over the affected muscles. The weakest current that will cause contraction should be used. The treatment should be given for ten minutes, three or four times weekly, and should be kept up, if necessary, for several months. If after six or eight weeks of electric treatment there is no demonstrable im- provement the outlook is very gloomy. Still, even here a successful issue is not impossible. The treatment of the later stages of infantile paralysis is chiefly surgical, and has for its object the prevention or correction of deformities. Chronic Poliomyelitis. — There is practically no remedy for this disease. Massage, hydrotherapy, and electricity have seemed to be of some avail, but no permanent good has been achieved by these or other measures. Gowers has spoken favorably of strychnin and arsenic. In cases with a history of syphilis, mercury and iodids should be tried. NEURITIS. Careful search should be made for the exciting cause — rheu- matism, gout, syphilis, alcoholism, metallic poisoning, mechan- ical injury, or neighboring inflammation — with the view of removing it if possible. Absolute rest is imperative. When the nerves of the limbs are affected the muscles should be im- mobilized by means of splints and bandages, as in the treatment of fracture. In acute cases, irrespective of the cause, counterirritation is of service. This may be accomplished by applying linear blis- ters or painting iodin along the course of the inflamed nerve. In mild forms of the disease hot applications of lead-water and laudanum will suffice. Occasionally cold in the form of an ice-bag proves more grateful than fomentations. Coal-tar derivatives (phenacetin, antipyrin) and salicylates are useful in 63O APPLIED THERAPEUTICS. relieving pain. Such combinations as the following are often efficacious : & Acetphenetidini, giss (6.0 gm.) ; Salol, 3J (4.0 gm.). — M. Fiant chartulae, No. xii. Sig. — One every three or four hours. R Codeinse sulphatis, gr. iij (0.2 gm.) ; Acetanilidi, Salophen, aa £j (4.0 gm. ) . — M. Fiant chartulae, No. xii. Sig. — One every three or four hours. When the pain is very intense subcutaneous injections of morphin must be used. As soon as the pain and tenderness have distinctly lessened warm baths and gentle friction may be employed. In localized neuritis inunctions with mercury and belladonna ointment may also be used with great advantage in this stage. When the symptoms of irritation have completely subsided massage and electricity should be resorted to for the purpose of restoring the functions of the nerves and muscles. The faradic current should be used if the muscles respond to it. In the more severe cases in which faradic excitability is lost, labile and interrupted galvanic currents should be applied with the pole that produces the best contractions. Even with extreme atrophy these measures sometimes succeed in effecting decided improvement. Passive movements and extension will be required to overcome contractures and deformity. Tonics, especially strychnin and arsenic, are often of service in the later stages of the disease. Sciatica. — The first indication is to remove the cause. This may be some affection of the pelvic organs requiring sur- gical intervention, or it may be rheumatism, gout, syphilis, or metallic poisoning, and then general as well as local treatment must be resorted to. In acute cases rest in bed is essential. Free evacuation of the bowels should be secured in order to deplete the pelvic veins. When there is a definite history of rheumatism or the attack has been induced by cold, salicylates should be given in full doses. When there is reason to suspect syphilis iodids should be given a fair trial. Irrespective of the cause, phe- nacetin or antipyrin may be useful in relieving pain. Counter- irritation often affords much relief. When the pain is very severe this is best accomplished by means of small blisters or light touches of the actual cautery applied over the points of greatest tenderness. In some cases acupuncture (see p. 43 8 J acts very satisfactorily. In milder cases the Scottish douche — DISEASES OF THE NERVOUS SYSTEM. 63 1 in which a stream of warm water of gradually increasing tem- perature is directed on the course of the nerve until the pain subsides, when it is suddenly changed for a cold jet — is an efficient remedy. Agonizing pain must be relieved by injec- tions of cocain (} gr. — 0.016 gm.), chloroform (5-10 min. — 0.3-0.6 c.c), guaiacol (2-3 min. — 0.1-0.2 c.c), or morphin (|— J- gr. — 0.008-0.016 gm.), made deeply and as near to the nerve as possible. Morphin should be withheld as long as possible on account of the grave danger of inducing the mor- phin habit. In some cases deep injections of distilled water act remarkably well. Massage is indicated only when the acute symptoms have subsided, and should then not be too energetic. Electricity is rarely needed, even if there has been much wasting. In obstinate cases of sciatica the following treatment, outlined by S. Weir Mitchell, often acts most hap- pily : A long flannel bandage is firmly applied from the foot to the groin, and renewed twice a day. The leg is slightly bent at the knee and kept nearly straight at the thigh, and in this position secured to a light side splint extending from the axilla to the ankle by a few turns of a bandage. Care is of course taken to prevent pressure on the heel. After a few days the joint-angles are slightly changed at each dressing. Still later passive motion is carefully employed, and after about three or four weeks the splint is removed during the day and replaced at night. Finally, guided as to time by the presence or absence of pain, the splint is removed altogether, the band- age being kept on somewhat longer, and gentle massage being used between each application after pain has quite disappeared. A full diet, cod-liver oil, and iron as needed, are given during the whole period. Any points of persistent pain that may be left at the close of the treatment are treated by counterirritants, preferably by small blisters or light touches of a white-hot Paquelin button. The patient must not sit at all during the first week after getting up, but must stand or walk, and that only with crutches. He may be upright or lying on a bed, but not seated. Among other measures which have proved successful in individual cases may be mentioned hydrotherapy in the form of warm baths or mud baths, galvanism (5-7 milliamperes), the continued application of ice-bags, and nerve-stretching, either by forcibly flexing the thigh upon the body or by cut- ting down upon the nerve itself. NEURALGIA. An effort should be made to adapt the treatment to the eti- ology of the disease. Causes of reflex irritation — carious 632 APPLIED THERAPEUTICS. teeth, errors of refraction, nasal obstruction, neoplasms, and cicatrices — should be sought for, and when found removed if possible. When the disease is associated with anemia, iron and arsenic will be indicated. If there is any suspicion of syphilis, mercury and iodids should be tried. When a malarial element is present, quinin may effect a cure. When rheuma- tism is an etiologic factor, salicylates and alkalis may prove beneficial. In gouty subjects much may be expected from regulation of diet, systematic exercise, and the administration of alkalis. The occupation of the patient, a blue line on the gums, and lead in the urine may lead to the recognition of plumbism, and in this case the iodids will be indispensable. All influences that tend to induce a morbid excitability of the nerves or of their centers — mental or physical fatigue, emotional excitement, sexual excess, over-indulgence in tobacco, tea, coffee or alcohol — should be removed so far as possible. In every case of neuralgia we must endeavor to improve the general nutrition, which is almost always disturbed. The measures to be employed for this purpose include an abun- dance of fresh air, proper food, regular hours, adequate pro- tection from the vicissitudes of weather, systematic exercise, frequent bathing with friction, and the use of such tonics as iron, arsenic, cod-liver oil, and hypophosphites. If the patient cannot take active exercise rest with massage should be sub- stituted. Neuralgia in neurasthenic patients is sometimes successfully managed by a modified Weir Mitchell treatment. A change of residence to a warm dry climate has been known to effect a complete cure. Special Treatment. — The list of agents recommended for the cure of neuralgia is bewildering. " Numerous are the means at our disposal for combating the disease, quite as numerous are the patients who, after hundreds of unsuccessful trials, give up all medicines and all physicians " (Hirt). Among the internal remedies most worthy of confidence may be men- tioned the coal-tar analgesics (phenacetin, antipyrin, and ace- tanilid), morphin, bromids, cannabis indica, croton chloral, gelsemium, cafTein, nitroglycerin, and salicylates. The coal-tar analgesics are the most generally useful anodynes for the attack. Their action, moreover, is prompt. From 5-8 gr. (0.3-0.5 gm.) of one of these drugs may be given every two or three hours, according to the intensity of the pain. The fact must be borne in mind that these agents when used contin- uously not only lose in potency, but may also unfavorably influence general nutrition. Morphin is undoubtedly the most certain means we possess of affording temporary relief, but on DISEASES OF THE NERVOUS SYSTEM. 633 account of the danger of inducing the opium habit it should be employed only as a last resort. Under no circumstances should the patient himself be allowed to use the hypodermic syringe. In mild attacks bromids in large doses sometimes succeed. Combinations of a bromid with phenacetin or anti- pyrin may often be prescribed advantageously. Cannabis indica is especially valuable in migraine, in which affection it may be given in doses of from J— J gr. (0.0 1 6-0.03 gm.). Cro- ton chloral, in . doses of from 5-10 gr. (0.3-O.65 gm.), and tincture of gelsemium, in doses of 10 min. (0.6 c.c.) or more, are occasionally serviceable in trifacial neuralgia. Caffein, in doses of from 3-5 gr. (0.2-0.3 gm.), is often efficacious. Com- binations of caffein with phenacetin or with bromids in many cases do more good than single drugs. Nitroglycerin, in doses of from 1 1 * gr. (0.0004-0.0012 gm.), has been highly recommended in migraine-like attacks with signs of vasocon- constriction. Neuralgia brought on by exposure to cold and wet is favorably influenced by the salicylates. In such the following combination will be found of value : R Acetphenetidini, Salophen, aa giss (6.0 gm.) ; Codeinse sulphatis, gr. iij (0.2 gm.). M. Fiant chartulse, No. xii. Sig. — One powder every two or three hours. Dana and others have spoken favorably of strychnin in heroic doses in tic douloreux (see p. 145). I/OCal Treatment. — Heat, dry or moist, may be applied for its soothing effect. In some cases cold in the form of an ice-bag is more grateful. Menthol and chloral camphor are useful in neuralgia of superficial nerves when the pain is slight. Congelation of the skin by ethyl chlorid occasionally has a good effect. Acupuncture and aquapuncture are effective, but are not suitable for use about the face. In obstinate cases active counterirritation by means of blisters or the thermocautery will be found a potent remedy. In trifacial neuralgia the blis- ters may be applied behind the ear. Even when the pain is very intense injections of cocain (-§-— j gr. — 0.008-0.0 1 6 gm.) upon the nerve often bring relief, but the grave danger of establishing a habit must never be forgotten. Cocain may also be introduced through the unbroken skin by cataphoric action (see p. 482). Electricity is sometimes of service. Bennett and Hammerschlag have each treated 9 cases of trifacial neuralgia by the injection of osmic acid into the nerve with good results. Schlosser, Oswalt, Kiliani, and others report favorably upon deep injections of alcohol. No matter what agent is employed, 634 APPLIED THERAPEUTICS. however, treatment by injection rarely affords relief for more than a year or two. Finally, when all other measures fail, recourse may be had to surgical interference. Nerve-stretching and nerve-section are the operations usually performed. Lasting benefit is rarely obtained from either operation, although excision is more re- liable than stretching. In trifacial neuralgia removal of the Gasserian ganglion or division of its sensory root usually affords permanent relief. In the last few years the mortality of this procedure has been much reduced. In Horsley's series of 120 cases it was 3.3 per cent., and in 27 cases reported by Frazier it was 3.7 per cent. CHOREA. Rest of body and mind is the most important factor in the treatment of the disease. No matter how slight the attack may be the child should be taken from school. In all except the mildest cases rest in bed in a quiet, well-ventilated room is essential. When the movements are so violent as to bring about contusions the bed should be padded or the child put in a hammock. It is almost always advisable to exclude the child's playmates, even his own brothers and sisters, from the sick-room. Excitement of all kinds should be proscribed. Gentle massage may be of benefit, especially in poorly nourished children, but gymnastic exercises should be reserved for the period of convalescence. Daily warm baths (95 F. — 35 C.) are often beneficial. In older children, and especially in neurotic cases, the wet-pack may be used with great advan- tage. As M. Allen Starr has pointed out, a change of air, especially a change to the seashore, is often of the utmost ser- vice in obstinate cases. In all cases of chorea reflex irritation — ocular defects, adher- ent prepuce, etc. — should be carefully sought for, and when found removed if possible. On account of the tendency of chorea to recur, children who have once suffered from the dis- ease should not be overtaxed in school, and should be guarded, as far as possible, from attacks of rheumatism. Medicinal Treatment. — Arsenic is by far the most useful remedy. The dose should be gradually increased until physi- ologic effects are produced. In a child of five or six years we may give 3 min. (0.2 c.c.) of Fowler's solution three times a day, and increase the dose by a minim (0.06 c.c.) a day until physiologic effects are seen. These are puffiness about the eyes, nausea, griping pains or diarrhea. In many cases from 10-15 mm - three times a day can be taken before untoward symptoms develop. When these occur the drug should be suspended for two or three days and then resumed at a dose DISEASES OF THE NERVOUS SYSTEM. 635 slightly less than the child was receiving when the phenomena of salivation appeared. Arsenic should always be given after meals, and well diluted. While taking large doses of arsenic the patient should be kept under close observation, as albu- minuria, conjunctivitis, inflammatory diseases of the skin, or even multiple neuritis may develop independently of the usual untoward effects. In the cases in which arsenic fails or is not well borne, cim- icifuga may succeed. A dose of 10 min. (0.6 c.c.) of good fluid extract may be given three times after meals and grad- ually increased to \ dr. (2.0 c.c.) or more. Antipyrin, in doses of from 30-60 gr. (2.0-4.0 gm.) a day, has been strongly ad- vocated by Dujarden-Beaumetz, Legroux, Starr, Comby, and others, but when used so freely this drug may cause prostra- tion, acute anemia, cyanosis, and hemoglobinuria. When symptoms of acute rheumatism are present salicylates are of service, otherwise they usually fail. When the movements are very violent and interfere with sleep, hyoscin hypodermically in doses of from yxro^Tiro °^ a & r - (0.0003-0.0006 gm.) twice daily, often acts most happily. If hyoscin fails recourse must be had to chloral, bromids, or morphin, but these drugs should not be used unless the symptoms are of great severity. Chloral- amid and trional are reliable hypnotics. Iron is often required to combat the marked anemia which is present in many cases. Chorea Insaniens. — Powerful sedatives like hyoscin, chloral, and morphin are required to allay the violent excita- bility and jactitation. Inhalations of chloroform are sometimes useful. Stimulants are almost always required. When the patient is unable to swallow no time should be lost in resorting to forced feeding. Severe cases of chorea complicating preg- nancy will call for the induction of premature labor. EPILEPSY. Although in the vast majority of cases epilepsy is an incur- able disease, yet much can often be done to lessen the fre- quency of the paroxysms. Hygienic treatment is of the utmost importance. Moderate exercise, both mental and physical, is beneficial. Idleness and seclusion have a baneful effect. Children should be kept at school, but competition and overstudy should be avoided. Home training must be carried on with the greatest care, much tact and firmness being required to prevent loss of self-control. Children who are particularly irascible are often much better trained in a special institution. Adults should follow, if possible, some light and 636 APPLIED THERAPEUTICS. agreeable pursuit, preferably one which will permit them to spend the greater part of the day in the open air, and which will not add to the risk of physical injury should attacks come on without warning. The establishment of so-called epileptic colonies or farms, where patients can be employed in agricul- tural pursuits, has proved a great boon to many epileptics of the bread-winning class. In such institutions as are to be found at Biellefeld, Potsdam, and Stettin in Germany, at Zurich in Switzerland, at Chalfont St. Peter in England, and at Craig Colony in New York, large numbers of sane epileptics are able to support themselves under proper care and super- vision. The diet should be nutritious, but simple and readily diges- tible. As a rule a diet that is for the most part vegetable will be found to be best adapted to the patient's condition, but when the disease is associated with lowered vitality a fair amount of animal food should be permitted. Overloading of the stomach is a potent factor in precipitating attacks. The principal meal is best taken at midday, and full evening meals should be avoided. The assertion made by Richet and Toulouse that it is advantageous to reduce the sodium chlorid taken with food to a minimum — that is, to 2J— 3 gm. a day — has been con- firmed by several observers. Tea, coffee, alcohol, and tobacco should be used very spar- ingly, if at all. The patient must be constantly warned against excesses of every kind. The digestive functions should be brought to the highest possible state of efficiency. The bowels must be regulated by diet, and, if necessary, by mild aperients. Liberal water-drinking, frequent bathing, followed by friction of the skin, light exercise in the open air, and other measures which favor elimination are to be recommended. General ton- ics, like iron, arsenic, and cod-liver oil, are sometimes required to combat anemia and malnutrition. Although very few cases of epilepsy are purely reflex, local irritation — phimosis, adherent prepuce, worms, a foreign body in the nose or ear, and painful cicatrices — should be carefully sought for, and if found removed. Epileptic patients ought not to marry. Special Treatment. — Among palliative remedies the bromids, originally recommended by Locock in 1853, h°ld the first place. The ammonium and sodium salts are generally preferable to the potassium salt, being less depressing and less irritating to the stomach. In cases in which the digestive tract is especially sensitive, or in which only a mild effect is desired, the strontium salt may be selected with great advantage. A DISEASES OF THE NERVOUS SYSTEM. 637 combination of bromids sometimes acts more satisfactorily than a single bromid. N The amount of the drug required varies with the severity of the case and the susceptibility of the individual, and must be determined experimentally in each case. The requisite daily dose usually ranges between 1 and 2 drams (4.0-8.0 gm.). The addition of one or two drops of Fowler's solution to each dose of bromid is useful in pre- venting the occurrence of acne. When the attacks occur at irregular intervals the bromid is best given in equal doses thrice daily after meals. When, however, some periodicity is mani- fested it is advisable to administer the drug in relation to the time of the attacks. Thus in nocturnal epilepsy a single large dose at bedtime may suffice. Again, in women, when the seizures occur only at the menstrual periods, active medication may be restricted to the week preceding each period. When the convulsions occur at long intervals and show no tendency to increase in frequency, it is better to dispense with special medication entirely and to rely upon hygienic and dietetic measures to lessen the excitability of the nerve-centers. In every case it is of the utmost importance to limit the dose of the bromids to the smallest possible amount that will control the seizures. Relief that comes only with saturation is gener- ally dearly purchased. Mention has already been made of the fact that the with- drawal of salt from the diet renders the patient more susceptible to the action of the bromids. The theory is that the tissues deprived of sodium chlorid more readily take up the bromids owing to the lack of other halogen bases in the dietary. Cer- tain drugs, not very effective in themselves, are of service when combined with the bromids in that they lessen the amount of the latter required to control the convulsions. Antipyrin is one of the best of these auxiliary remedies. A daily dose of 10 gr. (0.6 gm.) not infrequently doubles the power of the bromids. Such a combination as that mentioned on page 114 proves valuable in many cases. Antipyrin may also be used in those cases in which the bromids, even in small doses, are not well borne. Acetanilid in daily doses of from 8-10 gr. (0.5-0.6 gm.) is sometimes substituted for antipyrin. In noc- turnal epilepsy chloretone (5 gr. — 0.3 gm.) or sulphonal (5-10 gr. — 0.3-0.6 gm.) is often a useful adjuvant to the bromids. On account of its tendency to accumulate in the system and cause chronic poisoning, sulphonal should not be used contin- uously for longer periods than a week or ten days. Horse nettle {solanum carolinense) is another remedy which appears to increase the activity of the bromids. From J— 1 fl. dr. (2.0- 638 APPLIED THERAPEUTICS. 4.0 c.c.) of the fluid extract may be given thrice daily. When the circulation is weak a combination of digitalis or of adonis vernalis with the bromids, as recommended by Bechterew, will be found efficacious. In petit mat nitroglycerin in doses of ^ 2^ gr. (0.0006-0.003 gm.) is sometimes of more service than the bromids. Flechsig's treatment, which consists in giving large doses of opium for six weeks and then the bromids for two weeks (see p. 97), has been employed with some success in obstinate cases. It is not tolerated, however, by many patients and its employ- ment necessitates a supervision that can be furnished only in fully equipped hospitals. Moreover it is not without danger. Surgical Treatment. — Many attempts have been made to combat epilepsy by surgical treatment. Recourse has been had to castration, circumcision, clitoridectomy, tracheotomy, ligation of the carotids, ligation of the vertebral arteries, re- moval of the superior cervical sympathetic ganglia, and excision of certain cortical areas. Fortunately most of these measures are purely of historical interest. Trephining offers some hope of relief in certain cases of focal epilepsy, although it has to its credit less than 4 per cent, of recoveries. Clark l thus summarizes the present status of trephining : I. Idiopathic epileptics with typi- cal grand mal seizures should never be trephined. 2. Idio- pathic epileptics in whom the seizures are of the Jacksonian type should be trephined only when infantile cerebral palsies can be excluded, and when the family and personal degeneracy is at a minimum. If operation is determined upon in such cases a very thorough removal of the epileptogenic area should be made ; even then but a fraction of I per cent, recover from their epilepsy. Traumatic epileptics may be trephined when the injury is definitely proved and stands in direct causal rela- tion and has existed not more than two years. The prognosis will then largely rest upon the degree of the neurotic predis- position present. The earlier trephining is resorted to after convulsions begin, the better the prognosis. Treatment of the Attack. — When an aura is perceived it is often possible to arrest the paroxysm by the inhalation of amyl nitrite. Patients may provide themselves with this drug in the form of pearls which may be crushed in the handker- chief. When the attack is preceded by a local spasm forcible extension of the part sometimes succeeds in aborting it. If a sensory aura is felt in a limb the part may be firmly grasped or encircled with a tight ligature. The patient himself often learns by experience some method by which he can suppress 1 Medical Record, Jan. 12, 1901. DISEASES OF THE NERVOUS SYSTEM. 639 seizures of which there is due warning. During the attack there is little to be done beyond protecting the patient from injuring himself. The head should be slightly raised, the clothes loosened, and a piece of cork or firm rubber pushed between the teeth. If necessary inhalations of amyl nitrite or chloroform may be used. In the status epilepticus the most reliable measures are inhalations of chloroform, ether, or amyl nitrite, hypodermic injections of hyoscin (y^- gr. — 0.0006 gm.) or of morphin (J gr. — 0.016 gm.), enemas of chloral (20-30 gr. — 1.3-2.0 gm.), and the hot bath. NEURASTHENIA. The treatment of neurasthenia must vary with the cause of the disease and the circumstances and idiosyncrasies of the patient. In every case an earnest effort should be made to determine the exciting cause and to remove it if possible. With this in mind the family history of the patient, his occupation, habits, and amusements, and the condition of his various organs must be carefully studied. In the milder forms of the disease, especially when overwork has been the exciting factor, a month or two of rest with change of scene will often effect a cure. In such cases quiet travel, so planned that it will interest the patient without fatiguing him, is frequently attended with excellent results. A prolonged sea-voyage is sometimes very useful. In other cases the " wilderness cure " of S. Weir Mitchell may be recom- mended with advantage. In the absence of any special gastric disturbance, the diet should be simple, readily digestible, and abundant. Tea, cof- fee, alcohol, and tobacco are better avoided. A tepid sponge bath in the morning, provided it be followed by a good reaction, is beneficial. The wet pack, sitz-bath, spinal douche, and Scottish douche are of service in individual cases. The question of exercise is an important one. When the physical strength is fairly well maintained exercise in the open air, systematically carried out and cautiously increased, often yields admirable results, but the fact cannot be too strongly emphasized that any exertion pushed to the point of fatigue is distinctly harmful. In many cases it is advisable to substitute for active exercise passive movements and massage. When there is marked muscular weakness as well as ner- vous inefficiency rest is imperative. This may be relative or absolute. In some cases the addition of from three to five hours to the time usually spent in bed, or a rest in bed of a 64O APPLIED THERAPEUTICS. few hours during the day, will suffice. When, however, the symptoms are severe it will be necessary for the patient to give up all work for a period of from six to twelve weeks. In such cases much good accrues from the " rest cure " introduced by S. Weir Mitchell. This treatment includes not only rest but also full feeding, isolation, and artificial exercise. Of course, the details of the treatment must vary in each case, and only the outlines can be given here. Rest. — In bad cases, for the first two or three weeks at least, rest must be absolute, the patient not being allowed to feed himself nor to leave the bed to pass urine or to empty the bowels. As to this point Mitchell says : " In some instances I have not permitted the patient to turn over in bed without aid, and this I have done because sometimes I think no motion desirable and because sometimes the moral influ- ence of repose is of use." As improvement becomes manifest by a gain in weight, in muscular strength, and in nervous energy, some relaxation is permissible, and the patient may be allowed to sit up in bed to take meals and to indulge for a short time each day in reading or simple games. After four or five weeks he may be permitted to sit up in a chair for five or ten minutes a day, the time being gradually lengthened until at the end of a week or ten days he is up for from four to five hours. Active exercise is now cautiously introduced, and soon he is allowed to go out for a short walk or a drive. Finally, it is desirable that he should spend a week or two at the sea- shore or in the country before returning to his home. Feeding. — In most cases the diet at first should be restricted to milk. From 4-5 oz. ( 1 20.0- 1500 c.c.) should be given every two hours, and this amount gradually increased until at the end of a week or ten days from 8-10 oz. (235.0-300.0 c.c.) are given every two hours. Little by little solid food may now be added until at the end of two or three weeks the patient is getting each day three full meals with from 3-4 pints (1.5-2.0 L.) of milk in the intervals. The solid food may include stale bread with butter, soft-boiled or poached eggs, thoroughly cooked cereals, oysters, sweet breads, broiled or roasted meats, green vegetables, cooked fruits, milk-puddings, and ice cream. The evening meal should be light. Isolation. — This is an essential element in the treatment. No one should be permitted to see the patient except the medical attendant and the nurse. Even the writing and receiving of letters are to be forbidden. The permanent return of the patient at the close of the treatment to his family and friends should be effected very DISEASES OF THE NERVOUS SYSTEM. 64 1 gradually. Any infringement of these rules is almost sure to mar the success of the treatment Artificial Exercise. — This is supplied in the form of massage and electricity. Through these measures the good effects of active exercise can be secured in a measure without the expen- diture of any energy on the part of the patient. Massage should not be practised until the second or third day of the treatment, and even then it should be introduced very grad- ually. At first the seances should not last longer than a few minutes, but ultimately they may be increased to an hour a day. It is very important, as Dercum has urged, that the mas- sage be performed by the nurse instead of another person with whom the patient would have to become acquainted. Electricity, according to Mitchell, is the least necessary part of the treatment. It is, however, a useful adjuvant. Like the massage it should be introduced very gradually, otherwise it is likely to excite the patient and so prove harmful. A slowly interrupted faradic current is generally preferred. This should be applied once a day to each group of muscles in such strength as to elicit slight contractions. Success in the rest treatment will depend quite as much upon the way in which the various measures are applied as upon the measures themselves. The fact must not be lost sight of that suggestion and discipline play a conspicuous part in the treatment ; hence the importance of having all the details sys- tematically and strictly carried out. It is always advisable to furnish a program indicating exactly what shall be done at each hour of the day. It is absolutely necessary that the nurse chosen to conduct the treatment shall be not only skil- ful and robust but also discrete, tactful, and agreeable to the patient. Finally, the more thoroughly the physician is able to inspire confidence in the patient and to convince him that his disease is not an incurable one, the more likely is he to effect a cure. Medicinal Treatment. — Drugs are of little value except in meeting underlying conditions and in combating special symptoms. When there is anemia, iron and arsenic will be found useful. Small doses of strychnin are sometimes bene- ficial, but more often the drug is useless or actually harmful. Indigestion may be sufficiently severe to demand a modifica- tion of the dietetic treatment and the use of special remedies (see p. 555)- Such drugs as asafetida, valerian, and sumbul are often helpful in allaying nervous irritability. The follow- ing pill, introduced by Goodell, may often be given with ad- vantage : 41 642 APPLIED THERAPEUTICS. ft Arseni trioxidi, gr. ss (0.03 gm.) ; Ferri sulphatis exsiccati, Extracti sumbul, aa gr. xx (1.3 gm.) ; Asafoetidae, gr. xl (2.6 gm.). — M. Fiant pilulse, No. xx. Sig. — One three or four times a day. Every effort should be made to secure sleep by general measures — tepid baths, wet-packs, and gentle massage — before resorting to drugs. If a somnifacient becomes absolutely necessary, sodium or ammonium bromid, chloralamid, or tri- onal may be given. Chloral and morphin should be withheld on account of the grave danger of inducing a drug habit. Severe headache may call for an occasional dose of phenacetin or of a bromid. Constipation can usually be controlled by diet and abdominal massage, but in some cases mild laxatives, like cascara sagrada, sodium phosphate, or the combination of aloin, belladonna, and strychnin will be required. HYSTERIA. By proper mental, moral, and physical training much can be done to prevent the occurrence of hysteria in those who through inheritance are predisposed to the disease. Prophy- lactic treatment includes the inculcation of absolute obedience, self-restraint, and self-denial, a judicious education, suitable outdoor exercise, hygienic surroundings, temperate living, and the avoidance of all that tends to morbid emotionalism or sen- timentalism. In developed hysteria treatment must be directed both to the mind and the body, but especially to the former. To be suc- cessful the physician must be able to inspire absolute confidence and faith in the mind of the patient. She must be impressed repeatedly with the fact that her condition is a curable one, and that with her thorough co-operation restoration to health will certainly follow. To intimate that her symptoms are feigned or are wholly within her control is an egregious error. The physician's authority must be unquestioned and his in- structions must be rigidly carried out. Want of firmness and of decision is a common cause of failure. Harsh measures are occasionally needed, but they should be adopted only after the most careful consideration. In many cases no method of treatment proves successful until the patient has been removed from her customary surroundings and separated from her sym- pathetic relatives and friends. Suggestion is employed consciously or unconsciously in the treatment of hysteria by every successful physician. Without DISEASES OF THE NERVOUS SYSTEM. 643 it many of the remedies recognized as efficacious become wholly impotent. The cures which have been ascribed to the application of magnets and of various metals (metallotherapy) to the surface of the body seem to have been solely the result of suggestion. Complete hypnotism is by no means so gen- erally useful as continuous suggestion. Certain symptoms — paralysis, aphonia, blindness, contracture, and anesthesia — are sometimes removed by a single hypnotic seance, but on the whole the action of hypnotism is disappointing. Moreover, in the event of failure it seems capable of still further lowering the will-power and of increasing the emotional excitability. The physical condition of the patient must not be neglected. The general measures referred to under neurasthenia (see p. 639), such as hydrotherapy, systematic exercise in the open air, massage, and electricity, are equally applicable here. In grave cases of hysteria the treatment associated with the name of S. Weir Mitchell (see p. 640) often yields admirable results, but it is not suitable in every case, and considerable judgment must be exercised in the selection of proper subjects for it. Concerning this point Playfair writes : " The worse the case is the more easy and certain is the cure ; and the only disappoint- ments I have had have been in dubious, half-and-half cases." Apart from their moral effect, drugs have but little influence upon hysteria. They must often be used, however, to meet underlying conditions and to combat special symptoms. Iron and arsenic are useful when there is anemia. Antispasmodics, like valerian, sumbul, asafetida, and camphor, are serviceable in allaying abnormal nervous irritability. Occasionally more powerful sedatives, like the bromids, phenacetin, and chloral- amid, may be demanded, but the continuous use of such rem- edies is always to be condemned. Such drugs as morphin, alcohol, and chloral are distinctly dangerous. When hysteria is complicated by local disease special treat- ment will be required, but no operation should ever be per- formed for the relief of nervous symptoms unless there exists an actual organic lesion. Treatment of Special Symptoms. — Convulsions. — Iso- lation of the patient is imperative. Firm pressure over the ovarian region is often successful. The affusion of cold water over the face is useful. Inhalations of amyl nitrite, or even of chloroform, may be employed if necessary. Strong faradic currents applied to the spine are occasionally efficacious. An- esthesia is best treated by electricity, especially by the faradic wire-brush. Static electricity, owing to the profound mental impression which it produces, is also useful. Hyperesthesia 644 APPLIED THERAPEUTICS. and pain often yield to the continuous or interrupted galvanic current. In paralysis the patient should be instructed how to regain by long-continued practise the use of the affected part. This process of re-education demands the exercise of great firmness and patience. Swedish movements, massage, and faradization are useful adjuvants. In aphonia the faradic cur- rent, applied by means of special electrodes, is the most re- liable remedy. In contractures the most useful measures are massage, passive movements, and faradization. In obstinate cases it may be advisable to straighten the affected joint under an anesthetic and then apply a splint to the limb. WEIGHTS AND MEASURES, APOTHECARIES' WEIGHT. Troy grains. Scruples. Drams. Troy ounces. Pound, gr. 20 = 9 I 60 = 3 = 31 480 24 8 = I 1 5760 = 288 = 96 = 12 = ft> 1 APOTHECARIES' (WINE) MEASURE. Minims. Fluidrams. Fluidounces. Pints. Gallon. Tt\, 60 = f£ I 480 = 8 = fg I 7680 = 128 = 16 = Ol 61440 = 1024 = 128 = 8 = C. 1 APPROXIMATE FLUID MEASURES. Teaspoonful = f^j. Tablespoonful = f^iv. Dessertspoonful = fgij. Wineglassful = f|ij. Teacupful = f^iv. A drop is usually considered equivalent to a minim, but this is the case only with a drop of water under certain conditions. The size of the drop varies with the shape of the vessel from which the liquid is being dropped and with the character of the liquid. The broader and thicker the lip of the bottle the larger is the size of the drops. Again, the lighter the liquid and the greater its viscidity the larger is the size of the drops. Chloroform and bromin, being very heavy, each drop about 250 drops to the fluidram ; tinctures, spirits, and fluid extracts drop from 130 to 150 drops to the fluidram ; oils, except castor oil, from 105 to 140 drops to the fluidram ; syrup, from 45 to no drops to the fluidram ; and waters and solutions, from 60 to 90 drops to the fluidram. WEIGHTS AND MEASURES. 645 I myriagram (Mg.) I kilogram (Kg.) I hectogram (Hg.) I decagram (Dg.) I gram (Gm.) I decigram (dg.) I centigram (Cg.) I milligram (mg.) METRIC WEIGHTS. 10,000 grams. 1000 grams. 100 grams. 10 grams. weight of 1 cubic centimeter of water at 4 C. tenth part of I gram, or 0.1 gram. hundredth part of I gram, or 0.01 gram. thousandth part of I gram, or 0.00 1 gram. METRIC MEASURES OF CAPACITY. I myrialiter (Ml. i) = \ I kiloliter (Kl. 1) = j 1 hectoliter (HI. 1) = j 1 decaliter (Dl. 1) = / I liter (L.) = j I deciliter (dl. or L. .1) = -/ I centiliter (cl. or L. 01) = \ I milliliter (ml. or j L. 001) ~ \ 10 cubic meters, or the measure of 10 milli- liters of water. 1 cubic meter, or the measure of 1 milliliter of water. 100 cubic decimeters, or the measure of 1 quintal of water. 10 cubic decimeters, or the measure of I myria- gram of water. I cubic decimeter, or the measure of I kilo- gram of water. 1 00 cubic centimeters, or the measure of 1 hectogram of water. 10 cubic centimeters, or the measure of I deca- gram of water. I cubic centimeter (c.c), or the measure of I gram of water. RULES FOR CONVERTING DRAMS AND GRAINS INTO THEIR METRIC EQUIVALENTS. To convert drams into grams, multiply the number of drams by 3.9 grams, which is the number of grams in 1 dram. To convert grains into the corresponding metric quantity, multiply the number of grains by .065, which is the metric equivalent of 1 grain. RULES FOR CONVERTING METRIC QUANTITIES INTO DRAMS AND GRAINS. To convert grams into drams, divide the number of grams by 3.9. To convert grams into grains, divide the number of grams by .065. EQUIVALENTS OF APOTHECARIES' IN METRIC WEIGHTS. Grain. Gram. Grain. Gram. .0324 = .0648 = .1296 .3240 .5184 = .6480 = .9720 = I.2960 = I.944O = 2.5920 3.888 -5-5-0 i 1 I Gram. Grain .OOO324 l .OOO43 I .OO064 2 .OO086 5 .OOI29 8 .OOI62 10 .OO324 15 .00648 20 .OI08 30 .Ol62 40 .02l6 60 646 APPLIED THERAPEUTICS. EQUIVALENTS OF APOTHECARIES' IN METRIC MEASURES. !inims. Cubic centimeters. Fluidounces. Cubic centimeters I = O.061 I = 29.57 2 = O.I23 2 = 5914 3 = O.185 3 = 89.OO 5 = O.308 4 = II8.29 7 = O.43I 6 = 17742 10 = O.616 10 = 295-73 15 = O.924 12 = 355-0O 20 = I.23 16 = 473-17 30 = I.84 20 = 59i-5o 40 = 2.46 24 = 71000 60 = 3-7 32 - 946.35 PERCENTAGE IN SOLUTIONS. To estimate the quantity of a drug required to make a fluidounce or pint of a solution of a given percentage, multiply the weight of a fluid- ounce or a pint of the liquid to be used as the solvent by the percentage. Thus, in an ounce of a 10 per cent, aqueous solution of silver nitrate there are 45.5 grains, 455.7 grains (weight of a fluidounce of water) x o. I (percentage) = 45.5 grains. In a pint of the same solution there are 729. 1 grains. 7291 grains (weight of a pint of water) x 0.1 (percentage) = 729 I. If a pint of a 1 : 1000, 1 : 100, or 1 : 40 solution be required, divide 7291 by 1000, 100, or 40, as the case may be, to determine the quan- tity of the drug. Thus, in a pint of corrosive sublimate solution (1 : 1000) there are 7.29 grains of the drug. 7291 grains h- 1000 = 7.29 grains. To determine the weight of a fluidounce or pint of a liquid other than water, multiply 455.7 or 7291 by the specific gravity of the liquid, and the product will be the weight desired. INDEX [To obviate the inconveniences attending the use of two separate indexes — an Index of Diseases and an Index of Remedies — the author has employed but one general index. The name of each disease is printed in bold-faced type, and under it are grouped the remedies employed in the disease.] Abortion, threatened opium, 96 viburnum prunifolium, 140 Abrin, 447 Abrus, 447 Abscesses carbolic acid, 389 formalin, 404 hydrogen dioxid, 408 iodoform, 320 Acacia, 460 Aceta, 19 Acetanilidum, 347 Acetonemia. See also Diabetes mel- litus. hypodermoclysis, 496 infusion, 496 sodium bicarbonate, 172 Acetphenetidinum, 351 Acetum, 451 Acetylsalicylic acid, 400 Acid, acetic, 451 agaric, 264 arsenous, as an antimalarial, 414; as a poison, 307 benzoic, 401 boracic, 411 boric, 411 camphoric, 264 carbazotic, 394 carbolic, 387; as a poison, 368 cathartinic, 206, 207 chromic, 451 cinnamic, 190, 278 citric, 469 gallic, 357 hydriodic, 317 hydrobromic, 116 hydrochloric, 181 hydrocyanic, 160 lactic, 452 Acid, nitric, 449 nitrohydrochloric, 449 osmic, 453 oxalic, 249 phosphoric, 301 picric, 394 prussic, 160 pyrogaiiic, 453 quinic, 244 salicylic, 395 sozoidolic, 390 sulphuric, 448 sulphurous, 407 tannic, 354 thymic, 392 trichloracetic, 451 Acidum aceticum, 451 arsenosum as a poison, 307; as an antimalarial, 414 benzoicum, 401 boricum, 411 camphoricum, 264 citricum, 469 gallicum, 357 hydriodicum, 317 hydrobromicum dilutum, 116 hydrochloricum, 181 hydrocyanicum, 160; as an anti- emetic, 170; as a poison, 160 lacticum, 452 nitricum, 449 nitrohydrochloricum, 449 osmicum, 453 oxalicum, 249 phosphoricum, 300 picricum, 394 salicylicum, 395 sulphuricum, 448; as an antihydrotic, 264; as a poison, 449 sulphurosum, 407 tannicum, 354 647 648 INDEX. Acidum trichloraceticum, 451 Acne ichthyol, 335 Rontgen rays, 505 sulphur, 201 sulphurated lime, 340 Aconite, 60; as an antipyretic, 352; as a local anesthetic, 159; as a poison, 62 Aconitin, 60 Acromegaly pituitary body, 345 Actinomycosis potassium iodid, 315 Actinotherapy, 504 Action, cumulative, of drugs, 37 Actol, 373 Acupuncture, 438 Addison's disease suprarenal gland, 68 Adenitis arsenic iodid, 311 blue ointment, 327 Crede's ointment, 374 Donovan's solution, 331 ferrous iodid, 295 ichthyol, 335 iodin, 318 lead iodid, 317 mercuric iodid, 331 oxid, 333 Adeps lanae, 464 hydrosus, 464 Adonidin, 56 Adonis vernalis, 56 Adrenalin, 66; as a circulatory stimu- lant, 59; as a hemostatic, 378 ^Ether, 118; as a local anesthetic, 161; as a circulatory stimulant, 123; as a spinal cord depressant, 150 ^Ethylis bromidum, 128 carbamas, no chloridum, 129 Agaricin, 264 Agurin, 223 Alcohol, 43; as a poison, 45; as a sto- machic, 179 Alcoholism treatment, 46 Ale, 44 Alexin of Buchner, 430 Alkaloids, definition of, 18 Allium, 282 Allspice, 191 Almonds, bitter, 462 sweet, 462 Aloe, 204 Aloin, 204 Alopecia. See also Seborrhea. Alopecia actinotherapy {Alopecia areata) , S°4 cantharides, 441 capsicum, 186 pilocarpin, 261 Alteratives, 305 Althaea, 461 Alum, 361; as an emetic, 168 ammonioferric, 295 Alumen, 361; as an emetic, 168 Amaurosis strychnin, 144 Amboceptor, 430 Amenorrhea aloes, 204 apiol, 248 cimicifuga, 138 Dewees' mixture, 249 Dover's powder, 271 hot foot-bath, 495 iron, 247 oxalic acid, 249 pennyroyal, 256 potassium permanganate, 248 senecio, 249 treatment, 247 Ammonia, 41 Ammoniacum, 280 Ammonii acetas, 262 bromidum, 115 carbonas, 276; as a circulatory stimu- lant, 43 chloridi, 275 iodidum, 316 salicylas, 399 valeras, 135 Ammonium valerate, 135 Amygdala, 462 Amyl nitrite, 69 Amylis nitris, 69 Amylum, 463 Analgesics, 130 Anaphrodisiacs, 244 Anemia arsenic, 310 cod-liver oil, 304 iron, 290 massage, 486 mercuric chlorid, 486 treatment, 547 Anemia, pernicious treatment, 547 Anemia, splenic treatment, 548 Anemonin, 65 Aneson, 106 Anesthesia, infiltration, 86 Anesthesin, 156 INDEX. 649 Anesthetics, general, 118 local, 153 Aneurysm, aortic bleeding, 503 calcium cnlorid, 383 gelatin, 382 electricity, 483 ice-bag, 492 Moore-Corradi treatment, 483 potassium iodid, 315 veratrum, 64 Angina pectoris amyl nitrite, 70 arsenic, 310 atropin, 80 chloroform, 127 digitalis, 51 erythrol tetranitrate, 72 Hoffmann's anodyne, 136 nitroglycerin, 71 opium, 96 potassium iodid, 315 treatment, 615 Anisum, 191 Anodynes, 130 Antacids, gastric, 170 Anthelmintics, 422 Anthemis, 176 Anthracene derivatives, 198 Anthrax carbolic acid, 389 Antianthrax serum, 436 Anticonvulsants, 130 Antidysenteric serum, 437 Anti-emetics, 168 Antifebrin, 348 Antihydrotics, 262 Antimalarials, 414 Antimeningococcic serum, 434 Antimonii et potassii tartras, 271; as an emetic, 167; as a poison, 272 Antimonium, 271 Antimony, 271 and potassium tartrate, 271. See Tartar emetic. Antinosin, 322, 391 Antipneumococcic serum, 434 Antipyretics, 346 Antipyrin, 350 Antisepsis, gastro-intestinal, 386 surgical, 385 Antiseptics, 383 urinary, 386 Antispasmodics, 131 Antistreptococcus serum, 433 Antitoxin diphtheria, 431 tetanus, 432 Antitoxins, 428 Antituberculous serum, 435 Antityphoid serum, 437 Antivenene, 437 Anus, fissure of Anesthesin, 156 belladonna, 79 iodoform, 320 orthoform, 155 silver nitrate, 371 Aphrodisiacs, 244 Apiol, 248 Apocodein hydrochlorid, 274 Apocynum, 225 Apolysin, 352 Apomorphinas hydrochloridum, 273; as an emetic, 166 Apoplexy bloodletting, 503 croton oil, 211 electricity, 481 ice-cap, 492 massage, 485 strychnin, 144 treatment, 624 Appendicitis treatment, 571 Aqua hydrogenii dioxidi, 408 Aquae, 19 Arbutin, 240 Arecolin hydrobromid, 165 Argentamin, 373 Argenti nitras, 370 oxidum, 370 Argentum, 369 colloidale, 374 Argyrol, 373 Arhythmia digitalis, 52 Aristol, 321, 392 Arnica, 444 Arseni bromidi, 312 iodidum, 312 trioxidum, 305 Arsenic, 305 trioxid, 305, 456 Arsenic-poisoning dialyzed iron, 293 ferric hydrate, 293 treatment, 308 Arsenum, 305 Arteriosclerosis erythrol tetranitrate, 72 nitroglycerin, 71 potassium iodid, 314 Arthritis blisters, 441 blue ointment, 327 Crede's ointment, 374 dry heat, 495 ichthyol, 335 650 INDEX. Arthritis iodin, 318 iodoform, 320 massage, 486 Asafetida, 134 Aspidium, 423 Aspidosperma, 274 Aspirin, 400 Asthma amyl nitrite, 70 arsenic, 310 belladonna, 78 bromids, 113 cannabis indica, 101 chloralamid, 106 chloroform, 126 conium, 151 cubeb, 288 gelsemium, 149 grindelia, 283 heat, 495 heroin, 99 Hoffmann's anodyne, 136 lobelia, 152 opium, 96 paraldehyd, no potassium iodid, 315 nitrate, 229 quebracho, 274 stramonium, 81 treatment, 587 Astringents, 353 Atoxyl, 312 Atropin, 75; as an antihydrotic, 263; as a mydriatic, 161 Aurantium, 470 Auri et sodii chloridum, 336 Bacteriolysins, 429 Bacteriolysis, 430 Balsam dipterocarpus, 446 of copaiba, 234 of Peru, 279 of Tolu, 279 Balsams, definition of, 18 Balsamum Peruvianum, 279 Tolutanum, 279 Barii sulphidum, 456 Basham's mixture, 292 Bath, cold, 491 hot-air, 494 hot-vapor, 494 hot-water, 494 Russian, 495 Turkish, 494 Bearberry, 240 Bed-sores. See also Ulcers. balsam of Peru, 279 Bed-sores glycerin, 467 lead plaster, 365 treatment, 513 Beer, 44 Belladonna, 75; as an antihydrotic, 263; as a mydriatic, 162; as a poison, 77 Benzaldehydum, 463 Benzoinum, 277 Benzonaphthol, 395 Benzosol, 287 Benzosulphinidum, 473 Berberin, 379 Betanaphthol, 394 Betanaphthol-bismuth, 395 Betol, 401 Bismuth subsalicylate, 376, 399 Bismuthi subcarbonas, 376 subgallas, 376 subnitras, 374 subsalicylas, 376, 399 Bismuthum, 374 Bites, insect ammonia, 42 witch-hazel, 360 Bites, snake- alcohol, 47 antivenene, 437 Black haw, 140 wash, 331 Blastomycosis Rontgen rays, 505 Blaud's pills, 292 Blepharitis mercuric oxid ointment, 333 Blisters, 438 Blood-letting, 501 Blood-root, 282 Blue mass, 210, 326 ointment, 327 Boils sulphurated lime, 340 Boneset, 177 Borax, 412 Brain, congestion of aconite, 62 elaterium, 215 hot foot-bath, 495 ice-cap, 492 mustard, 443 potassium bromid, 114 Brand treatment of typhoid fever, 492 Brandy, 43 Brayera, 424 Bright's disease. See Nephritis. Bromidrosis. See also Hyperidrosis. chromic acid, 452 formaldehyd, 404 potassium permanganate, 409 INDEX. 6 5 I Bromin, 454 Bromipin, 454 Bromism, in Bromoform, 116 Bromoformum, 116 Bromum, 454 Bronchitis, acute aconite, 62 ammonium carbonate, 276 chlorid, 275 apomorphin, 274 benzoin, 278 codein, 99 conium, 151 grindelia, 283 heroin, 99 hyoscyamus, 81 iodin (locally), 318 ipecac, 270 lactucarium, 138 lobelia, 152 mustard (locally), 443 opium, 96 potassium citrate, 275 quebracho, 274 squill, 288 stupe of oil of turpentine, 446 tartar emetic, 272 treatment, 584 Bronchitis, chronic ammonium chlorid, 275 apomorphin, 274 arsenic iodid, 311 benzoin, 277 cannabis indica, 101 cod-liver oil, 304 copaiba, 234 creosote, 284 guaiacol carbonate, 287 ipecac, 270 oil of eucalyptus, 281 of myrtle, 282 of santal, 288 opium, 96 physostigma, 148 potassium iodid, 315 senega, 282 strychnin, 143 tar, 288 terebene, 289 terpin hydrate, 289 treatment, 585 Bronchopneumonia. See Pneumo- nia, catarrhal. Broom, 225 Brown mixture, 462 Brucin, 141 Bruises. See Contusions. Bryonia, 215 Bubo iodin, 318 mercurial ointment, 327 Bubonic plague antitoxin, 436 vaccines, 436 Buchner's alexin, 430 Buchu, 239 Buckthorn, 199 Burns anesthesin, 157 bismuth subgallate, 376 boric acid, 412 carbolic acid, 390 carron oil, 173 chloretone, 106 continuous warm bath, 495 hypodermoclysis, 496 ointment of zinc oxid, 368 orthoform, 156 picric acid, 396 sodium bicarbonate, 172 Bursitis blue ointment, 327 iodin, 318 Butternut, 202 Butyl-chloral hydras, 104 Cachets, 27 Cacodylate of sodium, 312 Cactus grandiflorus, 58 Cade, oil of, 445 Caffein, 54; as a diuretic, 222 Calabar bean, 146 Calamin, 369 Calcii carbonas, 377; as an antacid, 173 chloridum, 383 glycerophosphas, 302 bypophosphis, 302 lactas, 383 lactophosphas, 302 phosphas, 301 sulphidum hydratum, 456 Calcium chlorid, 383 lactate, 383 sulphid, 340, 456 Calculus, biliary. See Cholelithiasis. Calculus, renal. See Nephrolithiasis. Calomel, 330; as a cathartic, 209; as a diuretic, 232 Calumba, 175 Calx, 410 chlorinata, 406 sulphurata, 340 Cambogia, 212 Camphor, 132; as a circulatory stimu- lant, 58 Camphora, 132 652 INDEX. Camphora monobromata, 133; as an anaphrodisiac, 246 Cannabis indica, 100 Cantharis, 440; as an emmenagogue, 249; as a stimulant to genito- urinary tract, 241 Capsicum, 185 Capsules, 27 Caraway, 192 Carbo, 413 Carbolic acid, 387 Carbolic-acid poisoning alcohol, 47 magnesium sulphate, 217 treatment, 389 Carbuncle carbolic acid, 389 Carcinoma Rontgen rays, 505, 506 Cardamomum, 188 Carminatives, 184 Caroid, 184 Carron oil, 172 Carum, 192 Caryophyllus, 188 Cascara sagrada, 198 Cascarilla, 178 Cassia fistula, 201 Castor oil, 208 Cataplasmata, 30 Cathartics, 193 Cathartin, 198, 206, 207 Cathartinic acid, 207 Caustic potash, 454 soda, 455 Caustics, 447 Cautery, actual, 438 Cephaelin, 269, 271 Cerata, 29 Cerates, 29 Cerebral depressants, 89 excitants, 74 Cerebral hemorrhage. See Apo- plexy. Cerebrospinal fever treatment, 515 Cerii oxalas, 170 Cetaceum, 464 Charing. See Erythema intertrigo. Chalk, 377 Chamomile, 176 Charcoal, 413 Charts, 30 Chartulae, 27 Chaulmoogra oil, 445 Chenopodium, 426 Chilblains aconite, 159 ammonia liniment, 42 Chilblains calcium chlorid, 383 creosote, 285 ice, 492 ichthyol, 335 iodin, 319 turpentine liniment, 237 Chimaphila, 241 Chirata, 176 Chiretta, 176 Chloasma lactic acid, 453 Chloral, 10 1 camphorated, 103 Chloralamid, 104 Chloralformamid, 104 Chloralose, 105 Chloralum hydratum, 10 1 as a poison, 102 Chloretone, 106; as a local anesthetic, 157 Chlorin, 406 Chlorinated lime, 406 Chloroformum, 123; as an anthelmin- tic, 427; as a rubefacient, 446; as a spinal cord depressant, 150 Chlorosis treatment, 547 Chlorum, 406 Cholagogues, 193 Cholelithiasis treatment, 573 Cholera atropin, 78 camphor, 133 enteroclysis, 498 heat, 495 hypodermoclysis, 496 tannic acid, 356 vaccine, 436 treatment, 531 Cholera infantum treatment, 566 Chordee. See also Gonorrhea. camphor, 132 hops, 139 monobromated camphor, 134 opium, 96 potassium bromid, 114 Chorea acetanilid, 349 antipyrin, 350 arsenic, 310 chloral, 103 chloroform, 126 cimicifuga, 138 gelsemium, 149 hyoscin, 83, 118 hyoscyamin, 82 INDEX. 653 Chorea opium, 96 potassium bromid, 113 salicylic acid, 397 wet-pack, 493 treatment, 634 Chromii trioxidum, 451 Chrysarobinum, 444 Chrysophanic acid, 198, 206 Cimicifuga, 137 Cinchona, 415 Cinchonidin, 420 Cinchonin, 420 Cinchonism, 416 Cinnaldehydum, 190 Cinnamic aldehyd, 190 Cinnamomum, 190 Circulatory depressants, 59 stimulants, 39, 40; acceleration of heart-beat from, 40; increase of blood-pressure from, 39 Citrine ointment, 332 Citrophen, 352 Clemen's solution, 312 Cloves, 188 Clysters, 26 Coca, 83 Cocain, 83; as a local anesthetic, 153; as a mydriatic, 163; as a poison, 85; as a respiratory stimulant, 73 Cocaina, 83 Cocainism, 85 Cocainization, medullary, 87 Cocculus indicus, 265 Codeina, 99 Cod-liver oil, 303 Coffee, 54 Colchicina, 336 Colchicum, 336 Cold, 491 cream, 463 Colic asafetida, 134 atropin, 78 camphor (intestinal), 132 chloroform, 126 hot bath, 495 morphin, 96 oil of cloves (intestinal), 189 peppermint (intestinal), 187 Collapse adrenalin, 68 ammonia, 42 atropin, 78 camphor, 132 digitalis, 50 enteroclysis, 499 ether, 57, 123 hot bath, 495 Collapse infusion, 496 strychnin, 143 Collargol, 374 Collodia, 25 Collodion, 468 Collodions, 25 Collodium, 468 Colloidal silver, 374 Colocynthis, 212 Columbo, 175 Comedo sulphur, 201 Complement, 430 Complementophilic group, 430 Compound cathartic pills, 212 Condurango, 176 Confections, 27 Conium, 151 Conjunctivitis boric acid, 412 calomel (phlyctenular), 330 copper sulphate (granular), 367 jequirity (granular), 447 mercuric oxid (phlyctenular), 333 organic silver salts (purulent), 373 silver nitrate (purulent), 371 zinc sulphate, 269 Constipation abdominal massage, 486 aloes, 204 belladonna, 79 blue mass, 326 calomel, 209 cascara sagrada, 199 castor oil, 208 colocynth, 212 compound cathartic pill, 212 croton oil, 211 enemata, 197 enteroclysis, 499 euonymus, 202 glycerin suppositories, 467 ipecac, 271 magnesia, 199 magnesium citrate, 219 sulphate, 217 oxgall, 204 phenolphthalein, 208 physostigma, 148 podophyllum, 213 rhubarb, 206 Rochelle salt, 218 Seidlitz powder, 219 senna, 207 sodium phosphate, 219 strychnin, 144 sulphur, 200 vegetable cathartic pills, 212 654 INDEX. Constipation treatment, 563 Contusions alcohol, 47 ammonium chloride, 276 arnica, 444 camphor, 132 chloroform, 127 ichthyol, 335 lead-water, 364 opium, 98 witch-hazel, 364 Convallamarin, 56 Convallaria, 56; as a diuretic, 224 Convulsions treatment, 130 Copaiba, 234 Copper arsenite, 313 sulphate, 366 Coriandrum, 192 Corn smut, 257 Corneal opacities dionin, 99 Corns acetic acid, 451 chromic acid, 452 salicylic acid, 398 trichloracetic acid, 451 Corn-silk, 242 Cornutin, 74, 253 Corrosive sublimate, 327; as a germi- cide, 385 Coryza. See Rhinitis, acute. Cosmolin, 465 Cotarninae hydrochlorid, 380 Cotton-root, 257 Cough cannabis indica, 101 chloroform, 126 codein, 99 heroin, 99 hydrocyanic acid, 160 hyoscyamus, 81 opium, 96 treatment, 267 Counterirritants, 438 Cowling's rule for dosage, 38 Cream of tartar, 227 Crede's ointment, 374 Creolin, 391 Creosotal, 285 Creosote, 283 Creosotum, 283 Cresol, 39 t Cresols, 391 Creta, 377 Croton chloral. See Butyl-chloral hy- drate. oil, 206 Croton-chloral hydrate, 104 Croup, membranous. See Diphtheria. Croup, spasmodic treatment, 580 Cubeba, 235 Culver's root, 203 Cumulative action of drugs, 37 Cupping, 501 Cupri arsenis, 313 sulphas, 366; as an emetic, 167 Curare, 150 Cusso, 424 Cycloplegics, 161 Cystitis, acute boric acid, 412 corn-silk, 242 hops, 138 hyoscyamus, 81 vegetable salts of potassium, 227 Cystitis, chronic benzoic acid, 401 boric acid (injection), 412 buchu, 239 copaiba, 234 pareira, 241 silver nitrate (injection), 372 urotropin, 404 uva ursi, 241 Dandelion, 177 Deadly nightshade, 75 Decocta, 20 Decoctions, 20 Defecation, painful belladonna, 79 Delirium tremens apomorphin, 274 cannabis indica, 101 chloralamid, 105 hyoscin, 83, 118 opium, 96 paraldehyd, 109 potassium bromid, 114 treatment, 46 Delphinin, 65 Demulcents, 458 Deodorizers, 383 Depilatories, 448 Dermatol, 376 Desiccated thyroid extract, 68 glands, 341 Dewee's emmenagogue mixture, 249 Diabetes insipidus strychnin, 145 treatment, 542 Diabetes mellitus. See also Aceto- nemia. antipyrin, 350 INDEX. 655 Diabetes mellitus arsenic, 310 bromid, 313 codein, 99 gold and sodium chlorid, 336 jambul, 339 massage, 486 opium, 97 phosphoric acid (thirst), 301 sodium bicarbonate (coma), 172 uranium nitrate, 341 treatment, 539 Diaphoretics, 257 Diarrhea, acute betanaphthol-bismuth, 395 bismuth salicylate, 400 subgallate, 376 subnitrate, 375 subsalicylate, 376 blue mass, 326 calomel, 210 camphor, 132 castor oil, 208 chalk, 173 creosote, 284 Epsom salt, 217 hematoxylon, 359 kino, 358 krameria, 358 lime-water, 173 magnesia, 200 mercury with chalk, 326 oil of cajuput, 191 opium, 97 rhubarb, 206 salol, 400 sodium sulphocarbolate, 390 tannalbin, 356 tannigen, 356 treatment, 565 Diarrhea, chronic betanaphthol-bismuth, 395 bismuth salicylate, 400 copper sulphate, 367 iron sulphate, 294 lead acetate, 364 silver nitrate, 372 thymol, 392 zinc sulphate, 269 treatment, 568 Diastase, 184 Diethylbarbituric acid, in Diethylmalonylurea, in Digestants, 180 Digitalin, 48 Digitalinum germanicum, 48 Digitalline cristallisee, 48 Digitalis, 47; as a diuretic, 222; as a poison, 49 Digitophyllin, 48 Digitoxin, 48 Dionin, 99 Diphtheria alcohol, 47 antitoxin, 431 boric acid, 412 corrosive sublimate, 328 hydrogen dioxid, 409 ice-poultices, 492 lime-water, 173 Loffler's solution, 293 quinin, 419 strychnin, 143 tincture of ferric chlorid, 293 treatment, 523 Disinfectants, 383 Disseminated sclerosis gold and sodium chlorid, 336 hyoscyamin, 82 Diuretics, 220 Diuretin, 223 Dobell's solution, 172 Donovan's solution, 306, 331 Dosage, 38; Cowling's rule for, 38; influence of age, sex, and weight on, 38; Young's rule for, 38 Dover's powder, 92 Drastics, 195 Dropsy apocynum, 226 caffein, 223 calomel, 232 convallaria, 224 copaiba, 234 digitalis, 52, 222 diuretin, 223 Epsom salt, 217 elaterium, 215 heat, 495 compound jalap powder, 214 Niemeyer's pill, 52 pilocarpin, 260 scoparius, 225 Southey's tubes, 611 squill, 224 theobromin, 223 theocin, 223 vegetable salts of potassium, 226 Drugs, circumstances modifying effects of, 37 . composition of, 17 methods of administering, 35 preparations of, 19 Dusting-powders, 459 Dysentery enteroclysis, 498 hydrogen dioxid, 409 ice-suppositories, 492 6;6 INDEX. Dysentery ipecac, 270 magnesium sulphate, 217 methylene-blue, 421 opium, 97 quinin, 419 silver nitrate, 372 treatment, 569 Dysmenorrhea antipyrin, 350 belladonna, 78 camphor, 132 cannabis indica, 10 1 senecio, 249 viburnum prunifolium, 140 Dyspepsia. See Indigestion. Ecbolics, 251 Eclampsia, puerperal bleeding, 503 chloral, 103 chloroform, 126 hypodermoclysis, 496 pilocarpin, 260 potassium bromid, 113 veratrum, 65 Eczema, acute black wash, 331 boric acid, 412 carbolic acid, 390 hydrocyanic acid, 160 lead subacetate, 365 picric acid, 394 Rontgen rays, 505 zinc carbonate, 369 oxid, 368 Eczema, chronic ammoniated mercury, 332 arsenic, 310 calomel, 330 ichthyol, 335 oil of cade, 445 resorcin, 393 salicylic acid, 397 sulphur, 201 tar, 288 thymol, 392 Ehrlich's lateral-chain theory, 429 Elaterin, 215 Elaterium, 215 Electricity, 475 static, 475 Elephantiasis thiosinamin, 444 Elixiria, 21 Elixirs, 21 Emetics, 166 Emetin, 269 Emmenagogues, 247 I Emodin, 198, 206 Emollients, 458 Emphysema ammonium carbonate, 277 bleeding, 503 heroin, 99 quebracho, 274 strychnin, 143 treatment, 590 Emplastra, 29 Empyema treatment, 604 Emulsa, 24 Emulsions, 24 Endermic method of administering drugs, 37 Endocarditis, chronic adonidin, 57 alcohol, 47 apocynum (dropsy), 226 belladonna plaster, 79 bleeding, 503 caffein, 55 calomel, 210 chloralamid (insomnia), 105 convallaria, 56 digitalis, 50 elaterium (dropsy), 215 Epsom salt (dropsy), 217 Hoffmann's anodyne, 136 hyoscin (insomnia), 83 ice-bag (palpitation), 492 jalap (dropsy), 214 massage, 486 morphin, 96 Nauheim treatment, 490 Niemeyer's pill, 52 nitroglycerin, 71 paraldehyd (insomnia), no squill, 225 strophanthus, 53 strychnin, 143 theobromin, 223 treatment, 607 Endometritis ichthyol, 335 iodin, 318 silver nitrate, 372 tannic acid, 355 Enemas, 26, 197 Enemata, 197 Enteritis, acute. See Diarrhea, acute. Enteroclysis, 498 Enterorrhagia. See Hemorrhage. Epididymitis guaiacol, 286 local bleeding, 503 silver nitrate, 371 INDEX. 6$7 Epilepsy acetanilid, 349 amyl nitrite, 70 antipyrin, 350 bromopin, 454 chloral, 103 chloretone, 106 horse-nettle, 131 hydrobromic acid, 116 monobromated camphor, 134 potassium bromid, 113 urethane, no treatment, 635 Epinephrin, 66 Epispastics, 438 Epistaxis. See also Hemorrhage. h adrenalin, 68 antipyrin, 351 cold, 492 gelatin, 381 tannic acid, 355 vinegar, 451 Epithelioma actinotherapy, 504 arsenic, 309 pyrogallol, 453 Vienna paste, 455 zinc chlorid, 369 Epsom salt, 216 Ergota, 251; as a hemostatic, 378; as a poison, 254 Ergotin, 253 Erigeron, 239 Eriodictyon, 471 Erotomania hyoscin, 83 monobromated camphor, 133 potassium bromid, 114 Erysipelas Crede's ointment, 374 grindelia, 283 ichthyol, 335 lead-water and laudanum, 198 tincture of ferric chlorid, 293 treatment, 534 Erythema bismuth subnitrate, 375 boric acid, 412 camphor, 132 talc, 467 zinc carbonate, 369 oxid, 368 Erythema intertrigo bismuth subnitrate, 375 boric acid, 412 camphor, 132 chalk, 377 starch, 463 talc, 468 42 Erythema intertrigo zinc carbonate, 369 oxid, 368 Erythrol tetranitrate, 72 Escharotics, 447 Eserin, 146; as a myotic, 165 Essential oils, definition of, 18 Ether, 118. See JEther. compound spirit of, 136 hydrobromic, 128 nitrous, spirit of, 260 Ethyl alcohol, 43 bromid, 128 carbamate, no chlorid, 129, 158 oxid, 118 Eucain, 153 Eucalyptol, 280 Eucalyptus, 280 Eugenol, 188, 191 Eumydrin, 163 Euonymin, 202 Euonymus, 202 Eupatorium, 177 Euphthalmin, 164 Euquinin, 420 Europhen, 321 Exalgin, 349 Excitomotors, 140 Exodin, 198 Exophthalmic goiter belladonna, 79 calcium glycerophosphate, 302 digitalis, 52 electricity, 483 ice-bag. 492 thymus gland, 344 treatment, 550 Expectorants, 266 Extracta, 26 Extracts, 26 Faradism, 477 Febrifuges, 346 Fel bovis, 203 Felon silver nitrate, 371 Fennel, 192 Ferratin, 297 Ferri carbonas, 292 chloridum, 292 citras, 295 et ammonii sulphas, 295 hydroxidum, 293 cum magnesii oxido, 293 hypophosphis, 297 iodidum, 295 lactas, 297 658 INDEX. Ferri oxalas, 297 phosphas, 295 pyrophosphas, 296 subsulphas, 294 sulphas, 294 tartras, 294 valeras, 135, 297 Ferrum, 289 albuminatum, 296 dialysatum, 293 reductum, 291 Fevers aconite, 353 alcohol, 47 camphor, 132 chloralamid, 104 cold, 492 hops, 139 _ hydrobromic acid, 116 hydrochloric acid, 182 musk, 137 pilocarpin, 260 quinin, 419 spirit of mindererus, 262 of nitrous ether, 262 strychnin, 143 Fibrolysin, 444 Filariasis methylene-blue, 421 Filix-mas, 423 Finsen's light treatment, 504 Fish berries, 265 Fixed dressings, 459 oils, definition of, 18 Flatulence. See also Tympanites. asafetida, 134 camphor, 132 capsicum, 186 carbolic acid, 390 cardamom, 188 charcoal, 413 Hoffmann's anodyne, 137 oil of cajuput, 190 of turpentine, 237 peppermint, 187 strychnin, 144 Flavoring agents, 469 Flaxseed, 459 Fluidextracts, 23 Fceniculum, 192 Formal, 402 Formaldehydum, 402 Formalin, 402 Fowler's solution, 306 Foxglove, 47 Frangula, 199 Franklinism, 475 Freckles lactic acid, 453 Frenkel's treatment of locomotor ataxia, 486 Friar's balsam, 277 Fruit-sugar, 473 Fuller's earth, 468 Fumigation, administering drugs by, 37 Galla, 357 Gall-stones. See Cholelithiasis. Galvanism, 475 Gambir, 358 Gamboge, 212 Ganglion iodin, 318 Garlic, 282 Gastralgia ammonia, 42 arsenic, 310 bismuth subnitrate, 375 cannabis indica, 101 chloroform, 127 hydrocyanic acid, 160 menthol, 157 strontium bromid, 116 treatment, 558 Gastrectasis. See Stomach, dilata- tion of. Gastritis, acute bismuth subnitrate, 375 cerium oxalate, 170 hydrocyanic acid, 160 lavage (toxic), 501 mustard, 443 opium, 97 turpentine stupes, 237 Gastritis, chronic. See Indigestion. Gelatin, 380 Gelseminin, 148 Gelsemium, 148 Geni to -urinary tract sedatives, 242 stimulants, 233 Gentian, 174 Geranium, 359 Germicides, 383 Gin, 43 Ginger, 189 Glands, enlarged. See Adenitis. Glandulae suprarenales siccas, 66 thyroidae siccas, 341 Glandular thymus, 344 Glauber's salt, 218 Glaucoma arecolin hydrobroma, 165 eserin, 148 pilocarpin, 261 Glonoin, 71. See Nitroglycerin. INDEX. 659 Glucosids, definition of, 18 Glutol, 404 Glycerinum, 466 Glycerita, 26 Glycerites, 26 Glyceryl trinitrate, 71 Glyceryls nitras, 71 Glycyrrhiza, 461 Goa powder, 444 Goiter iodin, 318 thyroid gland, 343 Goiter, exophthalmic. See Exoph- thalmic goiter. Gold and sodium chlorid, 336 Golden seal, 379 Gonorrhea. See also Chordee. argyrol, 373 bismuth subnitrate, 376 copaiba, 234 copper sulphate, 367 cubeb, 235 hydrastin hydrochlorate, 380 ichthyol, 336 lead acetate, 364 methylene-blue, 421 oil of santal, 236 picric acid, 394 potassium permanganate, 409 salol, 400 silver nitrate, 372 soluble salts of silver, 372 sulphate, 368 Gossypii cortex, 257 Goulard's cerate, 365 extract, 365 Gout arsenic, 310 colchicum, 337 guaiac, 338 lithium salts, 231 massage, 486 piperazin, 244 potassium iodid, 315 Turkish bath, 495 uric-acid solvents, 243 vegetable salts of potassium, 226 treatment, 542 Granatum, 423 Graves' disease. See Exophthalmic goiter. Green hellebore, 63 Gregory's powder, 206 Griffith's mixture, 250 Grindelia, 283 Guaiacol, 286 compounds, 287 Guaiacolis carbonas, 28$ Guaiacum, 338 Guaiamar, 287 Gum arabic, 460 Gum-resins, definition of, 18 Gums, definition of, 18 Gurjun balsam, 446 Gutta-percha, 469 FLematoxylon, 359 Hair, superfluous barium sulphid, 456 calcium sulphid, 456 hydrogen peroxid, 409 Hamamelis, 360 Hands, disinfection of, 385 Haptophore groups, 429 Hashish, 100 Hay fever. See also Asthma. adrenalin, 68 cocain, 88 Hay's treatment of serous effusions, 602 Headache acetanilid, 349 antipyrin, 350 caffein, 55 calcium chlorid, 383 ergot, 256 hydrobromic acid, 116 hot foot-bath, 495 ice-cap, 492 menthol, 158 mustard plaster, 441 phenacetin, 351 potassium bromid, 114 quinin (malarial), 417 Heart, degeneration of arsenic, 310 caffein, 55 digitalis, 51 massage, 486 Nauheim treatment, 488 nitroglycerin, 71 strophanthus, 53 strychnin, 143 treatment, 613 Heart, hypertrophy of aconite, 62 veratrum viride, 64 Heartburn antacids, 170 Heart-failure, sudden. See Collapse. Heat, 493 Hedeoma, 251 Hedonal, in Hellebore, 63 green, 63 white, 63 Hematemesis. See Hemorrhage. Hematogen, 296 66o INDEX. Hematoxylon, 359 Hemlock, 151 Hemogallol, 297 Hemol, 297 Hemophilia calcium chlorid, 385 gelatin, 381 treatment, 549 Hemoptysis. See Hemorrhage. Hemorrhage acetic acid, 451 adrenalin, 68 alum, 361 ammonio-ferric alum, 295 amyl nitrite, 70 antipyrin, 351 calcium chlorid, 383 cold, 492 enteroclysis, 499 ergot, 378 ferric chlorid, 292 gelatin, 381 hydrastinin, 380 hypodermoclysis, 496 infusion, 496 Monsel's solution, 294 nitroglycerin, 72 oil of erigeron, 239 of turpentine, 237 opium, 97 stypticin, 380 tannic acid, 355 witch-hazel, 360 treatment, 377 Hemorrhoids adrenalin, 68 anesthesin, 157 belladonna, 79 calcium chlorid, 383 iodoform, 321 nutgall ointment, 358 stramonium ointment, 81 sulphur, 201 witch-hazel, 360 Hemostatics, 377 Hemp, Canadian, 225 Indian, 100 Henbane, 81 Heroin, 99 Herpes zoster picric acid, 394 zinc oxid, 368 Hexamethylenamina, 404 Hiccough camphor, 132 Hoffmann's anodyne, 136 musk, 137 nitroglycerin, 71 oil of amber, 140 Hoffmann's anodyne, 136 Holocain, 153 Homatropin hydrobromid, 163 Honey, 474 Honeys, 25 Hook-worm disease betanaphthol, 395, 427 thymol, 392, 427 Hops, 138 Horse -nettle, 131 Hot baths, 494 pack, 494 Humulus, 138 Huxham's tincture, 415 Hydragogues, 195 Hydrargyri chloridi corrosivum, 327* as a germicide, 385 mite, 330; as a cathartic, 209; as a diuretic, 232 cyanidum, 332 iodidum flavum, 331 rubrum, 331 nitras, 332; as a caustic, 455 oxidi flavi, 333 rubric 333 salicylas, 333 subsulphas, 167, 333 succinimidum, 334 unguentum, 327 Hydrargyrum, 322 ammoniatum, 332 cum creta, 210, 326 Hydrastin, 379 Hydrastina, 379 Hydrastinin, 379 Hydrastis, 379; as an oxytocic, 256; as a stomachic, 180 Hydrocyanic acid, 160 Hydrogen dioxid, 408 Hyoscin, 75, 163 hydrobromid, 82, 117 Hyoscina, 81 Hyoscinae hydrobromidum, 117 Hyoscyamin, 75, 82 Hyoscyamina, 82 Hyoscyamus, 81 Hyperchlorhydria lavage, 501 sodium bicarbonate, 172 Hyperemesis. See Vomiting, excess- ive. Hyperidrosis. See also Niglit-sweats. agaricin, 264 alum, 361 belladonna, 78 chromic acid, 452 formaldehyd, 404 lead-plaster, 365 salicylic acid, 397 INDEX. 66 1 Hyperidrosis sulphuric acid, 449 tannic acid, 355 tannofarm, 356 Hypertrichosis Rontgen rays, 505 Hypnotics, 89 Hypodermic method of administering drugs, 35 Hypodermoclysis, 496 Hypophysis cerebri, 345 Hysteria asafetida, 134 bromids, 114 camphor, 132 chloralamid, 105 cold bath, douche, or spray, 493 electricity, 482 gold and sodium chlorid, 336 massage, 486 monobromated camphor, 134 paraldehyd, 109 sumbul, 139 valerian, 135 treatment, 642 Ice-poultice, 490 Ichthalbin, 335 Ichthargan, 335 Ichthoform, 335 Ichthyol, 334 Ichthyosis thyroid gland, 343 Idiosyncrasy, 37 Immune body, 430 Impotence phosphorus, 300 strychnin, 145 yohimbin, 245 treatment, 245 Incompatibilities, 30 Incontinence of urine belladonna, 78 strychnin, 144 Index, opsonic, 430 Indian hemp, 100 Indigestion alcohol, 180 arsenic, 310 asafetida, 134 bismuth subgallate, 376 subnitrate, 375 calomel, 210 capsicum, 186 carbolic acid, 390 charcoal, 413 creosote, 284 enteroclysis, 498 gentian, 175 Indigestion hydrastis, 180 hydrochloric acid, 181 ipecac, 271 lavage, 501 lime-water, 173 nitrohydrochloric acid, 450 nux vomica, 144 pancreatin, 183 pepsin, 183 rhubarb, 207 silver nitrate, 372 sodium bicarbonate, 171 sulphocarbolate, 390 stomachics, 174 strontium bromid, 116 treatment, 565 Infiltration anesthesia, 86 Influenza antipyrin, 350 cinnamon, 190 Dover's powder, 271 quinin, 419 treatment, 517 Infusa, 20 Infusion, 496 Infusions, 20 Inhalation, administering drugs by, 37 Insomnia cannabis indica, 10 1 chloral, 103 chloralamid, 105 chloralose, 106 chloretone, 106 hedonal, 111 hyoscin, 83 opium, 96 paraldehyd, no sulphonal, 108 trional, 109 urethane, no veronal, in treatment, 90 Intertrigo. See Erythema intertrigo. Intravenous injection of drugs, 36 Intussusception enteroclysis, 499 Inunction, administering drugs by, 36 Iodin, 317 Iodipin, 319 Iodism, 314 Iodoformum, 319; as a local anesthetic, 159; as an antiseptic, 384; as a poison 3*9 Iodol, 321 Iodothyrin, 342 Iodum, 317 Ipecacuanha, 269 as an emetic, 167 662 INDEX. Iris, 202 Iritis adrenalin, 68 atropin, 79 dionin, 99 eserin, 148 local bloodletting, 503 mercury, 330 Iron, 289 albuminates, 296 ammonium sulphate, 295 carbonate, 291 chlorid, 292 citrate, 295 dialyzed, 293 hydroxid, 293 hypophosphite, 297 iodid, 295 lactate, 297 oxalate, 297 phosphate, 296 pyrophosphate, 296 Quevenne's, 291 reduced, 291 subsulphate, 294 sulphate, 294 tartrate, 294 valerate, 135, 297 Irritants, 438 Itch. See Scabies. Itrol, 373 Ivy-poisoning. See Rhus-poisoning. Jaborandi, 258 Jalapa, 213 Jambul, 339 Jamestown weed, 80 Jasmine, yellow, 149 Jaundice, catarrhal ammonium chlorid, 276 boric acid (pruritus), 412 carbolic acid (pruritus), 389 enteroclysis, 499 hydrocyanic acid (pruritus), 160 sodium phosphate, 219 vegetable salts of potassium, 226 Jequirity, 447 Joints, inflammation of. See Ar- thritis. Juglans, 202 Juniperus, 239 Kamala, 425 Kaolinum, 468 Keloid thiosinamin, 443 Keratitis atropin, 79 boric acid, 412 dionin, 99 eserin, 148 formaldehyd, 404 holocain, 155 mercuric oxid, 333 pilocarpin, 261 Kidneys, inflammation of. See Nephritis. Kino, 358 Kousso, 424 " . Krameria, 358 Kryofin, 352 Labarraque's solution, 407 Laborde's method in asphyxia, 73 Lactophenin, 352 Lactose, 472 Lactucarium, 138 Lady Webster's pills, 204 Lanolin, 464 Largin, 373 Laryngismus stridulus belladonna, 78 gelsemium, 149 musk, 137 potassium bromid, 113 Laryngitis, acute aconite, 62 benzoin inhalations, 278 creosote, 284 iodin (externally), 318 menthol, 158 treatment, 580 Laryngitis, chronic alum, 361 menthol, 158 silver nitrate, 372 tannic acid, 355 treatment, 581 Laryngitis, tuberculous anesthesin, 157 cocain, 154 guaiacol, 286 iodoform, 320 lactic acid, 452 morphin, 96 orthoform, 156 treatment, 582 Laudanum, 91 Lavage, 500 Lavandula, 472 Lavender, 472 Laxatives, 193 Lead, 362 acetate, 364 INDEX. 663 Lead iodid, 317 nitrate, 365 oleate of, 365 oxid, 366 subacetate, 365 Lead-poisoning treatment, 363 Lead-water and laudanum, 364 Leeching, 507 Leiter's tubes, 490 Lemon, 469 Leprosy chaulmoogra oil, 446 gurjun balsam, 446 Leptandra, 203 Lettuce, wild, 138 Leukorrhea alum, 295 ammonio-ferric alum, 361 belladonna, 78 hydrastis, 380 ichthyol, 335 oak bark, 360 tannic acid, 355 zinc sulphate, 368 Leukemia Rontgen rays, 506 treatment, 548 Levulose, 473 Licorice root, 461 Lily of the valley, 56 Lime, 410 chlorinated, 406 sulphurated, 340 Lime-water, 172 Limon, 469 Linimenta, 25 Liniments, 25 Linseed, 459 Linum, 459 Liquor antisepticus, 411 calcis, 172 cresolis compositus, 391 gutta-perchae, 469 Liquores, 19 Litharge, 366 Lithii benzoas, 232 bromidum, 116 carbonas, 231 citras, .232 salicylas, 398 Liver, cirrhosis of treatment, 575 Lobelia, 151 as an expectorant, 275 Locomotor ataxia antipyrin, 350 cannabis indica, 101 electricity, 482 Locomotor ataxia Frenkel's exercises, 486 gold and sodium chlorid, 336 opium, 96 treatment, 625 Ldffler's solution, 295 Logwood, 359 Lotio flava, 330 nigra, 331 Lotiones, 25 Lotions, 25 Lozenges, 28 Lugol's solution, 317 Lumbago. See Muscular rheumatism. antipyrin, 350 acupuncture, 438 cimicifuga, 138 electricity, 483 salicylic compounds, 397 Lumbar puncture, 507 Lunar caustic, 370 Lungs, edema of. See also Dropsy. belladonna, 78 caffein, 55 . local bloodletting, 503 strychnin, 144 Lungs, tuberculosis of. See also Tuberculosis, pulmonary. Lupulinum, 138 Lupus vulgaris actinotherapy, 504 arsenic, 309 lactic acid, 452 pyrogallol, 453 Rontgen rays, 505 thiosinamin (scarring), 444 Lycetol, 244 Lycopodium, 468 Lysidin, 244 Lysol, 392 Magnesia, 199 as an antacid, 173 Magnesii carbonas, 200 citras, 219 oxidum, 173, 199 ponderosum, 173, 20c sulphas, 216 effervescens, 216 Magnesium oxid, 199 Malarial fever amyl nitrite (chills), 70 arsenic, 310 methylene-blue, 421 quinin, 417 Warburg's tincture, 262 treatment, 516 Male fern, 423 664 INDEX. Mandrake, 213 Mangani dioxidum praecipitatum, 248 Manganum, 248 Mania cannabis indica, 10 1 chloral, 103 conium, 151 croton oil, 211 hyoscin, 83, 118 nrethylene-blue, 420 paraldehyd, 109 Manna, 198 Marshmallow, 461 Massa hydrargyri, 210, 326 Massae, 27 Massage, 484 Masses, 27 Materia medica, definition of, 17 Matico, 235 May apple, 212 Measles treatment, 527 Medullary cocainization, 87 Mel, 474 Melaena neonatorum gelatin, 381 Melancholia hyoscin, 118 Mellita, 25 Meniere's disease gelsemium, 149 pilocarpin, 261 Meningitis, acute ice-cap, 492 local bleeding, 503 lumbar puncture, 507 opium, 96 treatment, 515 Meningitis, cerebrospinal treatment, 515 Menorrhagia cimicifuga, 138 ergot, 255 hydrastinin, 380 stypticin, 380 Mentha piperita, 187 viridis, 187 Menthol, 157 Mercurial ointments, 327 Mercuric chlorid, 327; as a germicide, 385 cyanid, 332 nitrate, 332 oxici, 333 salicylate, 333 sulphate, 333 succinimid, 334 Mercurous chlorid, 330; as a cathartic, 209; as a diuretic, 232 Mercury, 322 ammoniated, 332 bichlorid, 327 biniodid, 331 cyanid, 332 nitrate, 332 oxid, 333 protiodid, 331 salicylate, 334 subsulphate, 167,-333 with chalk, 326 Mercury-poisoning, 322 Mesotan, 399 Metacresol, 391 Methylaldehyd, 402 Methylatropin, 163 Methyl-blue, 414 Methylene-blue, 420 Methylis salicylas, 399 Methylpropylcarbinolurethane, 1 1 1 Methylthionin hydrochlorid, 420 Metric system, 645 Metrorrhagia ergot, 255 gelatin, 381 hydrastinin, 380 stypticin, 381 thyroid gland, 343 Mezereum, 340 Migraine. See also Neuralgia. amyl nitrate, 70 antipyrin, 350 butyl-chloral hydrate, 104 caffein, 55 cannabis indica, 10 1 ergot, 256 methylene-blue, 484 nitroglycerin, 72 potassium bromid, 114 Mindererus, spirit of, 262 Misturae, 20 Mixture, Basham's, 292 brown, 462 Dewees's, 249 Griffith's, 249 neutral, 228 Mixtures, 20 Monkshood, 60 Monsel's salt, 294 solution, 294 Moore-Corradi treatment of aneurysm, 483 Morphin, 91 Morphinism, 95 Moschus, 137 Motor nerve depressants, 150 Mouth, administering drugs by, 35 Mucilages, 20 Mucilagines, 20 INDEX. 665 Mucous patches chromic acid, 452 mercuric nitrate, 332 potassium chlorate, 230 silver nitrate, 372 trichloracetic acid, 451 Mumps treatment, 538 Musk, 137 Musk-root, 139 Mustard, 168; as a counterirritant, 442 Myalgia. See Rheumatism, muscular. Mycosis fungoides Rontgen rays, 505 Mydriatics, 161 Myelitis treatment, 627 Myotics, 165 Myristica, 189 Myrrha, 250 Myrtol, 281 Myxedema thyroid extract, 343 Naphthalinum, 394 Narcein, 91 Narcotin, 91 Nativelle's digitaline, 48 Nauheim treatment, 488 Nephritis, acute. See also Dropsy and Uremia. Basham's mixture, 293 cupping, 503 digitalis, 222 hot baths, 485 pilocarpin, 260 vegetable salts of potassium, 227 treatment, 616 Nephritis, chronic. See also Dropsy and Uremia. apocynum (dropsy), 226 Basham's mixture, 293 caffein (dropsy), 223 digitalis, 222 heat, 495 erythrol tetranitrate, 72 nitroglycerin, 71 pilocarpin, 260 potassium iodid, 315 theobromin, 223 treatment, 618 Nephrolithiasis lycetol, 244 piperazin, 244 piperidin tartrate, 244 quinic acid, 244 vegetable salts of potassium, 227 treatment, 622 Nerve depressants, 150, 153 Neuralgia acetanilid, 349 aconitin, 63 antipyrin, 350 arsenic, 310 blisters, 441 butyl-chloral hydrate, 104 cannabis indica, 10 1 chloral camphor, 103 electricity, 482 gelsemium, 149 menthol, 157 methylene-blue, 420 opium, 96 osmic acid, 453 phenacetin, 351 phosphorus, 300 potassium bromid, 114 quinin, 419 strychnin, 145 veratrin, 65 Neurasthenia calcium glycerophosphate, 302 cold douche or spray, 493 electricity, 482 gold and sodium chlorid, 336 hydrotherapy, 493 massage, 486 orexin, 179 phosphorus, 300 strychnin, 144 sumbul, 139 treatment, 639 Neuritis blisters, 441 cautery, 438 ■ electricity, 481 iodin, 318 massage, 485 salicylic compounds, 395 strychnin, 144 treatment, 629 Neutral mixture, 228 principles, definition of, 19 Nevi sodium ethylate, 456 trichloracetic acid, 451 Niemeyer's pill, 52 Night-sweats antihydrotics, 263 Nipples, fissured benzoin, 278 collodion, 469 glycerin, 467 orthoform, 156 Nitrites, 69 Nitrogen monoxid, 127 Nitroglycerin, 71; action of, 71; as a circulatory stimulant, 57 666 INDEX. Nitrous ether, spirit of, 262 oxid, 127 Nosophen, 322, 391 Novocain, 157 Nutgall, 357 Nutmeg, 189, Nux vomica, 141; as a poison, 142; as a circulatory stimulant, 30; as a stomachic, 180 Nymphomania camphor, monobromated, 134 hyoscin, 81 potassium bromid, 114 Oak, white, 360 Obesity thyroid gland, 343 Oil, amber, 140 birch, 399 cade, 445 cajuput, 190 carron, 172 castor, 208 chaulmoogra, 445 cod-liver, 303 croton, 211 erigeron, 239 eucalyptus, 280 gaultheria, 399 juniper tar, 445 myrtle, 281 santal, 236 tar, 287 turpentine, 236; as an expectorant 289; as a counterirritant, 446; as an anthelmintic, 427 Ointment, blue, 327 Ointments, 28 of mercury, 327 Oleate of lead, 365 Oleates, 29 Oleatum plumbi, 365 Oleoresins, definition of, 18 Oleum betulae, 399 cadinum, 445 cajuputi, 190 cubebse, 235 erigerontis, 239 gaultheriae, 399 gynocardiae, 445 morrhuae, 303 myrti, 281 olivae, 464 ricini, 208 santali, 236 succini, 140 terebinthinae, 236; as an anthelmin- tic, 427; as a counterirritant, 446; as an expectorant, 289 Oleum tiglii, 211 Onychia lead nitrate, 366 Opium, 91; as an anti-emetic, 170; as a diaphoretic, 261; as a poison, 94 Opium-pfiisoning artificial respiration, 73 atropin, 80 caffein, 55 cocain, 88 electricity, 483 lavage, 501 potassium permanganate, 409 strychnin, 143 tannic acid, 356 treatment, 94 Opsonic index, 430 Opsonins, 430 Orange, 470 Orchitis belladonna ointment, 79 guaiacol, 286 local bloodletting, 503 mercury and belladonna ointment, 327 Orexin, 179 Organic acids, 19 Orphol, 395 Orthocresol, 391 Orthoform, 155 Osteomalacia calcium phosphate, 302 phosphorus, 300 Otorrhea boric acid, 412 formaldehyd, 404 Ovarium, 345 Oxgall, 203 Oxytocics, 251 Ozena. See Rhinitis, chronic. Pack, cold, 491 hot, 494 Palpitation belladonna, 79 digitalis, 52 Hoffmann's anodyne, 136 ice-bag, 492 Palpitation, abdominal nitroglycerin, 71 Pancreatinum, 183 Papain, 184 Papayotin, 184 Papers, 30 Papoid, 184 Paracresol, 391 Paraffin, 465 Paraform, 402 INDEX. 667 Paraformaldehyd, 402 Paraldehydum, 109 Paralysis agitans conium, 151 hyoscin, 83 hyoscyamin, 82 Paregoric, 91 Paresis, postoperative, intestinal physostigma, 148 Pareira brava, 241 Parsley, 248 Pearson's solution, 306 Pediculosis capitis ointment of stavesacre, 65 tincture of cocculus indicus, 265 Pediculosis pubis blue ointment, 327 corrosive sublimate, 328 Pelletierin, 423 Pemphigus arsenic, 310 Pennyroyal, 251 Pepo, 425 Pepper, black, 186 cayenne, 185 Peppermint, 187 Pepsinum, 182 Pericarditis blisters, 441 calomel, 330 iodin, 318 local bloodletting, 503 potassium iodid, 315 treatment, 604 Pernicious anemia treatment, 547 Peronin, 100 Pertussis. See Whooping-cough. Peruvian bark, 415 Petrolatum, 465 Pharmacodynamics, definition of, 17 Pharmacy, definition of, 17 Pharyngitis, acute aconite, 62 capsicum, 186 potassium chlorate, 230 rhus glabra, 359 sodium benzoate, 278 tincture of ferric chlorid, 293 treatment, 552 Pharyngitis, chronic alum, 361 ammonium chlorid, 275 D obeli's solution, 172 iodin, 319 silver nitrate, 372 tannic acid, 355 tincture of ferric chlorid, 293 treatment, 553 Phenacetin, 351 Phenazon, 350 Phenocoll hydrochlorid, 352 Phenol, 387. See also Carbolic acid. Phenolphthalein, 208 Phenylis salicylas, 400 Phlebitis, acute Crede's ointment, 374 Phlebotomy, 503 Phosphorus, 298; as a poison, 298 Phosphorus-poisoning copper sulphate, 367 treatment, 299 Phthisis. See Tuberculosis, pulmo- nary. Physostigma, 146 as a myotic, 165 Physostigmin, 146 Picrotoxin, 74 Picrotoxinum, 265 Pills, 27 Blaud's, 292 blue, 326 compound cathartic, 212 Lady Webster's, 204 Niemeyer's, 52 Plummer's, 209 vegetable cathartic, 212 Pilocarpin, 258; as a myotic, 165 Pilocarpus, 258 Pilulse, 27 Pimenta, 191 Pinkroot, 426 Piper, 186 Piperazin, 244 Piperidin tartrate, 244 Piperin, 187 Pituitary body, 345 Pix liquida, 287 Plasters, 30 Pleurisy treatment, 601 Plumbi acetas, 364 iodidum, 317 nitras, 365 oxidum, 366 subacetas, 365 Plumbum, 362 Plummer's pills, 209 Pneumonia, catarrhal treatment, 591 Pneumonia, croupous ammonium carbonate, 277 antipneumococcic serum, 434 belladonna, 78 bleeding, 503 blisters, 441 caffein, 55 camphor, 132 668 INDEX. Pneumonia, croupous cocain, 88 digitalis, 52 hypodermoclysis, 496 ice-bag, 492 musk, 137 strychnin, 143 veratrum, 65 treatment, 519 Podophyllum, 213 Poliomyelitis electricity, 482 massage, 485 strychnin, 144 treatment, 628 Pollantin, 437 Pomegranate, 423 Porter, 44 Potassii acetas, 228 bicarbonas, 227 bitartras, 227 bromidum, in; as an anaphrodisiac, 246; as a somnifacient, in carbonas, 227 chloras, 229 citras, 228; as an expectorant, 275 dichromas, 452 et sodii tartras, 218 hydroxidum, 454 iodidum, 313 nitras, 228 permanganas, 409; as an emmena- gogue, 248 Potassium dichromate, 452 hydroxid, 454 vegetable salts of, 226; as expec- torants, 275 Poultices, 30 Powder, compound jalap, 214 licorice, 207 Dover's, 269 Gregory's, 206 Seidlitz, 218 Powders, 27 Preparation of drugs, 19 Priapism hyoscin, 81 monobromated camphor, 134 potassium bromid, 114 treatment, 627 Protargol, 373 Protectives, 458 Protoveratrin, 63 Prunus Virginiana, 178 Pruritus boric acid, 412 camphorated chloral, 103 carbolic acid, 159 creosote, 285 Pruritus hydrocyanic acid, 160 ichthyol, 335 resorcin, 393 RCntgen rays, 505 thymol, 392 Prussic acid, 160 Pseudoleukemia Rontgen rays, 506 Psoriasis ammoniated mercury, 332 arsenic, 310 chrysarobin, 445 oil of cade, 445 pyrogallol, 453 sulphur, 201 tar, 288 thyroid gland, 343 Ptyalism. See Mercury-poisoning. Puerperal eclampsia. See Eclamp- sia, puerperal. Pulsatilla, 65; as an emmenagogue, 251 Pulveres, 27 Pulvis effervescens compositus, 218 Pumpkin seed, 425 Punicin, 423 Purgative, 198 Purgatives, 195 Purgen, 208 Purpura haemorrhagica calcium chlorid, 383 gelatin, 381 oil of turpentine, 237 treatment, 549 Pyoktanin, 414 Pyrogallol, 452 Quassia, 175 Quebracho, 274 Quercus, 360 alba, 360 Quevenne's iron, 291 Quicklime, 410 Quicksilver, 322 Quincke's lumbar puncture, 507 Quinic acid, 244 Quinina, 416; as antipyretic, 352; as oxytocic, 256; as stomachic, 180 Rachitis calcium phosphate, 302 cod-liver oil, 304 ferrous iodid, 295 phosphorus, 300 thymus gland, 345 Radium, 506 Ragwort, 249 INDEX. 669 Raynaud's disease erythrol tetranitrate, 72 nitroglycerin, 72 Receptors, 429 Rectum, administering drugs by, 36 Relapsing fever treatment, 514 Renal calculus. See Nephrolithiasis. Resina, 238 Resins, definition of, 18 Resorcinol, 393 Respiration, artificial, 73 Respiratory depressants, 74 stimulants, 73 Rhamnus purstuana, 198 Rheum, 206 Rheumatism, acute blue ointment, 327 ferrous iodid, 295 ice-pack (hyperpyrexia), 493 ichthyol, 335 iodin, 318 iron iodid, 295 lead-water and laudanum, 366 oil of gaultheria, 400 opium, 98 salicylic compounds, 397 vegetable salts of potassium, 226 treatment, 536 Rheumatism, chronic ammonia liniment, 42 arsenic, 310 cimicifuga, 138 cod-liver oil, 304 Donovan's solution, 331 dry heat, 495 guaiac, 338 iodin, 318 massage, 486 potassium iodid, 315 salicylic compounds, 397 serpentaria, 178 sulphur, 201 Turkish bath, 495 treatment, 544 Rheumatism, muscular aconite liniment, 63 ammonia liniment, 42 belladonna ointment or plaster, 79 camphor liniment, 133 capsicum liniment, 186 chloroform liniment, 127 cimicifuga, 138 Dover's powder, 261 electricity, 483 opium, 97 pilocarpin, 260 salicylic compounds, 397 turpentine liniment, 237 Rheumatism, muscular treatment, 545 Rheumatoid arthritis arsenic, 310 cod-liver oil, 304 guaiacol carbonate, 287 hot air, 496 massage, 486 potassium iodid, 315 treatment, 545 Rhinitis, acute adrenalin, 68 camphor, 133 cocain, 88 Dover's powder, 271 hot foot-bath, 495 menthol, 158 witch-hazel, 360 treatment, 577 Rhinitis, chronic chromic acid, 452 citric acid (pzena), 470 Dobell's solution, 172 eucalyptol, 281 ichthyol (atrophic), 335 iodin, 319 menthol, 157 potassium permanganate, 409 treatment, 578 Rhubarb, 206 Rhus glabra, 359 Rhus-poisoning black wash, 331 grindelia, 283 sodium hyposulphite, 410 zinc carbonate, 369 Ricin, 208 Rickets. See Rachitis. Ringworm ammoniated mercury, 332 beta-naphthol, 395 chrysarobin, 445 corrosive sublimate, 328 Rontgen rays, 505 sodium hyposulphite, 410 sulphur, 201 sulphurous acid, 407 I Rochelle salt, 218 Rontgen ray therapy, 505 Rooms, disinfection of, 387 Rosa, 472 Rosin, 238 Rottlera, 425 Rubefacients, 438 Rubella treatment, 527 Rue, 252 Russian bath, 494 Ruta, 252 670 INDEX. Sabina, 251 Saccharin, 473 Saccharum lactis, 472 Sal ammoniac, 275 Salicinum, 401 Salines as diuretics, 220 Salivation atropin, 78 hydrogen dioxid, 409 myrrh, 250 potassium chlorate, 231 rhus glabra, 359 Salol, 400 Salophen, 401 Saltpeter, 228 Sandalwood, oil of, 236 Sanguinaria, 282 Santoninum, 425 Sapo mollis, 459 Saponins, definition of, 19 Sarsaparilla, 339 Sassafras, 191, 461 Savine, 251 Scabies balsam of Peru, 279 beta-naphthol, 395 sulphur, 201 Scalds. See Bums. Scammonium, 213 Scarlet fever treatment, 525 Scheele's green, 313 Schleich's infiltration anesthesia, 86 Schott treatment, 488 Sciatica actual cautery, 438 acupuncture, 438 antipyrin, 350 blisters, 441 cimicifuga, 138 massage, 486 methylene-blue, 421 nitroglycerin, 72 salicylic compounds, 397 treatment, 630 Scilla, 224; as an expectorant, 288 Scleroderma thiosinamin, 445 Scoparin, 225 Scoparius, 225 Scopola, 81 Scopolamin, 81 hydro bromid, 81, 163 Secale cornutum, 252 Scurvy treatment, 548 Sea-sickness chloralamid, 105 chloretone, 106 Sea-sickness potassium bromid, 114 Seborrhea resorcin, 393 sulphur, 201 Seidlitz powder, 218 Senecio, 249 Senega, 281 Senna, 207 Sensory nerve depressants, 153 Serpentaria, 178 Serum, anti-anthrax, 436 antidiphthericum, 431 antidysenteric, 437 antimeningococcic, 434 antipneumococcic, 434 antistreptococcus, 429 antituberculous, 435 antityphoid, 437 bubonic plague, 436 Shock adrenalin, 68 alcohol, 47 ammonia, 42 atropin, 78 adrenalin, 59 enteroclysis, 498 ether, 57 hot bath, 495 hypodermoclysis, 496 infusion, 496 strychnin, 143 Sidonal, 244 Silver, 369 citrate, 373 colloidal, 374 lactate, 373 nitrate, 370 oxid, 370 soluble salts of, 372 vitellin, 373 Sinapis alba, 442 nigra, 442 Sleeping sickness atoxyl, 312 Slippery elm, 461 Small-pox treatment, 528 Snake-bite. See Bites, snake-. Snakeroot, black, 137 Virginia, 378 Soap, green, 459 Soapstone, 467 Soda, caustic, 455 Sodii, arsenas, 306 benzoas, 278 bicarbonas, 171 boras, 412 bromidum, 115 INDEX. 671 Sodii cacodylas, 312 ethylas, 456 hydroxidum, 456 iodidum, 316 nitris, 73 phenolsulphonas, 390 phosphas, 219 salicylas, 398 sulphas, 218 thiosulphas, 410 Sodium hydroxid, 455 nitrite, 73 sulphocarbolate, 390 Solanum carolinense, 131 Solutions, 19 Somnifacients, 89 Southey's tubes, 611 Sozoiodol, 390 Spanish flies, 440; as an emmenagogue, 249; as a stimulant to genito-urinary tract, 441 Spartein, 152, 225 Sparteinae sulphas, 152 Spearmint, 187 Spermaceti, 464 Spermatorrhea hops, 139 hyoscin, 83 monobromated camphor, 134 potassium bromid, 114 treatment, 244 Sphacelotoxin, 253 Spice -poultice, 189 Spigelia, 426 Spinal cord depressants, 145 excitants, 140 Spirit of mindererus, 262 of nitrous ether, 262; as a diuretic, 233 Spirits, 21 Spiritus, 21 aetheris compositus, 135 glycerylis nitratis, 71 nitrosi, 262; as a diuretic, 233 Sprains arnica, 444 camphor liniment, 133 capsicum, 186 chloroform liniment, 127 dry heat, 495 ichthyol, 335 lead-water, 364 massage, 486 opium, 98 witch-hazel, 360 Sputum, disinfection of, 388 Squill, 224; as an expectorant, 288 Staphisagria, 65 Starch, 463 Stavesacre, 65 Stereoptenes, definition of, 18 Sterility thyroid gland, 343 Stomach, cancer of. See also Vom- iting, excessive. bismuth subnitrate, 375 cerium oxalate, 170 condurango, 177 creosote, 285 gentian, 175 hydrochloric acid, 182 hydrocyanic acid, 160 opium, 95 treatment, 561 Stomach, chronic catarrh of. See Indigestion. Stomach, dilatation of. See also Indigestion. gastric antiseptics, 386 lavage, 501 olive oil, 465 physostigma, 148 sodium hyposulphite, 411 strychnin, 144 treatment, 562 Stomach, ulcer of anesthesin, 157 bismuth subnitrate, 375 cerium oxalate, 170 cocain, 88 creosote, 286 hydrocyanic acid, 160 magnesia, 200 orthoform, 156 silver nitrate, 372 sodium bicarbonate, 172 treatment, 559 Stomachics, 174 Stomatitis boric acid. 412 copper sulphate, 367 hydrogen dioxid, 409 myrrh, 250 potassium chlorate, 230 permanganate (gangrenous), 409 rhus glabra, 359 silver nitrate, 372 sodium bicarbonate, 172 hyposulphite (thrush), 411 treatment, 551 Stools, disinfection of, 386 Stovain, 157 Stramonium, 80 Strictures thiosinamin, 444 Strontii bromidum, 115 iodidum, 316 6j2 INDEX. Strontii salicylas, 399 Strophanthinum, 53 Strophanthus, 53; as a diuretic, 222 Strychnin, 141. See Nux Vomica. Strychnina, 141 Strychnin-poisoning amyl nitrite, 70 chloral, 103 physostigma, 146 potassium bromid, 113 treatment, 143 Stupes, turpentine, 237 Stypticin, 380 Sudorihcs, 257 Sugar, fruit, 473 milk, 473 Sulphonal, 107 Sulphonethylmethan, 108 Sulphonmethan, 97 Sulphur, 200 Sulphurated lime, 340 Sulphuric acid, 448 Sumac, 359 Sumbul, 139 Sunstroke. See Thermic fever. Suppositories, 28 Suprarenal extract, 68 gland (see also Adrenalin): as a cir- culatory stimulant, 66 glands, desiccated, 68 Suprarenin, 66 Sylvester's method in asphyxia, 73 Sweating, excessive. See Night- sweats. Syncope alcohol, 47 ammonia, 42 digitalis, 50 ether, 57 Synovitis blisters, 441 blue ointment, 327 dry heat, 495 iodin, 318 local bloodletting, 503 massage, 486 Syphilis. See also Mucous patches, Ulcers, venereal, and Warts. atoxyl, 312 cod-liver oil, 304 ferrous iodid, 295 gold and sodium chlorid, 336 mercurials, 324 potassium chlorate, 231 iodid, 314 Syrupi, 21 Syrups, 21 Tabell^e, 28 Tablets, 28 Tachycardia. See Palpitation. Talc, Venetian, 466 Talcum, 466 Tallerman apparatus for applying dry heat, 495 Tamarindus, 198 Tanacetum, 251 Tannalbin, 356 Tannigen, 356 Tannin, 354 Tannoform, 356 Tansy, 251 Tapeworm thymol, 392, 427 treatment, 422 Tar, 287 camphor, 394 Taraxacum, 177 Tartar emetic, 271; as an emetic, 167 Tellurium, 265 Terebenum, 289 Terebinthina, 236 Terpin hydrate, 289 Terpinol, 289 Testis, 345 Tetanus amyl nitrite, 70 antitoxin, 432 carbolic acid, 389 chloral, 103 chloroform, 126 magnesium sulphate, 217 opium, 97 paraldehyd, 109 physostigma, 147 potassium bromid, 113 treatment, 535 Tetany calcium chlorid, 383 Tetramethylthionin hydrochlorid, 420 Tetranitrol, 72 Tetronal, 109 Thalii acetas, 266 Thebain, 91 Theobromina, 223 Theocin, 223 Theophyllin, 223 Therapeutics, definition of, 17 Thermic fever cold bath, 493 enemata of ice-water, 499 hypodermoclysis, 496 venesection, 504 Thiocol, 287 Thiol, 336 Thiosinamin, 443 Thymol, 392 INDEX. 6/3 Thymol iodid, 321 Thymolis iodidum, 321 Thymus gland, 344 Thyroid extract, 341 glands, desiccated, 341 Thyroidism, 342 Tic douloureux. See Neuralgia. Tinctures, 22 Tinnitus aurium cimicifuga, 138 gelsemium, 149 hydrobromic acid, 116 pilocarpin, 261 Toadstool-poisoning atropin, 80 Toe-nail, ingrowing potassa, 455 Tonics, 289 Tonsillitis aconite, 62 calx sulphurata, 340 guaiac, 338 ice-poultice, 492 salophen, 398 sodii benzoate, 278 treatment, 553 Toothache chloral camphor, 103 menthol, 158 creosote, 285 oil of cloves, 188 Torticollis. See Wry-neck. Toxaphore groups, 429 Toxins, 428 Tragacantha, 460 Traumaticin, 469 Trinitrin, 71. See Nitroglycerin. Trional, 108 Triturates, 28 Triturationes, 28 Troches, 28 Tropococain, 155 Tuberculin, 435 Tuberculosis, pulmonary. See also Night-sweats. alcohol, 47 arsenic, 310 blisters, 441 calcium hypophosphite, 302 cannabis indica (cough), 10 1 chloroform (cough), 127 cinnamic acid, 190 codein (cough), 99 cod-liver oil, 304 creosote, 284 carbonate, 285 eucalyptol, 281 guaiacol carbonate, 286 heroin (cough), 99 43 Tuberculosis, pulmonary hydrocyanic acid (cough), 160 iodoform, 321 mercuric succinimid, 334 oil of myrtle, 281 opium (cough), 96 orexin (anorexia), 179 strychnin, 143 terebene, 288 treatment, 592 Turkish bath, 494 Turlington's balsam, 277 Turpentine, 236 Turpeth mineral, 167 Tympanites. See also Flatulence. asafetida, 134 carminatives, 184 gastro-intestinal antiseptics, 386 oil of turpentine, 237 physostigma, 148 Typhoid fever alcohol, 47 beta-naphthol, 395 caffein, 55 camphor, 132 cold, 492 intestinal antiseptics, 386 lime-water, 173 musk, 137 physostigma, 148 strychnin, 143 turpentine, 237 treatment, 509 Typhoid vaccine, 437 Typhus fever treatment, 514 Ulcers anesthesin (painful), 157 burnt alum (exuberant granula- tions), 361 charcoal (foul), 413 chloretone (painful), 106 citrine ointment (indolent), 332 continuous warm baths (phage- denic), 495 copaiba (indolent), 235 copper sulphate (indolent), 367 formaldehydum, 404 glutol, 404 hydrogen dioxid, 408 iodoform, 319 lead-plaster, 365 orthoform (painful), 156 potassium permanganate (foul), 409 resin cerate (indolent), 238 silver nitrate, 371 674 INDEX. Ulcers trichloracetic acid (tuberculous), 45i Unna's gelatin dressing (indolent), 382 zinc oxid (acute), 368 Ulcers, corneal calomel, 330 Ulcers, venereal black wash, 331 carbolic acid, pure, 389 mercuric nitrate, 332 nitric acid, 450 sulphuric acid, 449 trichloracetic acid, 451 yellow wash, 330 Ulmus, 451 Uncinariasis. See Hookworm dis- ease. Unguenta, 28 Uranii nitras, 341 Uremia amyl nitrite, 70 bleeding, 503 chloral, 103 chloroform, 126 croton oil, 211 elaterium, 215 enteroclysis, 499 hot baths, 495 hypodermoclysis, 496 infusion, 496 lumbar puncture, 508 opium, 97 pilocarpin, 260 potassium bromid, 113 treatment, 617 Urethane, no Urethritis. See Gonorrhea. Uric-acid solvents, 243 Urine, incontinence of belladonna, 78 strychnin, 144 Urosin, 244 Urotropin, 404 Urticaria boric acid, 412 calcium chlorid, 383 camphor, 133 hydrocyanic acid, 160 ichthyol, 335 Ustilago maydis, 257 Uterus, cancer of oil of turpentine, 238 opium, 95 potassium permanganate, 409 Uterus, fibroma of ergot, 255 thyroid gland, 343 Uterus, inertia of ergot, 255 quinin, 256, 419 strychnin, 145 Uva ursi, 240 Vaccination, 528 Vaccines, 428 bubonic plague, 436 cholera, 436 typhoid, 437 Valeriana, 135 Vallet's mass, 292 Valvular disease. See Endocarditis, chronic. Variola treatment, 528 Vaselin, 465 Vasoconstrictors, 66 Vasodilators, 66 Vegetable cathartic pills, 212 Venesection, 503 Veratrina, 159; as a circulatory depres- sant, 63 Veratrum, 63; as a poison, 64 Vermifuges, 422 Veronal, in Vesicants, 438 Viburnum prunifolium, 140 Vienna paste, 455 Vina, 24 Vinegar, 451 Vinegars, 19 Vitriol, blue, 366 green, 294 oil of, 448 white, 367 Vleminckx's solution of, 341 Volatile oils, definition of, 18 Vomiting, excessive aconite, 63 arsenic, 310 bismuth subnitrate, 375 blister, 441 carbolic acid, 390 cerium oxalate, 170 cocain, 88 creosote, 284 hydrocyanic acid, 160 ipecac, 270 lime-water, 172 menthol, 170 nux vomica, 145 opium, 96 orexin, 179 potassium bromid, 114 treatment, 168 INDEX. 675 Wahoo, 202 Warburg's tincture, 422 Warts acetic acid, 451 caustic potash, 455 soda, 455 chromic acid, 452 salicylic acid, 398 sodium ethylate, 456 trichloracetic acid, 451 Warts, venereal calomel, 330 carbolic acid, pure, 389 chromic acid, 452 trichloracetic acid, 451 Wash, black, 331 yellow, 330 Waters, 19 Whiskey, 43 White hellebore, 63 oak, 360 precipitate, 332 Whooping-cough amyl nitrite, 70 antipyrin, 350 asafetida, 134 belladonna, 78 bromoform, 116 camphor, 132 chloral, 103 chloroform, 126 gelsemium, 149 hyoscyamus, 81 oil of amber, 140 potassium bromid, 113 quinin, 419 treatment, 532 Wild cherry, 178 Wines, 24, 44 Wintergreen, oil of, 399 Witch-hazel, 360 Wool-fat, 464 hydrous, 464 Worms, intestinal treatment, 422 Wormseed, American, 426; Levant, 425 Writer's cramp treatment, 486 Wry-neck atropin, 78 capsicum, 186 electricity, 483 gelsemium, 149 hyoscyamin, 82 Xeroform, 391 Yellow fever treatment, 530 Yellow jasmine, 149 wash, 330 Yerba santa, 471 Yohimbin, 245 Young's rule for dosage, 38 Zea, 242 Zinci acetas, 368 carbonas, 369 chloridum, 369; as an escharotic, 457 oxidum, 368 phenolsulphonas, 390 phosphidum, 301 sulphas, 367; as an emetic, 167 valeras, 135 Zincum, 367 Zingiber, 189 SAUNDERS' BOOKS on Nervous and Mental Diseases, Children, Hygiene, Nursing, and Medical Jurisprudence W. B. SAUNDERS COMPANY 925 WALNUT STREET PHILADELPHIA 9, HENRIETTA STREET CO VENT GARDEN, LONDON THE SUPERIORITY OF SAUNDERS* TEXT=BOOK In a series of articles entitled "WHAT ARE THE BEST MEDICAL TEXT-BOOKS?" a well known medical journal compiled a tabulation of the text-books recommended in those schools which are members of the American Association of Medical Colleges. The text- books were divided into twenty (20) subjects and under each subject was given a list of the various books with the number of times each book is recommended. Saunders' books head ten (10) of the twenty (20) subjects, the largest number head- ed by any other publisher being three (3). In other words, Saunders' books lead in as many subjects as the books of all the other publishers combined. A Complete Catalogue of Our Publications will be Sent upon request SAUNDERS' BOOKS ON Church and Peterson's Nervous and Mental Diseases Nervous and Mental Diseases. By Archibald Church, M. D., Professor of Nervous and Mental Diseases and Medical Jurisprudence, Northwestern University Medical School, Chicago ; and Frederick Peterson, M. D., President New York State Commission on Lunacy : Professor of Psychiatry at the College of Physicians and Surgeons, N. Y. Handsome octavo, 944 pages ; 341 illustrations. Cloth, $5.00 net ; Sheep or Half Morocco, $6.50 net. RECENTLY ISSUED— NEW (6th) EDITION This work has met with a most favorable reception from the profession at large. It fills a distinct want in medical literature, and is unique in that it furnishes in one volume practical treatises on the two great subjects of neurology and psychiatry. In preparing this edition the work has been thoroughly revised and new articles on Psychasthenia and Psychotherapy added. The recent views in regard to the motor area of the Rolandic region have necessitated the rewriting of the chapter pertaining to the related subjects. A number of new illustrations have also been added. A feature of much value is the very full and complete review of recent problems of psychiatry. OPINIONS OF THE MEDICAL PRESS American Journal of the Medical Sciences " This edition has been revised, new illustrations added, and some new matter, and really is two books. . . . The descriptions of disease are clear, directions as to treatment definite, and disputed matters and theories are omitted. Altogether it is a most useful text-book." Journal of Nervous and Mental Diseases "The best text-book exposition of this subject of our day for the busy practitioner. . . . The chapter on idiocy and imbecility is undoubtedly the best that has been given us in any work of recent date upon mental diseases. The photographic illustrations of this part of Dr. Peterson's work leave nothing to be desired." New York Medical Journal "To be clear, brief, and thorough, and at the same time authoritative, are merits that ensure popularity. The medical student and practitioner will find in this volume a ready and reliable resource." DISEASES OF CHILDREN. KerrV Diagnostics qf Diseases qf Children Diagnostics of the Diseases of Children. By LeGrand Kerr, M. D., Professor of Diseases of Children, Brooklyn Postgraduate Med- ical School, Brooklyn. Octavo of 542 pages, fully illustrated. Cloth, $5.00 net; Half Morocco, $6.50 net. FOR THE PRACTITIONER Dr. Kerr' s work differs from all others on the diagnosis of diseases of children in that the objective symptoms are particularly emphasized. The constant aim throughout has been to render a correct diagnosis as early in the course of the disease as possible, and for this reason differential diagnosis is presented from the very earliest symptoms. The many original illustrations will be found helpful. New York State Journal of Medicine " The illustrations are excellent and numerous. It will meet the needs of the great mass of physicians who treat the diseases of infancy and childhood." Kerley's Treatment qf Diseases qf Children Treatment of the Diseases of Children. By Charles Gilmore Kerley, M. D., Professor of Diseases of Children, New York Polyclinic School and Hospital. Octavo of 628 pages, illustrated. Cloth, $5.00 net ; Half Morocco, $6.50 net. JUST ISSUED— THE NEW (2d) EDITION This work has been prepared for the physician engaged in general practice. The author presents all the modern methods of management and treatment in greater detail than any other work on the subject heretofore published. The methods suggested are the results of actual personal experience, extending over a number of years of hospital and private practice. There is an excellent illus- trated chapter on Gymnastic Therapeutics. The British Medical Journal " Dr. Kerley's book is one of the best on the subject that has come under our notice. All through it shows evidence of ripe experience and sound judgment." SAUNDERS' BOOKS ON GET A • THE NEW THE BEST l\ IT1 © T 1 C